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Partnership in education: The involvement of service users in one midwifery programme in New Zealand
Nurse Education in Practice (2005) 5, 274–280
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Partnership in education: The involvement of service users in one midwifery programme in New Zealand Deborah Davis *, Carolyn McIntosh School of Midwifery, Otago Polytechnic, Private Bag 1910, Dunedin, New Zealand Accepted 24 February 2005
KEYWORDS
Summary While policy directives in New Zealand and internationally urge us to involve service users in educational programmes for health professionals, there is a dearth of literature suggesting ways that this might fruitfully be accomplished, especially for involvement at the more strategic levels of curriculum planning and development. To enable educators of health professionals to respond creatively to policy directives or the philosophical orientations of their own professions, there is a pressing need for educators to share and debate their ideas and experiences of involving service users in their programmes. This paper provides a description of service user involvement (at a variety of levels) in a direct entry midwifery programme at Otago Polytechnic in the South Island of New Zealand. Since its inception, the school of midwifery has sought active and meaningful ways to work in partnership with women, in the education of midwives. This paper specifically describes user involvement in four key areas; contribution to the curricula, programme monitoring, development and strategic planning, recruitment of students and staff and participation in student clinical experience and assessment. c 2005 Elsevier Ltd. All rights reserved.
Midwifery education; Service user involvement; Consumer involvement
Introduction
Government policy directives in New Zealand and internationally, increasingly urge those involved
in health service provision and the education of health professionals, to involve users of health services 1 in their service development strategies or education programmes (Le Var, 2002; New Zealand 1
* Corresponding author. Tel.: +64 3 479 6151; fax: +64 3 474 8486. E-mail addresses: [email protected], [email protected].
The literature variously refers to users of services, consumers, patients, and clients. The term ‘‘users of service’’ will be mostly used in this article. Because the various terms reflect nuance in meanings, when discussing other published literature the terminology used by those authors will be used.
1471-5953/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2005.02.002
Partnership in education Qualifications Authority, 1995; English National Board for Nursing, Midwifery and Health Visiting, 1996; Department of Health, 1998). In the past, service user involvement has involved token or sometimes, exploitive activities such as patient satisfaction surveys that did not impact on service provision or quality (Wilcock et al., 2003) or patients used as ‘‘clinical material’’ for the benefit of students in various health programmes (Kelly and Wykurz, 1998). New policy directives require that we move beyond the tokenism and exploitive relationships of the past and involve service users in ways that provide them with a real voice and real influence, in the shape and strategic developments of our services and programmes. There is a dearth of literature on how this might be achieved (Costello and Horne, 2001) particularly in the area of education for health professionals. The direct entry2 midwifery programme at Otago Polytechnic in New Zealand commenced in 1992 and has involved women as users of maternity services, in the programme since its inception. This article aims to contribute to the current lack of literature by providing an overview of the history and development of the programme, the professional context in which it operates and offers some positive and constructive ways in which service users can be involved in an educational programme.
Background Throughout the 1970s in New Zealand, midwifery as a profession was almost obliterated and subsumed as a specialty of nursing. Within a context of increasing medicalisation, the Nurses Act 1971 effectively ended the ability of midwives to attend women in childbirth under their own authority. Midwives or obstetric nurses as they had become, could only work under the supervision of a medical practitioner (Papps and Olssen, 1997). Midwifery education throughout the 1980s was integrated into the Advanced Diploma of Nursing (which offered minimal theory or clinical experience in midwifery), resulting in large numbers seeking midwifery training overseas. By 1984, 81% of midwives in New Zealand had gained their qualification overseas (Donley, 1998). Throughout the 1980s consumer and midwifery activists concerned with increasing medicalisation and intervention in childbirth, institutionally fo2 ‘‘Direct entry’’ refers to midwifery programmes that do not require applicants to have previous nursing qualifications. In New Zealand midwifery educational preparation is through a Bachelor of Midwifery degree.
275 cussed care, inadequate educational preparation of midwives and the potential loss of midwifery as a profession, began campaigning for change (Donley, 1998). This was a struggle that eventually resulted in the 1990 Amendment to the Nurses Act that provided the legislative framework that allowed for midwifery autonomy and direct entry midwifery education. Midwives in New Zealand today can provide care to childbearing women through all phases of childbirth under their own authority and access public maternity funding for their services. Five education providers offer direct entry midwifery education. Women as users of maternity services and midwives campaigned together successfully to bring about change and this foundation of partnership has provided a template for the development of the practice and profession of midwifery since that time (Guilliland and Pairman, 1995). Midwives have since sought ways of living this partnership with service users not only at the individual woman and midwife interface, but also at the professional level and within midwifery education.
