Memorandum by the Nursing & Midwifery
Council (PS 58)
The Nursing & Midwifery Council (NMC) is
the UK regulator for two professions, nursing and midwifery. The
primary purpose of the NMC is protection of the public. It does
this through maintaining a register of all nurses, midwives and
specialist community public health nurses eligible to practise
within the UK and by setting standards for their education, training
and conduct. Nurses and midwives, of which there are currently
around 674,000 registered with the NMC, renew their registration
every three years.
It may be helpful to set out the regulation
that the NMC, the largest regulator on the delivery of healthcare
in the UK works to in the role of safeguarding the public. The
responsibilities of the NMC are set out in the Nursing and Midwifery
Order (2001) and include:
Maintaining a register of nurses
Consulting on and setting standards
for education, ethics and conduct
Giving advice to registrants, employers
and the public
Dealing with allegations of unfitness
to practise, lack of competence and ill health
Setting the standard for the function
of the Local Supervising authorities and the supervision of midwives
Quality assurance of the Local Supervising
The NMC has also worked and continues to work
closely with other health regulators on matters such as the recommendations
arising from the Shipman Inquiry and the programme of regulatory
reform set out within the White Paper Trust, Assurance and
Safetythe Regulation of Health Professionals in the 21st
As our response is related to the regulatory
responsibilities that we are charged with we would like to offer
the following comments:
1. All nurses & midwives are benchmarked
to the standards set out within the Code. If registrants
fail to comply with the standards, their registration may be at
risk in order to safeguard the public. The NMC recognises that
patient safety is everybody's business and by clearly stating
within the Code that nurses and midwives "make the care of
people your first concern" we are ensuring that this places
patients at the centre of healthcare being delivered across all
environments of care. The Code serves to increase individual's
mindfulness of the professional requirements placed upon them
to make patient care safer. It aims to demonstrate patient &
public safety by highlighting the contributory factors for reducing
risk and increasing safety, for example, good communication, team
working, education and training and working conditions.
2. The Code clarifies the responsibility
of nurses and midwives to alert someone in authority regarding
any concerns about their working environment. There are shared
responsibilities in providing care which do not always fall on
individual professionals. In these circumstances, nurses and midwives
have a duty to ensure that those in positions of authority are
aware of any issues which have an impact on the ability of a nurse
or midwife to provide safe and effective care and/or in which
patient safety could be compromised.
3. The NMC considers seriously all complaints
made about registrants and all allegations are investigated thoroughly
and fairly. Most complaints about nurses and midwives can and
should be resolved locally, where the care was given or the incident
happened. However, if the problem is so serious that the nurse
or midwife may not be safe to care for patients, the NMC needs
to know about it. NMC guidance for both the public and employers
sets out the process to progress this.
4. The aim of all the NMC's standards, including
the Code, is to improve how care is provided in all environments
whether directly or indirectly. The Code sets out the core principles
and values that nurses and midwives must work with to ensure safe
and effective practise is carried out within their level of competency.
The use of the phrase "you must" within the Code makes
this responsibility clear, reminding nurses and midwives that
the care of patients is their first concern. However, the Code
by itself cannot prevent poor practise from ever occurring. For
professional self-regulation to work effectively requires nurses,
midwives, employers and the NMC to work together in partnership.
All the NMC Standards can be accessed via our
website at: http://www.nmc-uk.org/.
5. The NMC reviews and maintains standards
of nursing and midwifery education for practice and post-qualifying
programmes ensuring that students can demonstrate their fitness
for practice prior to entry to the register.
6. In 2005/6 the NMC worked with key stakeholders
to produce Good Health and Good Character Guidance (The Guidance)
accessible to students and registered nurses and midwives
but in particular for use by programme providers, (Universities
and placement providers). The public can raise fitness
to practise issues regarding students but with the universities
and placement providers and not the NMC as we have no fitness
to practise regulatory function with students. This was published
on the NMC website and updated in 2008 and refers in particular
to nursing and midwifery programmes leading to NMC registration.
