While the general view amongst teachers, assessors and experienced midwives was that students at the point of registration should, at the very least, be safe, have the right attitude and be effective communicators, there were five other areas of competence where either views were very mixed between interviewees about what would be expected of qualifiers, or where the general view was that qualifiers would vary in terms of ability.
5.2.3.1 Being accountable
The views expressed by students suggest that they were anxious about the prospect of having to take on accountability. All students stated they had an understanding of the legislation and rules governing their practice as midwives and that they had thought through what it means to be accountable. There were differing views on the extent to which midwives should be accountable at the
point of registration. Several midwives and students suggested a midwife, at the point of registration, must be prepared to assume the responsibilities of a midwife and to be accountable for her own practice. Experienced midwives pointed out that a midwife is ‘clearly accountable’ at the point of registration, for example:
… because at the end of the day, they’ve got their number on the register and they have to be responsible for their actions (experienced midwife).
On the other hand, there were midwives who said that although they would expect a midwife at registration to understand what it means to be accountable, they would not be sure if a midwife, at that stage, would be able to ‘use that accountability in action’. Two teachers were adamant that their students were not ready to take on the responsibilities of independent practice, at the point of registration. A small number of assessors suggested that midwives would need more experience before they could cope with the responsibilities in the community because they would have to work virtually alone there. The emphasis in these statements was on the lack of support available to midwives working in the community. The range of views suggest that, although a midwife is legally accountable for her practice at the point of registration and should understand the implications of that accountability, she would need support initially to assume that accountability ‘in action’.
5.2.3.2 Decision making
Although it is suggested in the previous section that the capability of a midwife at registration is limited in terms of decision-making, a number of assessors and experienced midwives outlined specific minimum expectations relating to decision making at the point of registration. Two key themes were identified, the first is that a midwife should be able, and willing, to make general day-to-day decisions about care for a woman with normal pregnancy. Beyond that, it was accepted that a new midwife would need considerable support from a more experienced midwife. It was acknowledged that even experienced midwives would need support with decisions in complicated situations. The second key
requirement was that a midwife should be able to ‘decide that things are not normal’ and seek help.
5.2.3.3 Individualised care
As discussed, the need for a midwife to be able to provide individualised care was identified as a key element of competence. It is suggested that this involves respecting the autonomy of each woman and empowering women to make informed choices. While one experienced midwife said she would expect a midwife at the point of registration to be encouraging women to make informed choices, including those about whether to have interventions or not, most midwives and assessors acknowledged that a midwife would need support to provide individualised care. These interviewees suggested that a midwife should be able to adapt her practice ‘to a degree’ but further learning would be required for a new midwife to be able to adapt her care to the needs of all individuals and across the full range of practice situations.
Assessors and experienced midwives identified two key aspects of competence that would be expected at the point of registration in terms of providing individualised care. The first is that a midwife should appreciate that women have different needs and that she should aim to adapt her practice to meet those needs. This should include balancing women’s wishes with what is required for safe practice. The second requirement is that a midwife should be able to make an accurate assessment of each woman’s needs, and that this should include being able to assess women in the their own environment.
5.2.3.4 Agent of change
Statements of anticipated course outcomes in most curriculum documents included the notion that midwives once they had qualified would be agents of change (See Mountford et al, 1995). This implies that new midwives will bring new practices and theories, which they have learnt while on the programme, with them to the practice area, thus introducing new ideas to other midwives and to students. A number of students interviewed were keen to be let loose to develop their own style of practice. However, several interviewees also suggested that
being an agent of change can be quite difficult for new midwives. It may involve challenging the way things have been done for many years and will require midwives to be reasonably confident. Further it is suggested that new midwives may be tempted to take the easy way out and ‘go with the flow’ in order to avoid the wrath of disapproving experienced midwives who may not be receptive to new ways of working. As suggested in the following quote, qualifying midwives can face resistance from more experienced midwives:
… again midwifery is a strange profession really, everybody does it their own way and there are lots of midwives who expect you to copy their way of doing things and if you don't then they think you're not doing it right but especially at this stage in the course when we've really adapted our own way of practice, we've picked little bits out what we've seen from various midwives and developed our own method of practice but some find that difficult to come to terms with, if we don't do things exactly their way then we get pulled up on it (student midwife).
In terms of what would be expected at registration, several experienced midwives suggested qualifiers should be able to question the ways things are done although, initially, they may not have the confidence to stand up to other midwives and professionals. It was suggested that new midwives should be developing their own style of research-based practice and that if midwives were not prepared to that at registration, they would never be. One midwife suggested that there are other ways in which a midwife can challenge practice without confrontation. For example, by asking a more experienced midwife to intervene where they are concerned about unnecessary intervention.
5.2.3.5 Teaching
The fifth area identified where it was suggested midwives would have mixed abilities at registration was teaching. The general view was that midwives at the point of registration would not be expected to have a role in teaching other students. However, assessors and teachers did say that they would expect
midwives to be able to provide education for women, at least on a one-to-one basis.
In Figure 5.1, the nature of competence at the point of registration is summarised, based on the analysis.
Figure 5.1 Competence at the point of registration
Limitations Minimum requirements
Areas where expectations of interviewees differed considerably
Experience
Care for women who are ill or have complications Ward management Making decisions Confidence Safe Self sufficiency Evidence-based practice Personal and professional awareness Attitude Communication Being accountable Making decisions Individualised care Agent of change Teaching