The Newborn Infant Physical Examination (NIPE) can be performed by any health professional deemed suitably qualified (Public Health England, 2016). Health professionals must, however, be educated, clinically competent and remain updated in this procedure. Following validation with the Nursing Midwifery Council (NMC), the University of Manchester has integrated the theoretical component of the NIPE into the pre-registration education of student midwives. This article examines this experience, in order to offer a working exemplar of this process for other institutions considering this change.
The NIPE is an established and integral element of child health surveillance in the UK, and is based on standards set by the UK National Screening Committee (Public Health England, 2016). The key aim of the NIPE is to identify and refer all babies born with congenital abnormalities of the heart, hips, eyes or testes, where these are detectable, within 72 hours of birth (Public Health England, 2016)
The role of the midwife in NIPE
The NIPE can be performed by any suitably qualified health professional (Public Health England, 2016); although health professionals must be educated, clinically competent and remain updated in this procedure. Historically, the NIPE was predominantly performed by medical teams; however, in recent years, the junior doctor role has been affected due to changes in working time directives (European Commission, 2000). This has resulted in fewer junior doctors available to perform the NIPE, leading to a recognition by stakeholders that there is key opportunity to address this shortfall by encouraging more midwives to embrace the NIPE role. Consequently, there has been an increase in midwives accessing NIPE continuing professional development (CPD) modules, which vary greatly in structure throughout the UK (Rogers et al, 2017).
Changes to the junior doctor role have by no means been the only reason for an increased number of midwives accessing NIPE training, and the course has in fact been on offer through the CPD route for over a decade. The aspiration to offer high-quality care, married with the encouraging evidence that mothers have been positive about the NIPE being carried out by midwives, has further prompted the increase in midwives accessing training on the NIPE (Bloomfield et al, 2013). The Extending Midwife/nurse Roles in the routine Examination of the Newborn (EMREN) study suggested that not only was mothers' satisfaction improved when midwives performed the NIPE on postnatal wards, but allowing midwives to undertake this procedure may also result in financial savings of up to £2.5 million nationally (Townsend et al, 2004). This has been further supported by more recent work by Yearley et al (2017) who found that respondents believed that training midwives to complete the NIPE not only met service need, but also helped to provide a responsive maternity service.
This is not a new path for midwives and has been suggested as part of role development for many years: in 2010 the report Midwifery 2020 (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010) acknowledged that this aspect of care should be an integral component of midwifery care. This idea has since been supported by the NHS National Maternity Review (2016), which suggests that midwives undertaking this role are fundamental to offering a personalised service.
Role changes and trends in continuing professional development
During the curriculum planning process, both the university team and stakeholders noted the pressure of performing additional clinical procedures in an already busy midwifery role. This has been recognised as a factor for the one-third of midwives who, following their NIPE education, do not carry out the role in clinical practice (Steele, 2007). More recently, in addition to midwives accessing the NIPE CPD module, neonatal nurses have been shown to need the NIPE qualification. Many neonatal teams already have NIPE-qualified neonatal nurses firmly embedded into their workforce plans (Jones and Ashworth, 2016), and neonatal nurses are now increasingly viewed as another key team member in a prime position to carry out this role on postnatal wards.
As with many areas of health care, roles are shifting as medicine evolves (Cummings, 2014). Workloads are changing, and services are being challenged by increasing patient numbers. Rogers et al (2017) emphasise the benefit of midwives being able to carry out the NIPE, which can assist with timely transfer of women from hospital to the community—also stressed by the stakeholders as part of this educational consultation.
It is now recognised that many roles that were once viewed as ‘extended qualifications’, and accessed as CPD, could in fact be embedded in pre-registration programmes for both nurses and midwives. The NIPE is one example. This has been explored in depth by Yearley et al (2017), who found that 25% of the midwifery educators who responded to their national survey now offer some form of pre-registration NIPE education leading to a qualification.
The need for NIPE education
Following a wide consultation with both local and national stakeholders in maternity care in 2012, the team at the University of Manchester explored how it could develop the undergraduate training of student midwives to meet the new challenges of the midwifery workforce. The consultation indicated that there was a national shortage of midwives with the skills to perform the NIPE, and as a result of this, new mothers and their babies were at risk of delays, waiting for this procedure to be completed before transfer home. This often meant that women and their new babies either returned to a clinic for the examination to be performed before their baby was 72 hours old, or the role was undertaken by community teams, requiring an additional home visit. All of these options were seen to be problematic due to challenges with postnatal bed flow, the increase in workload for community teams, and the inconvenience of having to return to clinics with a new baby so soon after transfer home. In addition to these challenges, heads of midwifery services expressed concerns in relation to being able to release qualified midwives from busy clinical areas to complete theoretical assessment of the NIPE when undertaking the NIPE award post-qualification (Personal correspondence, 2016).
