Developing a review process for Australian midwives: A report of the Midwifery Practice Review project process

Article Outline

• Summary
• Introduction
• Development approach
  • Initial development of the Midwifery Practice Review process
  • Consultation using the first draft of the Midwifery Practice Review process
  • Pilot testing with the next draft of the Midwifery Practice Review process
  • National Reviewer Training on the Midwifery Practice Review process
  • Finalising and implementing Midwifery Practice Review process
• Discussion
• Conclusion
• Acknowledgements
• References
• Copyright

Summary 

Objective

To develop a formal, robust and transparent process that supports and enables midwives to reflect on their own midwifery practice in relation to recognised professional standards and to identify, prioritise and act upon individual professional development and learning needs for the provision of safe, high quality care to women and their families within the full scope of midwifery practice. This process was part of a national project commissioned by the Australian College of Midwives and funded by the Australian Council for Safety and Quality in Health Care and is part of the Continuing Professional Development, MidPLUS program developed by the Australian College of Midwives.

Approach

A multi-method, staged approach was used to develop the national Midwifery Practice Review process. Data to inform the development of the Midwifery Practice Review process was collected through a literature review, workshop consultations, written submissions and the pilot testing of a draft process. Finally, a national training workshop was undertaken to train reviewers to carry out reviews and to ensure the final process was validated and was feasible and acceptable to midwives and consumers.

Setting

Maternity care settings in each state and territory throughout Australia.

Participants

Midwives, other health professionals and consumers of midwifery care.

Findings

The Midwifery Practice Review process was developed through research and national consultation prior to being validated in practice.

Key conclusions

The Midwifery Practice Review process is currently being implemented and evaluated in Australia.

Implications for practice

The Midwifery Practice Review Project established a national validated process for assessing the ongoing competence of midwives. The resulting program helps to reinforce responsibility and accountability in the provision of quality midwifery care through safe and effective practice.

Keywords: Midwifery peer review, Midwifery Practice Review, Professional practice review, Credentialling, Clinical competence

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Introduction 

In recent years a range of initiatives have been developed by the Australian Council for Safety and Quality in Health Care (ACSQHC) and others to reduce the risk for patient harm and to improve the safety and quality of health care. These initiatives are designed to assist health care providers to ensure that care is provided only by suitably qualified professionals whose performance is maintained at an acceptable level. National standards of credentialling and compulsory Continuing Professional Development frameworks for medical practitioners are examples of these initiatives.¹ Currently there are no such nationally consistent systems in place for midwives, who collectively care for more than 250,000 women and their families in Australia each year. While Nursing and Midwifery Regulatory Authorities (NMRAs) in all jurisdictions share the same purpose, to protect the public, the processes used for achieving this purpose vary from one state and territory to another. Some jurisdictions require that midwives demonstrate recency of practice or state that they are competent while others do not. Even those jurisdictions that do demand recency of practice do not stipulate what that practice should be in order to demonstrate competence.

Quality and safety measures for midwives are currently largely the responsibility of employers. Currently employers use a myriad of variable standard training, credentialling, and accreditation processes in an effort to ensure their midwifery staffs provide competent care. However, the certification of accreditation or credentialling that midwives attain from participating in such processes is often not recognised by different employers or across different states/territories.² Current systems also rely on the individual midwife to assess and prioritise their own professional development needs. This generally occurs without routine access to training and other activities to maintain competence and enhance knowledge and skills. These shortfalls in nationally consistent mechanisms were the impetus to develop this project.

In 2005, the Australian Council for Safety and Quality in Health Care provided funding for the Australian College of Midwives to develop a rigorous peer review process for Australian midwives. The project was undertaken during 2006 and 2007 and the final Midwifery Practice Review process was launched in September 2007. The authors of this paper were employed by the Australian College of Midwives to lead the development process with wide consultation and collaboration. This paper describes the development of the Midwifery Practice Review process highlighting the approach that was undertaken. It is hoped that understanding the approach taken to develop Midwifery Practice Review will assist the implementation of this new and exciting professional development initiative.

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Development approach 

The Midwifery Practice Review project aimed to develop and test a nationally consistent, formal, robust and transparent process. This process is designed to support and enable midwives to reflect on their own midwifery practice in relation to recognised professional standards and to identify, prioritise and act upon individual professional development and learning needs for the provision of safe, high quality care to women and their families within the full scope of midwifery practice. A multi-method, staged approach was undertaken to develop, test and implement the Midwifery Practice Review process. These stages were to:

Fig. 1 presents an overview of the stages and the activities that were undertaken. The project was governed by a Project Management Committee (PMC). The PMC was composed of representatives from the Australian College of Midwives, the Australian Nursing and Midwifery Council (who represents the nursing and midwifery regulatory authorities), Maternity Coalition (national consumer organisation), and the national industrial organisation for nurses and midwives, the Australian Nursing Federation. Ethical approval from the university where the Project Director was based was sought prior to commencement.

