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5 December 2007
						 
						Susan Yorke
						 
						Registrar
						 
						Midwifery Council of New Zealand
				
				
						Dear Susan
				
		
		
				
						Consultation on the Midwifery Council Recertification Programme
				
		
		
				
						Thank your for the opportunity to participate in the consultation process.
						We have discussed the programme at length with our members and, in doing so, have had particular reference to the matters discussed at the recent  meeting held in Auckland.
				
						Before considering the specific questions asked, we feel it is important to
						recognise the initial recertification programme was an important step for the
						profession in establishing an ongoing quality assurance programme. While
						there has been much criticism of elements of the programme, the fact
						remains it was essential for such a programme to be set in place, not only to
						meet the requirements of the Health Practitioners Act but also to provide an
						element of reassurance to the public at large. Further, the initial programme
						has made midwives more aware of the need for ongoing education. The
						initial programme has also created the opportunity to evaluate and amend
						the programme, based on feedback received over the last three years and
						during the current consultation.
				
				
						One of the issues which has become apparent since the programme was
						implemented is the issue of scope of practice. While the initial indications
						may have been there was an expectation all midwives would practice across
						the full scope of practice, it has become apparent many midwives do not, as
						a general rule, practice across the full scope and, in some cases, resent being
						told they must do so.
						There is a need to recognise the profession of midwifery, like so many
						others, has a variety of scopes of practice which depend upon the
						interests and role of the individual at the particular time. And there
						is a need to recognise some midwives contribute quite significantly
						in specialist roles, the nature of which may be such that asking them
						to practice across the full scope of practice fails the recognise the
						specialist skills they have acquired and the additional experience. An
						example of such specialisation is the full time tutoring staff at the
						various Schools of Midwifery.
				
				
						Another issue which needs to be recognised is many midwives have
						found a role in which they are competent and comfortable, have
						chosen to practice in that area and have no wish or desire to work outside
						that area. In many cases they also feel quite strongly they would not be safe
						to undertake activity outside their chosen area or work. An example might
						be the core staff of a secondary hospital who may be extremely competent in
						that arena but feel right out of their comfort zone and competence if asked
						to provide, for example, postnatal care.
				
				
						A third issue is professional development. A number of midwives have
						commented they have no wish to develop beyond their current role. While
						very keen to ensure they carry out that current role as best as is possible,
						they have no real interest in research, presenting papers or many of the other activities classed as professional development and resent being asked
						to participate in these.
				
				
						It is suggested the profession needs to recognise the different scopes and
						aspirations of its individual members while still requiring each individual
						midwife to maintain their competence both in any chosen field and generally.
				
						
								It is seen as very possible for the re
								‐
								certification programme to be restructured
						
						in such a way as to enable recognition of specialist skills and
						different scopes of practice while still maintaining a programme which
						ensures competence.
				
				
						One could start by defining several basic scopes of practice. These could
						include, for example:
						Midwives practising across the full scope of practice 
						
								(eg some independent 
						midwives and community midwives employed by DHBs)
				
				
						Midwives whose usual scope of practice is restricted to primary care 
						
								(eg
						
						some independent midwives and midwives employed in primary birthing units)
						 
						Midwives whose usual scope of practice is restricted to secondary and tertiary care (eg midwives employed in acute units and delivery suites in base hospitals) Midwives with a specialist scope of practice (eg midwifery tutors, lactationconsultants)
				
						
								The next step would be to establish a re
								‐
								certification
								 
						
						programme structured to meet the needs of those different
						groups. For example, the programme could include certain
						elements which are compulsory for all midwives 
						
								
										(eg CPR  
								
						
						
								
										training). 
								
						
						
								Every midwife, regardless of which group she classified herself in,
						
						would be required to complete those elements. Then there would be
						optional elements. Those with a specialist scope of practice could be
						required to undergo additional elements relevant to their specialisation,
						those who wished to develop in the profession could chose additional  elements relating to professional development while those who wished toremain focussed on their current role and scope would complete elementsappropriate for that scope. All midwives would have to complete a similarprogramme in terms of effort and maintenance of competence but theywould have greater options in respect of the optional parts of theprogramme. Examples of how this might work are shown in attached TableOne.
				
