Although statutory supervision has been embedded in the midwifery profession for over 100 years, midwives' knowledge of statutory supervision and the role of the supervisor of midwives (SoM) is limited (McDaid and Stewart-Moore, 2006). A recent systematic review of the literature concluded that there was significant inconsistency in both midwives' and SOMs' understanding of the purpose of statutory supervision. This review found that there is a need to improve midwives' and SoMs' knowledge of the statutory framework (Henshaw et al, 2013).
Most midwives first encounter the notion of statutory supervision as a student midwife. Students attend lectures around the role of the SoM and the Local Supervising Authority (LSA) during their programme of education. Students may encounter statutory supervision while they are in clinical placement if they are involved in a clinical incident and need to provide an account of their involvement for investigation purposes; although, students would usually seek the support of their personal academic tutor rather than a SoM in this instance (Kitson-Reynolds and Ferns 2013). In addition, student midwives will sometimes refer to Nursing and Midwifery Council (NMC) publications in essays or read articles about statutory supervision in journals.
However, these traditional methods of learning regarding statutory supervision may have some potential drawbacks. Student midwives are required to learn and retain a vast amount of information during their education programmes. Unsurprisingly, students become ‘strategic’ about what they choose to learn and retain depending on the demands of their assessments (Wood, 2004), meaning students may read around the topic of statutory supervision to include in an assessment, but not necessarily retain that knowledge for future use. Even those who have contact with a SoM in clinical practice may do so due to an untoward incident, and depending on how this situation is handled by the SoM and the quality of support the student receives, she or he may develop a negative view of supervision, which could impact on any future contact with supervisors of midwives.
Many student midwives still attend cohort lectures about the statutory framework and supervision at university, but lectures are far from an ideal model of learning. A study by Stuart and Rutherford (1978) found that medical students' concentration levels fell in lectures after 15 minutes and the optimum length of a lecture should be around 30 minutes. Many university lectures are longer than this so it is reasonable to assume that most students will disengage with their learning around statutory supervision at some point. Introducing regular activity into traditional lectures can help to re-set concentration levels (Burke and Ray, 2008) but as Race (2001) points out, what teachers think students do in lectures and what students actually do can be completely unrelated to the lecture itself. Some observed student behaviours during lectures include: daydreaming, doodling, texting, using social media, sleeping, copying notes from presentations and working on assignments for other modules (Race, 2001; Jones and Philp, 2011).
Midwifery is a practical profession and students place the most value on learning activities that are relatable to clinical practice (Wilson, 2008; NMC, 2011). Therefore it makes sense that involving student midwives directly with the process of statutory supervision would raise the profile of supervision among students and enhance understanding of the purpose of supervision. In order to facilitate the students' involvement with statutory supervision in a supportive way, it is necessary to consider how to approach this, and the supervisor's responsibility for student midwives.
Currently the NMC (2014: 4) endorses that SoMs must:
‘Contribute to the development and operation of local frameworks that will enable student midwives to have access to a supervisor of midwives’.
SoMs must also (NMC, 2012: 27):
‘Ensure that a local framework exists to provide support for student midwives to enable them to have access to a supervisor of midwives’.
This suggests that the NMC would like statutory supervision to be inclusive of student midwives but do not prescribe how this should be done. Therefore, each supervision team has the autonomy to choose its own framework to enable students to have access to statutory supervision. As Bacon (2010) suggested, student midwives should be able to access statutory supervision as easily as midwives can. In 2013 the Head of Midwifery, Anita Fleming and the supervision team at East Lancashire Healthcare Trust, in conjunction with the Lead Midwife for Education, Judith Shaw at the University of Central Lancashire decided unanimously to include student midwives in the annual supervisory review process and develop a tool to enable this.
At the start of this process, 48 student midwives based at this Trust were asked to write down one word, which they initially associated with the term ‘supervisor of midwives’. Twenty-four responses were received which generated 14 words; these words were fed into an online programme to create a picture of the student's views. Within these programmes the words that are used most frequently appear bigger. Although some students associated ‘supervisor of midwives’ with support and leadership, the majority of students viewed the SoM to be more of a manager or boss and in some students this evoked feelings of anxiety (Figure 1).
The annual supervisory review
The annual supervisory review is currently a constant feature in the career of a midwife. As intentions to practise arrive annually, there is usually a flurry of activity from both midwives and SoMs to arrange the annual supervisory review. The NMC (2012: 26) states that:
‘At least once a year, a supervisor of midwives meets each midwife for whom she is the named supervisor of midwives to review the midwife's practice and to identify her education needs…’
Although the annual supervisory review can be an opportunity for the midwife to reflect on the year's events and plan for future professional development, there are some anxieties that still exist among midwives with regard to this process. When speaking to newly qualified midwives about their first annual supervisory review, some of the concerns raised included feeling unprepared for a review, not knowing what to expect and fear of being in trouble (Figure 2). Therefore, the aims of commencing an annual supervisory review process for student midwives were to:
Development of the process
Consideration was given to each supervisor's existing workload. Currently there are 17 SoMs within this Trust with a 1:18 SoM-to-midwife ratio. This is greater than the recommended workload of 1:15 (NMC, 2012), although plans are in place to rectify this in the near future by improved succession planning. The 48 student midwives training at the Trust during the development of this process included both 3-year pre-registration students and post-registration nurses undertaking the shortened midwifery programme. In order to equally share the workload, each supervisor was allocated two or three students. The supervisors who were assigned three students always had a student within their allocation who was in their final year of training. This will allow their caseloads to reduce as the final-year student completes the programme. SoMs who have been allocated two students this year will be allocated three students next year. This allows the SoMs' student caseload to alternate between two and three students over the coming years and ensures equity of workload. Students were given the opportunity to change their SoM should they wish to do so.