Whilst the Guidance refers to both good health and good character,
consideration is being given to removing the health requirement,
along with other health regulators. This follows concerns raised
following the 2007 DRC inquiry which looked at how equality duties
were being addressed in nursing, teaching and social work.
7. Nursing and midwifery are self-regulating
professions. A significant aspect of self-regulation is the moral
understanding of knowing what is right or what is important (DH
All registrants are required to abide by the NMC rules, standards
and The Code (NMC 2008). Pre-registration students are
expected to work towards being able to apply the Code at the point
of registration. An important determinant of good character is
the individual's commitment to, and compliance with, the Code.
8. Good character is important as nurses
and midwives must be honest and trustworthy (NMC, 2004). Good
character is based on a person's conduct, behaviour and attitude,
as well as any conviction and cautions that are not considered
compatible with professional registration and that might bring
the profession into disrepute. A person's character must be sufficiently
good for them to be capable of safe and effective practice without
supervision. As an outcome of the White Paper Trust Assurance
and Safety the NMC is also taking forward this year work on
student engagement which draws on previous work on student values
and people skills. It aims to increase professional identity and
awareness of the role of regulation and public protection at an
early stage of their career.
9. NMC guidance requires that all applicants
must be considered as individuals and programme providers should
assess each of them to decide what the effect a conviction or
cautions might have on the person's ability to meet the NMC requirements
for entry to a programme leading to registration. If an applicant
has a conviction or caution, the relevance, seriousness and circumstances
in which the offence was committed must be taken into account.
10. The Universities Central Admission Service
(UCAS) or CATCH (Scotland) will request references as part of
the application process. A Criminal Records Bureau (CRB) or Disclosure
Scotland check will also be done because students may be working
unsupervised with vulnerable client groups. Programme providers
should check that all selected applicants are not named on any
lists of those barred from working with children (POCA) or vulnerable
adults (POVA) and List 99. They should also check applicants'
identity and any change of name by checking passports or other
relevant formal documents that include photographic identify.
11. Applicants should be reminded that if
they are offered a place it is their responsibility to notify
the university if their character status changes in the time between
the offer being made and beginning the programme. As a student
progresses on the programme they are required to inform the programme
provider of any pending charges, and resulting cautions or convictions.
The NMC requires education providers to have in place local Fitness
to practise panels to consider such cases and determine whether
the student should continue on their programme. The panel should
have representation from education and service partners. Depending
on the programme under consideration, there should be a nurse,
midwife or specialist community public health nurse representative.
The midwife representative should be a supervisor of midwives.
Additional nurse representatives should be co-opted to make sure
that there is representation from the same field of practice as
the student, such as from adult, children's, mental health or
learning disability nursing
12. Essential Skills Clusters (ESCs) There
are profession specific ESCs for nursing and midwifery as their
roles, responsibilities and client group needs are different.
In nursing there are UK-wide generic skills statements set out
under broad headings that identify skills to support the achievement
of the existing NMC outcomes for entry to the branch, and the
proficiencies for entry to the register. They aim to provide clarity
of expectation for the public and profession alike and seek to
address concerns about potential skill deficits. ESCs must be
incorporated into pre-registration nursing programmes for all
new students commencing from September 2008.
13. Review of pre-registration nursing education-
A new framework for pre-registration nursing education is to be
developed with a view to ensuring that the new nurse of tomorrow
is able to work safely and effectively to meet the needs of the
people in their care as the delivery of healthcare services continues
14. At the Nursing and Midwifery Council
(NMC) meeting on 4th September 2008, Council members agreed to
a set of principles that will form a new framework for pre-registration
nursing education. The principles were developed following a three-month
consultation in which over 3000 nurses, members of the public
and stakeholder organisations took part. The consultation asked
what nursing education should look like in the future, explored
whether nurses should be generalists or specialists, if they should
be graduates, and how much of their training should be conducted
in the community. It also looked at how new nurses should be supported
after they first qualify. Feedback from major stakeholders, including
professional bodies and unions, as well as recent developments
in UK health policy and other inter-related work within the NMC
was also considered when developing the principles that will shape
the new framework.
