The newborn and infant physical examination (NIPE) is a national screening programme in the UK that involves a full physical assessment, history-taking, health promotion and education (Baker, 2010). The aim of the programme is early identification of conditions and diseases in newborn babies (Baker, 2010), and Public Health England (2016) recommends that the examination is carried out within the first 72 hours of life to ensure that prompt and appropriate treatment is commenced if required.
The examination has been a vital part of the child health surveillance programme in the UK since the 1960s (Hayes et al, 2003) and was conducted by neonatal senior house officers within the hospital setting before discharge (Mckinnon, 2017). However, in more recent times, there has been a shift towards midwifery-led care, which has increased rates of homebirth and births in standalone midwife-led units (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010; National Maternity Review, 2016). There is also increasing workload and pressure on junior doctors, which has caused constraints on the amount of clinical time available to complete the NIPE. This has become one of the main drivers behind training midwives to complete the NIPE (Baker, 2010). There is a demand for expanding services to include more outpatient provision, including at home or in standalone birth centres, for services such as the NIPE, which can be satisfied by training midwives to complete the examination. This is also an opportunity for multidisciplinary working between junior neonatal doctors and midwives and a chance for midwives to widen their scope of practice (Baker, 2010). It is therefore important to consider the legal, ethical and professional issues surrounding the role of the midwife in conducting the NIPE.
NIPE in the curriculum
Midwives have been well supported in the literature as the best placed professional to conduct the NIPE (Department of Health, 1999; Lomax, 2001; Mitchell, 2003; Bloomfield et al, 2003a; 2003b; Osborne, 2017). However, Dunn (2001) disagrees with this view, contending that paediatricians should uphold responsibility for the NIPE in order for their skills to be maintained, raising concerns about the medicolegal challenges of midwives taking on this role.
Training programmes for midwives to complete the NIPE began in 1998 (McDonald et al, 2012) after it was recognised from multiple research projects that the NIPE for term, healthy neonates could be performed by appropriately trained health professionals (Lee et al, 2001; Royal College of Midwives (RCM), 2002; Hall and Elliman, 2006; Davies and McDonald, 2008; Public Health England, 2016; NHS Quality Improvement Scotland, 2008). Training and maintenance of competence for junior doctors in the field is variable, as training consists of a ‘see one, do one, teach one’ approach (McDonald et al, 2012; Mckinnon, 2017). Registered midwives are legally obliged to maintain clinical skills and competencies (Nursing and Midwifery Council (NMC), 2015), and Trusts and Health Boards usually ensure that midwives' competency is upheld by putting in place a minimum number of examinations that midwives must carry out each year (Aneurin Bevan University Health Board, 2015). Midwives are also personally responsible for maintaining competence working with the multidisciplinary team to continually develop clinical skills such as obstetric emergency drills and neonatal examination as part of their professional duties and in line with NMC revalidation (Foster and Lasser, 2011; NMC, 2015; 2018). This strengthens the argument for midwives completing the NIPE, as there are ratified training programmes in place for midwives that do not exist for junior doctors.
Yearley et al (2017) examined the inclusion of the NIPE within pre-registration midwifery courses. An interactive link was distributed to lead midwives for education in the UK and this questionnaire explored education in relation to the NIPE both as a part of the pre-registration course (Yearley et al, 2017) and as a post-registration standalone module (Rogers et al, 2017).
Of the 58 education institutions that were invited to participate, 40 (68.9%) completed questionnaires. The first part of the study (Yearley et al, 2017) found that one-quarter of these institutions (n=10) incorporated the NIPE as part of the pre-registration course and 37.5% (n=15) planned to establish the NIPE as part of their course within the next 2-5 years. The institutions reported that incorporating NIPE in the midwifery curriculum provided clear benefits, such as encouraging the philosophy of midwifery and meeting future service needs, which will in turn deliver an accessible maternity service (Yearley et al, 2017). However, 30% (n=12) of institutions had no plans to include NIPE in the programme, citing lack of space in the curriculum, lack of qualified staff to teach the NIPE, few qualified midwives/paediatricians to support the students in clinical practice and a belief that it is suitable for inclusion in the midwifery curriculum (Yearley et al, 2017). Although barriers were noted, Yearley et al (2017) stated that the benefits of providing NIPE education within the pre-registration programme outweighed the disadvantages. Following this study, it is feasible that the NMC could include the NIPE in the revised midwifery standards, expected to be published in 2020.
NIPE in practice
One of the most influential studies encompassing neonatal examination was the EMREN study (Townsend et al, 2004). This study was multifaceted and comprised an evaluation of the literature considering neonatal examination, and a prospective randomised controlled trial. The main focus of the EMREN study was to determine the most appropriate health professional to complete this screening examination.
The study was carried out by randomising mothers and babies to one of two groups: those to be examined by senior house officers and those to be examined by midwives. Midwives and senior house officers were video recorded while conducting the examination, and the videos were reviewed by an independent consultant and senior midwife. The study also included interviews, surveys, consultations and assessments.
