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Analysis

Consultant midwives: the next generation!

12 June, 2008

Consultant midwives: the next generation!

The recent failure to fill a number of consultant midwife posts may be due to lack of structured and individualised preparation for possible candidates. Jane Rogers and Annette Weavers describe a mentorship programme that aimed to provide an objective view into clinical midwifery leadership and develop skills necessary for this position.

The recent failure to fill a number of consultant midwife  posts may be due to lack of structured and individualised preparation for possible candidates. Jane Rogers and  Annette Weavers describe a mentorship programme that aimed to provide an objective view into clinical midwifery leadership and develop skills necessary for this position.

 

Midwives magazine: April 2005

 

 Introduction

 

This is a personal story of a year's mentorship programme for an `acting' consultant midwife. It outlines the rationale and aims of the mentorship programme, some of the achievements of this midwife and her mentor and an evaluation of the year's work. It concludes with some thoughts on the value of this and other ways to address the issue of succession planning for consultant midwives. Committed to a vision of strong midwifery clinical leadership, the district general hospital (DGH) had funding for a consultant midwife post in 2002, but had failed to appoint a suitable candidate.

 

The funding for the post was subsequently withdrawn and in 2004 a decision was made by the head of midwifery (HOM) not to readvertise but to seek mentorship for a midwife from within the unit, Annette Weavers, (AW) who would take on an acting consultant midwife role for the period of one year. Jane Rogers (JR), who worked in a neighbouring Trust, was invited to take on the mentorship - she had been in post as a consultant midwife for just over three years at this point.

 

The DGH is typical of many maternity units similarly situated, having good academic links and keen students of midwifery. There have been some sustained radical changes in midwifery priorities and organisation, although there is a strong medical influence on care. The DGH is suffering from chronic staff shortages due to its geographical location. It was recognised that morale was patchy and there was a need for an objective viewpoint and outsider input into clinical midwifery leadership. Following many years of clinical practice, AW had been in a lecturer practitioner (LP) post for three years, which was a combined academic position with the link university.

 

The HOM was keen on developing midwives, and successfully negotiated with the education provider to secure part funding for the developmental consultant midwife role (0.2 whole time equivalent), and also to second a midwife into the LP role for the year. JR's background was similar in that following a long period of time in clinical practice, she had been an LP in the same unit where she took on a consultant midwife role. An instinctive understanding, generated through having very similar backgrounds may have had an impact on the empathetic rapport AW and JR quickly developed. The overall goal of JR's secondment was to raise the midwifery profile in the DGH, with the main focus being on clinical practice.

 

Objectives aiming to contribute to this goal were set and agreed with the HOM and further objectives were agreed with AW, with examples being to:

 

  • Refine skills related to clinical effectiveness

  • Develop confidence with regard to handling confrontation and conflict

  • Contribute to the strategic development plans for the maternity service. JR committed a day a fortnight to mentorship for one year. The following are just a few examples of the work undertaken to achieve the goals identified.

 

Consultant midwife clinic and audit

This idea was developed during discussion about how best to carry out the clinical leadership and practice part of the role. Previously, AW had carried a caseload that inevitably entailed periods of time working on-call. JR had done the same and both had experienced the difficulties inherent in combining this with a full diary of strategic and academic commitments.

 

JR had heard and read about the success of a colleague's consultant clinic (Dunkley-Bent, 2004), in particular its achievement in reaching vulnerable women and therefore meeting a public health goal. In addition, this way of practising has the potential to influence the practice of midwives if the consultant involves them in the planning and implementation of the woman's care. It was therefore decided that both AW and JR (with her colleague in her own Trust) would begin a weekly consultant clinic for women with specific needs that necessitate extra midwifery input and planning. Common examples are women requesting caesarean section (CS) because of fear of childbirth and those requesting low intervention or home birth for a vaginal birth after CS. An audit tool was designed to evaluate the clinic's usefulness and it is hoped that findings from this audit will be published in the future.

 

Clinical governance framework

 

One of the opportunities of the consultant midwife role is to influence the implementation of the clinical governance framework. In practice, this is likely to mean something different in each Trust, even though the overall structure and aims are similar. In AW's Trust, there were a number of different groups and individuals with roles that had aims related to clinical governance. One of the issues was the line of accountability and validation procedure when producing multidisciplinary guidelines for practice, which was not consistent. To resolve this, a meeting took place between the HOM, the clinical director, AW and JR and a framework includingaccountability was formulated and agreed by the clinical governance committee.

