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Supervised Practice Programme

SUPERVISED PRACTICE PROGRAMME

Midwife’s name

Signature

Midwife PIN

Local Supervising Authority Midwifery Officer

Programme Lead Supervisor of Midwives’ name

Signature

Named Supervisor of Midwives’ name

Signature

Academic Mentor’s name

Signature

Clinical Mentor’s name

Signature

Clinical Mentor’s name

Signature

Programme start date

Planned date of completion

Actual date of completion

Hours Completed

Supervised Practice Programme

SUPERVISED PRACTICE PROGRAMME

Contents The aim of the programme...........................................................................................5

Overall objectives of this supervised practice programme.......................................5

Programme specification..............................................................................................5

Assessment..................................................................................................................6

Assessment of competence.....................................................................................6

Assessment of theory...............................................................................................6

Successful programme.................................................................................................7

Unsuccessful or incomplete programme......................................................................7

Proficiency Assessment Criteria...................................................................................8

Investigation recommendations and proficiencies from investigation report................9

Check list prior to commencement of the programme................................................10

Health assessment.....................................................................................................11

Employment issues....................................................................................................11

The role of those involved in this supervised practice programme............................12

Orientation to practice................................................................................................15

Supervised practice programme details.....................................................................15

Formal review of programme................................................................................... 16

Agreement on content and length of programme.......................................................17

Proficiency: Accountability..........................................................................................18

Proficiency: Effective Communication........................................................................23

Proficiency: Administration and Care of women in labour with an epidural................29

Proficiency: Neonatal Resuscitation...........................................................................34

Proficiency: The use and interpretation of Cardiotocograph (CTG)...........................37

Proficiency: Documentation and Record Keeping......................................................41

Proficiency: The use of intravenous syntocinon in labour to initiate or augment uterine contractions................................................................................................................44

Proficiency: Medecines Management........................................................................49

Proficiency: Professional Behaviour...........................................................................54

Proficiency: Demonstrate the ability to provide intrapartum care for a woman with a previous history LSCS................................................................................................61

Proficiency: Be able to recognise acute maternal physical deterioration and make the appropriate interventions and referrals.......................................................................64

Supervised Practice Programme 3

Agreement on conclusion of the programme.............................................................66

Appendix one..............................................................................................................67

Appendix two..............................................................................................................68

Appendix three...........................................................................................................69

Reading Log...............................................................................................................70


The aim of the programmeThe aim of this programme is to provide a formal process that develops and assesses the midwife’s competence in order for her to return to working competently without direct supervision.

Overall objectives of this supervised practice programme To provide a positive and encouraging learning experience for the midwife that

will facilitate him/her to gain the required experience and knowledge in order to achieve the agreed outcomes.

To facilitate the midwife to achieve the level of competence necessary to practise midwifery safely (Standards for the supervised practice of midwives 2007 standard 4.2).

To facilitate a supportive environment, which enables the midwife to reflect on practice and become a confident, competent practitioner of contemporary practice.

Programme specification The LSAMO must agree the programme before the midwife starts (NMC

Standards for the supervised practice of midwives 2007 standard 4.3).

The midwife should be supernumerary during the course of the programme. This means that the midwife should work with a degree of direct and indirect supervision and have the opportunity to discuss ongoing clinical care and decision making with her/his clinical mentor (NMC Standards for the supervised practice of midwives 2007 standard 4.5).

During the period of supervised practice, the midwife must not be involved in the teaching or mentoring of students (NMC Standards for the supervised practice of midwives 2007 standard 4.6). If there are issues surrounding an individual’s ability to act as a mentor then this must be addressed separately and on an individual basis.

To ensure that all concerned have a clear focus on the requirements of this programme it should be ensured that the programme has measurable objectives and clear outcomes, with the midwife and the mentor providing clear evidence of achievement.

The objectives and learning outcomes will relate to the specified needs and proficiencies identified within the supervisory investigation as being of concern, and from the NMC Domains and ‘Essential skills clusters’ (NMC Standards for pre-registration midwifery education 2009).

The midwife should have input into the design and content of the programme in relation to the learning outcomes, which should be directly related to the identified practice needs and documented within the specific supervised practice programme.


The midwife will need to pass all the elements of the programme (practice and academic work) to complete the programme successfully.

Information pertaining to the supervised practice programme should be confined to individuals on a ‘need to know’ basis. This should include those individuals who are able to contribute to a positive experience for the midwife, such as the Head of Midwifery (HOM) and shift leaders. The HOM has the authority to sanction supernumerary status for the midwife and facilitate other employment issues. The shift leaders should be aware in order to ensure adequate support for the midwife

Assessment Assessment of clinical competenceClinical midwifery practice is assessed by clinical mentor

The midwife must demonstrate ability and competence to the standard of a newly qualified midwife (Level 3) to be deemed competent and fit to practise as a midwife; this is different to an employer’s requirement to be fit for role. Any aspects of extension of role or employment status will be determined by employers.

It is expected that the minimum standard (level 3) is acceptable to complete a programme of supervised practice.

Marking criteria – Assessment Criteria for clinical practiceLevel 3 Pass The midwife can demonstrate competence in the areas of midwifery practice assessed by this programme (Midwife at point of registration).

Level 2 and below Fail The midwife has not demonstrated competence (attitude, knowledge, skills abilities) in the areas assessed by this programme (Student / Maternity Care Assistant).

Stage 1 Developmental period

The clinical mentor will be working with the midwife at all times in a teaching capacity.

Stage 2 Assessment of competence

The clinical mentor will be working with the midwife at all times and assessing the midwife’s proficiency in the clinical environment.

Assessment of theoryTheoretical midwifery knowledge assessed by academic mentor

The format for demonstrating theoretical knowledge will be in the form of a 3000 word academic essay with the title:

‘A structured reflection on the situation which resulted in supervised practice ensuring that all the proficiencies set are covered’


An academic marking grid is used (see Appendices 2 and 3) to demonstrate fair means of assessment. Assessment will be based on a 40% pass rate.

Midwives without a midwifery degree will be assessed at level 2 and all degree trained midwives will be assessed at level 3.

A system of moderation should be utilised in line with University regulations.