Service user involvement in development of the profession Midwives established the New Zealand College of Midwives in 1989 as part of the push for recognition of midwifery as a separate profession from nursing. Service users have had a pivotal role in the New Zealand College of Midwives since it inception and are involved at all levels of the organisation as members and on the executive committee. The College functions to provide professional leadership to midwifery and (among other roles) is involved with professional development and quality assurance of midwifery services. The standards for practice were developed in consultation with service users, acknowledging the woman as central to care. Select midwifery standards for practice 1. The midwife works in partnership with the woman 2. The midwife upholds each woman’s right to free and informed choice and consent throughout the childbirth experience 3. Midwifery care is planned with the woman 4. The midwife is accountable to the woman, to herself, the midwifery profession and to the wider community for her practice 5. The midwife negotiates the completion of the midwifery partnership with the woman (New Zealand College of Midwives, 2002)
276 These standards provide the basis for the Standards Review process in New Zealand and this process is seen as a quality assurance mechanism for maternity services at the individual midwife level. Standards Review committees are available in all major centres and are comprised of a panel of two service users and two midwives who are specially trained in the Standards Review process. As part of this process midwives provide their clients with feedback forms that are returned anonymously to a Standards Review Committee. When midwives book a Standards Review (the expectation is that this will occur annually) this feedback is made available to the midwife. The midwife then compiles certain practice statistics and reflections on her practice in relation to the Standards for Practice, and meets with the panel to discuss her practice and professional development. This process provides service users, as clients of the midwife and as members of the committee, with an opportunity to provide midwives with feedback on the midwife’s practice and therefore, to play an important role in the professional development of midwives at an individual level. The process is not a punitive one but aims for continuous quality improvement by assisting midwives individually in their professional development. Service user input is recognised as central to this process and they are involved in a very real and influential way in the Standards Review processes. The New Zealand College of Midwives Standards for Practice, is an important element of the professional framework in which midwifery functions in New Zealand. The central role of women within maternity services and the partnership relationship between woman and midwife is acknowledged within this and other regulatory documents (Midwifery Council of New Zealand, 2004; Ministry of Health, 2002). This forms part of the professional and legislative framework that midwives work within and in providing a framework for midwifery practice and maternity services they also provide an important framework for midwifery education.
Direct entry midwifery at Otago Polytechnic Otago Polytechnic was the first education institution to commence a Bachelor of Midwifery programme in New Zealand following the required legislative changes in 1990 and the first to offer this programme internationally. The programme began as a trial programme in 1992 with its first graduates entering practice by the end of 1994. With the cen-
D. Davis, C. McIntosh tral role that service users had played in bringing about midwifery autonomy and direct entry midwifery education, it was obvious that women as service users would contribute to the development of the programme and the education of midwives of the future. Since its inception, the school of midwifery has sought active and meaningful ways to work in partnership with women, in the education of midwives. The following pages will discuss four key areas in which service users are involved in the midwifery programme at Otago Polytechnic; contribution to the curricula, programme monitoring, development and strategic planning, recruitment of students and staff and participation in student clinical experience and assessment.
Contribution to the curricula Following the relevant legislative changes allowing direct entry midwifery, Otago Polytechnic began planning its Bachelor of Midwifery program. From the beginning planning stages service user involvement was sought and their input contributed to the content and processes of the curricula. This was achieved through focus groups and consultation documents that were sent to a variety of identified stakeholders, which included service user groups. Representatives of a variety of service user groups or individual service users are invited to present guest lectures or form part of discussion panels throughout the programme. These might include (but are not limited to) such groups as; the Homebirth Association, La Leche League, disability support group and individual women who share their experiences of childbirth and maternity services.
Programme monitoring, development and strategic planning The New Zealand Qualification Authority (NZQA) is the government agency responsible for the approval, accreditation and monitoring of degree programmes in New Zealand (New Zealand Qualifications Authority, 1995). NZQA identifies external involvement in a programme as a criterion of quality management. They require programmes; to allow the views of stakeholder representatives of relevant industries and professions, academic and research communities, Maori and other communities to be taken into account. This is reflected in the polices, management structures, and evaluation procedures which make up the quality management systems.
Partnership in education (The New Zealand Qualifications Authority, 1995, p. 9) The school of midwifery chooses to acknowledge Parents Centre, the Homebirth Association and La Leche League (among others) as important stakeholder groups and as such they are involved in the monitoring and development of the midwifery programmes at Otago Polytechnic. Representatives of these groups provide membership to the Permanent External Advisory Committee (PEAC) for the School of Midwifery. The PEAC also consists of representatives from local Maori, the student body, industry (hospital and independent midwifery services), the college of midwives and other educational institutions. Meetings are held twice a year and significant issues for the programme and curricula are discussed. All programme evaluation results and other relevant documentation are made available to the PEAC and they have input into any changes or developments in the midwifery programmes. Involvement of these stakeholder groups provides the school with a variety of perspectives when considering programme content and processes. Maintaining these consumer networks allows us to preserve the variety of service user perspectives within our programmes and also provides the midwifery school with a strong support network from our stakeholders. A recent example of this was during the restructuring of the Otago Polytechnic. The council plan involved merging the schools of nursing and midwifery. The school was easily able to rally support from all relevant stakeholders, including service user groups to voice strong support for the maintenance of separate schools as a point of quality. The committee considering submissions on the proposed restructuring was moved to comment on the ‘‘snowstorm’’ of submissions received regarding the proposed changes to the structure of the schools. This has led to a revision in the plan and retention of the school of midwifery as a separate entity. So the maintenance of networks with stakeholder and community groups means that the school is embedded in a community that has input and interest in its quality, processes and outcomes.
Recruitment of students and staff Prospective students apply to enter the programme and these applications are considered against predetermined criteria. A panel independently reviews each application and scores them against the criteria, coming together as a group to compare scores and discuss applications. The panel
277 may vary from year to year but always includes two representatives from the school of midwifery and one representative from a stakeholder service user group. Similarly, applications for teaching staff positions within the school of midwifery are reviewed by a panel that also includes a service user representative. In this way, the service user perspective is acknowledged, valued and utilised within the processes of staff and student selection for the school of midwifery.