Townsend et al (2004) discovered that there were no statistical differences between examinations conducted by senior house officers or midwives in terms of appropriate referrals. However, the video assessments were more revealing in that the examinations conducted by the midwives were assessed as superior to those conducted by the senior house officers (Townsend et al, 2004). Interestingly, maternal satisfaction was greater in the midwife group. Townsend et al (2004) also examined potential cost savings by increasing the number of babies examined by midwives, and the findings indicated that if all low-risk babies were examined by a midwife, a cost saving of approximately £2 per baby would be made. If this were extended to midwives examining all babies on maternity wards, the cost saving would increase to approximately £4.30 per baby (Townsend et al, 2004). As this study was completed 13 years ago, it is reasonable to assume that the savings would be greater today. The findings of this study indicated that midwives were valued by both parents and health professionals in conducting the NIPE, and that they are potentially more competent to complete this than some junior paediatricians. It also showed a vast cost saving that could potentially be made, while increasing maternal satisfaction with the service received. Townsend et al (2004) concluded this study by stating that the results showed that it was clear that midwives were the most appropriate professional to complete the NIPE, as considered by healthcare professionals and parents alike.
Professional considerations
Townsend et al (2004) also found that 44% of midwives were qualified to complete the NIPE, but that only 2% undertook the NIPE in practice. This is an interesting finding as the training programme is extensive; however, other evidence shows that midwives do not feel competent to complete the examination and fear litigation (Birth Project Group, 2015). Midwives may also be ethically challenged if they do not feel competent and may have come to this decision after considering the principles of beneficence and non-maleficence.
Completing the NIPE is an extension of the midwives' role, which increases the autonomy of practice; however, this also involves increased accountability (Baker, 2010). There are many advantages to midwives performing this role, including a more holistic approach to care, increased job satisfaction for midwives, increased maternal satisfaction, shorter waiting times for discharge and shorter inpatient stays (Hayes et al, 2003). There is also evidence to show that midwives are equally as competent in completing the neonatal examination and that they do so more thoroughly, providing more health promotion information within the examination (Bloomfield et al, 2003b; Townsend et al, 2004; Mcdonald, 2013).
Accurate record-keeping is also an essential component of the neonatal examination and is an important part of the midwife's work. The NMC Code (2015) states that accurate and concise records are an essential part of the midwives' role and form an important part of communication with the multidisciplinary team. Midwives have a legal duty to maintain accurate and detailed records relating to the care they give within the scope of practice (Griffith et al, 2010; NMC, 2015).
Legal and ethical considerations
The NMC Code (2015) states that midwives are held accountable for practice, including any errors made, and that midwives must practice within the scope of practice at all times. Foster and Lasser (2011) state that by ensuring that midwives work within the scope of practice, this limits actions to those who have been appropriately trained which in turn intends to ensure safe care for mothers and babies.
International law and ethical frameworks form the basis of midwifery practice (Griffith et al, 2010). During day-to-day midwifery practice, including while completing the NIPE, midwives use basic principles such as consent, information-giving, confidentiality, accountability and duty of care, all of which are governed by legal statutes and professional bodies (Griffith et al, 2010; NMC, 2015). Midwifery practice is directed by multiple ethical approaches. A principle-based approach was described by Beauchamp and Childress (2001) and is a commonly used in healthcare settings. This approach argues that regardless of personal morals and views, four principles (respect for autonomy, non-maleficence, beneficence and justice) can be used to consider moral dilemmas (Griffith et al, 2010).
Midwives are autonomous practitioners who are accountable for the care provided (International Confederation of Midwives, 2018); however, the principle of autonomy described by Beauchamp and Childress (2001) relates to respecting the rights of individuals and supporting them in informed choices. In regards to the NIPE, respect for patient autonomy is vital so that parents can make informed choices regarding the examination and any follow-up or treatments required. However, it is also important to consider the increased autonomy for midwives when they are trained to complete the NIPE. This principle is used in basic midwifery practice and midwives are duty bound to ensure that practice is embedded in information-giving, consent, privacy and confidentiality (Beauchamp and Childress, 2001). Non-maleficence and beneficence are principles that should work in tandem with each other (Griffith et al, 2010). The NMC Code (2015) is broadly deontological in its approach, focusing on duty and the rightness of actions rather than the consequences (Clarke, 2015); however it also expresses a desire to provide benefit to patients while not causing or minimising harm. Beneficence is essential in healthcare and creates a duty that any care given is to the benefit of the patient (Jones, 2005). Non-maleficence underpins the NMC Code (2015) and calls on professionals to do no harm in the course of their work. These form the basis of midwifery practice and are also relevant to midwives completing the NIPE. The principle of justice aims to preclude discrimination and ensure equality (Jones, 2005). This is also embedded throughout the NMC Code (2015) and therefore should underpin midwifery practice.
Conclusion
Despite the NIPE traditionally being conducted by medics, there has been growing evidence to support midwives as the most appropriate practitioner to carry out the examination. It could be argued that this presents an ethical dilemma in itself, as although this extension of the midwife's role was evaluated extensively when it was introduced, there has been little evaluation in recent years with the exception of Osborne (2017). There are robust, ratified training programmes in place for midwives to enable them to widen their scope of practice to include the NIPE. There are proven benefits to women and families, midwives and to the wider NHS, which strengthens the support for midwives to carry out this examination routinely. Midwives are legally and ethically bound to work within the NMC Code (NMC, 2015) and with the multidisciplinary team to ensure safe and appropriate care for neonates and their families. Legal and ethical principles form the basis of midwifery practice, which informs the care that is given to women and their families. In some areas, the NIPE is being included in pre-registration programmes, and despite the mixed views surrounding the value of this, recent studies suggests that it may be rolled out nationally in the future. From the literature it is clear that although it raises medico-legal challenges, midwives who have completed the NIPE training are suitably competent practitioners, and are often the preferred professional to complete this examination. Midwives are professionally, legally and ethically supported in carrying out the NIPE, as long as they do so within their scope of practice and within local guidelines and policies.