Standards of presentation of written work

Any written work presented for the assessment should

Be typed

Be referenced

Demonstrate the appropriate and agreed level of critical thinking

Formative and summative work should be submitted by the dates agreed at the first meeting

Successful programmeFollowing the successful completion of the supervised practice programme, the midwife will continue to receive ongoing support and guidance from her named supervisor who will also continue to review her practice as appropriate (Standards for the supervised practice of midwives 2007 standard 6.2). The midwife will return to her/his normal working environment, but should not be allowed to return straight away to a practice area where there is minimal supervision or support.

Unsuccessful or incomplete programmeThe LSAMO should be kept informed of progress throughout the programme and should also be involved in the decision of the final outcome. Ideally, the LSAMO will attend or be informed of the outcomes of the initial, interim and final review meetings.

The LSAMO must become involved if the midwife is having difficulty in meeting the proficiencies/learning objectives. The LSAMO, in conjunction with the midwife, and the Investigating/Programme lead supervisor of midwives should review the midwife’s progress on the programme.

Where a midwife fails to meet the objectives set within the programme, and has been given every reasonable opportunity and support to do so, the LSAMO will automatically refer the midwife to the NMC (Standards for the supervised practice of midwives 2007 standard 3.5). The employing Head of Midwifery should be informed.

Where the supervised practice programme is linked to a Trust/ Health Board capability procedure, the midwife should understand from the outset that failure to meet the required competence might result in further disciplinary action. The Trust/ Health Board, where applicable, should be informed of the outcome of the programme.

If a midwife is unwilling to undertake a supervised practice programme the supervisor of midwives must then refer the case to the LSAMO. The midwife should understand that this will result in a referral to the NMC (Standards for the supervised practice of midwives 2007 standard 3.5)


Clinical Proficiency Assessment Criteria (adapted from Harrison 2001)

Status Level of achievement Assessment Level

No clinical experience Cannot perform this activity satisfactorily to participate within the clinical environment. 0

Student,

Maternity care assistant

Can perform this activity, but not without constant supervision, assistance and/or guidance. (Novice)

1

Student

Maternity care assistant

Can perform this activity satisfactorily, but requires some supervision and assistance and/or minimal guidance. Developing knowledge base & skills. (Advanced beginner)

2

Midwife at point of registration

Can perform this activity satisfactorily without supervision, assistance and/or guidance; with acceptable speed and quality of work with understanding and appropriate application Identify the problem, relevant information and uncertainties. (Competent and able to account for their actions)

3

Midwife (post preceptor period)

Can, independently perform this activity satisfactorily, with more than acceptable speed, quality and with initiative and adaptability to specific problems as and when they arise. Explore interpretations and connections, with junior midwives and learners, etc. (Proficient and therefore fully accountable)

4

Experienced midwife Can perform this activity satisfactorily with more than acceptable speed and quality and with initiative and adaptability. Can lead/instruct/assess other practitioners in performing this activity. Can prioritise alternatives and implement conclusions. Can explore interpretations and connections and advise/assist others to do so. (Specialist)

5

Experienced midwife with ongoing post-degree education.

Utilises Research and development activity to inform the evolution of evidence based practice. Envisions and directs strategic innovation. (Consultant, expert)

6

The NMC uses the term “standards of proficiency” to describe the skills and ability required to practise safely and effectively without the need for direct supervision.


Investigation recommendations and proficiencies from supervisory investigation report. (Please copy and paste the findings from the supervisory investigation)


Check list prior to commencement of the programmeTask Date

completedSignature

Investigation report sent to LSAMO for approval

(Standards for the supervised practice of midwives 2007 standard 3.1)

Following approval from LSAMO:

Feedback to midwife in presence of her named supervisor

RCM/ Recognised Union Representative or work place colleague may be present for support ONLY

Copy of investigation report to Registrant

Recommendation for supervised practice entered onto database

Investigation outcome summary report to Head of Midwifery

Head of Midwifery support for the programme in writing

Academic mentor identified

Clinical mentors, minimum of 2, identified

Template completed and given to midwife

Ensure that the midwife has a copy of NMC ‘The Code’ and ‘Midwives rules and standards’

Please print and give a copy of the NMC circular 32/2007 Standards for the supervised practice of midwives to the midwife

The standards can be accessed on the NMC website

http://www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=3288




Health assessmentBefore the programme commences the midwife should be assessed by Occupational Health. The Supervisor facilitating the programme should make the appropriate referral to the Trust/ Health Board Occupational Health Department (Standards for the supervised practice of midwives (2007) standard 3.2).

The programme cannot commence without occupational health clearance.

Health assessment Date

Assessed as fit to undertake the programme

Additional considerations made by Occupational Health

Everyone involved in the supervised practice programme should be aware that the health of the midwife can be re-assessed at any time during the programme, if the midwife displays signs or symptoms of health problems.

Employment issuesWhilst on supervised practice the midwife is not eligible to practise unsupervised anywhere else in the United Kingdom and must not practise as a midwife anywhere else including any work outside the LSA (this includes working as an agency midwife or on the midwifery bank) (Standards for the supervised practice of midwives 2007 standard 3.3).

If the midwife holds a nursing post elsewhere the midwife must inform her/his employer/s of the need to undertake supervised practice and the employer should liaise with the supervisor of midwives. If the midwife is self employed, they must inform their clients.

If the supervised practice programme is to take place outside the midwife’s usual place of employment a rationale for this should be discussed with the midwife, the LSAMO and the current employer and be documented.

An honorary contract, CRB and occupational health clearance is required if working in another practice setting. Discussions should take place locally relating to expenses occurred.


The role of those involved in this supervised practice programme Role of the Local Supervising Authority Midwifery Officer (LSAMO)

The LSAMO exercises the function of the Local Supervising Authority (LSA). An investigating supervisor of midwives will have investigated the incident and will have made a recommendation to the LSA for the next course of action.

The LSAMO:

Agrees the supervised practice programme (Standards for the supervised practice of midwives 2007 standard 4.3).

Provides the supervisors of midwives with support and guidance.

Explores any concerns raised by the midwife about the decision for supervised practice, the programme and the final outcome.

Signs off the programme.

Programme Lead Supervisor of Midwives

The Programme Lead Supervisor of Midwives will normally be the investigating supervisor of midwives. They will:

Plan with the midwife, named supervisor and academic mentor an individual supervised practice programme which is structured and includes objectives that are individual to the midwife concerned, are based on NMC requirements for competence and practice and are related to the incident(s) that occurred (Standards for the supervised practice of midwives 2007 standard 4.2).