Participation in student clinical experience and assessment Students in the Bachelor of Midwifery programme are offered a variety of clinical experiences. They are placed for blocks of time in the hospital setting but a large proportion of their clinical experiences are gained in a continuity, community situation. The majority (73.5%) of women in New Zealand are cared for by a midwife as lead maternity carer who will provide continuity of care to a woman from early pregnancy through to four to six weeks postpartum (Ministry of Health, 2003). The focus of clinical experiences in the first year of the Bachelor of Midwifery programme is on assisting students to understand the woman’s experience of childbirth and maternity services. The clinical component of first year involves students ‘‘following through’’ several women’s experience from early pregnancy to six weeks postpartum. The school of midwifery advertises in a variety of relevant settings, newspapers and newsletters to attract women willing to involve a student in their experience. The student is ‘‘attached’ to the woman rather than the midwife and the woman is given clear information about the expectations and role of the student. In the second year of the programme students again ‘‘follow through’’ several women’s maternity experiences but this time focussing on the role and skills of the midwife. In the first year, midwifery teaching staff liaise directly with the woman concerned to gain feedback on the student and this feedback contributes to the student’s assessment for the course. In the second year of the programme the supervising lecturer liaises both with the woman and midwife who is caring for the woman. Again the feedback obtained here contributes to the student’s clinical assessment for the course. During the third year of the programme students are placed with a midwife or group practice for significant blocks of time; 10-week placement, 14-week placement, and 4-week rural placement.
278 During these placements, supervising lecturers liaise regularly with the midwife with whom the student is working. It is expected that the midwife will obtain feedback from the women with whom the student has been involved. In discussion with the supervising lecturer, the midwife completes the clinical assessment of students in the third year of the programme, incorporating feedback from women where required on the clinical assessment forms. Clinical assessment forms for each year of the programme are a little different (reflecting the knowledge and skill level expected in each year) and are based on the New Zealand College of Midwives Standards for Practice and so incorporate a woman centred approach to midwifery care. Most clinical subjects in the programme involve clinical skill examinations. In the first year of the programme this includes such skills as taking blood pressure, administering medications, and basic antenatal and postnatal physical assessment. The assessment criteria include, not just proficiency or competency in the particular skill, but require the student to demonstrate the performance of the skill in the context of communicating and working with a woman as the central focus. The following criteria are used to assess the communication and information sharing aspect of each clinical skill. Assessment criteria for communication aspects of clinical examination Introduces self and provides woman with an explanation of their role Approaches the interaction with appropriate body language, eye contact, demeanour, manner and tone of voice and interacts with the client in a culturally safe manner Ascertains woman’s knowledge and understanding of procedure Facilitates the opportunity for the woman to ask questions Elicits verbal consent to procedure At a beginning level, provides the woman with accurate and appropriate information in a way that facilitates clear understanding Facilitates information sharing (giving feedback and eliciting feedback) and the woman’s involvement throughout procedure and responds appropriately to shared information or non-verbal cues
Maternity service users are employed for the examination to role-play for these student examinations. Immediately following the clinical examination there is an opportunity for the student,
D. Davis, C. McIntosh lecturer and midwife to discuss the episode. The service user is able to give the student feedback on her perspective of the skill performed and this feedback contributes to the final mark the student receives for the examination. Our experience of this process has been extremely positive. We have developed a pool of women who are skilled in this role and we have also found that the service user perspective or feedback in this situation has a profound effect on the student. Service user involvement in clinical experience and assessment varies throughout the three years of the programme but as others have identified (Costello and Horne, 2001; Twinn, 1995) in each scenario clear communication between educators and service users is necessary to ensure that these experiences are effective for all concerned. Service users need to be clear on their role and what is expected of the student in each situation.