						The emphasis is on maintaining relevant competence while allowing the
						individual midwife to identify their own learning needs. It is strongly
						suggested a model of this nature would meet the needs of the Health
						Practitioners Act and enable the Midwifery Council to have certainty over
						
								the re
								‐ 
								certification programme while enabling midwives to undertake a
						
						programme which specifically identifies with their scope of practice. Moving
						to the questionnaire, we respond as follows:
				
				
						
								We are responding to the questionnaire as a co
								‐ 
								operative of health providers
						
						of which over 300 LMC midwives are members. Our responses reflect, as
						best we are able, the collective views of those members.
						Technical Skills Workshops:
				
				
						
								
										
												Technical Skills Workshops 
										
								
						
						
								We agree the Technical Skills workshops should remain a once
								‐in‐everythree‐
						
				
		
		
				years requirement, with the caveats that the workshops need to be
				tailored to the needs of the participants and the facilitators of the workshops
				need to be able to demonstrate greater skill and experience than the
				participants.
				
						We believe the Technical Skills Workshops have
						assisted midwives to maintain competence, with the
						usefulness ranging from “Neutral” to “Very Useful”. The
						range illustrates the workshops were set at one level
						which some midwives were already at or beyond in
						terms of specific skills.
				
				
						We suggest future workshops could be run with a 
						number of options so participants could select the areas in which they feel
						the greatest need to enhance their skills.
						CPR
				
				
						
								
										CPR 
								
						
						We agree CPR should remain an annual requirement, as it is for nearly all
						health professionals. We believe CPR is very useful in maintaining
						competence. CPR is an essential skill which research has shown to atrophy if  not regularly updated.Neonatal Resuscitation
				
						
								
										
												
														Neonatal Resuscitation 
												
										
								
						
				
				We agree Neonatal Resuscitation should remain an annual requirement. We
		
		believe Neonatal Resuscitation is very useful in maintaining competence. It
		is an essential skill which research has shown to atrophy if not regularly
		updated.
		Breastfeeding Updates
		
				
						
								
										Breastfeeding Updates 
								
						
				
				
						We believe breastfeeding updates should remain a once
						‐in‐every‐three‐
						years
				
				requirement for all midwives whose scope of practice includes primary care
				and/or postnatal care.
		
		
				We believe breastfeeding updates should be a voluntary requirement for all
				midwives whose scope of practice does not include primary care and/or
				postnatal care.
		
		
				We believe the breastfeeding updates have assisted midwives to maintain
				competence only to a limited extent, with the usefulness ranging from “Not
				at all” to “Very Useful”, with most commenting either “Neutral” or “Useful”.
		
		
				The range illustrates the existing knowledge base of attendees.
				For those midwives whose scope of practice is focussed on postnatal care or
				lactation consultancy, the updates were of little or no relevance. For such
				midwives, more advanced education would be appropriate.
				Midwifery Standards Review
		
		
				
						
								
										
												
														Midwifery Standards Review 
												
										
								
						
				There is one body of opinion which maintains all
		midwives should undertake peer review at the same
		regular interval and every two years would be
		appropriate. There is another body of opinion which
		maintains core midwives are employees and therefore
		it is the responsibility of the employing organisation
		to ensure their competence and therefore peer review
		should be optional for core midwives.
		