Act as an advocate for the midwife on the programme in facilitating her learning needs and will be responsible for ensuring that the content of the programme will support the learning outcomes.

The supervisor of midwives will take responsibility for reviewing progress and will act as overall verifier of the programme outcomes.

Should issues arise during the programme the supervisor of midwives will assist in resolving them.

This supervisor will negotiate with the Head of Midwifery to ensure the supervised practice period and supernumerary status is supported by the Trust/ Health Board. If the midwife is recommended to work outside her/his usual Trust/ Health Board the LSAMO will be consulted to assist in that negotiation with the relevant Head of midwifery.

Facilitate review meetings.


Named supervisor of midwives

The named supervisor of midwives will provide confidential support during the programme.

The midwife may contact her to discuss in confidence, her progress and any areas of concern. The named supervisor is also responsible for retaining this supervised practice record within the midwife’s supervisory records and transferring as appropriate if the named supervisor changes. The record must be retained for 25 years and noted on the LSA database.

This supervisor should be involved in the decision making in relation to the achievement of the programme.

The named supervisor should always be present at progress meetings even if the midwife requiring this supervised practice programme chooses not to engage or utilise her as a support person. This serves as advocacy and further support.

Role of clinical mentor(s)

The clinical mentor(s) should be experienced in the area of practice relating to the programme objectives and be on the register of midwife mentors as a sign off mentor (Standards for the supervised practice of midwives 2007 standard 4.5). The clinical mentor does not have to be a supervisor of midwives. The clinical mentor(s) is/are not responsible for further mistakes or omissions made by the midwife whilst on supervised practice.

The clinical mentor(s) will:

Help to ensure that the midwife remains supernumerary for the duration of the programme, and that the midwife also can only make decisions under the supervision of a clinical practice mentor for the proficiencies identified.

Will work with the midwife at all times in the clinical environment and provide clinical advice and guidance to the midwife.

Identify learning opportunities, clinical cases, clinical forums, etc., appropriate to facilitating the learning outcomes.

Be responsible for teaching the midwife during the developmental stage of the programme and subsequently be responsible for assessing the clinical competence of the midwife against the learning outcomes set in the programme.

Provide formal and informal feedback on clinical care given by the midwife on a shift by shift basis highlighting areas of competent practice and also areas that need development in the daily diary.

Identify with the midwife any additional learning needs that become apparent during the programme and liaise with the facilitating supervisor of midwives

Inform the facilitating supervisor of midwives if any additional incidents of unsafe practice occur during the programme (Standards for the supervised practice of midwives 2007 standard 5.6).

Provide a verbal report to the facilitating supervisor of midwives at an interim point and a written report at the final review meeting. This report will provide clear evidence from the clinical perspective of where the midwife has or has not demonstrated competence.


Role of the Academic Mentor (Midwife with a Teaching Qualification)

The role of the academic mentor is to:-

Generate, with the Programme Lead Supervisor, a contract/plan of academic supervision including learning resources required, the amount of dedicated study time required, providing guidance on accessing and updating their learning skills to inform their understanding and academic ability

Mark the assessment to the determined criteria

Utilise a system of moderation to support fair judgement

Provide formative and summative feedback on the work to the midwife and programme lead supervisor throughout the programme.

Role of the Head of Midwifery (HOM)/ Director of Midwifery (DOM)

If the midwife is employed the Head/ Director of Midwifery (HOM/ DOM) needs to agree to the supervised practice programme and should be informed of the programme objectives. This is because there are planning and cost implications for the service. The HOM/DOM should be informed about the outcome of the programme.


Orientation to practice following an absence of six months or moreFollowing a period of absence of six months or more or if undertaking supervised practice in another unit, an agreed period of orientation of not less than 75 hours should precede the supervised practice programme.

During this time the midwife must be supernumerary and under direct supervision at all times.

Supervised practice programme details

The midwife must work in a supervised capacity at all times during this supervised practice programme

Throughout any supervised practice the midwife remains accountable for her actions

The period of supervised practice should not be less than 150 hours and not greater than 450 hours, not including annual leave (Standards for the supervised practice of midwives 2007 standard 4.4).

Supervised practice programmes must aim to be completed within 6 months of the programme commencing (Standards for the supervised practice of midwives 2007 standard 4.9).

For portfolio development, academic work, and attendance at study sessions, time allocated on this programme is 1 day a week pro-rota (7 ½ hours a week if full time).

A single extension of 150 hours can be made at the discretion of the LSAMO (Standards for the supervised practice of midwives 2007 standard 4.4).

This programme may be extended if there is sickness or other absence during the programme (programme extension to be agreed with the LSAMO and negotiated with the Head of Midwifery).

It is recommended that a week of annual leave is taken during the programme.


Formal review of programmeA formal review of the programme will take place regularly at the following intervals and should be attended by the midwife, the programme lead supervisor of midwives, named supervisor, academic mentor and if possible the clinical mentors (Standards or the supervised practice of midwives 2007 standard 5.3). This will be in addition to the informal meetings which will take place between the midwife, the supervisors of midwives, academic mentor and clinical mentors.

Initial meeting:

150 hour review date:

300 hour review date:

Final review date:

All of the formal meetings will have notes of the meeting taken which should be signed by the midwife. Additional meetings will be arranged as necessary.


Agreement on content and length of programme

We the undersigned agree that the content and length of programme meet with the objectives set for this supervised practice programme.

Name LSA Midwifery Officer

Signed DATE

Name Programme Lead Supervisor of Midwives

Signed DATE

Name Academic Mentor

Signed DATE

Name Named Supervisor of Midwives

Signed DATE

Midwife agreement

I agree to undertake the programme as set out within this document

Name Midwife

Signed

Date


Proficiency: AccountabilityProficiency Outcome as a practising midwife: ‘As a professional you are personally accountable for your actions and omissions in your practice and must always be able to justify your decisions’ (NMC The Code: Standards of conduct, performance and ethics for nurses and midwives 2008).

No Benchmark Statements Evidence

Clinical Level Achieved (minimum level is 3) Date

AchievedSignature of Mentor

150 hr Review

300 hr Review

450 hr End Review

1 A practising midwife is responsible for providing midwifery care to a woman and baby during the antenatal, intranatal and postnatal periods, in accordance with such standards as the NMC may specify from time to time. Therefore a midwife must be familiar with:

The NMC The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC 2008).

