Sue Hayward

Chief Nursing and Midwifery Officer

Waikato District Health Board

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Contents

1 Introduction 4

1.2 Vision 4

1.2 Waikato DHB’s strategic imperatives 4

2 Accountability 5

3 Expectations 6

3.1 Midwifery clinical decision-making and documentation 7

3.2 Partnership care 8

3.3 Bedside handover 9

3.4 Intentional Rounding 9

3.5 Releasing Time to Care 9

3.6 Assignment workload manager 9

3.7 Professional development framework 10

4 Summary 11

5 Strategic aims 12

Strategic aim 1 12

Strategic aim 2 13

Strategic aim 3 14

Strategic aim 4 15

Professional development framework for midwifery 16

Professional development framework for moving into designated senior midwifery roles 17

Role expectations for designated senior midwifery roles 18

Reference list 20

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People at heartTe iwi Ngakaunui

Give and earn respect – Whakamana

Listen to me; talk to me – Whakarongo

Fair play – Mauri Pai

Growing the good – Whakapakari

Stronger together – Kotahitanga

Values

Pae taum

ata Ratonga a iwi Manaaki

H

aum

aru

Effective and efficient care and services

People centred services

A centre of excellence in learning,

training, research,

and innovation

Safe, quality health

services for all

Health equity for high need

populations

Productive partnerships

Whanaketang

a

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VisionHealthy people. Excellent care

MissionEnable us all to manage our health and wellbeing

Provide excellent care through smarter, innovative delivery

Waikato DHB Strategy

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1 Introduction1.2 VisionThe vision, Healthy People, Excellent Care has been set by the Waikato District Health Board (Waikato DHB) and Executive Group following engagement and consultation with wider groups. This is the vision when working at the Waikato DHB we all work towards achieving. The skills and knowledge midwives hold and use in care delivery contribute to achieving this vision. Commitment to working together with other members of the health care team in a manner that women and their families find acceptable will make this vision achievable.

1.2 Waikato DHB’s strategic imperativesEach midwife must use their knowledge and skills whether as a beginner or experienced practitioner, in a way that supports and improves maternity care and the clients’ experience. To guide in prioritising where care delivery is to be focused:

• Achieving health equity for high needs population

• Ensuring quality health services for all

• Providing people centred care

• Delivering effective and efficient care and services

• Becoming a centre of excellence in teaching training and research

• Developing productive partnerships

The four midwifery strategic aims (pages 12-15) align with the DHBs strategic imperatives. These aims provide the direction for the next five years. The actions needed to achieve the aims can be utilised by midwives either individually or as part of the wider team. Utilising these provides a mechanism to support individual accountability with evidence informing performance reviews and the setting of objectives. The DHB imperatives inform the direction and activities of the DHB, the midwifery strategic aims indicate how they can be achieved. Midwifery practice contributes to and influences the success of each of the DHB imperatives.

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2 AccountabilityEach midwife is accountable for their practice, they are also accountable as members of the health care team to know and understand how they influence achievements both clinically and organisationally. Accountability is the requirement to demonstrate and take responsibility for performance; this is both as an individual and as part of a health care team. In order to ensure understanding of accountability the following describes the principles and supporting structures:

• Expectations are clarified and understood: Midwifery at Waikato 2017-2021, position descriptions and the professional development frameworks all describe levels of expectations and minimum requirements of midwifery roles.

• Decisions are transparent and rational: policies governing practise, professional behaviours and evidenced based clinical protocols are in place and accessible e.g. policies housed on the DHBs intranet site, Lippincott Clinical Procedures etc.

• Feedback is the expected norm: yearly performance appraisals support and provide ongoing guidance and real time feedback should be given by managers and peers.

• Responsibility is understood and accepted: each midwife must be cognisant of their scope of practice: Position Descriptions indicate levels of authority and participation in the Quality Leadership Programme is encouraged to provide evidence of how responsibility is demonstrated.