15. Council also agreed that the project
is now ready to move to the next phase which is to use the principles
to develop new Standards of proficiency for pre-registration nursing
education and new Standards for preceptorship¹, aimed to
be in place for academic year 2010/11. This will involve further
consultation so we will be seeking the views of our stakeholders
once again as this work continues to progress. This also links
to the work undertaken by our government colleagues via the Modernising
Nursing Careers workstream.
16. A review of pre-registration midwifery
education was completed in 2007 and new standards are being implemented
at this time.
17. Health Care Support Workers- Due to
the unique relationship that registered nurses and midwives have
with Health Care Support Workers (HCSWs), Council determined that
there was a need to explore issues around regulation of this group.
The NMC hosted the UK Summit meeting in February 2008 with key
stakeholders from across the UK "Health Care Support Workers:
exploring developmentsa UK debate" to explore and
debate aspects around the regulation of HCSWs. While there was
general agreement that HCSWs should be regulated, there was great
debate on options, advantages and disadvantages on any possible
regulation. Outcomes from this debate were presented at Council
in June and were shared with key stakeholder organisations. The
NMC will continue to engage with stakeholders from across the
UK and keep abreast of relevant workstream and policy developments.
18. The NMC's UK Wide QA Framework provides
assurance of the quality of professional education for nurses
and midwives. The Framework addresses risks to public safeguarding
that are part of preparing practitioners who are fit for practice.
Detailed information including a good practice bulletin is available
via the NMC website.
19. The content of this response is informed
by some of the information described in the reports received from
Local Supervising Authorities for the supervisory year 2006/7.
In addition, issues identified to the midwifery unit during conversations
with midwives who contact the midwifery advisers for guidance
in relation to practice or supervisory issues.
20. There is a level of concern about the
safety of maternity care in Englanda review by the Healthcare
Commission (2008) underlined the variability in the quality of
care in different maternity units around the country and the recent
independent inquiry undertaken by the Kings' Fund (2008) found
there to be shortcomings in the way care is organised and there
were issues around clinical leadership, staffing levels and deployment,
training, information and guidance as well as the role of hospital
boards. The findings and recommendations of the Healthcare Commission
and Kings Fund inquiry may assist in providing a steer for this
inquiry. Other recent reports that have had a significant impact
of the provision of maternity care include the National Service
Framework (NSF) for Children, Young People and Maternity Services
(DH2004), Maternity Matters (DH 2007), the NICE antenatal, intrapartum
and postnatal guidance (2006-2007), the CEMACH report Saving Mothers'
Lives (2007) and the recently published RCOG Standards for Maternity
21. Supervision of Midwives is a statutory
requirement for the profession and the NMC sets Standards for
the preparation and practice of supervisors of midwives (2007).
The supervisory framework aims to monitor and improve the standards
of midwifery practice and care and lead to better outcomes for
women. Supervision applies to every midwife in the UK regardless
of where they are employed.
22. Although a statutory requirement the
supervisory mechanism is not formally funded but supported usually
through employers, either in the NHS or the independent sector.
There is an expected minimum standard ratio of 1 supervisor of
midwives to a caseload of 15 midwives. However, there is inconsistent
application to this standard across the UK with some services
demonstrated to have a ratio of 1 supervisor of midwives with
up to 30 midwives to support. Those units with low supervisor/midwife
ratios are able to support more proactive supervision and through
this function, enhance the safety of women and babies. Examples
of such activity include support for newly qualified midwives,
targeting particular practices where greater expertise is required
such as the interpretation of CTGs (electronic foetal heart monitoring),
record keeping and supporting the provision of normal birth.
23. A key role of a supervisor of midwives
is to monitor and support the practice of midwives to ensure protection
of the public. A frequent duty of the supervisor of midwives is
to investigate adverse events surrounding the care of a woman
during childbirth regardless of where the event took place. The
outcome of this investigation is reported to the Local Supervising
Authority. This function often sits within the clinical governance
framework in NHS bodies but is separate to the investigation undertaken
by the employer. This may be seen as duplicative if the role of
supervision of midwives is not understood.