The NMC Midwives rules and standards (NMC 2004).

Documented discussion and structured questioning with named supervisor.

Demonstrate understanding in reflective essay.

Testimony of mentors.

Undertake a presentation to named supervisor and mentors of the key points in these 2 documents.

2 You are accountable for your own practice and you cannot have that accountability taken from you by another registered practitioner, nor can you give that accountability to another registered practitioner.

Neither you nor your employing authority should arrange for anyone to act as a

Attend NMC Fitness to practice hearing.

Write a reflection on the visit.






150 hr Review

300 hr Review

450 hr End Review

substitute for you other than another practising midwife or a registered medical practitioner.

If you are supervising a student, you remain professionally accountable for what they do, including the consequences of their actions and omissions. (Rule 6, Midwives Rules and Standards (NMC, 2004).


Testimony of other professionals.

Attend a mentor update session.

3 A midwife must be able to clearly differentiate between the meaning of accountability towards:

women and their families in their care

their employer

the NMC

themselves

working within a legal framework



4 The midwife must always be able to justify actions taken.

Documented discussion and structured





150 hr Review

300 hr Review

450 hr End Review

questioning with named supervisor.




Evidence of justification of actions taken, by including 5 anonymised copies of care records.

5 Where possible the decisions made by the midwife must be evidence based.



Undertake the review of an existing guideline and benchmark against National guidance and if necessary update applying new research findings relevant to the guideline.

Provide copies of 5 sets of anonymised records





150 hr Review

300 hr Review

450 hr End Review

demonstrating evidenced based practice.

6 Ensure that women are given every opportunity to give informed consent of their own free will.

Evidence of facilitating informed consent by including 5 anonymised copies of care records.








150 hr Review

300 hr Review

450 hr End Review

7 The midwife must always be able to demonstrate on-going education and practice experience (fulfilling PREP requirements) to maintain accountability.

Midwife must state identified learning needs and develop action plans to achieve required learning outcomes.

Documented discussion and structured questioning relating to PREP with named supervisor.

Present an individual learning plan to named supervisor detailing learning needs and action plans on how these will be achieved for the next year.

If Evidence, for example a study day, or attendance at a particular activity has not yet happened by either the 150 or 300 hour review please enter NYF (Not Yet Facilitated). At each of these reviews, if particular activities have not yet been facilitated , reassurance will be sought that, for example dates, times, venues, etc,, have been arranged to ensure evidence is completed and in place for the final 450 hour end review. At the final 450 hour review, if level 3 is not achieved, reasons for the failure must be clearly evidenced to justify the failure of the supervised practice programme.

The named supervisor can provide all the information in one document if appropriate.

You may use the same five sets of records if they provide all the evidence required

You are only expected to prepare one presentation for student midwives ensuring that all areas identified are covered


Proficiency: Effective CommunicationProficiency Outcome: The practitioner must be effective in communicating appropriately to optimise the outcomes for mothers, babies and their families under her care.



Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

1 Be able to define normality and be competent to work within the sphere of practice as defined within the Midwives Rules and The Code of Conduct (NMC, 2008).


Demonstrate understanding in reflective work.





Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

2 Be able to recognise deviation from normal and /or when the mother’s needs fall outside the scope of midwifery practice and make appropriate referral to a practitioner best deemed to deal with the situation with the appropriate skills and knowledge.

Demonstrate to mentors how to use an obstetric early warning system to aid referral to an appropriate practitioner.

Testimony of mentor and other professionals.

Evidence of justification of referrals made by including 5 anonymised copies of care records.

Attend unit update days.

3 Be familiar with Trust’s/ Health Board’s procedures, protocols, guidelines and proficiencies pertaining to the need for referral when the clinical need arises.

Include copies of these with a summary of main points for each document.



Evidence of justification of referrals made by including 5 anonymised




Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

copies of care records.

4 Recognise the working of the multi-professional team and contribute to care within the framework of care delivery.

Documented observation by mentors in daily diary.

Evidence of multi-professional team care planning by including 5 anonymised copies of care records.

Demonstrate ability to do this in reflective work.

Attend 2 multi-professional meetings.

5 Team working in the best interests of individual women.

Testimony of mentor.

6 Communicate with women throughout their pregnancy, labour and the period following birth.

Documented observation by mentors.


Testimony of others.




Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

Evidence of multi-professional team care planning by including 5 anonymised copies of care records.

7 1 Listen to women, jointly identifying their feelings and anxieties about their pregnancies, the birth and the related changes to themselves and their lives within the context of their culture and personal beliefs.

2 Enable women to think through their feelings and make informed choices, based on the best available evidence about their own health, the health of their babies and families, and how they can be improved.

3 Document discussions within notes, thus enabling planning of needs to be understood by all professionals contributing to care.

4 Continue to communicate and provide support to women when their pregnancies are in difficulty.

Documented observation by mentors.


8 Be able to discuss and/or negotiate with other professionals about further interventions which are appropriate for

Through discussion and structured questioning by named supervisor.




Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

individual women, considering their wishes, context and culture.

Documented observation by mentors and named supervisor.



9 Draw on the skills of others to optimise health outcomes and resource use.





10 Consistently document accurately and legibly full details behind the reasoning of all actions taken and referrals made.

Evidence of referral to multi-professional team and reasons for doing so by including anonymised copies of care records.

11 Ensure the confidentiality and security of written and verbal information acquired

Documented discussion with named supervisor




Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

within professional capacity. on the NMC standards for record keeping. Midwife to present key points.

12 Disclose information about individuals and organisations only to those who have a right and need to know it once proof of identity and right to disclosure has been obtained.

Documented discussion with named supervisor on the NMC standards for confidentiality. Midwife to present key points.

13 Be able to represent the midwife’s own considered views and experiences within the context of broader health and social care policies in the interests of women, babies and their families.





14 Make effective use of the framework for statutory supervision of midwives.

Documented discussion with named supervisor.

Testimony of named supervisor.




Achieved

Signature of Mentor

150 hr Review

300 hr Review

450 hr End Review

15 Gain feedback from women, their families, colleagues and other professionals and appropriately applying this to practice.

Documented observation by named supervisor and mentors.

