Essay: Continuous professional development (CPD) for midwifery

Introduction:
Continuous professional development (CPD) is an essential component of midwifery practice (Nursing and Midwifery Council (NMC), 2015), which encourages midwives to improve their practice in line with evidence based research. CPD can be facilitated using a personal development plan (PDP). A PDP, enables the midwife to identify their learning needs, plan how to meet the identified need for both personal and professional development and finally to reflect upon the learning experience (Makinson, 2001). The aim of the following PDP is for the student midwife to achieve the goal of perineal suturing under the direct supervision of a registered midwifery mentor (NMC, 2009).
The learning needs, which Makinson (2001) identified as the first stage in creating a PDP, can be categorised into knowledge, skills and attitude. I already possess some components of the requisite knowledge, skills and attitude, however I need to develop others in order to meet the objective of the PDP.
Knowledge required
Skills required
Attitude required
Good understanding of suturing techniques
Reasons for suturing the perineum
Good awareness of the anatomy of the pelvic floor
Identification and classification of perineal trauma
Identification of the most appropriate suturing technique for the identified perineal tear
Ability to undertake the appropriate repair
Positive and willing attitude towards developing this skill
Confidence in my own ability
Confirmation from mentor that they have confidence in my ability to perform perineal suturing
Professionally delivering woman centred information to gain informed consent
Maintaining maternal dignity at all times
Table 1: Knowledge, skills and attitudes required.
A strengths, weaknesses, opportunities and threats (SWOT) analysis was undertaken to clearly identify my strengths and weaknesses and understand the opportunities and threats which I face in realising my goal. This can be used to plan how to meet the identified learning needs (Makinson, 2001).
Strengths
Weaknesses
Opportunities
Threats
Good understanding of the rationale behind perineal suturing.
Can build a good rapport with women and their families and can explain perineal suturing to them.
Confident in record keeping for perineal suturing.
These strengths have been confirmed by my mentors, in clinical practice.
Knowledge of the anatomy of the pelvic floor.
Identification of perineal anatomy following vaginal delivery.
Theoretical knowledge and practical experience of suturing techniques.
Familiarity and knowledge of suturing techniques.
Practical experience of suturing.
Observe perineal suturing in the clinical setting
Expand knowledge through lectures in university, additional reading, discussion with mentors and skill sessions in university and clinical practice.
Understand and observe in theatre the impact of suturing a third or fourth degree tear and to gain a greater understanding of the impact this has on the perineal anatomy.
To utilise simulation within university and placement settings.
Identify and gain informed consent from a woman in my care with a simple first or second degree tear. The woman should have an effective epidural and we should have built a strong rapport.
Lack of appropriate opportunities to undertake first or second degree repair in clinical practice.
Lack of confidence to perform the repair
Woman withdraw consent for the procedure
Table 2: SWOT analysis.
By using specific, measureable, achievable, realistic and time-bound (SMART) objectives for the PDP, I have systematically planned the learning progression I will undertake to achieve my PDP goal (Cottrell, 2003).
Specific
What do I want to do?
Measurable
What will I do to achieve this?
Achievable
What resources / support do I need to be successful?
Realistic
What shall my success criteria be?
Time dependant
What are my target dates for achieving this?
To suture a simple first or second degree perineal tear under direct supervision from a registered midwifery mentor
By the last week of my labour ward placement (08/06/2017), I will have sutured a perineal tear. In order to achieve this goal, I will discuss with my registered midwifery mentor my SMART objectives so that we can work together to achieve the goal, along with my scope of practice and the appropriateness of performing perineal suturing.
Defined processes include revising the perineal anatomy, observing my registered midwifery mentor suturing, attending a university and placement simulation skills session. Additionally, I will review the lecture notes, evidence based guidelines and trust guidelines.