The existing annual supervisory review form for midwives, used at the Trust, was amended to make it more applicable to students. The front page of the form now contains the student's details and year of training commencement. There is a short section explaining the purpose of statutory supervision that the SoM uses to open her discussion with the student, the SoM can then clarify any questions that the student may have regarding the statutory framework. Students are asked to reflect on any challenging aspects of clinical placements and to identify areas of clinical practice that they enjoy. The questions are aimed at eliciting responses that will give a true reflection of the students' experiences in the clinical area. A section around mandatory training was added so that the students can see which training should be done within the university and which training should be done within the Trust. A record-keeping audit of the student's own European Directives was added, which provided assurance that the students were documenting their experiences correctly and that all required signatures were present.
The students were asked to evaluate the form they had used shortly after the meeting had taken place. This was to ensure that the annual review form was fit for purpose and to seek opinion on whether the students felt that any extra questions needed to be added or existing questions changed. The students were not required to put their name on the evaluation form. Questions on this evaluation form include:
The students were all informed by email of the name and contact details of their own supervisor. They were all emailed their own copy of the student annual supervisory review form and the evaluation form. A short explanation about the annual review and its purpose was sent, along with instructions on how and when to access their own SoM for their review. In order to allow students to reflect on practice it was recommended that first-year students complete at least one clinical placement before arranging their annual supervisory review. Students were informed that their review could be arranged at any time convenient to both student and SoM during the academic year. Students were also informed that SoMs tend to be very busy with intentions to practise during January and February so may be unable to meet for annual supervisory review during this time. It was made clear to the students that it was their responsibility to contact their SoM and arrange their review. The Approved Education Institution (AEI) currently requires student midwives to include evidence of meeting with a SoM annually in their portfolios. This is in order to demonstrate that the students have made effective use of the statutory framework for the supervision of midwives (NMC, 2009). The students therefore retain their review forms to meet this requirement.
Evaluation, outcomes and implications for the future
The evaluation of this model and process is still in its early stages, but 24 students based at the Trust have now had an annual supervisory review. Since the beginning of this process, nine of the 48 students have left the course either permanently due to qualifying, or temporarily due to maternity leave. Fourteen evaluation forms have so far been returned and comments received have not only provided information about the students' thoughts in relation to the annual supervisory review form but their views on the process itself. To date, the students' responses have been overwhelmingly positive. All responses suggest that the form is fit for purpose and that it has helped to guide their discussion with their SoM. No changes or improvements to the form have been suggested. As contact with a SoM is a requirement of the AEI, it is expected that the remaining students will seek their annual supervisory review before the end of this academic year.
Additional comments have been added to the evaluations of the annual supervisory review; for example, one student commented that her supervisor helped her to reflect on a clinical issue and that she found this discussion to be very positive. Verbal feedback from students who have had their review is supportive of the process. For example, students have expressed a greater understanding about the role of the SoM especially regarding giving advice about continuing professional development and support for midwives and women after serious untoward clinical incidents. Overall, the students have found the annual supervisory review to be valuable (Figure 3).
Students were also asked to write one word, which they associate with the term ‘supervisor of midwives’, after their annual review. This word picture suggests that the students view their SoMs more in terms of support and guidance rather than managers (Figure 4). This may have positive implications for the future in terms of midwives understanding ability to differentiate between supervision and management.
Verbal feedback from SoMs has also been positive with some advantages to this process being highlighted. For example, SoMs have been approached by students to question them about evidence-based practice and Trust guidelines. Students have approached their SoM for support with reflection around clinical incidents or to debrief following an incident. Some students have also expressed an interest in statutory supervision and asked about training criteria for SoMs. This could have positive implications for future succession planning within statutory supervision if their interest can be maintained. Although there are also some perceived challenges for the SoMs, such as increased workload and time constraints, SoMs have found this generally easy to manage as the annual review can be done when it is convenient for both student and SoM. Most student annual reviews have taken, on average, 30 minutes to complete and SoMs have reported that the process has not added greatly to their supervisory workload. Some issues have been raised through the annual review process such as students not accessing the Trust's core mandatory training after their first year, even though this is an annual requirement. Missing signatures and block signatures on the students' EU documentation have also been identified. This has enabled appropriate action to be taken promptly to rectify these issues.
Conclusion
This is a local initiative that has been in operation for less than a year but is showing a positive impact on perceptions of statutory supervision and promotion of a greater understanding of the statutory framework for student midwives. Learning about statutory supervision in a practical way is helping students to realise the value of statutory supervision and how to utilise support from their SoM when required. This could have positive implications for statutory supervision and SoMs regarding clarity of understanding between supervision and management and future succession planning within the supervision team. Both students and SoMs have viewed this initiative favourably but the full impact of the outcomes of the initiative will not be known or measurable until current cohorts qualify and begin their careers as midwives.