24. The collaborative interrelation of good
governance mechanisms in maternity care must include the statutory
role of supervision. Opportunities to assist and develop the midwife
following complex events whereby the care has been sub-optimal
may therefore be lost if the supervisory mechanism is not supported
by the employing authorities. The NMC sets Standards for the supervised
practice of midwives (2007), this is a formal process with academic
and practice learning outcomes that seeks to assist the midwife
to improve her knowledge and skills so that she can demonstrate
that she is competent to practice and my be assessed as fit to
remain on the NMC Register.
25. Supervision of Midwives also enables
risk assessment and risk management, particularly if individual
women or groups of women are considered to be at risk. The most
common challenges in this area relate to supporting women's choice
around place of birth particularly home birth and access to maternity
services in labour. With the increasing birth rate nationally
women have reported that the maternity services are unable to
support home births and the lack of beds and staff within maternity
units results in frequent closure of maternity units in some areas.
This has a consequent effect on the safety of the women and unborn
babies and promotes potentially dangerous alternative choices
such as "freebirthing" (NMC A-Z advice 2008).
26. Supervision is a means of ensuring safety
for women and babies by maintaining the safety of midwifery care
and by supporting midwives to practise with confidence. The Government's
NHS modernisation programme aims to deliver consistent and high
quality care to all service users, with an increasing focus on
client choice and also on user involvement. Midwives have a head
start in this process with an established, effective system of
statutory supervision and a framework for the regulation of midwifery
27. Each Local Supervising Authority is
responsible for ensuring that statutory supervision of all midwives,
as required in the Nursing and Midwifery Order (2001) and the
NMC's Midwives rules and standards (2004) is exercised to a satisfactory
standard within its geographical boundary. Each Local Supervising
Authority has an appointed Local Supervising Authority Midwifery
Officer to carry out the Local Supervising Authority function.
Local Supervising Authority Midwifery Officer's are all practising
midwives with experience in statutory supervision and provide
a focus for issues relating to midwifery practice within each
area. They also contribute to the wider NHS agenda by supporting
public health and interprofessional activities at a Strategic
28. The role of the Local Supervising Authority
Midwifery Officer is unique: it does not represent the interests
of either the commissioners or providers of NHS maternity services.
Regular contact with all supervisors of midwives and with the
UK forum of Local Supervising Authority Midwifery Officers ensures
that they have detailed knowledge of contemporary issues.
29. Each Local Supervising Authority Midwifery
Officer is supported in their role by supervisors of midwives,
who are practising midwives and have undertaken further education
and training. Supervisors of Midwives develop and maintain safe
practice to ensure protection of women and babies. They meet regularly
with midwives and ensure a high standard of care is provided.
30. A supervisor of midwives function is
independent of the employer and they often work in a team. Their
role is different to the midwifery manager who is responsible
to the employer to make sure that maternity services run effectively.
The Supervisor of Midwives is accountable to the Local Supervising
Authority and is responsible for ensuring the safety of women
and babies receiving midwifery care.
31. The Department of Health document, Maternity
Matters (2007) recommends that maternity care must be comprehensive
and flexible to respond to the clinical and social needs of women
and their families. However, the sustainability of such provision
is costly and will require appropriate funding for maternity services
to be effective in supporting the implementation of government
policy and national body guidelines. There is considerable disquiet
around the centralisation of services and the closure of smaller
services that appear to have less activity, or are midwifery managed
birthing units. Additionally, there has been significant reconfiguration
of neonatal services. As a consequence, women have to travel further
in order to access maternity and neonatal services thus compromising
their safety and the safety of their babies.
32. The NMC Midwives rules and standards
describe the responsibilities and sphere of practice of a midwife.
A midwife may not arrange for anyone to act as a substitute, other
than another midwife or registered medical practitioner.
