registered midwife sop - dubai health authority professionals/scope... · scope of practice for...

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Scope of Practice for Registered Midwife (RM) Health Regulation Department Dubai Health Authority (DHA)

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Introduction Health Regulation Department in DHA is responsible for regulating midwifery practice in the Emirate of Dubai, United Arab Emirates. Scope of Practice (SOP) refers to the activities that registered midwives are educated, authorized and competent to perform as well as their decision making capacity. Such activities are established through the legislated definition of licensed midwifery practice, complemented by standards, limits, conditions and education and influenced by setting, environment and health needs of the population. The Eastern Mediterranean Region (EMRO) of the World Health Organization (WHO) in its Global Advisory Group Meeting in 2000 identified lack of legislation as the most prevailing reason for nurses and midwives not working to their full potential. The primary purpose of this document is to guide and direct midwives practice within this environment. Through this framework DHA health regulation meets its responsibility to regulate midwifery practice in the public interest and address incompetent, impaired or unethical practice amongst midwives. DHA health regulation in recognising its further responsibilities to ensure public safety and in line with its published expectations of the registered nurse, equally expects that registered midwives must self assess their competence and make individual decisions about their practice within unique circumstances and settings. Furthermore midwives retain accountability for their own practice and are accountable to the woman and her newborn, the public, their employer and the regulatory authority. To ensure consistency in midwifery standards throughout the UAE the following Midwifery Competency Framework has drawn largely on the work undertaken in 2007 to develop the Scope of Practice (SOP) for the Midwife, which was endorsed by the Health Authority of Abu Dhabi (HAAD) Nursing and Midwifery Advisory Committee in December 2007 and the Federal Department of Nursing (FDON) Midwifery Committee in January 2008. During the collaborative development of the SOP by midwifery representatives throughout the UAE, the International Confederation of Midwives (ICM) Essential Competencies for Basic Midwifery Practice (2002) provided an international guide and benchmark. In order to provide more detailed evidence guidelines for midwifery practice in Dubai the Midwifery Competence Framework has been modified and expanded. The Scope of Practice for the Licensed Midwife is endorsed by DHA health regulation and should be read in conjunction with DHA health regulation Code of Conduct and Ethics for Nurses and Midwives. DHA health regulation upholds that no midwife should be directed or compelled to undertake any practice that falls short of DHA health regulation standards or code of conduct requirements.

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International Definition of a Midwife

As accepted by the ICM Membership and Joint Study Group on Maternity Care, FIGO, WH0

A midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.

The sphere of practice: She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and postpartum period, to conduct deliveries on her own responsibility, and to care for the newborn and the infant. This care includes preventive measures, the detection of abnormal condition in mother and child, the procurement of medical assistance, and the execution of emergency measures in the absence of medical help.

She has an important task in counseling and education, not only for the women, but also within the family and community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynecology, family planning, and child care.

She may practice in hospitals, clinics, health units, domiciliary conditions or any other service.

Competency Standards

Four Domains of Practice have been identified. Core midwifery competency standards and associated performance criteria are located within these domains of practice which are guided by the ICM/WHO/FIGO (1992) and ICM (2005) Definitions of the Midwife and the ICM essential competency standards for the Midwife (2002).

Domains of Practice

1. Midwifery Practice and Comprehensive Care 2. Professional, Legal and Ethical Practice 3. Professional Development 4. Quality Improvement and Collaborative Healthcare

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Competency Statements Each Domain of Practice has competency statements and associated performance criteria that a midwife must demonstrate to fulfil regulatory requirements. Evidence of safety to practice is demonstrated when the registered midwife meets the competency criteria within the domains. The indicators and evidence guides are neither comprehensive nor exhaustive but rather provide examples of evidence of competence. NB: For the purpose of this document she may mean he in specific circumstances

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Domain 1 Midwifery Practice and Comprehensive Care Competency 1.1 Promotes health and provides education to the woman and her family

Indicator Sub Indicator Evidence Guide Examples 1.1.1 Midwives provide high quality, culturally sensitive health education and services to the woman and her family in order to promote healthy family life, planned pregnancies and birth spacing and positive parenting.