In order to be successful I need time to observe my registered midwifery mentor suturing, to utilise simulation skills sessions and to revise the necessary guidelines and anatomy. Additionally, an opportunity to talk to midwives about their experiences, needs and recommendations. To discuss my learning styles and needs with my registered midwifery mentor. I require positive reinforcement alongside constructive feedback in order to develop my skill.
My success criteria will be whether the woman is happy with the experience and receiving positive feedback from my registered midwifery mentor.
Additionally, my registered midwifery mentor signing off the relevant PAD skill and EC Statutory Requirements as achieved.
To be completed by the 8th June 2017- the final day of my delivery suite placement.
Table 3: SMART objectives
Within midwifery practice, reflection encourages the use of evidence-based practice to provide different approaches to learning and achieving a goal (Forrest, 2008). This PDP will utilise Gibbs’ model of reflection (Gibbs, 1988), as the analytical stage encourages the exploration of different methods of preparation to achieve the specific goal. Gibbs’ model also progresses to an action plan, which plans for positive improvements in future practice (NMC, 2009).
Description:
On the 3rd June 2017, whilst I was leading the care, Louise (pseudonym to maintain confidentiality (NMC, 2015)), delivered a live male following a spontaneous vaginal birth with pain relief from an epidural. A subsequent perineal assessment revealed a small second degree tear. After gaining informed consent from Louise, arranging for good lighting and whilst the epidural was still effective, I competently sutured Louise’s perineal trauma under direct supervision from a registered midwifery mentor.
Feelings:
Initially I felt nervous, as this was a new and daunting experience. However, due to additional learning and simulation in line with the SMART objectives I felt more confident in the suturing process than I had previously. Nonetheless, suturing human tissue was a new experience. With the encouragement of Louise and the direct supervision of my midwife mentor, my initial nervousness receded and I felt more confident in the task. On completion of the repair, I was really pleased that I had been able to put my learning into practice and the repair had been successful. This boosted my confidence.
Louise gave informed consent, as she reported she had confidence in my abilities following me leading her care throughout her labour and delivery. She was aware that I was under the direct supervision of my midwife mentor. Louise was grateful upon completion of the repair.
Evaluation:
A positive from this experience was the communication between my registered midwifery mentor and I, helping to facilitate effective learning. Chamberlain (1997) found that a lack of support, poor communication skills and inappropriate role modelling from the mentor can lead to a loss of skills and hinder learning. Therefore emphasizing the beneficial effect of my mentors support, on achieving the goal of effective perineal suturing under direct supervision.
Other facilitating factors include the use of multiple resources and training aids to develop the skill. Birch et al. (2007) conducted a study which found that a combination of lecture and simulation-based training appears to give the best short-term improvement in performance and communication skills.
The main negative was my communication with Louise during the suturing. I was focused on the perineal suturing and checking with my registered midwifery mentor that I was doing an effective job, consequently I was not communicating with Louise during the perineal repair process. Rowe et al. (2002) suggests that midwives and women have highlighted misunderstandings and a poor experience when communication is poor, as well as worsened outcomes. Nonetheless, following completion Louise stated that she was grateful with the repair and was comfortable pain wise.
Analysis:
In preparation for suturing a second degree perineal tear, I initially reviewed my lecture notes, evidence based guidelines and trust guidelines, to better understand the competencies required to complete the procedure (Sawyer et al., 2015). Found benefits of gaining theoretical knowledge prior to attempting the practical procedure in order to provide rationale behind the process (Srivastava et al., 2012).
The student studied the perineum independently and with her registered midwifery mentor, in order to facilitate a greater understanding of perineal anatomy. The Royal College of Midwives state that all midwives should have a sound knowledge of the perineal anatomy, in order for correct classification and alignment of the perineum (Tohill and Kettle, 2013). Sultan, Kamm and Hudson (2009) conducted a study with 75 midwives in which over half of the midwives could not correctly identify aspects of the perineal anatomy. This is supported by Zimmo et al. (2017) who utilised a questionnaire which found that 9.6% of n=86 midwives had an accurate and comprehensive knowledge on perineal anatomy. However, following a training course and repeating the questionnaire 54.6% of midwives had an accurate knowledge, emphasizing the importance of effective training. However, a limitation of the study is that the actual clinical practice was not evaluated since the data was based on questionnaires only. The data was self-reported, which is known to be prone to information bias, potentially affecting the validity of the findings (Pannucci and Wilkins, 2010).