33. The supporting role of maternity care
assistants and the role of the learner in the clinical environment
is often one of conjecture, particularly when a midwife in her
own assessment considers such a colleague to have particular competencies
and skills that can be delegated confidently to them. In all circumstance
however the midwife is accountable for the decision to delegate
and remains responsible for the whole or total care of the woman
34. As maternity services are becoming increasingly
congested and busy, there is evidence that midwives are delegating
inappropriately to non-regulated health care personnel who are
not trained and therefore not competent to provide midwifery care
(Kings College, London 2007). However, it is recognised that there
are many duties that a trained maternity support worker can provide
without direct supervision by a midwife. These duties will include
both direct care to mothers and newborns that is not midwifery,
in the acute hospital environment as well as in the community
clinics and women's homes. It is important therefore that the
current debate on the scope of practice of a midwife and the role
and duties of the maternity support workers are clarified. This
will enable maternity services to workforce plan with the appropriate
skill mix in order to deliver the spectrum of care to women and
their families safely without contravening regulatory standards
35. The NMC does not stipulate the management
provision for the leadership of maternity services. The NMC Midwives
rules and standards do not for instance, identify that maternity
services must be led by a midwife. However, both the Healthcare
Commission review and King's Fund inquiry supports the view that
maternity services require a strong midwifery leader and that
advocacy for maternity safety must be strengthened on the boards
of NHS bodies. Failure to adequately fund and develop maternity
services in response to government policy and national guidelines
compromises the care that women and babies receive (NMC The Code
2008). In addition, the mechanisms of support to midwives, such
as the facilitation of the supervisory function and their continuing
personal and professional development, which are regulatory requirements,
are critical to ensuring midwives are fit to practice.
36. Recent Local Supervising Authority reports
to the NMC identify the fitness to practice referrals to the regulatory
body. The typical examples of poor midwifery practice usually
involve issues such as:
Misinterpretation of the CTG (electronic
foetal heart monitoring)
Non-recognition of abnormal developments
in ante-natal care or in labour
Poor management in an emergency
Non-referral to an obstetrician for
either advice or to take over the direction of care
Poor record keeping of care provided
by the midwife and the reasons for decision-making.
Maladministration of drugs
37. It is imperative therefore that midwives
have the continued protection of mandatory training supported
by their employer, access to continued professional development
and the opportunity for supported or supervised practice in the
event of identified learning needs following periods of absence
from the profession or following incidents. To this end the NMC
sets minimum standards that must be achieved by nurses and midwives
related to their post-registration education and practice (NMC
The PREP handbook 2004).
38. Generally over this last year there
have been increased referrals to the NMC by Local Supervisory
Midwifery Officers to the Fitness to Practice department. Of significance
however, is the increased number of programmes for supported or
supervised practice and referrals to the NMC, of midwives still
quite junior in the profession. The mechanisms of effective mentorship
for students undertaking midwifery training and the onward support
of preceptorship on qualification in their first year of practice
cannot be under-estimated.
39. Much as it is not clear as to why this
is occurring, the context of how maternity services are provided
at present with increased activity on labour ward when the risks
to mothers and babies are at their highest, also contribute to
midwives making mistakes due to the pressure of the clinical environment.
This will be a significant contributor to this problem.
Analysis of the LSA reports to the NMC 2006/7-The
full analysis of these reports can be found on the NMC website.
CEMACH Saving Mothers' Lives (2007)
Department of Health (2004) National Service
Framework (NSF) for Children, Young People and Maternity Services
Department of Health (2007) Maternity Matters
Healthcare Commission (2008) Towards better
birthsa review of maternity services in England
Kings College London (2007) Support Workers
in Maternity Services
Kings' Fund (2008), Safe Births: Everybody's
Nursing and Midwifery Order (SI 2002/253)
NICE (2006-2007) antenatal, intrapartum and
NMC (2004) Midwives rules and standards for
NMC (2004) The PREP handbook 2004
NMC (2007) Standards for the preparation and
practice of supervisors of midwives
NMC (2007) Standards for the supervised practice
NMC (2008) The Code
NMC (2008) A-Z AdviceFreebirthing
RCOG (2008) Standards for Maternity Care, Report
of a Working Party
359 The regulation of the non-medical healthcare professions:
a review by the Department of Health (2006). Back