Discussion Internationally, there is a move toward greater service user involvement in health services including health care services and delivery but even more challenging is the involvement in educational provision of health care professionals. After an extensive search we found that there is a dearth of literature concerning the involvement of service users in midwifery education, which is of note since midwifery philosophy often cites the importance of a women centred approach to care. In view of the fact that there is such a gap in the literature on this topic it is important that those involved in the education of health professionals, share their experiences of user involvement and indeed, evaluate these aspects of their programmes. In exploring the literature on service user involvement in health education Forrest et al. (2000) have conceptualised the degree of consumer involvement as a continuum from closed model – no involvement of consumers to partnership, with integrated consumer involvement throughout. This model provides a useful framework for considering the level of involvement that service users have in educational programmes. They claim that while the rhetoric supports and policy directs programmes to incorporate service user involvement, there is little in the way of practical advice or support about how to achieve this, particularly at an integrated rather than token level (Forrest et al., 2000). Users of health services have historically performed as ‘‘clinical material’’ for students of
Partnership in education health programmes in what was mostly a passive and often dehumanising experience (Kelly and Wykurz, 1998). All health professionals have the generosity of service users to thank for aspects of their knowledge and skill development and it is important that we continue to explore learning opportunities that do not exploit members of our local or wider community. A number of studies have emerged that explore innovative ways of involving patients or users of health services in educational programmes for health professionals. Kelly and Wykurz (1998) reported on an innovation in medical education called ‘‘patients as teachers’’. This was introduced as a pilot project into medical curricula in the UK and involved partnering a medical student with a paid patient. Together the student and patient developed goals and activities to assist the student in his or her medical education. The main aim of the project and the main outcome following evaluation was that students experienced increased respect and understanding for their patient and the factors impacting on their health and quality of life. Costello and Horne (2001) conducted a study evaluating patient involvement in classroom teaching within a preregistration nursing programme. They concluded that with careful planning and facilitation, patient involvement in the classroom was an effective teaching strategy, which not only benefited students but also the patient participants. In the UK Fox (2003) explored nursing and midwifery curricula in relation to; the perceived relevance, the actual extent and the processes by which ‘‘consumerism’’ has been included in the curriculum. While Fox (2003) does not define ‘‘consumerism’’ in her research article, reading of the article suggests she is interested in understanding the degree to which ‘‘consumer wishes and needs’’ (Fox, 2003, p. 382) or ‘‘consideration of consumer issues’’ (p. 380) were central to the curricula she reviewed. Fox (2003) describes the policy context of health care in the UK and is concerned to understand how we are preparing students to meet the new consumer oriented approach to care. Fox (2003) reviewed the curriculum documentation of seven educational institutions in the UK and found that while assessments were patient focused (utilising case study, critical incidents for example) none of the documents identified the use of consumers as visiting teachers. In a group discussion with academic staff as part of the this research, the group admitted that there was limited consideration of consumer issues in their curriculum though they identified that the use of consumers as visiting teachers would be advantageous. They also identified two major con-
279 cerns in this respect; finding room in an already pressured curricula (especially pressured in terms of skill related elements) and access to appropriate service users (a situation arising from the location of programmes in educational rather than health service facilities). Fox’s (2003) research, particularly in the area of midwifery suggests that women as service users, if at all, are playing a very limited role in some midwifery education programmes. Rather than ‘‘consumer issues’’ being conceptualised as yet another element to be included in curricula it may be more advantageous to adopt a more integrated approach to skill development; one that is inclusive of the service user perspective and experience. Part of the skill or art of midwifery is performing a procedure in a way that integrates communication and holds the woman and her needs at the fore. There is no reason why technical skills, communication, and an appreciation for service user experiences or perspectives cannot be gained together. One need not be gained at the expense of the other. Our reading of this article in particular, suggests that the drive for user involvement in the education of health professionals is emanating from policy directives, (top down) rather than from a fundamental philosophical position of the profession (bottom up). As such, educators are struggling to implement a directive that is imposed on them, rather than evolving their educational strategies in ways that respond to an underpinning philosophical position that places women at the centre of midwifery practice. While the scant literature reviewed here so far focuses on the health service users role in facilitating the student’s clinical skills and understanding, there is an even greater dearth of literature suggesting ways that service users can be involved in strategic planning or curriculum development. Le Var (2002, p. 219) urges that a ‘‘strategic approach is needed to make user involvement an effective and workable reality’’ and provides several examples of good practice from throughout the UK. While the scant literature on the topic leaves one with the impression that there is little service user involvement at this more strategic level, this may be an erroneous assumption. So that educators of health professionals can respond creatively to policy directives or the philosophical orientations of their own professions, there is a pressing need for educators to share and debate their ideas and experiences of involving service users in their programmes. Certainly these initiates and innovations need to be evaluated and this is the next important step for the programme at Otago Polytechnic.
280
Conclusion Women as maternity service users have had a pivotal role in the re emergence of the midwifery profession in New Zealand and the maintenance of high standards of service provision. Together, women and midwives have brought about reform in maternity services and since that time have sustained ways of continuing to work in partnership. This includes partnership at the individual and professional levels including, the provision of midwifery education. Otago Polytechnic School of Midwifery has developed some meaningful and valued mechanisms for involving service users in our midwifery programmes. The passion and drive for service user participation comes from our genuine commitment to partnership with women and a foundational philosophy of midwifery as women centred. We acknowledge that histories and contexts vary and we do not suggest that our methods or processes are transferable. We offer our experiences in response to the lack of descriptive or evaluative literature available currently and hope that this might stimulate debate and innovation in other programmes.
References Costello, J., Horne, M., 2001. Patients as teachers. An evaluative study of patients’ involvement in classroom teaching. Nurse Education in Practice 1, 94–102. Department of Health, 1998. A first class service: quality in the New NHS. Department of Health, London. Donley, J., 1998. Birthrites. Natural Vs Unnatural Childbirth in New Zealand. The Full Courte Press, Auckland.
