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Learning to speak up

13 October, 2017

Learning to speak up

Gaps between official guidelines and clinical practice are worrying student midwives. We take a look at some of the issues.

Student midwives are increasingly wary of the gaps that can appear between what they are taught in the classroom and what they experience in units and on wards, according to feedback from the RCM Student Midwife Forum.

When witnessing these gaps, students are usually confronted by a couple of tough questions: What circumstances might explain the difference? And how do they start a conversation with superiors about discrepancies and the reasons for them?

This issue has become known as the ‘evidence/practice connection’, and it is now the subject of a study that will involve all the various stakeholders in exploring the problem and collecting all points of view. Ultimately, the aim is to come up with insights and ideas that will put students on a firmer footing when confronted with disjointed evidence/practice connections.

Why does the problem exist?         

‘There are certain units that don’t employ NICE guidelines for various reasons,’ says Professor James Walker at the University of Leeds. ‘Guidelines are just guidelines, and sometimes you need to adapt them to your own environment. But you should be following the general train of what the guidelines say unless you have a strong reason not to. There are also individual situations where the guidelines may not be suitable, so individual clinical decisions can override them. But again, there have to be reasons for that.’

Carmel Lloyd, RCM head of education and learning, highlights a wider practical issue: ‘It is fairly well documented that there is some time-lag between what students are taught in university and its translation to clinical practice. Within a trust it takes a little time to develop policies that respond to NICE guidelines. But once those NICE guidelines are published, that work should start straightaway. I think one of the issues is that some trusts are better at doing this than others.’

According to Dr Ellen Kitson-Reynolds, midwifery programme lead at the University of Southampton, her institute is one of those that focuses hard on guidelines. ‘I would say our maternity services are good at keeping guidelines up to date. I frequently talk about this with students. We have two consultant midwives who maintain the guidelines. I would have said that, five to 10 years ago, we would have seen a disconnect between guidelines and current practice. But today, when new evidence emerges, we are quick to follow it up.’

Anna Merrick, a newly qualified midwife, says she was made aware of the potential for a misalignment between evidence and practice right from the start of her studies. ‘It is definitely something we were told about. We were taught about best practice and the evidence base, but we were also warned that when we went into clinical areas we might see people practising in a different way. So were aware of it. Normally there was no danger in the situation, but just that something was being done differently. Even so, it could be uncomfortable sometimes.’

Don’t confront – enquire

When they find themselves in this situation, what should student midwives do? ‘While students are following orders within a unit, they are also independent practitioners and should highlight any concerns they might have,’ says Professor Walker. ‘To some extent it depends on how serious the matter is. From a student’s point of view, seeing different practice is good because it allows them to form in their own mind what good and bad practice might be. But if they do want to raise the matter, I think it’s about being inquisitive and wanting to learn rather than challenging. Don’t confront – enquire. In my unit, they can come and ask any question they want. I always say that there’s no such thing as a stupid question in a labour ward.’

Carmel agrees that simply asking the question is the best first step. Beyond that, most universities will have formal policies that outline what students should do if they want to raise a concern. ‘The normal procedure is for a student to discuss it with her named mentor and to try to deal with it in the practice arena. But if she feels for some reason she cannot do that, you would expect her to have a conversation with the linked tutor or her own personal tutor. When I was teaching, I would either support the student to deal with it herself or go directly back to the clinical area.’

The culture in Southampton is one of critical thinking and openness, says Ellen. ‘We want to give students the skills and the confidence to be able to challenge what they see if they think it isn’t working or isn’t quite right. But they have to do it in a professional way, without coming across as aggressive, and accepting that there might be a very good reason why things don’t match completely. They might also need support from me or somebody else in the midwifery team; but we have good open communication with senior management within maternity services, and we might be slightly different to other places in that sense.’

For Anna, a sense of structure and formality provides important support in developing the confidence to question practice. ‘It’s hard, especially when just starting your training, to have the confidence to speak up. But the university encouraged it, as they were always trying to champion best practice. Often in the clinical area we would have reflection sessions with teachers and midwives, and go through situations and talk about what we had seen. I would never question practice in front of a client, but the session meant we could have those discussions in a more open and comfortable way.’

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