1.1.1.1 Identifies, participates in and contributes to the development of

health education programs in the community 1.1.1.2 Provides the woman and her family with accurate information 1.1.1.3 Supports the woman and her family to promote health and well-

being

Knowledge of: • Communication in establishing and

maintaining helpful relationships • Healthy life style behaviours

• Positive parenting strategies

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Competency 1.2 Facilitates decision-making by the woman and her family

Indicator Sub Indicator Evidence Guide Examples 1.2.1 Midwives provide evidence-based information to the woman and her family facilitating them to make informed choices regarding their care.

1.2.1.1 Offers advice and midwifery care that respects the cultural and social needs of each woman and her family 1.2.1.3 Communicate relevant information effectively, using language that

is readily understood 1.2.1.4 Actively listens to the woman and her family and responds to their

needs 1.2.1.5 Facilitates learning opportunities through sharing of information 1.2.1.5 Advocates informed choice and shared decision-making

Knowledge of: • The effect of culture on

communication, such as when physical contact is appropriate and when it is not and how to address people

• The different forms and range of

effective communication, including verbal and non-verbal communication, touch, symbols and images

• Theories that inform and enhance

understanding of communication and the effective use of relationship and interpersonal skills

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Competency 1.3 Provides safe and effective antenatal care

Indicator Sub Indicator Evidence Guide Examples 1.3.1 Promotes the health and well-being of the pregnant woman and the fetus

1.3.1.1 Plan, implement and evaluate holistic antenatal care in collaboration with the woman and her family

1.3.1.2 Educates the woman and families about normal physiological changes of pregnancy and advise on strategies to relieve common discomforts

1.3.1.3 Assesses the growth and well-being of the fetus

1.3.1.4 Provides nutritional advice for pregnancy and lactation

1.3.1.5 Interprets and acts upon information from antenatal assessments

1.3.1.6 Interprets and analyses basic screening laboratory/ultrasound studies

1.3.1.7 Identifies health risk factors and refers care as necessary

Knowledge of: • Commonly used clinical protocols,

pathways, assessment frameworks and maternity care guidelines.

• The importance of giving constructive, positive feedback to others

• Factors that impact positively and negatively on women’s during pregnancy and well-being.

• The physiological changes that occur

during pregnancy & their impact on health.

• Care for the pregnant woman from conception to birth

• Care for the normal newborn • Potential risk factors during

pregnancy.

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Competency 1.3 Provides safe and effective antenatal care

Sub Indicator Evidence Guide Examples Evidence Guide Examples

1.3.2 Prepares the woman for labour, birth and parenting

1.3.2.1 Educates the woman about the onset and process of labour

1.3.2.2 Provides information about pain relief, birth positions and delivery

options to facilitate informed choices 1.3.2.3 Protects, promotes and supports breastfeeding in alignment with

current WHO/UNICEF guidelines

Knowledge of:

• Care of the woman during labour

• Pain relief during labour • Baby Friendly Accreditation

guidelines

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Competency 1.4 Provides safe and effective intrapartum care

Indicator Sub Indicator Evidence Guide Examples

1.4.1 Demonstrates an understanding of the physiology of labour

1.4.1.1 Recognizes the relevant critical diameters and landmarks of the maternal reproductive anatomy

1.4.1.2 Identifies the signs which indicate onset and progress of labour

1.4.1.3 Identifies the measures to assess fetal and maternal well-being in labour

1.4.1.4 Identifies the signs and indicators of deviations from

normal/complications

Knowledge of: • The physiology of normal labour

• Evidenced based midwifery skills for

appropriate interventions

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Competency 1.4 Provides safe and effective intrapartum care


1.4.2 Demonstrates competency in the skills needed to support the woman during childbirth

1.4.2.1 Promotes normal physiological childbirth 1.4.2.2 Identifies complications or deviations from normal 1.4.2.3 Implements midwifery care which reduces risk and harm to the

woman and fetus 1.4.2.4 Encourages and respects the woman’s preferences throughout labour and delivery, within safe parameters of practice

or safe delivery in an environment conducive to well being of mother and newborn as requested

1.4.2.5 Recognizes emergency situations and intervenes in an appropriate

and timely manner.