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• Figure 1. 

  Stages of the project and associated activities.

Initial development of the Midwifery Practice Review process 

A literature review was undertaken to identify Australian and the international literature regarding peer review processes. This literature review guided the development of the initial draft of the Midwifery Practice Review process. This review drew on the literature and examples of similar programs for midwives from the United Kingdom (UK), New Zealand (NZ), Canada, and New South Wales (NSW) in Australia. Similar type programs for other professions including mental health and critical care nurses were also investigated. An earlier paper provides an exploration of the issues relevant to the development of the Midwifery Practice Review process including an outline of existing systems, processes and models used to review midwifery practice in Australia and elsewhere (under review). Key documents from a number of countries and organisations were also identified (Table 1).

Table 1. Key documents used in the initial literature search

In NSW, the establishment of a number of midwifery led models with an increased emphasis upon the utilisation of midwives in the care of low risk healthy women has led to the development of The NSW Health Credentialling Framework.³ This Credentialling Framework provides a mechanism for midwives to demonstrate their competence and capability to practise in midwifery-managed continuity of care models.⁴ Governed by a mandatory Policy Directive released by NSW Health,⁵ the Credentialling Framework is administered by the NSW Midwives’ Association and must be adhered to by all midwives working in midwifery-managed models of care.

In New Zealand, the Health Practitioners Competence Assurance Act 2003 requires the Midwifery Council to be satisfied with a midwife's competence to practise within the Midwifery Scope of Practice each time that midwife applies for an annual practising certificate.⁶ The Midwifery Council of New Zealand administers a nationally consistent professional framework for the maintenance of the competence of all midwives irrespective of their work environment. This is known as the ‘Recertification Programme’.⁷ Since 2005, all New Zealand midwives who wish to retain a practising certificate, are required “to undertake the Midwifery Council's Recertification Programme to demonstrate their continuing competence to practise at the minimum level required for entry to the profession”.⁷, ⁸ A face-to-face discussion process, known as Midwifery Standards Review is one element of the Recertification Program.

The Nursing and Midwifery Council's (NMC) standards in the United Kingdom (UK) require midwives to be competent to support women to give birth normally regardless of the setting in which they are employed. Registration with the NMC is a requirement for employment as a midwife in the UK. In addition to meeting the requirements of the Post-Registration Education and Practice (PREP) standard to achieve registration, each practising UK midwife must have a ‘named supervisor of midwives’.⁹ The named supervisor of midwives provides a mechanism for support and guidance and each midwife must attend at least one review of their practice and identification of training needs with their named supervisor annually.⁹

The examples of processes that support the ongoing assessment of competence, reflection and professional development in NSW, NZ and the UK were important to explore and review in the initial development of the Midwifery Practice Review process. These were useful in the next stage of the project which included consultation processes.

Consultation using the first draft of the Midwifery Practice Review process 

A draft of what a Midwifery Practice Review might look like was developed from the literature review (Fig. 2). This draft was presented to practising midwives at consultation workshops in each state and territory. In total, 217 midwives attended these workshops and provided valuable feedback (qualitative and quantitative data) about the draft (Table 2).

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• Figure 2. 

  A summary of the initial draft Midwifery Practice Review process.

Table 2. Survey respondents and attendees at workshops - state or territory of residence

The NMRAs in each state and territory were consulted at this stage. An Advisory Group meeting was also held with representation from the Australian Association of Rural Nurses, Australian Lactation Consultants Association, Australian Society of Independent Midwives, National Association of Childbirth Educators, Perinatal Society of Australia and New Zealand, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Royal College of Nursing Australia, Rural Doctors Association of Australia, Women's Hospitals Australasia, and representation from the Chief Nursing Offices in some states.

A 21 item survey questionnaire sought to gather midwives’ and Advisory Group members’ feedback regarding the initial draft of the Midwifery Practice Review process. The questionnaire was divided into the following categories: demographic data, the preparation of a portfolio, the proposed content of the review process, reviewers and reviewer training, the scope of Midwifery Practice Review and the linking of Midwifery Practice Review to regulation. Surveys were distributed during workshops and were also made available electronically to midwives who could not attend workshops but expressed an interest either through telephone or email contact. In total, 136 surveys were received (Table 2). It is not possible to determine response rate as the survey was distributed widely at workshops and electronically (Table 3).