16 Keep up to date with evidence and apply evidence to practice and alert others to the evidence to apply to their own practice.

Undertake the review of an existing guideline and benchmark against national guidance if necessary update applying new research findings relevant to the guideline.






Proficiency: Administration and Care of women in labour with an epidural.Proficiency Outcomes: The practitioner will be able to care for a woman safely and competently with an epidural for the management of pain relief in labour




150 hr Review

300 hr Review

450 hr End Review

1 Discuss Trust/ Health Board policies and procedures relating to epidural.

Discussion with mentor.

2 Attend relevant training session. Provide evidence of attendance.

Assessment of competency against a Trust/ Health Board approved proficiency document.

3 Have knowledge of the anatomy of the spinal column and neurological tissues and be able to describe the principles of epidural anaesthesia.


Include in reflective essay.

4 Identify rationale for epidural anaesthetic in relation to individual patient circumstances such as maternal request.

Mentor to witness interaction and discussion with women on at least 5 occasions.

Provide 5 anonymised case records for portfolio.





150 hr Review

300 hr Review

450 hr End Review


5 Explain procedure and rationale to the woman demonstrating awareness of the need for gaining her informed consent.

Demonstrate in clinical practice.

Provide 5 anonymised case records for portfolio.


6 Be able to inform the anaesthetist of the need for epidural and be able to describe individual details relating specifically to each case.



7 Be aware of the clinical situations in which an epidural anaesthetic is not appropriate or the situations where specific screening is required prior to its setting up.



8 Be able to assemble the necessary equipment and items to carry out the procedure including intravenous fluid administration.

Demonstrate in clinical practice on at least 5 occasions.

9 Be able to correctly and comfortably position the woman and assist the anaesthetist in the insertion of the epidural cannulae.






150 hr Review

300 hr Review

450 hr End Review

10 Assist the anaesthetist to ensure that the epidural cannula is secured safely with the appropriate material according to the woman’s need.


11 Maintain asepsis throughout the whole procedure and be able to dispose of used equipment in a safe and appropriate way.

Discuss Trust/ Health Board policy with mentor for:

Disposal of sharps.

Sharps injuries.


12.1

12.1 Have an in-depth knowledge of the drugs administered via the epidural catheter, including dosage, action and side effects.

12.2 Be able to follow the anaesthetist’s prescription instructions and query any problems as appropriate.

Attendance at an epidural update.

Demonstrate a working knowledge of local policy including the Medicines policy.


Demonstrate knowledge of emergency procedures and use of resuscitation equipment.





150 hr Review

300 hr Review

450 hr End Review


13 Maintain dignity and privacy of the woman before, during and after procedure

Demonstration in clinical practice on at least 5 occasions.

14 14.1 Be able to monitor the woman appropriately and record all observations and actions accordingly

14.2 Maintain accurate records and document any actions / concerns as appropriate.

Demonstrate knowledge to mentor of Trust/ Health Board guidance

Discuss recognition of a deviation from the normal with mentor

Describe appropriate action/ referral

Demonstrate in practice by maintaining accurate and contemporaneous records.

Case note review (5 sets of own records)

15 15.1 Provide a plan of care for the woman having an epidural anaesthetic, including a record of observations.

15.2 Assess the pressure areas, record findings, evaluate and modify care as

Demonstrate in practice by maintaining accurate and contemporaneous records.

Case note review (5





150 hr Review

300 hr Review

450 hr End Review

required. sets of own records).

16 Recognise possible side effects and instigate correct interventions as appropriate.

Be able to identify to mentor signs of side effects to mother and baby.

Be able to take timely and appropriate action/referral.

Discussion with mentor and record in daily diary.






Proficiency: Neonatal ResuscitationProficiency Outcome: The practitioner will be competent to perform evaluation and initial resuscitation of the newborn infant.




150 hr Review

300 hr Review

450 hr End Review

1 Discuss Trust/ Health Board guidelines relating to neonatal resuscitation.

Discuss in reflective essay local Trust/ Health Board guideline on neonatal resuscitation.

Compare this with guidance from Resuscitation Council and discuss in reflective essay.

2 Midwives must be fully aware of the implications on practice as defined by the rules set out in the NMC's Midwives rules and standards (2004) and The Code (NMC 2008).

Discuss within reflective essay.

Discussion with named supervisor of midwives.

3 Have an awareness of predisposing factors, which may identify babies needing active resuscitation.

Prepare a short presentation for senior student midwives ensuring that these issues are covered.






150 hr Review

300 hr Review

450 hr End Review

4 Be able to check and ensure the resuscitaire is clean, stocked and in full working order.

Provide evidence of Trust/ Health Board guidance on daily maintenance of resuscitaire.

Evidence that this has been completed successfully on ten occasions.

5 Be able to identify babies needing active resuscitation.

Demonstrate from five sets of records assessment.

Discuss within daily journal evidence of five babies where resuscitation was anticipated (if possible).


6 6.1 Be able to correctly position the head to maximize air entry.

6.2 Know the rate and pressures required for effective inflation breaths and ventilation breaths.

6.3 Be able to recognize successful lung inflation and the action to take if unsuccessful.

Working with Practice Development Midwife/ Labour Ward Coordinator/Advanced Neonatal Practitioner undertakes at least five ‘mock’ resuscitations and Senior Practitioner write a testimony to your





150 hr Review

300 hr Review

450 hr End Review

6.4 Be able to confirm heart rate by a recognized method and what action is required.

6.5 Be able to perform effective chest compressions when appropriate.

6.6 Be aware of the drugs required for resuscitation including doses and where they can be found.

proficiency.

Attend an in house training session on neonatal resuscitation.

7 Demonstrate clear evidence that assessment and planned care is discussed with the mother and documented within the records.

Demonstrate from five sets of records.

Discussion with mentor

8 Maintain accurate records and document any actions taken as appropriate.

Provide evidence from at least five sets of records.

Review of records with mentor.






Proficiency: The use and interpretation of Cardiotocograph (CTG).Proficiency Outcome: The practitioner must be able to identify the relevant clinical situations in which to record a CTG. The practitioner must be able to appropriately and correctly apply the CTG equipment. Be able to interpret and document their findings and make referrals to the appropriate practitioner when findings are abnormal and/or difficult to interpret.