Knowledge of:

• Support for the woman during labour and delivery

• Evidenced based midwifery skills for appropriate interventions during emergency situations

• Advocacy

• Informed consent

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Competency 1.5: Provides safe and effective postnatal care

Indicator Sub Indicator Evidence Guide Examples 1.5.1 Demonstrates an understanding of the physiology of the post natal period

1.5.1.1 Identifies the normal process of involution and healing following

childbirth 1.5.1.2 Facilitates the process of lactation and bonding, supporting the

mother-newborn dyad 1.5.1.3 Recognizes maternal nutritional, physiological and emotional

needs and acts accordingly 1.5.1.4 Educates the woman about discomforts of the puerperium and

advises on strategies to relieve them 1.5.1.5 Recognizes deviations from normal and acts accordingly

Knowledge of: • Physiology of the post natal period

• Care of the mother and new born

post partum. • Evidenced based midwifery skills for

appropriate interventions

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Competency 1.6: Provides safe and effective care of the newborn

Indicator Sub Indicator Evidence Guide Examples 1.6.1 Demonstrates a knowledge of the physiology and needs of the newborn

1.6.1.1 Recognizes signs of newborn adaptation to extra-uterine life 1.6.1.2 Identifies factors relevant to growth and development 1.6.1.3 Identifies variations in the normal newborn and acts accordingly

appropriately 1.6.1.4 Implements health promotion and disease prevention strategies

Knowledge of: • Physiology and needs of the new

born

• Infection Control

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Competency 1.6: Provides safe and effective care of the newborn

Indicator Sub Indicator Evidence Guide Examples 1.6.2 Demonstrates competency in the skills needed to safely care for the newborn

1.6.2.1 Immediately assesses the newborn’s condition 1.6.2.2 Performs a detailed physical examination of the newborn 1.6.2.3 Promotes early breastfeeding 1.6.2.4 Performs interventions to facilitate adaptation to extra-uterine life 1.6.2.5 Recognizes deviations from normal and acts accordingly 1.6.2.6 Initiates emergency measures when necessary

Knowledge of: • Newborn assessment and care

• Evidenced based midwifery skills for

appropriate interventions • Neonatal resuscitation

• Infection control

• Health and safety and environmental

control

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Competency 1.7 Performs safe and effective pharmacological interventions

Indicator Sub Indicator Evidence Guide Examples 1.7.1 Demonstrates evidence based practice in use of pharmacological preparations relevant to midwifery practice

1.7.1.1 Educates the woman about the potential effects of medication

during pregnancy, birth and lactation 1.7.1.2 Educates the woman about any medications required by the

newborn 1.7.1.3 Accurately calculates medication doses for administration 1.7.1.4 Safely administers medications during pregnancy, birth and

lactation 1.7.1.5 Recognizes contra-indications and side effects and acts accordingly 1.7.1.6 Documents medication administration accurately

Knowledge of: • Medication administration and

management protocols (the rights of drug administration).

• Formula for calculating drug dosages

(all routes) • Pain management

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Domain 2: Professional, legal and ethical practice Competency 2.1 Functions in accordance with legislative and policy guidelines relevant to midwifery practice

Indicator Sub Indicator Evidence Guide Examples 2.1.1 To practice within a scope of competency and an ability to work independently and in collaboration with others. .

2.1.1.1 Maintains current license to practice as an outcome of self-regulation

2.1.1.2 Identifies unsafe practice and intervenes accordingly 2.1.1.3 Functions within a set midwifery scope of practice as delineated

by this document 2.1.1.4 Practices only to the level for which s/he is adequately prepared,

supervised and supported to perform 2.1.1.5 Utilizes relevant codes of conduct as a guide to midwifery practice 2.1.1.6 Contributes to policy development impacting on midwifery

practice 2.1.1.7 Interacts with policy makers and legislators to influence legislation

and regulation pertaining to midwifery practice

Knowledge of: • Regulatory and licensing requirement

and self regulation • Legislation governing midwifery

practice • Scope of Practice and scope of

practice decision making tool • Code of conduct and ethics for nurses

and midwives • Organisation policies • Practice setting standards

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Competency 2.2 Assumes responsibility and accountability for own actions and clinical decision making


