workforce campusreview. com. au
Decisions, decisions, decisions
Training in clinical reasoning needs to be a priority for midwives.
By James Wells
The safety and effectiveness of Australian midwifery practice could be improved with education fostering clinical reasoning and decision-making, a study from Southern Cross University has shown.
In a recently published paper, Dr Elaine Jefford and professor Kathleen Fahy of Southern Cross University’ s School of Health and Human Sciences concluded there is a lack of industry standards for teaching midwifery students clinical reasoning and decision-making and sweeping revisions to midwife education are needed to counter this.
Jefford says this could compromise the health of mothers and babies, and argues that university curriculums must be revised to include clinical reasoning in teaching and assessment, so new midwives do not have to rely solely on their own intuition during professional practice.
“ Professional standards around the world recognise the importance of midwives’ decision-making during childbirth and the health and safety of women and babies during childbirth critically depends on midwives’ decisionmaking skills,” Jefford says.“ These inconsistencies [ in Australia ] undermine the effectiveness and application of midwifery education into practice, as well as hindering a midwife’ s professional autonomy and the discipline generally. Ultimately, the health and safety of women and babies are compromised.”
Jefford and Fahy’ s study involved 26 practising midwives from various services across Australia, who each provided two clinical narratives. One narrative outlined something the midwife deemed an example of good clinical reasoning and the other detailed something she considered poor clinical reasoning. Jefford, who says the study was the first of its kind in the world, then assessed the narratives against a decision-making framework she devised.
Meanwhile, Jefford is collaborating with other researchers to develop an online learning package focusing on clinical reasoning and decision-making for students of midwifery. She hopes it will provide a structured, comprehensive and transparent approach to theories on decision-making processes.
Jefford also hopes this program will help encourage flexible frameworks for decisions, which she says are vital for effective midwifery practice.
“ The context for midwifery is different,” she says.“ Midwifery is not often an illness situation.”
The Australian College of Midwives has endorsed the study and is investigating how its conclusions might complement the college’ s National Midwifery Guidelines for Consultation and Referral.
“ There is always room for improvement in the teaching of clinical reasoning and decision-making skills and making it more explicit in the midwifery education curricula would assist with this,” ACM education adviser Ruth King says.“ Midwives should to be supported in taking a life-long approach to learning once they enter the workplace.”
But Jefford maintains midwifery should not be classified under the umbrellas of nursing or medicine; rather, it should act as a stand-alone profession. She explains that midwifery clinical practice and decision- making in Australia is now based on ethical and philosophic guidelines laid out by the International Confederation of Midwives and Australian College of Midwives.
Jefford says that while these frameworks add value to midwife training and practice, they do not acknowledge midwifery as a separate profession and ignore the philosophy behind midwifery, which has negative consequences for the training of midwives.
She explains this can lead to a process known as midwifery abdication, where midwives, consciously or unconsciously, surrender responsibility for their decisionmaking when caring for patients.
“ The [ study ] findings showed that half the midwives interviewed do have the ability to use clinical reasoning skills well, but fewer than half followed a process through to the end,” Jefford says.“ Although potentially unpalatable to the midwifery profession, it is important to acknowledge that a process called midwifery abdication does perhaps exist – failing to fulfil or be accountable for one’ s professional behaviour.”
As midwives also have professional responsibility towards their patient, the patient’ s family, community, organisation and the profession as a whole, Jefford says midwives are placed in a vulnerable position as they are forced to justify their actions to multiple parties.
Most midwives navigate this minefield by caring for their patients within legal and professional frameworks, the same frameworks Jefford says are insufficient for the midwifery profession.
She hopes the development of standardised teaching for clinical practice and decision-making will prevent midwifery abdication, and help new midwives make better decisions in the workforce. Jefford says universities have a vital role to play in ensuring midwifery students are properly educated in good decision-making processes. Furthermore, she says midwifery teaching packages and tools themselves must be extensively tested and trialled so as to ensure they are properly effective in teaching students.
This includes the online Enhanced Decision-Making and Assessment in Midwifery Tool( EDAM), which Jefford helped develop this year with researchers from Australia and the Netherlands in response to her study results.
“ This teaching resource is being embedded across the midwifery curricula at Southern Cross University,” Jefford says.
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