				We believe LMC midwives should do peer review
				every three years. We are advised MSR has assisted 
				midwives to maintain competence only in the range of “Not at all” to
				“Useful”, with most reporting “Not very” or “Neutral”. The main comment
				received is that MSR in its current format is not useful as the midwife is
				judged more on her ability to tell or write a story rather than her
				competence. It is suggested group peer review on a more regular basis (say
				six monthly) with an independent facilitator might be more effective as a
				review process. Also, all midwives should acknowledge and take
				responsibility for reviewing their own statistics regularly, at least annually.
				Elective Education
		
		
				
						
								Elective Education 
						
				
				We believe the elective education component should continue. We believe
				30 points is about right. We are advised Elective education has been “Useful
				or “Very Useful” in assisting the maintenance of competence. It is this
				section of the programme for which members report the greatest satisfaction
				as they are able to identify and met their own specific learning needs.
				Professional Activities
		
		
				
						
								
										Professional Activites 
								The professional activities component should not continue except as an optional or elective choice for those midwives for whom it is appropriate. For many midwives, the professional activities component is of little interest or relevance. They have no wish to further their education, to undertake research, speak at conferences or take any sort of management role. They simply want to be very good at what they currently do. 30 points is excessive for many midwives. The points in this component would be better as an elective option, not a compulsory choice. For some midwives (eg tutors) 30 points is barely sufficient while for others it is very difficult to attain. We are unable to comment on the effectiveness of the professional activities component. Most feedback has been as, with the exception of mentoring students, most members feel the component is a waste of their efforts. Scope of Practice 
				
		
		
				
						
								
										Scope of Practice 
								
						
						The requirement to work across the scope of practice 
						should be restricted to those midwives who practice 
						across the scope. Midwives who have some form of 
						specialist role should not be required to work across the 
						scope of practice. It may be necessary for midwives to 
						declare their scope of practise when applying for their 
						Annual Practicing Certificate and, if the scope changes, 
						for them to be required to demonstrate they have amended their recertification 
						activities to reflect the revised scope. For Maternity Managers 
				
				
						
								
										For Maternity Managers 
								
						
						We support midwives through the re ‐ certification programme by providing 
						regular reminders of their obligations, arranging compulsory and elective 
						education sessions. Previously we have assisted by working with NZCOM to 
						block book MSRs but that proved impractical to continue as NZCOM felt 
						unable to provide information about MSRs completed. We support midwives 
						to work across the scope of practice by regularly discussing scope of practice 
						issues within member meetings. 
				
				
						
								
										Finally 
								
						
						We believe the re ‐ certification programme does enable midwives to 
						demonstrate competence. We believe the re ‐ certification programme may 
						contribute to raising professional standards in some cases but do not feel 
						this is yet proven. We believe there should be a series of actions taken for 
						midwives who do not comply with the programme requirements. These 
						actions need to be taken in a planned manner with an appropriate timetable 
						with allowances made for circumstances which may delay participation (eg 
						maternity leave). There is a school of opinion which suggests the midwife is 
						responsible for ensuring her own competence. If a midwife signs the annual 
						declaration at the time of renewal of the APC and is subsequently found not 
						to be engaged in the re ‐ certification programme, then one warning only 
						should be given followed by withdrawal of the APC for non compliance 
						within three months. 
				
				
						Some feel such an approach would be too draconian and favour a more 
						measured approach as: 
						Warning of the consequences of non ‐ compliance, After three months, 
						second warning of consequences of non ‐ compliance. After a further three 
						months, current APC to be replaced with an interim practicing certificate 
						with conditions and a time limit not greater than six 
						months. After six months, if still no compliance or 
						limited compliance, interim practicing certificate 
						replaced with a practicing certificate requiring
						supervision for six months. After six months, if still no
						compliance, withdrawal of practicing certificate until  competence is demonstrated by completion of the  programme. Please refer to the opening comments. Also  we feel the present programme could be improved if the point setting process appeared more consistent with points being allocatedaccording to the level of education being provided. 
				
						Lastly, we feel the
						Council could clarify the rules around points for professional development
						activities using specific examples of points issued so there was improved
						clarity.
				
				
						Thank you for the opportunity to contribute and we hope our comments are
						useful
				
				
						
								Yours sincerely
								 
								Tony Mansfield
								 
								Chief Executive