2.2.1.1 Performs ongoing self-evaluation to determine strengths and

limitations in knowledge and skills 2.2.1.2 Consults and performs referrals as necessary 2.2.1.3 Assumes responsibility for delegation and supervision of

midwifery care (direct and indirect), which is relevant to the context and the competence of the person to whom care is delegated

2.2.1.4 Accepts responsibility for delegated activities relevant to the

context and own level of competence 2.2.1.5 Works collaboratively with other health care professionals to

improve the delivery of services to the woman and her family 2.2.1.6 Advocates for the woman and families to ensure promotion of a

healthy and safe birth

Knowledge of: • Self assessment techniques

• Referral process/s

• Appropriate delegation

• Woman and family rights

• Differences in cultural and religious

practices/needs

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Competency 2.3 Delivers care and practices midwifery within an ethical framework and social context


2.3.1.1 Implements midwifery care in a culturally respectful and

non-judgmental manner 2.3.1.2 Bases midwifery practice on ethical decision making 2.3.1.3 Works in partnership with the woman to support them in

making informed choices about their health 2.3.1.4 Acts to strengthen the woman in promoting health of self

and others 2.3.1.5 Communicates effectively with the woman, significant

others and health care professionals to optimize care 2.3.1.6 Advocates to protect rights of the woman and families in

relation to midwifery care

Knowledge of: • Advocacy

• Code of Conduct and Ethics for

nurses and midwives • Woman and family rights

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Domain 3: Professional development Competency 3.1 Demonstrates a commitment to development of self

Indicator Sub Indicator Evidence Guide Examples 3.1.1 The midwife is accountable for establishing, maintaining and evaluating her own life long learning needs to ensure continuing competence to practice.

3.1.1.1 Maintains knowledge and skills through actively

participating in continuing professional development programs

3.1.1.2 Uses valid research to inform midwifery practice

3.1.1.3 Actively engages in continuous self-assessment to

evaluate and enhance own practice

3.1.1.4 Maintains record of all learning and professional development activities attended

Knowledge of:

• Technological and scientific advances

• Life long learning

• Reflective practice

• Sources of evidence based research

• Professional practice portfolio

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Competency 3.2 Demonstrates a commitment to development of others and the profession

Indicator Sub Indicator Evidence Guide Examples 3.2.1 Contributes to the support, direction and teaching of colleagues to enhance professional development

3.2.1.1 Collaborates and shares professional knowledge with

others 3.2.1.2 Supports others less experienced or new to the profession

through formal and informal preceptor and mentor programs

3.2.1.3 Participates in facilitating and co-coordinating learning

opportunities for others 3.2.1.4 Contributes to health care policy as relevant to midwifery

practice 3.2.1.5 Identifies opportunities and contributes to nursing research 3.2.1.6 Refers to and disseminates current research to guide

midwifery practice

Knowledge of:

• Preceptor ship • Mentoring

• Maternity care policies and standards.

• Research and midwifery knowledge

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Domain 4: Quality Improvement and Collaborative Healthcare: This domain contains competencies to demonstrate that, as a member of the healthcare team, the midwife evaluates the effectiveness of care and promotes a midwifery perspective within the inter-professional activities of the team Competency 4.1 Recognizes and values quality improvement activities to monitor and improve standards of midwifery

Indicator Sub Indicator Evidence Guide Examples 4.1.1 Participates in quality improvement activities.

