This week, I have been involved in the assessment of trainee nurse associates (TNA) via viva voce examinations. As midwives, we have always questioned our remit, and if any aspects of the role can or should be delegated to other members of the team. Although this is a generic ‘nursing’ role, being an assessor prompted me to consider how midwives might be best supported and if the introductions of TNAs could help improve women's experiences of maternity services.
The TNA is a newly developed role, that was established to bridge the gap between health care assistant and registered nurse (Nursing and Midwifery Council (NMC), 2017). The recommendation was borne from the Shape of Caring Review, Raising the Bar (Health Education England, 2015), which recognised the vital role of health support workers in the provision of care and the fact that they nevertheless have little training. The TNA programme will offer this teaching and can stand alone or act as a gateway into nurse training via an apprenticeship model. The NMC have stated that they will regulate this role, which provides added protection via national standards.
The TNA will work in a variety of settings and aim to ensure that patients (women and service users) have compassionate and visible support. The TNA could therefore be described as the ‘bedside nurse’. Anyone who has beenhospitalised recently will know that the service relies on support workers, and that we are always grateful when we are listened to and our basic needs met. A telephone, a drink, a bed change and a sympathetic ear are what we need for emotional wellbeing; all of which might be provided by the health care support worker, but we need a degree of confidence that any concerns are communicated to the registered practitioner. The TNA will have a higher skill set, allowing them to make assessments, make a plan of care, refer as appropriate and be involved in preventative measures.
‘Maternity care belongs to a team of professionals who should work together effectively and to their strengths’
My personal nurse and midwifery training can be equated to an apprenticeship as we spent 20% of the time studying and 80% in practice, working with our mentors as integral members of the team.
At the point of registration (for both parts of the register) I felt confident and competent—something that current students often struggle with. I recognise that the profession has changed, and midwives need to have good academic grounding to practise effectively and to enable lifelong learning. However, we have seen health-care teams reduce in number and the introduction of long shifts means that staff numbers are low and mentorship is an eternal challenge.
Students now find that they spend about half their time in practice. It is yet to be confirmed whether simulation and reflection might substitute for ‘hands on’ experience when the new pre-registration standards are released. This is where the strength of apprenticeship models lie, because students learn ‘on the job’ by observing, listening and practicing, eliminating a theory-practice gap.
Midwifery is probably undergoing the most radical changes of our times. The Rules and Standards as set by the NMC have been revoked, and supervision has been taken out of statute. While we need to ensure that standards are maintained and the public protected, midwives must appreciate that the service cannot run effectively with low numbers and an ever-increasing case load. The term ‘midwife’ is still protected in law and this relates to attendance upon a woman in childbirth. This has never applied to the provision of antenatal and postnatal care; however, we are aware that specialised practitioners are required to assess risk and provide appropriate care to women during the pregnancy continuum. Could the TNA assist midwives in the provision of high standards of woman-centred, compassionate care? We have seen some successful schemes implemented into maternity care to support women, such as breastfeeding peer support workers, and there is no reason to think that other new roles will put women and babies at risk or erode the role of the midwife.
If peer support works in the provision of postnatal care, could the TNA help prepare women for breastfeeding and help to increase rates of success? Could the TNA talk and listen to women before their antenatal examination and feed back to the midwife regarding any anxieties or individual needs the women have?
To return to my assessments, I witnessed rigorous testing of students' communication skills, including active listening and the ability to signpost to other health professionals. In a simulation exercise where I was a postnatal woman, the students identified my needs, offered to help and teach me how to care for my baby, ensured that I had compassionate care and refered to other members of the team where needed. They did not act as registered practitioners and were aware of their boundaries and sphere of practice. They knew how the service worked and provided me with essential information, such as meal times and if my partner could stay overnight. We need to recognise that midwives do not have the time to spend at the ‘bedside’ and that the NHS has to be resource effective. Midwives are valuable assets and have the skills and expertise to provide care in low, high risk and emergency situations. There should be roles for which that midwives alone are trained and responsible. Perhaps in today's political climate we must accept that, while we can provide holistic care, those needs do not have to be determined by midwives but can be assessed by others and implemented under the supervision of, or by, midwives. Maternity care belongs to a team of professionals who should work together effectively and to their strengths. Midwives should be leaders and embrace change to facilitate that.