• Continuous improvement is in place: utilising, engaging with and driving changes and improvement through the Quality and Patient Safety agenda as well as Releasing Time to Care ensures that individuals and teams are accountable for outcome aligned to practice and organisational design.

Each identified senior midwifery role is allocated key activities to achieve the strategic imperatives with these also aligning with accountabilities.

Waikato DHB is committed to a Just Culture. The DHB is supporting this through the designing of safe systems, managing behavioural choices and creating a learning culture. It is the balancing of the need to learn from mistakes and the need to take disciplinary action that will promote organisational and individual accountability through just and fair consequences.

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3 ExpectationsEach midwife must be cognisant of their scope of practice as defined by the Midwifery Council of New Zealand (MCNZ), work within the MCNZ Code of Conduct and understand how to develop therapeutic relationships without breaching professional boundaries. www.midwiferycouncil.health.nz/midwives

Delivering care in a culturally competent manner is an absolute expectation, indicating an understanding commitment and active engagement with patients/service users and colleagues. Building on this, cultural humility as described by Trevalon & Murray-Garcia (1998) further supports lifelong commitment to self-evaluation and understanding how relational dynamics that occur between the midwife and women can affect how the health care delivered is accepted.

The following outlines expectations placed on midwives relating to quality of care, providing women centred care, providing effective care delivery processes, remaining current in knowledge, advancing practice and working in partnership with women and their families and our health colleagues. Minimum standards of care, knowledge acquisition, career progression and importantly the manner in which care is delivered are described, and are to be considered standards that are not negotiable.

Supporting these expectations, education and learning required to keep midwives clinically sound and opportunities to extend the way individual midwives may aspire to achieve, are provided via the Professional Development Unit. The Nursing and Midwifery Directorate is committed to the use of Practice Development methodology as it brings together sustainable evidenced, approaches to deliver measurable outcomes that make a difference in practice and can add to the body of knowledge. Practice Development methodologies support the transfer of many types of knowledge from learning to practice. Adopting person centred active learning; it is a facilitated process that makes use of critical reflection and generative discussion.

Midwives employed by Waikato DHB work in primary, secondary and tertiary maternity settings and contribute to the maternity client’s journey through her pregnancy, birth and postnatal experience. Midwives care for women and their babies holistically in whatever setting.

Specific workforce challenges exist for the acute services in which secondary/tertiary midwives practice at Waikato DHB. The fast turnover of clients coupled with high acuity pose particular challenges around recruitment and retention. Midwives contributed to a profile to celebrate their work setting.

Reducing client/patient/service user harm and suffering is the ultimate aim for all health workers. The Nursing and Midwifery Directorate has chosen the overarching framework Compassionate Connected Care (3Cs) as a way to equip midwives with the understanding of how midwifery care and organisational requirements can be merged and support the DHBs strategic imperatives. This framework described by Dempsey Wojciechowski, McConville and Drain,(2014) integrates the clinical, operational, cultural and behavioural aspects of care delivery and provides a way to work so all aspects of organisational requirements are met, while addressing the challenges faced to reduce client suffering or harm.

As described by Dempsey et al inherent suffering is often not preventable as this occurs because of the diagnosis and sometimes then by the treatment which can be painful or uncomfortable and generally causes a disruption to normal life. It is the avoidable suffering midwives can reduce, as this

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Clinical excellenceConnecting clinical

excellence with outcomes

Operational efficiencyConnecting efficiency

with quality

Caring behaviourConnecting

engagement with action

Organisational cultureConnecting mission, vision and value with

engagement

Compassionate connected care

Table 1:JONA Vol 44 no.10 (2014)

is associated with unmanaged pain, medication error, hospital acquired pressure injury (rare, but occurring in maternity), a fall or being treated without dignity and respect.

The domains of the 3Cs (Table 1) provides a visualisation of how each component can be supported by connecting actions with outcomes.