Following a discussion of the technique with my registered midwifery mentor on delivery suite, I observed her performing a second degree perineal tear repair, providing visualisation. My mentor supplemented the repair with a verbal description which helped me to link the theory I had reviewed, with the practical procedure. Evidence gathered from a randomised control trial (RCT), (Bjerrum et al., 2013) showed that healthcare professionals who had been shown a training video three times, performed better when repeating a skill, than the control group. A limitation of this trial was that the skill was tested in a simulation setting and consequently may not be generalisable to a clinical setting (Altman and Bland, 1998).
I attended a perineal repair simulation in the skills laboratory at university. It has been shown that the opportunity to practice a skill in a safe setting, such as the skills laboratory, prior to using the skill in clinical practice, establishes deeper learning (Cooper et al., 2012). A randomised control trial (RCT) conducted by Banks et al. (2007) indicated that training on inanimate objects before conducting perineal repair in the clinical setting, gave the student greater knowledge and competency. This RCT however had a small sample size (n=24) and the participants were all junior doctors, and as such generalisability should be applied with caution to student midwives (Altman and Bland, 1998). In the skills laboratory the perineal repair is simulated on a sponge, which is a cheap and convenient material. Although I found this useful to develop the technique and build my confidence, I found it difficult to visualise the anatomical structures of the perineum. My experience was in line with the findings of Crofts et al. (2006), who found that improved outcomes and skill levels from training with an anatomically accurate mannequin, compared to training with a less realistic simulation.
Positive reinforcement is very important in a learning environment, especially when new skills are being taught, such as perineal suturing (Skirton et al., 2012). Constructive, descriptive feedback is also very useful when used by the mentor to highlight future developmental goals (Duffy, 2013). Debriefing and providing feedback is valuable in the learning process. These are all techniques which I will seek to utilise when I become a mentor.
Conclusion:
I selected perineal suturing as the aim for my PDP. The process of preparing the PDP with a clearly identified aim, successfully achieving the aim through careful preparation and reflection upon the tools utilised in order to enhance the skill, has been discussed. This exercise has demonstrated the value of a PDP in advancing my midwifery practice and highlighted that my future focus should be upon my communication with the woman during perineal repair.
Action plan:
Reflection on the PDP process, has enabled the production of an action plan to support my transition from student midwife into a newly qualified midwife role.
A phenomenological study of newly qualified nurses (n=13) identified the importance of using their preceptor to seek support to improve their confidence and clinical skills (Kelly and Ahern, 2008). Hughes and Fraser (2011) support this finding by recognising that seeking support from the preceptor improved the experiences and outcomes for newly qualified midwives. From this evidence and following my experience of implementing the PDP, I plan to seek ongoing support from my preceptor throughout my preceptorship. This will include support to further enhance my perineal suturing skills (Kelly and McAllister, 2013).
In line with the NMC (2015), I will ensure that evidence based guidelines are regularly reviewed, so that I can develop my practice accordingly and in line with the best-available evidence. It has been shown that by developing practice in this way, both maternal health and experiences are improved (Austin et al., 2014).
The effectiveness of simulation as a training technique was assessed by a systematic literature review of 24 studies (Cooper et al., 2012). The review concluded that simulation does increase competence and confidence, this is supported by the evidence within the analysis section (Banks et al., 2007). Consequently I intend to continue to use simulation of perineal repair, to enhance my skill and build my confidence prior to repairing a perineal tear.