Rogers et al (2017) have demonstrated that NIPE CPD education varies throughout the country, including a range of module lengths, which has implications in relation to both funding and the release of workforce from busy clinical areas. They also suggest that there is a strong argument for a standardised NIPE programme across the UK. In addition to these challenges, more recently, access to CPD funding for health professionals has been considerably reduced. Although the NIPE has been listed as one of the priorities for academic and financial support, it remains a challenge for managers to release staff to attend any CPD courses, even those noted as priority.
The curriculum development team consulted other higher education institutions in England to assess whether other pre-registration midwifery teams were considering integrating the NIPE in their undergraduate programmes. It was apparent from these discussions that the education of student midwives was an area that could be supported to develop knowledge of the NIPE. This has since been supported by Yearley et al (2017), who have shown that it is being offered at other educational institutions, and will soon be included more widely.
NIPE at the University of Manchester
As a result, the Bachelor of Midwifery (Honours) degree curriculum planning team embedded the theoretical component of the NIPE into the 3-year pre-registration degree programme. To further support the initiation of NIPE theory in the three year degree course, theoretical instruction on anatomy and physiology was enhanced, including specialist lectures on body systems, which were taught by experts in biological sciences from the wider university. Furthermore, the application of the theory of anatomy and physiology to practice was taught by experienced neonatal and midwifery lecturers qualified in NIPE, who were active in clinical practice.
‘Not only was mothers’ satisfaction improved when midwives performed the NIPE on postnatal wards, but allowing midwives to undertake this procedure may also result in financial savings of up to £2.5 million nationally’
Curriculum planning: challenges and considerations
As the NIPE course entails a theoretical and clinical practice assessment carried out by a NIPE midwife mentor, consideration had to be given on how this might be achieved. In view of the timescale in which midwifery students must complete the course requirements, the academic team, in consultation with stakeholders, reviewed if incorporation of both the theoretical and clinical aspects of the NIPE was an achievable goal within the 3-year programme. Concerns were expressed over availability of NIPE mentors in practice who would be able to support, mentor and assess the increased numbers of students needing to complete clinical assessments in this timeframe. As previously suggested, there is a significant number of NIPE-trained midwives in practice who are not being supported to carry out the role. Yearley et al (2017) propose that the NIPE workload is unevenly spread throughout clinical areas, with some NIPE-trained midwives not being facilitated to maintain their NIPE skills due to role allocation. It was therefore important that the curriculum planning team could be confident that all aspects of the NIPE could be fully supported, and that students were not being offered an additional qualification that might never be achieved.
The planning team recognised that this was a new domain and we could not be sure how many students might register to complete the clinical aspect of the training. As Rogers et al (2015) indicate, only 13.7% of the midwifery workforce in the UK has NIPE qualifications, and this is variably distributed, so the availability of mentors needed to be considered. The team had to be assured that mentors would be available to support both the NIPE students and still accommodate workforce need. This was therefore discussed in depth with the heads of midwifery services. The vision was that supporting students at this point would in fact develop more mentors for the future, and as the students gained their qualification in practice, they could offer multifactorial roles as the NIPE examinations could be fitted around daily workload. The consultation with heads of midwifery services was vital to the planning of this change, and it was clear that it would be more practical to offer the summative clinical examinations assessment as a CPD aspect of the NIPE post qualification, and provide the theory component as part of the 3-year undergraduate programme. This may be explored further when revalidation of the course comes closer, but will be based around evaluation from students, stakeholders, and commissioners.
‘Most students stated that they were pleased to complete a course with this additional theory and to move towards the final aspect of the NIPE qualification. All students were successful in securing a post after completing the course’
Course design
The NIPE theory was therefore placed in the final 6 months of the 3-year Bachelor of Midwifery (Hons) programme. The timing was considered optimum as it built on the intense neonatal component already completed in the second year of the course. The decision was made by the planning group in consultation with all stakeholders that the newly qualified midwives should be taught theoretical knowledge on newborn assessments as near to qualification as possible. It was recognised by the team that the programme was already overwhelmed with mandatory theory, and how the additional topics would be incorporated had to be considered. As the team already had an experienced neonatal lecturer, some of the theory could be embedded within the second year midwifery care for complex needs unit, with the main aspects of the theory being embedded into the third year contemporary midwife practitioner unit. This has appeared to work well, and both units have been positively evaluated.