Table 3. Stated role of the survey respondents

The consultation phase found that the initial draft of the Midwifery Practice Review process was considered to be ‘about right’ with ‘some fine tuning necessary’. We did not define what ‘about right’ meant as it was meant to be a general response. Further refinement of the Midwifery Practice Review process occurred as a consequence of the discussion stimulated at the workshops and meetings and from the surveys that were received. This feedback identified two main issues that were further discussed. These were the inclusion of a practical ‘skills station’ in the review process and evidence of examples of documentation in the review preparation. As both of these areas were the most contentious they were ultimately removed from the Midwifery Practice Review process. Feedback regarding the initial draft of the Midwifery Practice Review process was also provided by The Project Management Committee.

Pilot testing with the next draft of the Midwifery Practice Review process 

As a result of the first stage of consultation, a second draft of the Midwifery Practice Review process was developed and used in the next phase of the project which included pilot testing. The pilot-testing phase was undertaken to ensure that Midwifery Practice Review met the needs of midwives and was a robust and supportive process. The pilot-testing phase included an observation of The NSW Health Credentialling Framework ³, ⁵ and the conduct of two 1-day workshops one in Queensland and the other in the Australian Capital Territory (ACT). The aim of these workshops was to test the process that was being proposed and to undertake this with midwives and consumers (the term consumer is used rather than ‘women’ as it is a term understood in Australia as referring to those with interest and experience in maternity care and recognises that consumers can also be men). A total of 16 midwives and 6 consumers participated in the pilot testing. The pilot test workshops were presented in a facilitative and interactive format and included observation of and participation in panel discussions. The feedback received from the midwives and consumers who participated was used to shape the Midwifery Practice Review process further.

Constructive and useful feedback was provided regarding the process of the training day and the materials developed to assist midwives to prepare for Midwifery Practice Review. Midwives reported that it took between 3 hours and 2 weeks to prepare their portfolios for their supported practice discussion. Both midwives and consumers felt that the process of review and training was “excellent”, “inspirational” and “constructive”. Overall, the midwives who participated in the pilot testing of Midwifery Practice Review reported that it provided a valuable way of reflecting on their practice in a supportive environment. The consumers who participated said that they felt ‘honoured’ and ‘privileged’ to be involved in such a process.

After the pilot-testing phase, the Midwifery Practice Review process was further refined. This involved meetings with the Project Management Committee and discussions at the national 1-day seminar that was part of the annual general meeting of the Australian College of Midwives. The revised methodology for Midwifery Practice Review was also presented to a second meeting of the Advisory Group and feedback was considered and incorporated as appropriate. During this phase of the project, the project team also worked closely with the midwives working on the development of a national Australian College of Midwives Continuing Professional Development (CPD) program, to ensure that the Midwifery Practice Review program would be an integral part of the overall CPD framework.

National Reviewer Training on the Midwifery Practice Review process 

The next phase of the project brought together midwives and consumers from around Australia for a national workshop. The purpose of this workshop was to train and support midwives and consumers who were interested in applying to become the first group of reviewers. Each state and territory branch of the Australian College of Midwives was asked to nominate two midwives and two consumers to attend the workshop.

The initial National Reviewer Training Workshop was held over 2 days at the end of November 2006. Whilst two consumers and two midwives from every state and territory were invited to attend this workshop, 22 participants representing every state and territory made up the final numbers of attendees. The workshop took a facilitative and interactive format with discussion, participant involvement, observation of role plays and participation in the Midwifery Practice Review process. Much of the 2 days was spent practising undertaking reviews and providing feedback to one another on the process. A second National Reviewer Training Workshop was held in June 2007 with more than 30 participants.

Finalising and implementing Midwifery Practice Review process 

A series of documents for Midwifery Practice Review, the terms of reference, position statements, policies and marketing material for the implementation and evaluation of Midwifery Practice Review were completed. The Midwifery Practice Review process designed for practicing midwives by practising midwives was launched at the 15th ACM Biennial Conference in September 2007.

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Discussion 

The Midwifery Practice Review was developed through the process of consultation and pilot testing. An outline of the final version of Midwifery Practice Review from the Midwife's Handbook is presented in Fig. 2. Participation in the Midwifery Practice Review program is voluntary. The Midwifery Practice Review program focuses only on midwives directly involved in providing care to women. It is not designed for midwives in equally important roles as educators, managers, policy-makers and researchers. Midwives are encouraged to undertake Midwifery Practice Review on a 3-yearly basis.

Midwifery Practice Review is relevant and open to all practising midwives in Australia. It is a formal, robust and transparent process that supports and enables midwives to reflect on their own midwifery practice in relation to recognised professional standards and identify, prioritise and act upon individual professional development and learning needs for the provision of safe, high quality care to women and their families within the full scope of midwifery practice (Fig. 3).