4.1.1.1 Recognizes that quality improvement involves ongoing

consideration, use and review of practice in relation to practice outcomes, standards and guidelines and new developments

4.1.1.2 Participates in case review activities

4.1.1.3 Participates in clinical audits

4.1.1.4 Uses appropriate risk assessment tools to identify actual and

potential risks

Knowledge of:

• Safe administration of therapeutic

substances

• Risk assessment tools

• Quality Management

• Performance indicators (key quality

characteristics)

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Competency 4.2 Demonstrates accountability for communication, consulting and collaborating with other health professionals and health providers regarding activities of care planning, implementation and evaluation of care

Indicator Sub Indicator Evidence Guide Examples 4.2.1 Recognizes that the membership and roles of healthcare teams and service providers will vary depending on an individual’s/groups needs and healthcare setting

4.2.1.1 Recognizes when to negotiate with, or refer to other healthcare

or service providers 4.2.1.2 Establish positive and productive working relationships with

colleagues

Knowledge of:

• Health care systems • Roles and responsibilities of various

models of interdisciplinary health teams

4.2.2 Recognizes that the membership and roles of healthcare teams and service providers will vary depending on an individual’s/groups needs and healthcare setting

4.2.2.1 Recognizes when to negotiate with, or refer to other healthcare

or service providers 4.2.2.2 Establish positive and productive working relationships with

colleagues

Knowledge of:

• Health care systems

• Roles and responsibilities of various models of interdisciplinary health teams

4.2.3 Demonstrates knowledge of effective inter-professional work practices which respect and utilize the contributions of members of the health team

4.2.3.1 Participates with members of the healthcare team in decision-

making 4.2.3.2 Reviews and evaluates care with members of the healthcare

team

Knowledge of: • Decision making frameworks

• Processes for referrals

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SCOPE OF PRACTICE DECISION MAKING

Decision making in midwifery practice is complex and relies on a number of factors. The Midwife should use the following steps to assist in making appropriate and accountable decisions. Step

1. Is the function within the scope of practice of the registered midwife? Midwifery practice in Dubai is guided by contemporary standards and policy endorsed by DHA HEALTH REGULATION and benchmarked against standards and procedures endorsed by national and international associations.

IDENTIFY • Is the activity within the scope of practice of the registered midwife? • Does the practice comply with midwifery standards, is it supported by

policy and is it supported by research/evidence based practice for this situation?

• Are there other standards or regulatory policy that I must consider and will the practice comply with these?

• Do I require regulatory authorization to perform this activity? Step

2. Is the function within the individual’s scope of practice? It is the responsibility of every midwife to understand and apply the relevant standards of professional practice within their own scope of practice. In making decisions in relation to their scope of practice midwives must actively engage in continuous self assessment and self regulation to ensure continuing competence to practice. IDENTIFY • Do I possess the current knowledge, training, skill and experience to

perform the function? • Are these skills and abilities documented in my employment file? • Do I have required authorization to perform this activity? • Do I require the expert assistance of other health professionals? • Have I met the requirements for delegation? • Have I met the requirements for supervision?

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Step

3. Is there an identified client/patient need or benefit? Midwifery care should occur in consultation with the woman and her family. IDENTIFY • Is there a legitimate need by the woman for this service? • Will the woman benefit from my performing this service? • Has the woman been consulted in the decision process?

Step 4. Does the employing facility support this function?

Midwives have the responsibility to practice within professional standards and guidelines which are supported by appropriate policies and procedures provided by employers. • Is this function identified within my role/job description? • Do I have the support of my supervisor to perform this function? • Is there organizational policy or procedure in place?

Step 5. Am I willing to accept accountability and responsibility for my decision?

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EVALUATE

SCOPE OF PRACTICE DECISION MAKING STEPS Question: How do I know what my current Scope of Midwifery Practice is?

ASK No

YES No

YES No

YES

No

Yes

No

YES

Step 1 Is the function within licensed midwifery practice?

Step 2 Is the function within the individual's scope of practice?

Step 3 Is there an identified need by the woman or identified benefit?

• Is the activity within the licensed midwifery practice? • Does the practice complies with midwifery standards

and supported by policy and is it supported by research/evidence based practice for this situation?

• Do I possess the current knowledge, training, skill and experience to perform the function?

• Are these skills and abilities documented in my employment file?

• Do I have required authorized to perform this activity?

• Do I require the expert assistance of other health professionals?

• Have I met the requirements for delegation? • Have I met the requirements for supervision?

• Is there a legitimate need by the woman for this service?

• Will the woman benefit from my performing this service?

• Has the woman been consulted in the decision process?

• Is this function identified within my role/job description?

• Do I have the support of my supervisor to perform this function?