D. Davis, C. McIntosh English National Board for Nursing, Midwifery and Health Visiting, 1996. Learning from Each Other: The Involvement of People Who Use Services and Their Carers in Education and Training. English National Board for Nursing, Midwifery and Health Visiting, London. Forrest, S., Masters, H., Brown, N., 2000. Mental health service user involvement in nurse education: exploring the issues. Journal of Psychiatric and Mental Health Nursing 7, 51–57. Fox, J., 2003. Consumerism 2: pre registration nursing and midwifery curricula. British Journal of Nursing 12 (6), 378– 386. Guilliland, K., Pairman, S., 1995. The Midwifery Partnership. A Model for Practice. Victoria University, Wellington. Kelly, D., Wykurz, G., 1998. Patients as teachers: a new perspective in medical education. Education for Health: Change in Learning and Practice 11 (3), 1357. Le Var, R., 2002. Patient involvement in education for enhanced quality of care. International Nursing Review 49, 219–225. Midwifery Council of New Zealand, 2004. Competencies for Entry to the Register of Midwives. Midwifery Council of New Zealand, Wellington. Ministry of Health, 2002. Maternity Services Notice Pursuant to Section 88 of the New Zealand Public Health & Disability Act 2000. Ministry of Health, Wellington. Ministry of Health, 2003. Report on Maternity 2000 & 2001. Ministry of Health, Wellington. New Zealand College of Midwives, 2002. Midwives Handbook for Practice. Christchurch, New Zealand. New Zealand Qualifications Authority, 1995. Quality Assurance for Degrees and Related Qualifications. New Zealand Qualifications Authority, Wellington. Papps, E., Olssen, M., 1997. Doctoring Childbirth and Regulating Midwifery in New Zealand: A Foucauldian Perspective. The Dunmore Press, Palmerston North, New Zealand. Twinn, S., 1995. Creating reality or contributing to confusion. An exploratory study of client participation in student learning. Nurse Education Today 15, 291–297. Wilcock, P., Brown, G., Bateson, J., Carver, J., Machin, S., 2003. Using patient stories to inspire quality improvement within the NHS Modernization Agency collaborative programmes. Journal of Clinical Nursing 12, 422–430.
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Partnership in education: The involvement of service users in one midwifery programme in New Zealand Deborah Davis *, Carolyn McIntosh School of Midwifery, Otago Polytechnic, Private Bag 1910, Dunedin, New Zealand Accepted 24 February 2005
KEYWORDS
Summary While policy directives in New Zealand and internationally urge us to involve service users in educational programmes for health professionals, there is a dearth of literature suggesting ways that this might fruitfully be accomplished, especially for involvement at the more strategic levels of curriculum planning and development. To enable educators of health professionals to respond creatively to policy directives or the philosophical orientations of their own professions, there is a pressing need for educators to share and debate their ideas and experiences of involving service users in their programmes. This paper provides a description of service user involvement (at a variety of levels) in a direct entry midwifery programme at Otago Polytechnic in the South Island of New Zealand. Since its inception, the school of midwifery has sought active and meaningful ways to work in partnership with women, in the education of midwives. This paper specifically describes user involvement in four key areas; contribution to the curricula, programme monitoring, development and strategic planning, recruitment of students and staff and participation in student clinical experience and assessment. c 2005 Elsevier Ltd. All rights reserved.
Midwifery education; Service user involvement; Consumer involvement
Introduction
Government policy directives in New Zealand and internationally, increasingly urge those involved
in health service provision and the education of health professionals, to involve users of health services 1 in their service development strategies or education programmes (Le Var, 2002; New Zealand 1
* Corresponding author. Tel.: +64 3 479 6151; fax: +64 3 474 8486. E-mail addresses: [email protected], [email protected].
The literature variously refers to users of services, consumers, patients, and clients. The term ‘‘users of service’’ will be mostly used in this article. Because the various terms reflect nuance in meanings, when discussing other published literature the terminology used by those authors will be used.
1471-5953/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2005.02.002
Partnership in education Qualifications Authority, 1995; English National Board for Nursing, Midwifery and Health Visiting, 1996; Department of Health, 1998). In the past, service user involvement has involved token or sometimes, exploitive activities such as patient satisfaction surveys that did not impact on service provision or quality (Wilcock et al., 2003) or patients used as ‘‘clinical material’’ for the benefit of students in various health programmes (Kelly and Wykurz, 1998). New policy directives require that we move beyond the tokenism and exploitive relationships of the past and involve service users in ways that provide them with a real voice and real influence, in the shape and strategic developments of our services and programmes. There is a dearth of literature on how this might be achieved (Costello and Horne, 2001) particularly in the area of education for health professionals. The direct entry2 midwifery programme at Otago Polytechnic in New Zealand commenced in 1992 and has involved women as users of maternity services, in the programme since its inception. This article aims to contribute to the current lack of literature by providing an overview of the history and development of the programme, the professional context in which it operates and offers some positive and constructive ways in which service users can be involved in an educational programme.
Background Throughout the 1970s in New Zealand, midwifery as a profession was almost obliterated and subsumed as a specialty of nursing. Within a context of increasing medicalisation, the Nurses Act 1971 effectively ended the ability of midwives to attend women in childbirth under their own authority. Midwives or obstetric nurses as they had become, could only work under the supervision of a medical practitioner (Papps and Olssen, 1997). Midwifery education throughout the 1980s was integrated into the Advanced Diploma of Nursing (which offered minimal theory or clinical experience in midwifery), resulting in large numbers seeking midwifery training overseas. By 1984, 81% of midwives in New Zealand had gained their qualification overseas (Donley, 1998). Throughout the 1980s consumer and midwifery activists concerned with increasing medicalisation and intervention in childbirth, institutionally fo2 ‘‘Direct entry’’ refers to midwifery programmes that do not require applicants to have previous nursing qualifications. In New Zealand midwifery educational preparation is through a Bachelor of Midwifery degree.