Following qualification, the students, who would be working as Band 5 midwives in supportive preceptorship programmes, would be offered the opportunity to progress to the next stage of the NIPE. This stage consists of a 1-day workshop offered by the university, and access to academic support, learning resources and the clinical practice assessment document.
The curriculum planning team recognised that the timescales in which newly qualified midwives felt ready to embark on the clinical assessment part of this qualification might vary, and that the influx of new knowledge from the preceptorship stage might be overwhelming. A decision was therefore made to offer a university-based theoretical workshop for this group of new midwives. This will be timed at 9 months post-qualification, half-way through the 18-month deadline to complete the summative clinical assessments.
The timescale for final completion was derived from in-depth discussions with experienced NIPE mentors and educators, as no evidence was available on the success of similar initiatives. The team explored the potential challenges to mentor support, but were given firm assurance by the main employing Trusts that this would be a priority, in view of the long term benefit of increasing numbers of NIPE-trained midwives. The NIPE workshop would provide a theoretical refresher, an update of all aspects of the NIPE examination, and an opportunity to meet with the academic team supporting the student. For those not embarking on the course until the later, this would act as a motivator to commence the unit.
After consultation with relevant stakeholders from midwifery and neonatal medicine, such as educators of NIPE, it was agreed at the validation of the Bachelor of Midwifery (Hons) degree that the clinical assessment would involve the completion of 20 summative clinical assessments within 18 months of qualification as a registered midwife. This includes an increase of five summative clinical assessments from the already established module for experienced and qualified staff undertaking the NIPE award at the University of Manchester as part of CPD. There is no guidance from NHS England on the number of examinations that must be completed in order to achieve the NIPE award, so this is determined by each higher education institution. Anecdotal evidence indicates that there is a wide variation in the number of summative clinical assessments that students must complete.
Results and progress
The first cohort of student midwives to experience the theoretical assessment of the NIPE award in their undergraduate programme have now completed their education.
The numbers returning for the second part of the NIPE have since been verified, and 56% of those who completed the Bachelor of Midwifery (Hons) course last September have been supported by employing Trusts to complete the final aspect of the training, leading to a recognised qualification in practice. In addition to local Trusts supporting the NIPE, students employed outside the local network have also been supported to register on the programme. The cost of the additional CPD component of the NIPE was considerably reduced in relation to other CPD units, with an additional reduction for Trusts registering ten students or more.
Other universities have approached pre-registration midwifery education differently and have integrated both the theoretical and clinical assessments of NIPE into their midwifery 3-year degree courses (personal communication, 2016). Despite success, concern over the number of mentors has ruled out the incorporation of clinical assessments in the 3-year timeframe at present, although students do have the opportunity to carry out simulation. However, it is envisaged that in the future, as a result of this change in the North West, there will be more qualified NIPE mentors in the workforce who could support the clinical assessments to be included.
The evaluations from students have been positive, with students agreeing that the changes to the course were beneficial, both in the terms of increased learning and employability. The team was aware that this was a new initiative and the students did not have a comparison, however other universities in the region are including the NIPE into the pre-registration programme. Most of the students stated that they were pleased to complete a course with this additional theory and to have the opportunity to gain the final aspect of the NIPE qualification, and all students were successful in securing a post following completion of the course.
Although no further academic credits were allocated to the NIPE, the clinical qualification is well recognised in practice. The heads of midwifery services have also viewed these changes as beneficial, as the reduction in CPD funding has brought additional challenges in ensuring fluidity of skill enhancement for NIPE-trained midwives (Jones, 2016). This change is not without some challenges, and the availability of midwifery NIPE mentors may still be one of the key areas where there is concern. This is being continually monitored by the academic team to ensure that support is available to students who embark on clinical practice assessments.
Conclusion
There is no doubt that the introduction of the theory component in the 3-year Bachelor of Midwifery (Hons) degree is viewed positively both by students and local stakeholders. The clinical skills of the NIPE examination, however, can only be achieved in practice with the support of registered NIPE colleagues. Some Trusts have adopted a firm strategy to achieve this by embedding this aspect of learning into the preceptorship programmes, recognising the benefits of this to the midwifery workforce. This will lead to improved satisfaction with maternity care, bed flow, and staff development.