• Do I accept responsibility for the performance and outcome of this function in this context and mindful of any competence?

DO NOT PROCEED Review & consult resources & seek

PROCEED

Step 4 Does the employing facility support this function?

Step 5 Am I willing to accept accountability for my decision?

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DELEGATION WITHIN THE SCOPE OF PRACTICE OF THE

REGISTERED MIDWIFE

DELEGATION BY REGISTERED MIDWIVES For the purpose of this document delegation is the conferring of authority to perform specific functions or tasks/activities in a specific situation, to a person whose role/job description and training allows them to perform such functions but does not have the authority to perform such functions without supervision. Only REGISTERED MIDWIVES are able to delegate. It is not permitted for Registered Nurses or Assistant Nurses to delegate tasks that are the domain of the qualified midwife. Registered Midwives who delegate health care tasks retain accountability for the decision to delegate and the subsequent performance of the delegated task. The decision to delegate is based on the midwife’s professional judgment and determination that the person to whom the delegation is to be given is competent to perform the function. DELEGATION must not be given in circumstances which involve a compromise to the woman or new born safety or a breach of legislation or professional standards. SUPERVISION Supervision is defined as the activities of oversight, direction, advice, guidance, support, monitoring or evaluating. Supervision can be of the individual or a group of persons and is usually for a defined time as determined by the licensed nurse depending on the situation and activity. Supervision can be direct where the Registered Midwife works with the Registered Nurse, Assistant Nurse or Health Care Assistant or Student Midwife and can provide observation and intervention where necessary. Supervision can be indirect where the Registered Midwife is not present and supervision is provided other than by direct observation. Processes which are the shared responsibility of the licensed midwife as well as the employer must be in place to support the Registered Nurse, Assistant Nurse or Health Care Assistant or Student Midwife in this situation.

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GLOSSARY OF TERMS ACCOUNTABILITY A Registered Midwife is answerable to the woman and her newborn, the employer, the regulator and the public for her decisions, actions and behaviours and for the consequences of those decisions, actions and behaviours. ASSISTANT NURSE A Person registered under the registered assistant nurse scope of practice COMPETENT Having the required abilities or qualities COMPETENCE The combination of skills, knowledge, attitudes, values and abilities that underpin effective performance as a nurse DUTY OF CARE A duty to use care toward others that would be exercised by an ordinarily reasonable and prudent person in order to protect them from unnecessary risk of harm PUBLIC The community of the Emirate of Dubai, United Arab Emirates REGISTERED NURSE A person registered under the registered nurse scope of practice SELF ASSESSMENT Self assessment of competence is a continuous process of examination against professional standards and guidelines. The midwife has the responsibility to maintain and further develop the competence necessary for their area of practice. The focus should be on improvement. SELF REGULATION Self regulation is a dynamic process for the health professional which involves accountable practice and sound decision making. Critical continuous self assessment of competence to practice and actions to maintain and enhance competence is its foundation.

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References

1. Australian Nursing & Midwifery Council (2006) National Competency Standards for the Registered Midwife, www.anmc.org.au

2. ACMI (2001) Australian College of Midwives Incorporated Competency

Standards for Midwives http://www.acmi.org.au

3. Australian Nursing and Midwifery Council (2006) National Competency standards for the Midwife

4. Department of Health & Medical Services (2008); Job Description/ Performance 5. Appraisal Midwife

6. Buscher, A., Wagner, L. (2004) Munich Declaration: nurses and midwives: A

force for health. An Analysis of implementation of the Munich Declaration 2004 (WHO publication) http://www.euro.who.int/document/e86640.pdf

7. Federal Department of Nursing, Ministry of Health United Arab Emirates (2007);

Scope of practice for the Midwife

8. Health Authority Abu Dhabi (2007); Scope of Practice for the Midwife, www.haad.ae

9. ICM/WHO/FIGO International Definition of the Midwife, ICM, The Hague

International Confederation of Midwives (2002) Essential Competencies for Basic Midwifery Practice http://www.internationalmidwives.org/modules.php?op=modload&name=News&file=article&sid=27

10. Nurses Board South Australia (2006); A Scope of Practice Decision – Making

Tool