Midwives are autonomous practitioners who are experts in normal pregnancy and birth (Horton and Astudillo, 2014; NMC, 2015a). Antenatally, midwives care for women in pregnancy from conception to established labour (Fraser and Cooper, 2012; Flint and Lambert, 2015) across community and hospital settings. As professionals, midwives are expected to conduct themselves appropriately in their practice, ethics, and education. The NMC Code provides the ‘values and principles’ (NMC, 2015b) expected of a midwife, underpinning their role. As a midwifery student, gaining an understanding of the Code provides a holistic foundation for studies. However, organisational values can juxtapose professional values.
This article will consider the role of the midwife in antenatal care, exploring the tension between the NMC's values and organisational demands (Duncan, 2010). As the antenatal period is the first time many families will engage in sustained contact with health services (Cumberlege, 2016), exhibiting these values is key in promoting trust in midwifery. Demonstrating how a midwife should act as an advocate, be accountable, practice competently and show leadership, this article will consider the Code's four themes of prioritising people, practicing effectively, preserving safety and promoting leadership and trust in relation to organisational demands, concluding with their application to student midwifery.
Prioritising people
Prioritising people places the woman's best interests at the centre of antenatal provision, through individualised care, advocacy, and an awareness of social needs. Providing multidimensional care, considering ‘bio-psycho-socio-spiritual’ needs (Mathibe-Neke et al, 2014), offers a holistic view of an individual, prioritising overall wellbeing (Williamson and Harrison, 2010). Working in partnership with women through open, two-way communication enables them to engage in their own care (Dahlberg and Aune, 2013; Raine et al, 2010), improving outcomes (Shaw et al, 2016). However, organisational culture does not always support woman-centred care.
Although prioritising people is key to quality midwifery (NMC, 2015b), the reality of providing care within an organisation can be at odds with a person-centred approach (Royal College of Nursing, 2016). Midwives are placed in conflict between providing personalised care based on individual choice, and applying the organisational expectations of following population-based guidance (Kotaska, 2011; Feeley et al, 2019), trying to offer personalised care in a system designed to cater for the masses (Finlay and Sandall, 2009). Managing the demands of trust policy and strains on resources can make the tension between ‘task-based’ and ‘values-based’ practice difficult to reconcile (Sharp et al, 2018), especially when practicing in a defensive environment, where the sense of risk is heightened (Hall et al, 2012).
It is a midwife's role to promote a woman's right to informed choice, advocating for their patient′s decisions, regardless of clinical advice or their own personal views. Risk management is embedded into societal norms, including healthcare (Coxon et al, 2016). Fear of litigation has led to a risk-averse culture in maternity care (Hall et al, 2012; Fraser, 2014; Feeley et al, 2019), with women being provided with a risk status from the beginning of their pregnancy (Healy et al, 2016). However, this fear-led approach can lead to physical health being placed above a holistic view of needs (Healy et al, 2016). The perceived power structures within healthcare, both within society and organisations, have led to coercion, with evidence being presented out of context to support certain viewpoints (Hall et al, 2012). As such, many women wanting to assert their right to autonomy, often in declining interventions, find themselves subject to opposition rather than support (Hall et al, 2012; Feeley et al, 2019).
Ultimately, choice is central to an individual's rights, positively impacting on wellbeing (Tracy and Page, 2019). A midwife supports this care model through responsive communication, building an appropriate care plan, and working in collaboration with the team of professionals around her. In building relationships, with women, their families, and with colleagues, midwives can provide women-centred, respectful care. Trust and respect is fostered, supporting a partnership of care, and the psychological risk is decreased (Hall et al, 2012), leading to care being based on evidence and fact. In encouraging a wider culture of respect and trust, care can move beyond system-based care to relationship-based care (Healy et al, 2016).
Practicing effectively
To practice effectively, a midwife must go beyond what is needed to how to provide it, relating skill to knowledge (Byrom and Downe, 2010). The NMC's core principles of communication, evidence-based practice and teamwork remain unchanged (NMC, 2015b). However, methods of care provision should be individualised. To guarantee quality and safe care, it is essential to build trust and relationships through providing women with the time and space for openness and understanding. With increasing demands on services, and limited resources, environmental and structural factors can make it difficult to personalise care (Smith and Dixon, 2008), especially where individuals require additional support.
A large element of antenatal care is advisory (Borrelli, 2014). A midwife has a duty to recognise individual communicative needs, and to access the best method of relaying information (NMC, 2015b). There are various barriers to communication, from language to disability. Poor communication can have severe consequences, through misunderstandings and miscommunication, as has been evidenced in Saving Lives, Improving Mother's Care reports (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, 2014; 2015; 2019; Meuter et al, 2015; NMC, 2015b). A midwife must be flexible, finding methods to engage women to facilitate equal and safe care (National Institute of Health and Care Excellence [NICE], 2008; Redshaw et al, 2013; NMC, 2015b; Homeyard et al, 2016).