Clinical excellence links to outcomes, operational efficiency and quality, caring behaviours to the service user’s experience and culturally to the DHBs vision Healthy People Excellent Care. The central component is; all care is delivered with compassion, with an understanding of what outcomes (goals) are being aimed for, being aware of how the care will be perceived by the woman, keeping quality at the forefront and knowing that by doing this the DHBs values are supported.

The Compassionate Connected Care framework guides the systems and process needed to support the work of midwives. These systems and processes are not an addition to midwifery work but should be viewed as essential and integrated structures allowing midwifery to be delivered effectively during the peaks and troughs of clinical demand.

The programmes of work and models of care delivery that support midwives and are expected to be utilised are described next:

3.1 Midwifery clinical decision-making and documentation The midwife bases her clinical decision-making upon making an assessment, plan interventions required, followed by an evaluation of the effectiveness of the intervention. The midwife enables the client to set her own goals and document these in the appropriate documentation, e.g. birth plan, care plan. Midwives fully utilise the documents specified in the setting where they work. For example, in the inpatient setting the antenatal – or postnatal care plan will reflect the midwifery assessment and supports the planning and intervention stage. The evaluation of the care delivered, outcomes and any escalation undertaken are always documented in the clinical notes.

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3.2 Partnership care

Supporting clinical excellence and operational efficiency the model of clinical service delivery within inpatient wards is “Partnership Care”. This model while still having elements of allocation has the midwives and nurses on each shift working in defined teams caring for a group of clients. The teams can consist of a mix of Registered Midwife, Registered Nurse, Enroled Nurse, Health Care Assistants. At the very minimum each team must:

• introduce themselves to their clients

• equitable work load in terms of acuity, (this is not necessarily the same as numbers)

• some knowledge of all the clients their team is caring for

• have planned support for high intensity interventions/procedures

• team based or ward based huddles

• staggered meal relief.

The teams must work in a culture that encourages case discussions and joint decision making around complex care planning and use opportunities that are presented to share knowledge. Working in Partnership Care permits the midwife/nurse to seek advice from colleagues when confronted with any aspect of clinical care that may need clarifying, or require a higher knowledge level or skill than they have at that point in time.

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3.3 Bedside handoverThe DHB’s policy is set out in the Clinical Handover (Bedside Handover) for Nursing and Midwifery procedure.

Supporting caring behaviour and engagement, this hand over process is to be carried out between shifts over the 24 hour period. Bedside handover actively includes the client and her Lead Maternity Carer if present using the Situation, Background, Assessment, Recommendation and Response (SBARR) communication tool to ensure a cohesive handover of information occurs. The client being part of the handover must be given the opportunity to participate and confirm that the information is correct.

3.4 Intentional Rounding The DHB’s policy is set out in the Interntional Rounding procedure.

Supporting all four domains of the CCC (3Cs) framework, Intentional Rounding is the process used to ensure every patient regardless of their acuity is seen and interacted with on a regular basis. Utilising Intentional Rounding in the maternity service allows clients the comfort and confidence that they will be seen at the very least every two hours. While essential aspects of care such as managing pain, assisting with personal needs and positioning are always to be addressed, other areas related to the client’s clinical needs are also included. Documented activities are noted in the care plan and evaluation of the care delivered is documented in the clinical notes.

3.5 Releasing Time to Care (RTC)Supporting all four domains of the CCC (3CS) framework, Releasing Time to Care (RTC) is a series of processes that enable midwives to create a working environment that is efficient, streamlined and gives more time to focus on midwifery care. The RTC methodology helps support quality and patient safety initiatives, whether local or global, provide the mechanism that improves audit results while giving midwives on the floor the opportunity to drive the changes needed in order to improve their practice environment and safety for women and their babies.

Every midwife must at the very least be aware of what activities are occurring within productives in their area, and for those with the increased enthusiasm and ability to drive change then engagement is most welcomed.