 

Birth centre and normal birth pathway

 

A midwife-led birth centre was already in existence at the Trust when the mentorship began. This is situated in a ward on a  different floor from the labour ward. Until recently three rooms were dedicated to the birth centre and up to 70 women gave birth there every month. The birth centre opened under the watchful gaze of both midwifery and medical staff, as it was an innovation for the service. One of the aims was to promote normality within the birth process. This led to challenging debates as to what is `normal'.Midwives were being called to defend their practice relating to `long labours' and `lack of active management'. At this juncture, it was decided to be proactive and introduce the All-Wales clinical pathway for normal labour with recommendations for midwifery practice, which has received acclaim in Wales (NHS Wales, 2003). An audit of the pathway was devised and implemented to monitor standards of practice.

 

Building on experiences of others

 

Another tactic chosen to broaden AW's  repertoire of managing change was for her to spend some time in the Trust where JR normally works. The dates were chosen to coincide with specific events, such as the monthly perinatal mortality meeting that is led by consultant midwives in rotation with two obstetricians. AW also took part in a  leadership development day for the senior midwives and registrars working on the labour ward. AW's firsthand experience of how this type of learning can work has encouraged her to organise a similar day in her own Trust, where the issues regarding clinical leadership are comparable.

 

Evaluation of the programme

 

AW and JR reached the objectives set out  in the initial agreement. The degree to which these were achieved is hard to measure, as with most aspects of consultant midwife posts. Achievement is confused by other initiatives being put in place concurrently, such as Sure Start programmes, multiprofes- sional learning and midwife-led care. It is also misleading to evaluate this role using quantitative methodology alone, since it is as much to do with quality of care as numbers of people, interventions or practices affected. It is our perception that the midwifery profile at the Trust has been strengthened. The midwife-led birth centre continues to thrive and practice is monitored and improved through audit. The consultant midwife clinic now attracts referrals from obstetricians as well as midwives. The  contribution of a practising midwife at the right level in the clinical governance hierarchy ensures that there is always a midwife keeping midwifery business high on the agenda. Importantly, there was support for a bid for a substantive consultant midwife post within the Trust hierarchy.

 

Did it work for us?

 

From AW's perspective, one of the assets of the programme was to have a mentor from outside the usual environment. This enabled objective assessment and reflection that contributed to building confidence in some of the new situations that were being faced. To actually observe a consultant midwife in action helped to identify strengths and  weaknesses within her own development  by learning through the master! Mentorship programmes are part of modern day midwifery, but they are often only found within the context of being newly qualified. From firsthand experience AW can certainly recommend mentorship for senior posts  as well, and she feels lucky to have had  this experience. JR was seconded one day a fortnight to the Trust and this amounted to little time in the Trust and her visibility among other midwives and at key meetings was not optimal. There were requests from some of the senior midwives for JR to spend some time with them and as she could not honour these requests it limited her potential circle of influence.With forward planning and support from her own Trust and university, an  arrangement could have been made for someone to act in a development role in JR's post, thus freeing up more time with AW. It was of great value to JR to spend time in another Trust, as she was able to analyse more clearly what was working (and what was not) in her own Trust.Without `stepping outside' and having a direct contrast, this picture would not have come into such sharp relief. She was also able to take back to her own service things that were working well at AW's Trust, so it was not all a one-way street. As JR was an `outsider', when directly challenging midwives and obstetricians she had to be more forthright than might be her usual style. This was a result of her time being limited and also because the change management opportunities for her could not encompass a deep and trusting working relationship. The follow-through needed to be effected by AW and so essentially JR was the catalyst and AW the implementer.

 

Conclusion  

 

This article has given a snapshot of mentor- ship that might act as a template for other programmes of succession planning. It is important to realise that in the case of mentorship one size does not fit all, and this is simply our personal account. However, some parts of our programme may usefully be employed within the context of more formal development, such as that evolving at the Wessex Deanery under the leadership of Fleur Kitsell, associate dean for consultant practi- tioner development. This programme is being designed and is aimed at aspiring consultant practitioners at all levels from several health- related professions. As there are clearly advan- tages to be gained by both parties and by at least one Trust, it is a strategy to be recom- mended if we are to harness every means of encouraging midwifery leadership. In recent years, some consultant midwife posts have been advertised and appointments not been made. There is a possibility that the `natural pool' of midwifery clinical experts was exhausted after the first few rounds of consultant appointments, with subsequent applicants not meeting the demanding criteria laid down by the government and regional boards. The result is a clear imperative for midwifery leaders and educationalists to provide a rigorous, credible and accessible pathway for aspiring consultants.

 

References

 

Dunkley-Bent J. (2004) A consultant midwife's community clinic. British Journal of Midwifery 12(3):144-71. NHS Wales. (2003) All-Wales clinical pathway for normal labour. See: www.wales.nhs.uk/sites/ home.cfm?OrgID=327 (accessed March 2005).

 

 

 

 

 

 

 

 

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