As an autonomous practitioner, a midwife is able to assess the most suitable antenatal pathway, offering further appointments to build trust and provide additional support, as appropriate (NICE, 2010). The methodology of delivering care reaches beyond assessing appropriate approaches, also using evidence-based practice as a foundation (NMC, 2015a; 2015b). The ‘deliberate’ use of research allows for the delivery of effective care, supporting best outcomes (Johansson et al, 2010; Jylhä et al, 2017). A midwife can build a suitable approach to promoting evidence-based care for that individual, evaluating if the approach is feasible, appropriate, meaningful and effective (Jylhä et al, 2017). However, with increasing demands on maternity services, balancing suitable, evidence-based individualised care with available resources is a challenge. The time and resources provided can limit care provision (Smith and Dixon, 2008).
Much of what enables midwives to practice effectively is facilitated by continuity of carer; a model of care that supports building trust and open communication (Homer et al, 2019). With trust and communication as building blocks in care, a midwife can work in partnership with a woman to find an appropriate, individualised method of care (Dunkley-Bent, 2018). However, organisational structure does not always allow for the benefits of continuity of care, as it is often a ‘postcode lottery’, with services seeing it as too expensive to implement (McCourt et al, 2011; Homer et al, 2019). In traditional models of maternity care, a woman may see a different midwife at every appointment, which does not support relationships and trust (Kirkham, 2010). Instead, care increasingly becomes a box ticking exercise (Boyle et al, 2016). As Kirkham (2010) aptly states, ‘a professional friend is very different from a friendly professional’. Nonetheless, a midwife must attempt to build relationships quickly to begin to address individual needs. Furthermore, it is essential that a midwife ensures good teamwork and communication with colleagues, through good documentation, to reduce the gap, and provide seamless care (NMC, 2015b; Knight et al, 2019).
Preserve safety
Protecting the public from harm is central to quality care, with a midwife promoting safety and trust in services. A midwife must balance advocating the ‘absence of harm’ alongside positive experiences for women (Sandall et al, 2010). Primarily, to maintain safety, a midwife must have a clear understanding of the boundaries of their role, practicing only within their sphere of competency (NMC, 2015b). Where a woman deviates from the norm, a midwife's duty is to refer care to a specialist, ensuring safe, appropriate and quality care is provided (Cumberlege, 2016). In this instance, a midwife co-ordinates care, acting immediately and sharing information appropriately and sensitively, to provide seamless care (Department of Health, 2017; Knight et al, 2019). Antenatally, referrals may be made to a range of services, including specialist midwives, obstetric or medical professionals, or social support services. The reasons for referral range from gestational diabetes and mental health issues to child protection issues (NICE, 2008).
However, where standards are not maintained, the consequences can be severe, leading to maternal and neonatal morbidity and mortality. Scandals within maternity, such as those at Morecambe Bay (Kirkup, 2015) and, more recently, Shropshire and Telford Trusts, demonstrate this (Wise, 2019). The duty of candour was born out of one such scandal (NMC, 2013). This duty of candour, being open, honest and accountable, is fundamental to providing safe antenatal care, and creating an environment of transparency (Francis, 2013; NMC, 2015b). Candour maintains a person-centred approach, placing the best interests of the women at the centre of care (Dalton and Williams, 2014). Where mistakes are made, candour means taking responsibility, maintaining trust, rectifying mistakes and learning lessons (NMC, 2015b). Mistakes must be immediately reported and documented, and an explanation and apology offered to those affected (Griffith, 2015).
Candour goes beyond individual responsibility to workplace culture (Dalton and Williams, 2014; Smith, 2015). However, organisations do not always promote this culture. Fear of litigation and pressure to maintain reputation can compromise the development of an open and honest culture (Dalton and Williams, 2014). Personal interests or the interests of an organisation should not impact openness and honesty (NMC, 2013). Employers should create an environment in which midwives can foster safe practice, in an organisational duty of candour (NMC, 2015c). Members of staff should feel able to raise concerns openly and without fear of repercussion (Francis, 2013; Griffith, 2015; NMC, 2015b; Windsor, 2017). Employees should feel empowered to improve patient care, where they feel this is necessary (Trueland, 2017), reflecting on and learning from experiences (Cumberlege, 2016).
Creating strong multidisciplinary workers who trust each other supports safe care (Kirkup, 2015) and a workplace culture, whilst prioritising safety. Despite the importance of communication in care, difficulties in communication have been noted as a key reason for lack of honesty (Birks, 2014). Maternity care is multidisciplinary; good communication and respect is essential to quality care for women in pregnancy, both for their safety during care, and for learning from events with poor outcomes (Cumberlege, 2016). In ensuring ‘shared, dynamic’ collaborative communication, in which all parties are actively engaged, midwives can support the development of trust and collaboration between professionals (Downe et al, 2010).
Ultimately, the ‘unusual’ should never be allowed to become normalised (Dickson and Obeysekera, 2019). The public expect to be safe in accessing antenatal care; a midwife must encourage trust in the service by promoting safety though openness, honesty and multidisciplinary working.
