The Nursing and Midwifery Council (NMC) are overhauling their fitness to practise systems and revalidation is the new process by which midwives will demonstrate, on a 3 yearly cycle, that they remain fit to practise.
The reason for this is to inspire greater public confidence in NMC registrants in the light of poor practice being exposed; for example, by the report into midwifery at Morecambe Bay. It is also a consequence of the inquiries by Sir Robert Francis QC into the standards of care at Mid-Staffordshire. Sir Robert recommended (Francis, 2013: Recommendation 229):
‘…that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional protection to the public.’
The NMC accepted this recommendation for all its registrants. The Royal College of Midwives (RCM) also recognised that it is essential for public safety that midwives are competent and safe practitioners, and the public should rightly expect health professionals to show they are up-to-date in their practice. They are involved in the national discussions about revalidation and are working with the NMC on the detail.
The intention is that revalidation will replace PREP (post-registration education and practice). PREP has been much criticised and, although we have all had to comply with its standards, it has never been audited and so fitness to practise through PREP could not be substantiated. So the new system, through revalidation, has to address this with a view to increasing public confidence in both nursing and midwifery, helping improve standards of care and generating a culture of continuous improvement.
Continuing professional development
The PREP system was one of self-declaration in which registrants would assure the NMC they had undertaken 450 hours of practice and 35 hours of continuing professional development (CPD) in 3 years. Revalidation will be slightly different. There will still be a need to undertake 450 hours of practice in 3 years (or 900 hours for those who wish to maintain both midwifery and nursing registrations). However, the hours needed for CPD will go up to 40 hours over 3 years. The nature of the CPD will also be slightly different because 20 of the 40 hours will need to participatory. This is to ensure that there is interactive learning in participation with other registrants and to guard against all CPD being done in isolation in front of a computer as e-learning. Participatory learning can take many forms; it could be formal classroom or on the job training or structured courses or be activities such as mentoring, coaching or shadowing. The important feature being that there is evidence of what has been done and evidence of learning through reflection.
Feedback
Another new component part of revalidation is feedback. And not just feedback for its own sake, but being responsive to feedback and using it to change personal practice as a consequence. This third party feedback is, however, causing some anxiety about who might provide it, how it might be collected and how to deal with negative feedback. In reality, midwives are likely to use a range of sources—as currently happens to provide evidence to supervisors of midwives for the annual, statutory review. Feedback could come from women, colleagues, mentors and through the appraisal system. Indeed, using complaints could be very valuable. They might feel like a negative source of information, but they are valuable stimuli for learning. And that highlights an important feature of revalidation: it is about an individual's continuing fitness to practise and not about managing that person's performance. The NMC will not be interested in seeing the original feedback, which will remain confidential to the midwife, but it will be interested in a reflective account on the feedback which demonstrates what has been learnt and how it has changed practice for the better or that it has reinforced good practice. It is likely that revalidation will require five reflective accounts over the 3 year period. More details will emerge because revalidation is going to be piloted during 2015 and adjustments to the proposed system will be made as a consequence.
There is a reasonable emphasis on the role of employers to support the system of revalidation. No good employer would want to employ a midwife who cannot revalidate and many will have sufficient CPD opportunities on offer to meet the NMC's criteria and have effective appraisal systems to contribute to the process. But revalidation applies to everyone: some midwives might not have one consistent employer, they might be self-employed or work on a casual basis through a bank or agency so they will have to think carefully about how they construct their revalidation. After all, it is ultimately the responsibility of the registrant to maintain their fitness to practise, keep up-to-date and have evidence to revalidate. It is a profoundly important aspect of professional practice to take this responsibility seriously as an individual.
The Code
There is one crucial part of the jigsaw which is not yet available: the revised NMC Code. Revalidation needs to be based on the Code and that is being revised. Its style and contents need to reflect a wide range of practice, not just clinical practice. It has to be relevant for midwives practising in education, research, leadership, policy and any other sphere and in any setting. To reflect this breadth, the Code needs to be permissive and not restrictive so that midwives can revalidate easily regardless of their scope of practice. And most importantly, the Code will also demonstrate to women and members of the public what they should expect from the care midwives give.
The draft Code has been the matter of wide public consultation and the revised version will be published by the NMC in December 2014. The sequence of events after that is that the revalidation process will be piloted between January and June 2015, with the first registrants actually going through the process in April 2015. As part of this, the NMC will decide how best to audit registrants' portfolios of evidence and how many it will audit in any one year to satisfy itself that the process is effectively protecting the public. The pilots will be evaluated with a view to launching the model in November 2015. Revalidation itself will start in December 2015 for those renewing their registration at that time and there will be evaluation of the effectiveness of revalidation in late 2016.
Revalidation will be on a 3 yearly cycle (as renewal is now) and the third party confirmation of the ability to revalidate will be part of midwives' annual supervisory review. The new elements of the system will be in addition to the annual notification of intention to practise process. However, it must be borne in mind that all the requirements of revalidation and the piloting process are subject to Council approval: it is unlikely the timetable will change but the underpinning details might.
Morecambe Bay
While all this is going on, the NMC has also responded to the Ombudsman's report into complaints about midwifery practice at Morecambe Bay (Parliamentary and Health Service Ombudsman (PHSO), 2014) and its views about statutory supervision of midwives (PHSO, 2013). The NMC has commissioned the King's Fund to review statutory supervision of midwives and they are due to report in December 2014. Midwives will therefore have to take account of what changes to supervision might come as a consequence of this review. The Ombudsman's report refers to issues in England, but the NMC and the King's Fund have to consider how this might affect all the UK countries. It is therefore not clear what the King's Fund might recommend about the future of NHS England as the local supervising authority (LSA), the LSA midwifery officers, supervisors of midwives or the supervisory process as it affects all practising midwives. However, what is clear is that the independent supervision system that midwives have enjoyed since the profession was regulated is a very good basis on which to build revalidation.