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Midwifery Assistants
						
						
								Response to the Consultation Document issued by 
								the Midwifery Council of New Zealand
						
				
		
		
				
						Essentially we believe the DHBNZ approach has some 
						fundamental flaws and they have failed to consider a 
						number of options which may be open to them. However, 
						we also see the introduction of healthcare assistants into maternity 
						care is probably inevitable. Therefore, we believe, if this is going to 
						happen, it must be regulated and an appropriate scope of practice 
						defined nationally and we would support the Midwifery Council in this.
				
		
		
				
						
								Introduction 
						
				
		
		This paper has been prepared in response to the 
		Consultation Document issued by the Midwifery Council of 
		New Zealand. 
		In preparing this response we have sought the views of 
		our members and others. 
		We thank the Council for the opportunity to make this 
		submission.
		
				
						
								Background 
						
				
		
		     The midwifery profession has seen a significant number 
		of changes over the last twenty years, many of which have been 
		positive as they have encouraged midwifery to develop as a 
		profession and midwives to practice as independent health 
		professionals responsible for their own practice. 
		     At the same time, there have been significant changes 
		in the environment both in the community and within health 
		care facilities. The Health & Disability Commissioner Act 1994 and 
		the Health Practitioners Competence Assurance Act 2003 have both 
		had a major impact on the way in which all health services, including 
		maternity services, are provided. 
		    During the same period, hospitals have been reorganised 
		three times and this has created a number of pressures including 
		tight budgetary controls and downsizing of staff. At the same time 
		there has been a push to move services out of hospitals and into the 
		community. 
		    These changes, amongst other factors, have created stress on 
		the midwifery workforce which has aggravated the shortage which was 
		recognised over ten years ago and which has now reached critical 
		levels in many regions and in both hospitals and in the community. It 
		is noted similar shortages exist in many other health professions (e.g. 
		nursing). 
		   While there are active programmes in place to recruit and 
		educate more midwives, the effects of an aging workforce and the 
		above mentioned stress mean the workforce is not increasing 
		sufficiently quickly to meet the need.
		
				
						
								DHBNZ Proposal – employment of midwifery assistants 
						
				
		
		DHBNZ have proposed the use of midwifery assistants as one way of 
		relieving the current midwifery workforce shortage. It is 
		recognised this would not relieve the shortage as such but the 
		use of midwifery assistants could enable the better use of 
		midwifery staff by freeing them of mundane tasks which do 
		not require midwifery skills to perform (e.g. data input, 
		cleaning).
		
				
						
								This proposal needs to be considered in context. 
						
				
		
		    It is noted many DHBs are already using healthcare 
		assistants in a variety of roles, largely unregulated. These roles include 
		‘hotel’ services (e.g. cleaning, assistance with hygiene) as well as 
		clerical roles. 
		    The use of assistants for hotel and clerical tasks is attractive to 
		DHBs as not only is the cost less than that of a health professional but 
		also these assistants can relieve the health professionals of those tasks 
		which do not require clinical expertise. 
		    Our members report many facilities are now using such 
		assistants although in a number of cases it is simply a change of title 
		(e.g. a cleaner has become a healthcare assistant who cleans). 
		    Our members also report there are a growing number of 
		facilities where healthcare assistants are assuming lower level clinical 
		tasks (e.g. dispensing medication, recording clinical observations, baby 
		bathing) although it appears the assistants undertaking these roles are 
		largely unregulated and without appropriate training. The use of 
		healthcare assistants for clinical tasks in maternity facilities appears, to 
		date, to be very limited. It is also noted at least one DHB is using 
		registered nurses to supplement the midwifery workforce.
		
				
						
								Comment on the DHBNZ Proposal 
						
						
						
				
		
		While the use of midwifery assistants might achieve the 
		DHBNZ objective of relieving the current midwifery shortage, it 
		appears there may be other options available which would 
		similarly relieve the shortage. 
		