150 hr Review

300 hr Review

450 hr End Review

1 1.1 Practitioners must be fully aware of the implications for practice as defined by the rules set out in the NMC guidance.

1.2 Practitioners must be familiar with all Trust/ Health Board protocols and procedures relating to CTG recording and interpretation.

Discussion with Supervisor of Midwives.

Demonstrate knowledge on local fetal monitoring guidelines and under pinning NICE guidance.

Demonstrate knowledge of any related guidelines.

Prepare a short presentation for student midwives relating to use of CTG and link to NICE guidance.

2 Practitioners must have knowledge of the anatomy and physiology of the fetal and placental cardiovascular circulation and be able to relate this to the observable components of the CTG.

Evidence of completion of K2 CTG training package or equivalent.


Include as part of presentation.





150 hr Review

300 hr Review

450 hr End Review

3 Practitioners must be adequately trained to set up and use the CTG machine.

Demonstrate knowledge of the use of CTG machines within the unit to include:

Cleaning and storageLoading of paperChanging settings e.g. time clock

4 Practitioners must be able to define clinical situations both antenatally and during the intrapartum periods when the use of CTG recording is required.


Demonstrate in practice.

Include as part of presentation.

5 5.1 Practitioners must know how to label the CTG appropriately.

5.2 Practitioners must be able to perform an abdominal palpation and record their findings including auscultation of the fetal heart rate prior to the application of the CTG.

5.3 Practitioners must be able to explain the rationale for regularly recording maternal pulse and verification of the fetal heart rate by auscultation upon the CTG tracing contemporaneously.



Review of 10 sets of case notes including CTG with mentor.





150 hr Review

300 hr Review

450 hr End Review

6 Practitioners must be able to clearly define and accurately record the parameters of the observable components of the CTG that enable an assessment of normality to be obtained.

Demonstrate the use of recognised antenatal and labour categorisations.



Review of 10 sets of case notes including CTG using a recognised framework.

- e.g. DR C BRAVADO

- NICE7 Practitioners must be able to recognise any

deviation from normal, record their actions and to whom they have referred the CTG for further assessment.



Discuss referral process with mentor.

8 Practitioners must explain the rationale of documenting all external influences and/or interventions that may affect the CTG, or enact a change in the parameters observed upon the trace as they occur contemporaneously.



Discuss referral process with mentor.





150 hr Review

300 hr Review

450 hr End Review

9 Practitioners must be able to verify the strength of contractions through abdominal assessment as the CTG can only show the frequency and length of contractions. This is of particular importance in the use of syntocinon to induce/augment uterine contractions.

Demonstration in practice.







Proficiency: Documentation and Record Keeping Proficiency Outcome: The practitioner must be able to document an accurate, contemporaneous and detailed record of all their actions relating to all aspects of care delivery.




150 hr Review

300 hr Review

450 hr End Review

1 1 Can demonstrate the ability to recognise accurate record keeping as required by Record keeping: Guidance for nurses and midwives (NMC 2009).

2 Can demonstrate knowledge of the Data Protection Act 1998 and the application of health records and understands the implications and actions arising from them.

Discussion with named Supervisor.

Demonstrate knowledge of NMC guidance Record keeping: Guidance for nurses and midwives in reflective essay.

2 Can identify rationale for maintaining accurate records.



3 3.1 Can identify and produce evidence of records that show all key entries required

date timed using 24hr clock signed (name printed) designation untrained entries are countersigned

Complete an audit of case notes using recognised Trust/ Health Board audit tool

5 sets containing own records5 sets of randomly selected completed





150 hr Review

300 hr Review

450 hr End Review

able to photocopy alterations – dated, signed, single cross

through allergies marked and recorded3.2 Can identify and produce evidence

that all documentation has all identifiers of the patient:

name date of birth hospital number ward

3.3 Can produce evidence of records that are factual, accurate and detailed information on the care, treatment and condition of the mother and/or baby.

3.4 Can demonstrate a working knowledge of local abbreviations that have been approved for use within their speciality.

3.5 The practitioner can produce a full record of assessment, planning and action required to address identified problems.

3.6 Can demonstrate clear evidence that assessment and planned care is discussed with the mother and documented within the records.

case notes Discuss audit findings

with mentor and write a short report.

Produce a short presentation to demonstrate knowledge about the importance of accurate documentation and record keeping.

Provide 5 sets of your anonymised case records demonstrating a high standard of record keeping.





150 hr Review

300 hr Review

450 hr End Review

3.7 Can demonstrate how to document omissions or errors in the provision of planned care.

4 Can demonstrate an understanding of why any deviations from guidelines should be documented including why and who has authorised such changes.

Discuss reasons and give examples of why this may happen.

Demonstrate knowledge of the local agreements and process.






Proficiency: The use of intravenous syntocinon in labour to initiate or augment uterine contractions.Proficiency outcome: The practitioner demonstrates that they are proficient to care for women with a syntocinon infusion.

Practitioners must be familiar and competent in the following defined proficiencies:

Intravenous drug administration

Effective communication

Documentation and record keeping

The use and interpretation of the cardiotocograph (CTG)


Clinical Level Achieved (minimum level is 3) * Date

AchievedSignature of Mentor150 hr

Review300 hr Review

450 hr End Review

1 Practitioners must have knowledge of uterine anatomy and physiology and the pharmacology of the action of syntocinon.

Discuss the pharmacological action of syntocinon with mentor.

Within essay include information on normal uterine anatomy and physiology and the action of syntocinon.

2 Midwives must be fully aware of the implications on practice as defined by the rules set out in the NMC's Midwives rules and code of practice.

Discuss within reflective essay.

Discussion with your named supervisor of midwives.





Review300 hr Review

450 hr End Review

3 Practitioners must be familiar with all Trust/ Health Board guidelines and procedures relating to the use of syntocinon in the initiation and augmentation of uterine contractions.

Provide evidence of Trust/ Health Board guideline on syntocinon use.

Bench mark this against NICE guidance.


4 Practitioners must be able to define clinical situations and changes within the clinical situation in the intrapartum period when the use of syntocinon is indicated.

Provide evidence from the case notes of five women you have cared for which demonstrates why syntocinon was used during labour.


5 Be able to explain the process to the woman including possible side effects to enable woman‘s consent to be given with understanding.

Demonstrated in practice.

Provide evidence from the case notes of five women you have cared for which demonstrate evidence of the discussion and involvement of the woman.