3.6 Assignment workload manager

Supporting operational efficiency and clinical excellence, Assignment Workload Manager (AWM) is the acuity tool the Waikato DHB is utilising that measures the work of midwives and nurses and then translate to rostering the right skill mix and number to match patient demand (i.e. numbers acuity and dependency). Entering the data while a CMM responsibility is delegated to appropriate midwives/nurses on each shift, and as such learning how to do this is essential. Understanding how the data is entered and how the calculations are created increases individual midwife/nurse’s opportunity to influence how this tool can be used in order to smooth out staffing variances, allocate the right team of staff to the acuity of inpatients rather than to number of patients, plan activity associated with high intensity treatments and planning breaks.

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3.7 Professional development frameworkEvery midwife must be aware of the Career Path framework and the minimum standards of knowledge and skills in practice expected of them dependent on years of practise. Achieving these and being engaged in quality and patient safety activities promotes a confident and competent midwifery workforce able to deliver the clinical care required to meet the needs of the maternity population.

Participating in the Quality and Leadership Programme (QLP)For Waikato DHB employees, more information is available in the Developing Our Staff section of the staff intranet.QLP provides the evidence midwives and their managers can use both as a way of advancing careers and receiving monetary acknowledgment of the contribution the midwife makes to client care. While participation in the QLP is not compulsory, for appointment to a senior midwifery role the minimum requirement for interview is achievement to the leadership domain on the QLP.

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4 SummaryEvery midwife working within the Waikato DHB is accountable for their own practise, responsible for understanding their scope as described by the Midwifery Council of NZ, expected to work in a caring compassionate manner and at the very least understand how their contributions to client safety and outcomes are connected to their own personal values, the clinical areas values and those of the DHB.

Midwives are a highly valuable component in the delivery of maternity care, and integral to the clinical team. Midwives are encouraged and to be congratulated when they lead where they stand.

The Nursing and Midwifery Directorate is in place and committed to support midwives to achieve the best outcomes possible for their clients, to provide advice and opportunities to extend and expand knowledge and skill acquisition during their career.

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STRATEGIC AIM 1:Lead and apply a strong midwifery culture which harnesses and values the contribution of midwives

Key objectives Outcome measures

Facilitate and apply leadership competencies for senior midwives that meet organisational requirements

• Organisations vision and values are demonstrated in the care environment

• Visibility and presence of midwives exist within all patient and staff safety forums

• Competencies have been identified and inserted in position descriptions

• Senior midwives are responsive to KPIs and data from audit to drive ongoing quality improvements

• PDU activities align with leadership development

Midwifery contribution to quality and patient safety will be demonstrated

• Releasing Time to Care series is implemented in a way that will show an increase in direct client care

• The skill mix for each ward/department is defined and matches patient demand (throughput) and predicted acuity or dependency

• Hand Hygiene audits reflect best practise and meeting target

• Culturally competent midwifery workforce as per the Midwifery Council statement in order to meet the needs of our Maori and culturally diverse population

5 Strategic aimsThe following four strategic aims are specific to midwifery while supporting the DHB strategic imperatives. The objectives and outcome measures indicate what we are to achieve and how success will be viewed.

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STRATEGIC AIM 2:Build workforce capability, readiness and capacity

Key objectives Outcome measures

Ensure a continuation of advanced roles and midwifery-led services to meet organisation requirements

• Each service has identified the roles required to provide safe care presently and into the near future

• Advanced roles have clear quality assurance frameworks e.g. credentialing, QLP

• Senior and advanced midwifery roles can describe their contribution to the model of care for improving population health outcomes

Establish the ‘entry workforce’ numbers, type and processes needed to sustain the midwifery workforce

• Evidence of collaboration with Wintec to ensure student numbers and quality reflect the population need

• A sustainable process that achieves intakes of an agreed number of midwifery graduates to maintain the employed midwifery workforce

• Employed graduate midwives are supported through preceptorship, education and mentoring. Graduate LMCs are supported when they access the secondary care facility