Promote professionalism and trust
As autonomous practitioners, midwives are in a unique position to influence practice based on professional values, beyond clinical skill (Deery and Fisher, 2017). Promoting professionalism concerns the ‘values and action’ required of a midwife, to promote good practice, trust and leadership, and act as a role model (NMC, 2015b; Deery and Fisher, 2017; Layland, 2018). To maintain the reputation of the profession, a midwife must uphold the conduct and character befitting the role (Deery and Fisher, 2017). A midwife's conduct requires a commitment to self-awareness of their behaviour and attitude (Donna, 2011; Deery and Fisher, 2016).
To promote good practice, a midwife must continually learn, keeping up to date with the latest research, as well as synthesising and sharing information with colleagues (NMC, 2015a; 2015b;Jylhä et al, 2017). Midwives must continually challenge their practice to avoid complacency, address poor practice and ensure evidence-based care is provided (Lavender and Chapple, 2004). Being reflective practitioners can support midwives to consider their behaviour, improving their practice (Taylor, 2010; Jylhä et al, 2017). There is a tension between the value of professional development by employers and the professional body. Organisational demands have made it increasingly difficult for midwives to access training (McInnes and McIntosh, 2012). However, it is the responsibility of the midwife to keep their training up to date (NMC, 2015b), and ensure registration requirements are met.
Every midwife must be a leader, not just those in formal leadership positions (NMC, 2015b). In being aware of how their behaviour influences others, midwives can ‘promote excellence’ (Deery and Fisher, 2017; NMC, 2015b) by embodying the values of the Code. This article has highlighted the need for the culture of care to be carefully considered, in order to address organisational–professional tensions. Promoting a values-based leadership (encouragement, influence, motivation and inspiration through action (Kraemer, 2011)) over a hierarchical leadership promotes good practice, endorses quality care and improves experiences for women (Deery and Fisher, 2017). Values-based leadership helps build a positive workplace culture, improving employee satisfaction, and women's experiences and outcomes (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). This ‘virtuous circle’ of good leadership and midwifery empowers other midwives to provide quality care (Byrom and Downe, 2010; NHS Leadership Academy, 2013). Leadership is essential to upholding reputation and promoting professional values on both individual and organisational levels.
The Code and the student
As a student midwife, understanding the Code shapes behaviour, values and practice (NMC, 2015b); students must learn to translate the theory of NMC values into clinical skills from the outset. Alongside the areas already discussed in this article, student midwifery brings its own challenges. Students must reconcile the balance between the demands of their university, mentor, trust and professional body.
As a student, learning to prioritise people is essential; not all women are comfortable with having students involved in their care. An individual's needs must be placed above a student's learning, and demands to meet competencies, respecting choices. Students must be aware of their competencies, not performing skills in which they have not been trained, regardless of external pressures. This is especially important in early placements, where clinical skills are limited. When learning, it is natural to make mistakes. However, the duty of candour lies just as strongly with students as with qualified midwives; a student must be honest when unsure or upon making a mistake, maintaining safety and trust. Values-based leadership can be demonstrated through showing compassion, empathy, kindness and respect, learning to demonstrate core midwifery values in education, placement and at home. Ultimately, a student must prioritise women's safety, being continually mindful of core values and behaviours. Practicing good communication and multiprofessional teamwork remains key to developing core midwifery skills, and learning to balance juxtaposing demands. However, this area would benefit from further research.
Conclusions
Advocacy, accountability, competency and leadership have emerged as key pillars of midwifery practice. However, these are not without their challenges. It is a midwife's duty, at any level, to ensure these key pillars are demonstrated across all elements of their role, balancing organisational demands with professional requirements. The themes of the Code are interlinked, working to support excellent practice. The foundations underpinning this are holistic care facilitated through communication and strong multiprofessional working. Fostering the development of these values within an organisational setting, midwives can support the development of a workplace culture in which person-centred, effective and safe care from midwives who lead by example can be nurtured, ultimately leading to better outcomes and positive experiences for women. Managing these values within an organisational context should be considered and developed from studentship. However, the management of demands placed on students would benefit from further research.
Key points
- The Code forms an important foundation of values and principles for midwives, and these must be considered throughout all areas of practice and antenatal care
- In prioritising people, a midwife advocates for the individual needs and choices of those in their care
- Practising effectively reaches beyond the knowledge of what is needed, also including the skill of how to carry out care.
- Safety is a central pillar of healthcare; a midwife must continually consider and promote safety to maintain trust
- Each midwife is called to be a leader, regardless of their role, by demonstrating core values
- The values of professional bodies and organisational demands juxtapose; it is the role of the midwife to reconcile these dual demands
CPD reflective questions
- What does it mean to prioritise people in antenatal care?
- How can I ensure I am a leader in my workplace, regardless of my role?
- How does the NMC code inform my practice in antenatal care?
- How can I reconcile deontological-utilitarian tensions?
- Do you frequently consider the application of The Code (NMC 2015b) to all areas of your practice?
- Communication is the golden thread running through midwifery practice. How do you use communication to facilitate quality antenatal care?
- In which areas of your role do you find juxtapositions between organisational and professional values?