6 Practitioners must be able to appropriately prepare and use the correct equipment for

Provide evidence of five occasions where infusion





Review300 hr Review

450 hr End Review

the administration of syntocinon. has been commenced.

Discuss with mentor importance of accurate preparation and administration and document this within daily journal.

7 Prior to the administration of syntocinon the fetal condition must be assessed by the use of CTG. This must be continued until birth of the baby is achieved.


Provide evidence from five sets of women’s records of use of CTG and syntocinon infusion.

8 Practitioners must be able to define the different guideline parameters used for the initiation and augmentation of uterine contractions in primiparous and multiparous women and women undergoing a vaginal birth after caesarean section.

Discuss with mentor.


9 Practitioners must be able to describe and recognize the side effects and complications of the use of syntocinon to initiate and augment uterine contractions


Prepare a short presentation for senior





Review300 hr Review

450 hr End Review

and act appropriately. student midwives ensuring that these issues are covered.

10 Practitioners must be able to recognize when the optimal use of Syntocinon is achieved and act appropriately to ensure this continues.

Provide evidence from five sets of women’s records to demonstrate this.


11 Practitioners must be able to explain the rationale for the use of the partogram whilst syntocinon is being used during labour. The importance of accurate fluid balance recording must also be demonstrated.

Provide evidence from five sets of clients’ case notes.


12 Practitioners must be able to verify the strength of contractions through abdominal assessment as the CTG can only show the frequency and length of contractions. This is of particular importance in the use of syntocinon to initiate and augment uterine contractions.


Provide evidence from five sets of women’s records.






Review300 hr Review

450 hr End Review

13 Administration of syntocinon must be clearly documented in the records, with commencement, changes in dosage clearly recorded on CTG and partogram.


Provide evidence from five sets of women’s records.







Proficiency: Medicines managementProficiency Outcome: The practitioner will be able to select, acquire and administer safely, a range of permitted drugs consistent with legislation, applying knowledge and skills to the situation which pertain at the time.




Review300 hr Review

450 hr End Review

1 Can demonstrate a working knowledge of Trusts/ Health Boards & NMC medicine policies and procedures.


Ensure has a copy of NMC guidelines for administration of medicines.

Demonstrate knowledge of NMC guidelines for administration of medicines in reflective essay.

Observation when undertaking 6 medicine rounds.

Access and discuss Trust/ Health Board guidelines with mentor.

2 2.1 Be able to identify the correct woman/baby for which medication is prescribed (ID band and verbal check, or case of baby, administration with maternal consent).

Be observed undertaking the medicine round with mentor x 6 occasions.

Write a short reflection on the 6 medicine rounds.





Review300 hr Review

450 hr End Review

2.2 Read the individual’s drug chart correctly (mother/baby’s details, including hospital number and weight).

2.3 Check individual for sensitivities/ allergies, and post drug incompatibilities/ interactions.

2.4 Can discuss the reason(s) why the woman/baby is prescribed the drug(s)

2.5 Can state the correct dosage range for all drugs administered

2.6 Can explain the possible side effects of drugs administered.

2.7 Initiate correct actions in the event of an individual experiencing a drug reaction

2.8 Be able to demonstrate that consent for administrations is gained.

2.9 Prepare medicines appropriately (timing, route and dosage).

2.10 Demonstrate the ability to give appropriate information to the woman regarding all aspects of drugs, such as action, side effects

Undertake correct documentation regarding drug administration.

Discussion with mentor showing an understanding.





Review300 hr Review

450 hr End Review

and specific care planning relating to the drug i.e. avoiding constipation

2.11 Correctly demonstrate accurate record keeping in relation to all aspects of drug administration.

2.12 Take appropriate actions if prescription is not correct/clear/accurate

3 Demonstrate appropriate action taken in the event of a drug error.

Discuss with your mentor the actions to be taken in the event of discovering a drug error.

4 Can state what constitutes a drug error Demonstrate an understanding of the policy relating to drug errors by discussion with your mentor.

5 5.1 Can discuss the pharmacist’s role within the ward setting.

5.2 Can explain how to order all drug types and how to obtain drugs ‘out-of-hours’.

5.3 Can explain how to order all drug types and how to obtain drugs ‘out-of-hours’.


Find out the local process for ordering drugs including out of hours.

Find out the process of ordering controlled drugs.

Demonstrate knowledge





Review300 hr Review

450 hr End Review

5.4 Aware of Patient Group Directions (PGDs) and what may be administered under these directions.

of local PGD through discussion with mentor.

Meet with ward pharmacist to discuss their role.

6 Can demonstrate knowledge and application of drugs that a midwife can legally supply and/or administer under midwives exemptions.

Read the Medicines Act 1968 relating to midwives exemptions.

Discuss the drugs that a midwife can legally supply and/or administer under midwives exemptions.

7 7.1 Can state how to assess the woman’s competence for self-administration of medication and/or the administration of medicines to her baby.

7.2 Demonstrate knowledge and application regarding drug use in the antenatal, intrapartum and postnatal period including affects on breast-feeding.

Write a short article considering the implications of medicines for a woman during her pregnancy, labour and postnatal period. Highlight the most common drugs that are contraindicated if the woman is breastfeeding.





Review300 hr Review

450 hr End Review

Discuss self administration of drugs for a mother and her baby with the woman in the presence of your mentor.






Proficiency: Professional BehaviourProficiency Outcome: The midwife will be competent to practise to the standard of professional conduct required of them in the exercise of their professional accountability and practice. (NMC 2004)


Clinical Level Achieved (minimum level is 3 Date


150 hr Review

300 hr Review

450 hr End Review

1 To demonstrate an understanding of the content of the Code: Standards of conduct, performance and ethics for nurses and midwives (NMC 2008) Midwives rules and standards (NMC 2004)



Undertake a presentation to named supervisor and a student midwife demonstrating the key points in these 2 documents.

2 Practise in accordance with The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC 2008), within limitations of the individual’s own competence, knowledge and sphere of professional practice, consistent with the legislation relating to midwifery practice.

Documented observation by mentors in diary.

Midwife must state identified learning needs and develop action plans to achieve required learning outcomes.






150 hr Review

300 hr Review

450 hr End Review

3 Be aware of the processes involved in consulting other healthcare professionals when the woman and baby’s needs fall outside the scope of midwifery practice (refer to proficiency on effective communication).