				
						These options could include:  
		
		    Recruitment of registered nurses who wish to
		become midwives, with the establishment of a specific
		training programme for them. Given the training they have already received, it is suggested such a programme wouldneed to be no longer than 12 months.     Recruitment of enrolled nurses/registered nurse assistants who have completed the additional six monthobstetric nursing training.     Evaluating the current processes used in facilities to maximize the use of healthcare assistants for non‐ clinicaltasks (e.g. hotel and clerical duties including data input)thus relieving the midwives of these tasks and allowingthem to focus on being midwives.     The DHBNZ proposal does not seem to considerthese or other options which may be available. Fundamental Issues     In considering any options, there are threefundamental issues which should be considered.• Firstly, NZhas a world leading maternity system which focuseson the needs of the woman and the relationship between thewoman and her midwife. The role of the midwife isparamount as her partnership with the woman requires her to be not only the clinician but also the teacher, confidant andsupport. Any option considered should not in anyway create arisk of damage to that relationship.• Secondly, the maternity service must be focused on the needsof women. Options considered must have as their driver theneeds of women, not the needs of DHBs and their staff. .Lastly, the professional role and responsibility of the midwifeis clearly defined in statute and cannot be delegated ortransferred except to another midwife or to an obstetrician ifclinical circumstances indicate that is appropriate. Any optionconsidered needs to recognise the profession of midwifery andnot create any risk to the profession in the short or long term.Midwifery Assistants     Although the proposal from DHBNZ does not appear to have considered the fundamental issues above, it appears inevitable DHBs will use midwifery assistants as it is the only option DHBNZ have considered.Given the seeming inevitability of midwifery assistants, it is necessary for the midwifery profession to be proactive in determining the roles of such assistants and ensuring the assistants are appropriately trained for those roles.The provision of high quality maternity care relies on all those involved having a clear understanding of their roles and responsibilities. The effect of such a change in the workforce means maternity providers need to consider the way midwives and potentially, midwifery assistants, are deployed in order to provide an efficient service to women and ensure that they receive care from the most appropriate person with the relevant skills. To quote the Royal College of Midwives: “A clear principle and an understanding of the midwife’s role must be established and a clear boundary perpetuated around that role, in order to ensure consistency in standards of care, protect the public and sustain a defined body of midwifery knowledge.”     The introduction of midwifery assistants, to support midwives and women, MUST be within a clear framework which defines their role, responsibilities and arrangements for supervision. The midwifery assistant may have a potential role in supporting women and assisting midwives as integral members of the midwifery team in facilities and in the community. Including them in the team may improve continuity of care, avoid unnecessary duplication of activities and increase the satisfaction of women. There is also the potential to develop a role in the community to provide practical support to women during the postnatal period.     It is vital this role does not undermine, conflict with, or obstruct that of the midwife and that the midwifery assistants’ training and remit complement the skills of the midwife without compromising the quality and safety of care.     Based on the above, it is clear if midwifery assistants are to be employed for roles which are in anyway clinical in nature, those assistants MUST• Be regulated as health practitioners • Have a clearly defined nationally consistent scope of practice• Have received the appropriate training • Be supervised by midwives • Be recruited and trained as workers specific to maternity care, not as general health care assistants     It is for the midwife to decide whether delegating a task is appropriate in the care of a woman and her baby. At all times, the midwife must have overall responsibility for the care of the woman and her baby.     Midwifery assistants should not be used to substitute for midwives or to cover shortfalls in midwifery staffing. The models of care should be developed to use the skills of the midwife and midwifery care assistant appropriately. Clinical governance and other quality systems and audit should explicitly address and include this role. Potential Scope of Practice for Midwifery Assistants The potential scope of practice for a midwifery assistant could include both clinical and non ‐ clinical tasks. Non‐clinical tasks could include: •Cleaning including instruments •Stocking supplies (and ensuring adequate supplies of equipment are available) •Bed making, linen changing •Other hotel services including meals and refreshments •Data entry (based on notes prepared by a midwife) •Making appointments Clinical tasks could include: •Assisting women to wash after birth •Changing dressings •Assistance to midwives during labour •Baby bathing and nappy changing Public health tasks could include: •Promoting good hygiene practices The addition of any other clinical or public health tasks will negatively impact on the role of the midwife. Potential Scope of Practice for Midwife Supervisors of Midwifery Assistants     Given the shortage of midwives and the stresses of providing good midwifery care, it would be unsurprising to find many midwives decline to undertake a supervisory as it will detract from the time they spend with their woman.     If a midwife is to be supervising midwifery assistants, it is essential the midwife be trained in the role of supervisor. Included in that training will need to be management skills, teaching skills and a very clear understanding of the limitations of the midwifery assistant role.     Further, given the additional responsibility a supervisor would assume, it will be necessary to remunerate supervisors to recognise their additional responsibilities and skills. Training of Midwifery Assistants It is not possible to provide constructive comment on training until or unless the scope of practice of a regulated, registered midwifery assistant is known.Tony Mansfield Chief Executive