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• Figure 3. 

  A summary of Midwifery Practice Review from the handbook.

Midwifery Practice Review sits within and is an integral component of the Australian College of Midwives’ broader CPD framework which is now known as MidPLUS. Midwives who undertake Midwifery Practice Review are automatically enrolled in the MidPLUS program if they are not already enrolled. Continuing Professional Development points are awarded for a midwife's successful completion of Midwifery Practice Review.

Certain challenges became evident during the development and pilot testing of the process. Firstly, there is a need to balance rigor of the process with being supportive and constructive. Many midwives feel anxious about the process and it is essential that the process is supportive and nurturing. Equally, it is important that the process is rigorous and has value for the midwives who undertake it.

The utility of the Midwifery Practice Review process while it remains voluntary has been questioned. Currently, NMRAs do not mandate participation in such a process and the processes to demonstrate proof of competence vary widely across Australia.¹⁰, ¹¹ In jurisdictions where there is an emphasis on declaring ‘competence to practise’ according to national competency standards, the uptake of Midwifery Practice Review is expected to be greater than in jurisdictions where no such impetus exists.¹² There is a role for the NMRAs to require midwives to show their continuing competence to practise. Professional standards, such as the demonstration of competence, are for the protection of the public interest. The requirement for practitioners to demonstrate that they are keeping up-to-date and are competent to practise is a worldwide issue. Incorporation of peer review processes like Midwifery Practice Review into employment contracts, position descriptions and performance appraisals will assist with greater uptake. It is likely that implementation of the Council of Australian Government's reforms to achieve national registration of health professionals by 2009 will result in more uniform requirements for demonstrating ongoing competence. Midwifery Practice Review could then become increasingly attractive to practicing midwives.

This project has a number of limitations. It was not possible to obtain the views of all Australian midwives during the development process. It is possible that only midwives who were informed and aware of the project or those who had information technology skills (that is, could use the internet) chose to participate. In addition, it is likely that only midwives who were members of the Australian College of Midwives participated in the development process. While this limitation is acknowledged, significant efforts were made to ensure that as many midwives as possible could contribute. This included open invitations to workshops, information presented at state conferences and professional forums, information in professional newsletters, which were widely distributed, the availability of an on-line survey form and an invitation for written submissions. The Advisory Group also provided an important contribution from midwifery leaders in education and practice roles and from representatives of other health professions and consumers across the country. The Project Management Committee ensured input was received from leaders in regulation and professional matters.

The size of the project was limited by the number of midwives who participated, the number of sites for consultation and pilot testing and the timeframe. It is difficult to determine whether the number of midwives and consumers who undertook pilot testing and the national training workshop was adequate; however, it was encouraging that the feedback was positive. The time frame and budget for the study also meant that it was not possible to undertake more pilot-testing processes. The sample included in the pilot-testing process, did, however, represent a broad range of midwives who work in maternity care in Australia in urban, regional, rural and remote settings. Each state and territory was represented and respondents identified working in a range of models of care, including public and private hospital maternity units and midwifery continuity of care schemes. These are broadly representative of the models of care options available in Australia. Despite these limitations, the process that was developed is rigorous and has been positively assessed by midwives and consumers who have undertaken it. Evaluation of the Australian college of Midwives Midwifery Practice Review program is planned for 18 months or so following the launch of the program in September 2007.

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Conclusion 

This project developed and validated an Australian Midwifery Practice Review process. This is a national process for midwives which reinforces individual midwives’ responsibility and accountability in providing quality midwifery care through safe and effective work practice. The process has been incorporated into the ACM's Midwifery Practice Review program, which is available to practicing midwives across Australia. While employers will continue to need to support the ongoing competence of their midwifery staff, the Midwifery Practice Review program provides an independent, nationally consistent mechanism for midwives to reflect upon their own practice and identify priorities for maintaining and enhancing their own practice.

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Acknowledgements 

The authors thank the Project Management Committee members for their advice, wisdom and leadership: Chris Cornwell (Chair), Karen Cook, Victoria Gilmore, Roz Donnellan Fernandez, Ingrid McKenzie, Denise Patterson, Tina Pettigrew, Bruce Teakle and Wendy Pearse. We also thank Barb Vernon and the Board of the Australian College of Midwives for their commitment and support. We also thank Dr Barbara Vernon and A/Professor Deborah Davis for their useful comments on this manuscript.

The Australian College of Midwives acknowledges the Australian Council (now Commission) on Safety and Quality in Health Care for their funding and support of the project.

Funding: Australian Council for Safety and Quality in Health Care.

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