Saturday, June 21, 2014

Supervision, again ...

My thoughts are returning to the supervision topic, as I prepare to attend more meetings in preparation for the introduction of some model of supervision for privately practising midwives.  This additional regulatory process is clearly intended to identify and manage midwives whose practice does not conform with accepted standards.

Becoming a mother is a quintisentially profound moment in a woman's life, regardless of her people group, education, wealth, or any other variable.   A midwife holds knowledge and skill of working in a way that protects, promotes, and supports wellness in the childbearing process and adjustment to motherhood. 
A greeting card that captures some of the wonder of becoming a mother.

The regulation of midwifery, and other health professions, is the process by which a society can have confidence in the profession, ensuring high standards of education and practice, and a reliable process of investigation and calling to account any midwife who is involved in care that leads to adverse outcomes, or allegations of professional misconduct.

In its Request for Tender – Privately practicing midwives models of supervision, the NMBA (2013) has stated that supervision is: “a critical mechanism in the training, support and ongoing safe practice of midwifery. It incorporates elements of direction and guidance through a process of professional support and learning which enables a practitioner to develop knowledge and competence, assume responsibility for their own practice and enhance public protection and safety.”

The Australian College of Midwives (ACM) has encouraged members to communicate the following points to the reviewers, either in the consultative process of focus groups, or via the online survey.  ACM states that:
  • Supervision should be a supportive, mentoring and advisory process, not a management or punitive process; 
  • There should be one supervision process for all midwives 
  • If supervision is mandated by the NMBA, the model should be developed, implemented and regulated by midwives, not other professions 
  • Supervision is not an inter-professional clinical review process 
  • The importance of current practices in Australia such as the ACM Midwifery Practice Review (MPR) program, should not be overlooked. 
  • The projects should also be mindful of other review and consultation processes currently happening, and that supervision should not been seen in isolation:
    • ACM evaluation of MPR

    • NMBA review of the Quality and Safety Framework

    • NMBA review of registration standards for both midwives and eligible midwives

    • ANMAC’s review of standards for prescribing programs and peer review programs

    Many midwives using social media have been quick to express their frustration and dismay at *yet another* level of regulatory control.  Questions asked include: 
    • Why are private practice midwives being subjected to supervision?
    • Haven't we jumped through enough hoops with eligibility, insurance, MPR, QSF, and all the codes and guidelines we have to follow?
    • The UK Health Ombudsman found their supervision system has problems - "Supervision is a statutory responsibility...the dual role of a Supervisor, providing support but also a regulatory function, allows for an inherent conflict of interest." Why are we introducing supervision if it is not working in the UK?
    • Who pays for supervision?
    • The UK review also found  "There is a weak evidence base in terms of risk for the continuation of an additional tier of regulation for midwives."
    •  What if the woman doesn't want a supervisor involved in her care? 
    •  Is the supervision remote or ... direct observation? 
    • How are the supervisors trained? Who trains them? 
    • Can a non-eligible midwife supervise an eligible midwife? 
    • What Body does the supervisor report to?
It appears to me that AHPRA has decided it needs to provide additional levels of regulation for some midwives (and they can, whether we like it or not).  The current investigation is seeking models of supervision, and from the NMBA (2013) request for tender (referenced above) I gather that the primary focus of supervision of privately practising midwives is to be those midwives who are entering private practice, ensuring that they develop "... knowledge and competence, assume responsibility for their own practice and enhance public protection and safety"  A large number of midwives have recently left hospital jobs, attracted by the possibilities of primary midwifery practice in their communities.  There has been no standard pathway for this exodus: each midwife has found her own way, achieved notation as an eligible midwife, and endorsement to prescribe, and hung up their shingle or joined a group practice.

In concluding this log, I would like to put my thoughts on the record.

Anything that comes from the NMBA needs to be of a regulatory nature, and that regulation needs to be transparent about what it is seeking to achieve, and properly managed and funded to maintain the integrity of the process.   This sort of regulatory professional supervision could be applied to all midwives who move into private practice, for a period, such as up to five years, with standards against which the midwife and the supervisor are able to assess performance.  Midwives who have had some years of experience in midwifery may be able to demonstrate their "knowledge, competence, and responsibility" over a shorter period of time (eg 1 year), while new graduates of a B Mid course, or midwives who are under Board investigation, may remain under supervision for the full five years, or more.

In developing my position on professional supervision, I must assume that any regulatory requirement must be funded, for the preparation and payment of supervisors, and the ongoing development of the program.

I do not agree with a process that attempts to integrate the regulatory surveillance role with a support role.  Mentoring and support are valuable elements of professional development, but are different, and should be separate from supervision. 

Your comments here, or in the facebook villagemidwife group, are welcome. 

1 comment:

Joy Johnston said...

The Melbourne focus group went ahead today, and was well attended by private practice midwives, and a few from State health departments.

Most participants spoke strongly against any form of punitive supervision, and that any suggestion of reporting to NMBA would only remove trust from the relationship. Most seemed to agree with ACM's position that if supervision is introduced it should be for the whole profession, not just PPMs. [But this contract is to advise on models of supervision for PPMs.] It was pointed out that eligible midwives have so much regulation and bureaucratic micromanagement already that it's getting ridiculous. I am of the opinion that if the NMBA considers it to be in the public interest to introduce some form of supervision into the regulatory processes, it needs to be fully integrated with the Quality and Safety Framework and all the codes we are expected to follow, and should be introduced in a staged way, fully funded, with research into its impact.