275 cussed care, inadequate educational preparation of midwives and the potential loss of midwifery as a profession, began campaigning for change (Donley, 1998). This was a struggle that eventually resulted in the 1990 Amendment to the Nurses Act that provided the legislative framework that allowed for midwifery autonomy and direct entry midwifery education. Midwives in New Zealand today can provide care to childbearing women through all phases of childbirth under their own authority and access public maternity funding for their services. Five education providers offer direct entry midwifery education. Women as users of maternity services and midwives campaigned together successfully to bring about change and this foundation of partnership has provided a template for the development of the practice and profession of midwifery since that time (Guilliland and Pairman, 1995). Midwives have since sought ways of living this partnership with service users not only at the individual woman and midwife interface, but also at the professional level and within midwifery education.
Service user involvement in development of the profession Midwives established the New Zealand College of Midwives in 1989 as part of the push for recognition of midwifery as a separate profession from nursing. Service users have had a pivotal role in the New Zealand College of Midwives since it inception and are involved at all levels of the organisation as members and on the executive committee. The College functions to provide professional leadership to midwifery and (among other roles) is involved with professional development and quality assurance of midwifery services. The standards for practice were developed in consultation with service users, acknowledging the woman as central to care. Select midwifery standards for practice 1. The midwife works in partnership with the woman 2. The midwife upholds each woman’s right to free and informed choice and consent throughout the childbirth experience 3. Midwifery care is planned with the woman 4. The midwife is accountable to the woman, to herself, the midwifery profession and to the wider community for her practice 5. The midwife negotiates the completion of the midwifery partnership with the woman (New Zealand College of Midwives, 2002)
276 These standards provide the basis for the Standards Review process in New Zealand and this process is seen as a quality assurance mechanism for maternity services at the individual midwife level. Standards Review committees are available in all major centres and are comprised of a panel of two service users and two midwives who are specially trained in the Standards Review process. As part of this process midwives provide their clients with feedback forms that are returned anonymously to a Standards Review Committee. When midwives book a Standards Review (the expectation is that this will occur annually) this feedback is made available to the midwife. The midwife then compiles certain practice statistics and reflections on her practice in relation to the Standards for Practice, and meets with the panel to discuss her practice and professional development. This process provides service users, as clients of the midwife and as members of the committee, with an opportunity to provide midwives with feedback on the midwife’s practice and therefore, to play an important role in the professional development of midwives at an individual level. The process is not a punitive one but aims for continuous quality improvement by assisting midwives individually in their professional development. Service user input is recognised as central to this process and they are involved in a very real and influential way in the Standards Review processes. The New Zealand College of Midwives Standards for Practice, is an important element of the professional framework in which midwifery functions in New Zealand. The central role of women within maternity services and the partnership relationship between woman and midwife is acknowledged within this and other regulatory documents (Midwifery Council of New Zealand, 2004; Ministry of Health, 2002). This forms part of the professional and legislative framework that midwives work within and in providing a framework for midwifery practice and maternity services they also provide an important framework for midwifery education.
Direct entry midwifery at Otago Polytechnic Otago Polytechnic was the first education institution to commence a Bachelor of Midwifery programme in New Zealand following the required legislative changes in 1990 and the first to offer this programme internationally. The programme began as a trial programme in 1992 with its first graduates entering practice by the end of 1994. With the cen-
D. Davis, C. McIntosh tral role that service users had played in bringing about midwifery autonomy and direct entry midwifery education, it was obvious that women as service users would contribute to the development of the programme and the education of midwives of the future. Since its inception, the school of midwifery has sought active and meaningful ways to work in partnership with women, in the education of midwives. The following pages will discuss four key areas in which service users are involved in the midwifery programme at Otago Polytechnic; contribution to the curricula, programme monitoring, development and strategic planning, recruitment of students and staff and participation in student clinical experience and assessment.
Contribution to the curricula Following the relevant legislative changes allowing direct entry midwifery, Otago Polytechnic began planning its Bachelor of Midwifery program. From the beginning planning stages service user involvement was sought and their input contributed to the content and processes of the curricula. This was achieved through focus groups and consultation documents that were sent to a variety of identified stakeholders, which included service user groups. Representatives of a variety of service user groups or individual service users are invited to present guest lectures or form part of discussion panels throughout the programme. These might include (but are not limited to) such groups as; the Homebirth Association, La Leche League, disability support group and individual women who share their experiences of childbirth and maternity services.
Programme monitoring, development and strategic planning The New Zealand Qualification Authority (NZQA) is the government agency responsible for the approval, accreditation and monitoring of degree programmes in New Zealand (New Zealand Qualifications Authority, 1995). NZQA identifies external involvement in a programme as a criterion of quality management. They require programmes; to allow the views of stakeholder representatives of relevant industries and professions, academic and research communities, Maori and other communities to be taken into account. This is reflected in the polices, management structures, and evaluation procedures which make up the quality management systems.