• Midwifery workforce reflects the demographics of our population

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STRATEGIC AIM 3:Midwifery uses and contributes to the delivery of effective health care based in research and acknowledged best practice

Key objectives Outcome measures

Develop, influence and implement processes that ensure maternity and newborn service users will receive safe and effective care

• Patient safety programmes have been implemented inclusive of:

- Releasing Time to Care

- Falls Minimisation

- Early Deterioration Detection System (ADDS) (Obstetric Early Warning Score, Primary Maternity ADDS and Newborn observation chart)

- Care Standards

- Organisational Audits

- Role imperatives

- Hand Hygiene practices

- Medication Safety

- Hospital acquired pressure ulcers

- Utilisation of evidence based midwifery procedures

• Risk minimisation is evident

• Midwives participate in research that contribute to the body of knowledge and inform midwifery practice

Demonstrate that midwifery practice is based in contemporary best practice

• Education plans are linked to learning needs assessments and workforce design. Training resources have been made available to primary maternity providers and NGOs

• Staff has access to policies and procedures that are up to date, consistent across the DHBs and based on evidence

• Results from patient safety programme reflect acceptable outcomes as per national and international benchmarking

• Implement culture of learning (based on DEU principles1) as the preferred midwifery student learning experience

• Integrate the use of virtual health delivery into learning programmes

1E.g. dedicated preceptor, increased in-practice presence from DHB and Wintec etc.

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STRATEGIC AIM 4:Improve care coordination across the health continuum to enhance timely access to health care for the Waikato population

Key objectives Outcome measures

In collaboration with key stakeholders, develop and implement primary- and rural midwifery strategies to meet key requirements of communities and new models of care

• Develop and implement integrated rural – and primary maternity models of care in conjunction with LMCs and key stakeholders to enable sustainability of service delivery and founded on continuity of care and the needs of women

• Develop processes that support ambulatory care and avoid unnecessary hospital admissions during pregnancy

• Develop a sustainable and flexible midwifery workforce

• Build and strengthen alliances across and within the maternity sector, including education, NGOs, primary, secondary and tertiary care

• Virtual Health Strategy and its delivery are integrated into models of care

• Developing models of service delivery that are inclusive of virtual health technologies

Implement smooth patient journeys across health settings

• Midwifery led discharge is utilised from postnatal inpatient secondary care

• Midwifery led clinics developed and implemented with evidence of quality service delivery

• Inter/intra- hospital transfer/retrievals occur in a timely and safe way

• Two-way communication between maternity services and LMCs occur in a timely, appropriate and effective way

• Virtual health technologies are increasingly explored to support clinical care delivery

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A centre of excellence in learning, training, research and innovation