Evidence of referrals by including 5 anonymised copies of care records.


4 Work collaboratively with other practitioners and agencies in ways which enable them to participate effectively in the care of woman, babies and their families. For example child protection.

Testimony of other healthcare professionals.



5 Practise in accordance with relevant legislation. This will include demonstrating knowledge of legislation relating to human rights, equal opportunities and access to patient records.


Review of local, regional and national legislation and guidelines.





150 hr Review

300 hr Review

450 hr End Review

6 Maintain confidentiality of information. This will include ensuring the confidentiality and security of written and verbal information acquired in a professional capacity.



7 Practise in a way which respects, promotes and supports individual rights, interests, preferences, beliefs and cultures.





8 Support the creation and maintenance of environments that promote the health, safety and wellbeing of women, babies and other family members.

Demonstrate an understanding of health and safety legislation through discussion and structured questioning by named supervisor.






150 hr Review

300 hr Review

450 hr End Review

9 Provide seamless care and, where appropriate, interventions in partnership with woman and other care providers during the antenatal, intrapartum and postnatal periods.

Through discussion and structured questioning by named supervisor

Demonstrate an understanding of reviewing previous history.

Undertake further assessment of needs.

Care planning and referral.

Evaluate care.

Keep women informed, facilitating choice, gaining consent and keeping them updated on progress.



10 Be able to plan and provide appropriate care for women during the intrapartum period demonstrating the ability to identify and manage appropriately any risks

Demonstrate an understanding of intrapartum care through discussion and structured questioning by named supervisor.

Documented observation





150 hr Review

300 hr Review

450 hr End Review

by mentors in diary.




11 Be able to demonstrate the ability to work as a team member:

supporting junior midwives and care assistants

communicating effectively with shift coordinators, the medical team, health visitors, specialist practitioners, physiotherapists, social workers, etc.




Testimony of others

12 Demonstrate the ability to handle situations in a professional and confidential manner.








150 hr Review

300 hr Review

450 hr End Review


13 Be able to manage and prioritise demands and workload.




Testimony of others

14 Demonstrate a positive attitude and remain calm under pressure.



Testimony of others

15 Be able to communicate in a professional manner at all times, using appropriate language.





Proficiency: Demonstrate the ability to provide intrapartum care for a woman with a previous history of caesarean section (LSCS).

Proficiency Outcome: The practitioner must be able to care for a woman who has chosen to undergo Vaginal Birth after Caesarean Section (VBAC) safely and effectively.




150 hr Review

300 hr Review

450 hr End Review

1 Understand and follow the Trust/ Health Board’s guideline on VBAC.


Reflection on situation resulting in need for supervised practice.

Review evidence used to support guideline.

Attend high risk antenatal clinic and reflect on session.

2 .Be able to plan care on an individual basis within the multi-disciplinary team.

Consider care for a woman for when VBAC is not advisable but the woman expresses a wish for VBAC despite the risks discussed.

Record keeping from episode of care of a women with VBAC (please anonymise).


Reflection on discussions with mothers.





150 hr Review

300 hr Review

450 hr End Review

3 Understand the risks associated with VBAC for both the mother and baby.

Record keeping from episode of care of a women with VBAC (please anonymise).



Attend LSCS review meeting.

4 Recognise and be able to respond appropriately to the complications associated with VBAC

Record keeping from episode of care of a women with VBAC (please anonymise.



Attend LSCS review meeting.


Proficiency: Be able to recognise acute maternal physical deterioration and make the appropriate interventions and referrals.Proficiency Outcome: The practitioner must be able to recognise acute physical deterioration in a woman and act appropriately.




150 hr Review

300 hr review

450 hr End Review

1 Attend ALERT course. Place booked for ……

Discussion with named Supervisor (SOM).

Reflection on learning and how this will be incorporated into your practice.

2 Be able to undertake all physical observations effectively.

Observation and discussion with mentor/SOM.

3 1 Be able to document all observations accurately

2 Be able to use the MEOWS chart as a means of assessment

Examples of charts used, care plans and records (please anonymise).

4 Be able to refer appropriately and in timely manner to any sudden physical deterioration.


Discussion with named SOM.





150 hr Review

300 hr review

450 hr End Review


Record in daily dairy.

5 Be able to care for women with complex obstetric and/or medical conditions as per Trust/ Health Board guidelines.




6 Review the latest “Saving Mothers’ Lives” report.


Reflection on learning and how this will be incorporated into your practice.






Agreement on conclusion of the programmePlease complete the names and print out this page before the final meeting to allow all parties to sign the agreed plan

We the undersigned agree to the conclusion of this supervised practice programme.

Signed DATE

Name Programme Lead Supervisor of Midwives

Signed DATE

Name Academic Mentor

Signed DATE

Name Named Supervisor of Midwives

Signed DATE

Name LSA Midwifery Officer

Midwife

I have been notified of the outcome of the programme as set out within this document

Signed DATE

Name Midwife


Appendix oneSources of Benchmark statements

Midwives Rules and Standards (NMC 2004)

The Code: Standards of conduct, performance and ethics for nurses and midwives (2008)

Standards for medicines management (NMC 2008)

Records keeping: Guidance for nurses and midwives (NMC 2009)

Midwifery standards of proficiency

(Adapted from Standards of Proficiency for Pre-Registration Midwifery Education (NMC 2009)

The NMC uses the term standards of proficiency to describe the skills and ability to practice safely and effectively without the need for direct supervision.

References

Clinical Proficiency Assessment Criteria adapted from:

Harrison, A. (2001) Competence is the key to safe supervision and delegation, The pharmaceutical journal (267) pp 89-91


Appendix Two - Example


Appendix Three - Example


Reading log Consider these questions:

Why did you read these particular articles?

How do they relate to your learning needs?

Were they interesting or useful?

What criticisms would you make of them?

For relevant articles please write a report on how they have enabled you to meet this objective and cross reference to the relevant benchmarking statement.

Title of Article/ Book. Author(s) Name of Journal or Publisher.

Date/ volume number.

Comments. Discussion with Supervisor.

Date / Signatures


Title of Article/ Book. Author(s) Name of Journal or Publisher.

Date/ volume number.

Comments. Discussion with Supervisor.

Date / Signatures


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