Partnership in education (The New Zealand Qualifications Authority, 1995, p. 9) The school of midwifery chooses to acknowledge Parents Centre, the Homebirth Association and La Leche League (among others) as important stakeholder groups and as such they are involved in the monitoring and development of the midwifery programmes at Otago Polytechnic. Representatives of these groups provide membership to the Permanent External Advisory Committee (PEAC) for the School of Midwifery. The PEAC also consists of representatives from local Maori, the student body, industry (hospital and independent midwifery services), the college of midwives and other educational institutions. Meetings are held twice a year and significant issues for the programme and curricula are discussed. All programme evaluation results and other relevant documentation are made available to the PEAC and they have input into any changes or developments in the midwifery programmes. Involvement of these stakeholder groups provides the school with a variety of perspectives when considering programme content and processes. Maintaining these consumer networks allows us to preserve the variety of service user perspectives within our programmes and also provides the midwifery school with a strong support network from our stakeholders. A recent example of this was during the restructuring of the Otago Polytechnic. The council plan involved merging the schools of nursing and midwifery. The school was easily able to rally support from all relevant stakeholders, including service user groups to voice strong support for the maintenance of separate schools as a point of quality. The committee considering submissions on the proposed restructuring was moved to comment on the ‘‘snowstorm’’ of submissions received regarding the proposed changes to the structure of the schools. This has led to a revision in the plan and retention of the school of midwifery as a separate entity. So the maintenance of networks with stakeholder and community groups means that the school is embedded in a community that has input and interest in its quality, processes and outcomes.
Recruitment of students and staff Prospective students apply to enter the programme and these applications are considered against predetermined criteria. A panel independently reviews each application and scores them against the criteria, coming together as a group to compare scores and discuss applications. The panel
277 may vary from year to year but always includes two representatives from the school of midwifery and one representative from a stakeholder service user group. Similarly, applications for teaching staff positions within the school of midwifery are reviewed by a panel that also includes a service user representative. In this way, the service user perspective is acknowledged, valued and utilised within the processes of staff and student selection for the school of midwifery.
Participation in student clinical experience and assessment Students in the Bachelor of Midwifery programme are offered a variety of clinical experiences. They are placed for blocks of time in the hospital setting but a large proportion of their clinical experiences are gained in a continuity, community situation. The majority (73.5%) of women in New Zealand are cared for by a midwife as lead maternity carer who will provide continuity of care to a woman from early pregnancy through to four to six weeks postpartum (Ministry of Health, 2003). The focus of clinical experiences in the first year of the Bachelor of Midwifery programme is on assisting students to understand the woman’s experience of childbirth and maternity services. The clinical component of first year involves students ‘‘following through’’ several women’s experience from early pregnancy to six weeks postpartum. The school of midwifery advertises in a variety of relevant settings, newspapers and newsletters to attract women willing to involve a student in their experience. The student is ‘‘attached’ to the woman rather than the midwife and the woman is given clear information about the expectations and role of the student. In the second year of the programme students again ‘‘follow through’’ several women’s maternity experiences but this time focussing on the role and skills of the midwife. In the first year, midwifery teaching staff liaise directly with the woman concerned to gain feedback on the student and this feedback contributes to the student’s assessment for the course. In the second year of the programme the supervising lecturer liaises both with the woman and midwife who is caring for the woman. Again the feedback obtained here contributes to the student’s clinical assessment for the course. During the third year of the programme students are placed with a midwife or group practice for significant blocks of time; 10-week placement, 14-week placement, and 4-week rural placement.
278 During these placements, supervising lecturers liaise regularly with the midwife with whom the student is working. It is expected that the midwife will obtain feedback from the women with whom the student has been involved. In discussion with the supervising lecturer, the midwife completes the clinical assessment of students in the third year of the programme, incorporating feedback from women where required on the clinical assessment forms. Clinical assessment forms for each year of the programme are a little different (reflecting the knowledge and skill level expected in each year) and are based on the New Zealand College of Midwives Standards for Practice and so incorporate a woman centred approach to midwifery care. Most clinical subjects in the programme involve clinical skill examinations. In the first year of the programme this includes such skills as taking blood pressure, administering medications, and basic antenatal and postnatal physical assessment. The assessment criteria include, not just proficiency or competency in the particular skill, but require the student to demonstrate the performance of the skill in the context of communicating and working with a woman as the central focus. The following criteria are used to assess the communication and information sharing aspect of each clinical skill. Assessment criteria for communication aspects of clinical examination Introduces self and provides woman with an explanation of their role Approaches the interaction with appropriate body language, eye contact, demeanour, manner and tone of voice and interacts with the client in a culturally safe manner Ascertains woman’s knowledge and understanding of procedure Facilitates the opportunity for the woman to ask questions Elicits verbal consent to procedure At a beginning level, provides the woman with accurate and appropriate information in a way that facilitates clear understanding Facilitates information sharing (giving feedback and eliciting feedback) and the woman’s involvement throughout procedure and responds appropriately to shared information or non-verbal cues
Maternity service users are employed for the examination to role-play for these student examinations. Immediately following the clinical examination there is an opportunity for the student,
D. Davis, C. McIntosh lecturer and midwife to discuss the episode. The service user is able to give the student feedback on her perspective of the skill performed and this feedback contributes to the final mark the student receives for the examination. Our experience of this process has been extremely positive. We have developed a pool of women who are skilled in this role and we have also found that the service user perspective or feedback in this situation has a profound effect on the student. Service user involvement in clinical experience and assessment varies throughout the three years of the programme but as others have identified (Costello and Horne, 2001; Twinn, 1995) in each scenario clear communication between educators and service users is necessary to ensure that these experiences are effective for all concerned. Service users need to be clear on their role and what is expected of the student in each situation.