Effective and efficient care and services

People centred services

Safe, qualtiy health services for all

Health equity for high need populations

Harness and value midwifery contribution

Contribute to seamless continuum of care

Build workforce capability

Deliver effective, evidence based care

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emen

t of a

de

fined

pat

ient

/clie

nt g

roup

•

Res

earc

hing

, eva

luat

ion,

de

velo

ping

and

im

plem

entin

g st

anda

rds

of m

idw

ifery

pra

ctic

e in

sp

ecifi

c ar

ea o

f pra

ctic

e •

Lead

s th

e de

velo

pmen

t of

path

way

s, p

roto

cols

and

gu

idel

ines

in th

e sp

ecifi

c ar

ea o

f pra

ctic

e

Clin

ical

Mid

wife

ry

Co

ord

inat

or

• C

oord

inat

es p

eopl

e,

syst

ems

and

reso

urce

s fo

r a

shift

or

grou

p to

ens

ure

serv

ice

deliv

ery

is m

et

• M

ay c

ontr

ibut

e to

coa

chin

g an

d su

perv

isio

n of

sta

ff •

Pro

mot

es a

qua

lity

envi

ronm

ent t

hat s

uppo

rts

and

faci

litat

es im

prov

ed

patie

nt o

utco

mes

and

ex

perie

nce

Ed

ucat

ion

ME

• C

ontr

ibut

e to

the

stra

tegi

c di

rect

ion

of m

idw

ifery

ed

ucat

ion

• Fo

cus

on s

kill

deve

lopm

ent a

nd e

duca

tion

of

mid

wiv

es w

ithin

clin

ical

are

as to

mee

t the

nee

ds

of c

lient

s•

Faci

litat

e le

arni

ng, d

evel

opm

ent a

nd d

eliv

ery

of

educ

atio

n in

clin

ical

and

cla

ssro

om s

ettin

gs•

Dev

elop

com

pete

ncy

and

capa

bilit

y of

the

mid

wife

ry w

orkf

orce

• P

rom

ote

an e

nviro

nmen

t tha

t con

trib

utes

to

on-g

oing

dem

onst

ratio

n an

d ev

alua

tion

of

com

pete

ncie

s•

Inte

grat

e ev

iden

ce b

ased

theo

ry a

nd b

est

prac

tice

into

edu

catio

n ac

tiviti

es

Mid

wife

C

oo

rdin

ato

r

• D

evel

op, i

mpl

emen

t and

coo

rdin

ate

spec

ific

clin

ical

, edu

catio

n an

d qu

ality

pro

gram

mes

ac

ross

Wai

kato

DH

B to

refle

ct s

trat

egic

di

rect

ion

• E

nsur

e pr

ogra

mm

es c

ontin

ue to

mee

t the

M

CN

Z ac

cred

itatio

n st

anda

rds

and/

or H

WN

Z re

quire

men

ts

• R

evie

w, i

mpl

emen

t and

eva

luat

e pr

ogra

mm

e ch

ange

s ba

sed

on re

gion

al a

nd/o

r na

tiona

l ch

ange

s •

Con

trib

ute

to s

ubm

issi

ons

on c

onsu

ltatio

n do

cum

ents

impa

ctin

g on

pro

fess

iona

ls,

prog

ram

mes

and

/or

heal

th o

f New

Zea

land

ers

Res

earc

h an

d Q

ualit

y

Mid

wife

Res

earc

her

• Le

ads

and

unde

rtak

es

mid

wife

ry o

r po

pula

tion

heal

th re

sear

ch a

nd

deve

lopm

ent a

ctiv

ity

usin

g ac

cept

ed re

sear

ch

met

hodo

logy

, loc

ally,

re

gion

ally

and

/or

natio

nally

• P

rom

otes

a re

sear

ch

envi

ronm

ent t

hat s

uppo

rts

and

faci

litat

es re

sear

ch

min

dedn

ess

and

rese

arch

ut

ilisat

ion

• S

uppo

rts

and

eval

uate

s pr

actic

e th

roug

h re

sear

ch

activ

ities

and

app

licat

ion

of e

vide

nce

base

d kn

owle

dge

Mid

wife

Co

nsul

tant

• P

rovi

des

prof

essi

onal

m

idw

ifery

adv

ice,

le

ader

ship

and

con

sulta

ncy

• In

crea

ses

effe

ctiv

enes

s of

pa

tient

car

e de

liver

y •

Lead

s qu

ality

impr

ovem

ent

• D

evel

ops

and

mai

ntai

ns

fram

ewor

ks fo

r po

licy

and

educ

atio

n•

Faci

litat

es m

idw

ifery

inpu

t in

to p

olic

y de

velo

pmen

t

19

Reference list:Demsey,C., Wojciechowski,S.,McConville,E.,& Drain,M. (2014) Reducing patient suffering through Compassionate Connected Care. Journal Nursing Administration, Oct; 44(10) 517-524.

Trevalon,M.,& Murray-Garcia,J.(1998). Cultural Humility versus Cultural Competence. Journal of Health Care for the Poor and Underserved, 9(2), 117-119

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