Discussion Internationally, there is a move toward greater service user involvement in health services including health care services and delivery but even more challenging is the involvement in educational provision of health care professionals. After an extensive search we found that there is a dearth of literature concerning the involvement of service users in midwifery education, which is of note since midwifery philosophy often cites the importance of a women centred approach to care. In view of the fact that there is such a gap in the literature on this topic it is important that those involved in the education of health professionals, share their experiences of user involvement and indeed, evaluate these aspects of their programmes. In exploring the literature on service user involvement in health education Forrest et al. (2000) have conceptualised the degree of consumer involvement as a continuum from closed model – no involvement of consumers to partnership, with integrated consumer involvement throughout. This model provides a useful framework for considering the level of involvement that service users have in educational programmes. They claim that while the rhetoric supports and policy directs programmes to incorporate service user involvement, there is little in the way of practical advice or support about how to achieve this, particularly at an integrated rather than token level (Forrest et al., 2000). Users of health services have historically performed as ‘‘clinical material’’ for students of
Partnership in education health programmes in what was mostly a passive and often dehumanising experience (Kelly and Wykurz, 1998). All health professionals have the generosity of service users to thank for aspects of their knowledge and skill development and it is important that we continue to explore learning opportunities that do not exploit members of our local or wider community. A number of studies have emerged that explore innovative ways of involving patients or users of health services in educational programmes for health professionals. Kelly and Wykurz (1998) reported on an innovation in medical education called ‘‘patients as teachers’’. This was introduced as a pilot project into medical curricula in the UK and involved partnering a medical student with a paid patient. Together the student and patient developed goals and activities to assist the student in his or her medical education. The main aim of the project and the main outcome following evaluation was that students experienced increased respect and understanding for their patient and the factors impacting on their health and quality of life. Costello and Horne (2001) conducted a study evaluating patient involvement in classroom teaching within a preregistration nursing programme. They concluded that with careful planning and facilitation, patient involvement in the classroom was an effective teaching strategy, which not only benefited students but also the patient participants. In the UK Fox (2003) explored nursing and midwifery curricula in relation to; the perceived relevance, the actual extent and the processes by which ‘‘consumerism’’ has been included in the curriculum. While Fox (2003) does not define ‘‘consumerism’’ in her research article, reading of the article suggests she is interested in understanding the degree to which ‘‘consumer wishes and needs’’ (Fox, 2003, p. 382) or ‘‘consideration of consumer issues’’ (p. 380) were central to the curricula she reviewed. Fox (2003) describes the policy context of health care in the UK and is concerned to understand how we are preparing students to meet the new consumer oriented approach to care. Fox (2003) reviewed the curriculum documentation of seven educational institutions in the UK and found that while assessments were patient focused (utilising case study, critical incidents for example) none of the documents identified the use of consumers as visiting teachers. In a group discussion with academic staff as part of the this research, the group admitted that there was limited consideration of consumer issues in their curriculum though they identified that the use of consumers as visiting teachers would be advantageous. They also identified two major con-
279 cerns in this respect; finding room in an already pressured curricula (especially pressured in terms of skill related elements) and access to appropriate service users (a situation arising from the location of programmes in educational rather than health service facilities). Fox’s (2003) research, particularly in the area of midwifery suggests that women as service users, if at all, are playing a very limited role in some midwifery education programmes. Rather than ‘‘consumer issues’’ being conceptualised as yet another element to be included in curricula it may be more advantageous to adopt a more integrated approach to skill development; one that is inclusive of the service user perspective and experience. Part of the skill or art of midwifery is performing a procedure in a way that integrates communication and holds the woman and her needs at the fore. There is no reason why technical skills, communication, and an appreciation for service user experiences or perspectives cannot be gained together. One need not be gained at the expense of the other. Our reading of this article in particular, suggests that the drive for user involvement in the education of health professionals is emanating from policy directives, (top down) rather than from a fundamental philosophical position of the profession (bottom up). As such, educators are struggling to implement a directive that is imposed on them, rather than evolving their educational strategies in ways that respond to an underpinning philosophical position that places women at the centre of midwifery practice. While the scant literature reviewed here so far focuses on the health service users role in facilitating the student’s clinical skills and understanding, there is an even greater dearth of literature suggesting ways that service users can be involved in strategic planning or curriculum development. Le Var (2002, p. 219) urges that a ‘‘strategic approach is needed to make user involvement an effective and workable reality’’ and provides several examples of good practice from throughout the UK. While the scant literature on the topic leaves one with the impression that there is little service user involvement at this more strategic level, this may be an erroneous assumption. So that educators of health professionals can respond creatively to policy directives or the philosophical orientations of their own professions, there is a pressing need for educators to share and debate their ideas and experiences of involving service users in their programmes. Certainly these initiates and innovations need to be evaluated and this is the next important step for the programme at Otago Polytechnic.
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Conclusion Women as maternity service users have had a pivotal role in the re emergence of the midwifery profession in New Zealand and the maintenance of high standards of service provision. Together, women and midwives have brought about reform in maternity services and since that time have sustained ways of continuing to work in partnership. This includes partnership at the individual and professional levels including, the provision of midwifery education. Otago Polytechnic School of Midwifery has developed some meaningful and valued mechanisms for involving service users in our midwifery programmes. The passion and drive for service user participation comes from our genuine commitment to partnership with women and a foundational philosophy of midwifery as women centred. We acknowledge that histories and contexts vary and we do not suggest that our methods or processes are transferable. We offer our experiences in response to the lack of descriptive or evaluative literature available currently and hope that this might stimulate debate and innovation in other programmes.
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