Managing projected midwifery workforce deficits through collaborative partnerships
Submitted: 9 March 2011 Accepted: 4 August 2011 Published: 24 February 2012
To address workforce shortages, the Australian Government funded additional nursing and midwifery places in 2009 pre-registration courses. An existing deficit in midwifery clinical placements, combined with the need to secure additional clinical placements, contributed to a serious shortfall. In response, a unique collaboration between Midwifery Academics of Victoria (MIDAC), rural and metropolitan maternity managers (RMM and MMM) groups and Department of Health (DOH) Victoria was generated, in order to overcome difficulties experienced by maternity services in meeting the increased need. This group identified the large number of different clinical assessment tools required to be being completed by midwives supervising students as problematic. It was agreed that the development of a Common Assessment Tool (CAT) for use in clinical assessment across all pre-registration midwifery courses in Victoria had the potential to reduce workload associated with student assessments and, in doing so, release additional placements within each service. The CAT was developed in 2009 and implemented in 2010. The unique collaboration involved in the development of the CAT is a blueprint for future projects. The collaboration on this project provided a range of benefits and challenges, as well as unique opportunities for further collaborations involving industry, government, regulators and the tertiary sector.
What is known about this topic? In response to current and predicted workforce shortages, the Australian Government funded additional midwifery places in pre-registration midwifery courses in 2009, creating the need for additional midwifery student clinical placements. Victorian midwifery service providers experienced difficulty in the supply of the additional placements requested, due to complex influences constraining clinical placement opportunities; one of these was the array of assessment tools being used by students on clinical placements.
What does this paper add? A collaborative partnership between MIDAC, RMM and MMM groups, and the DOH identified a range of problems affecting the ability of midwifery services to increase clinical placements. The workload burden attached to the wide range of clinical assessment tools required to be completed by the supervising midwife for each placement was identified as the most urgent problem requiring resolution. The collaborative partnership approach facilitated the development of a CAT capable of meeting the needs of all key stakeholders.
What are the implications for managers and policy makers? Using a collaborative partnership workshop approach, the development of a clear project focus where all participants understood the outcome required was achieved. This collaboration occurred at multiple levels with support from the DOH and was key to the success of the project. The approach strengthens problem solving in situations complicated by competing influences, a common occurrence in health service delivery, and where unilateral approaches have not or are unlikely to succeed.
The Australian healthcare system has experienced major challenges balancing increasing demand for health services with a decreasing professional health workforce,1–3 reflecting an international trend. Existing and projected deficits in the maternity care workforce provide an illustrative example of the vulnerability of the health system to staff shortages. Midwifery, obstetric and anaesthetic services are threatened with predictions of serious workforce shortages,4 a consequence of an aging and increasingly feminised health professional workforce. These threats are compounded by an 8.3% increase in births in Victorian public hospitals over the past 5 years.5,6 In 2008, the Commonwealth government announced Department of Education, Employment and Workplace Relations (DEEWR, formally DEST) funding for additional undergraduate places to boost the numbers of nursing and midwifery graduates entering the workforce.7 In Victoria, this increment translated to 280 new undergraduate places allocated for the 2009 intake, creating concern across the sector in regard to the lack of capacity to provide clinical placements for both new and existing tertiary places.8,9 This problem was exacerbated for undergraduate midwifery courses required to meet the then Nurses Board Victoria (NBV) course accreditation standard of a minimum of 1000 clinical placement hours per student throughout the course.10 Due to the nature of midwifery practice, student midwives are allocated to work a caseload with a qualified midwife during her rostered shift. The university-appointed clinical supervisor for the placement must divide their time across 8 to 10 students and is therefore unable to work one-to-one with individual students for more than 45–60 min per day. Consequently, it falls to the midwives employed by the service with whom the student is allocated to work to assume responsibility for supervising the student throughout the shift.10 Midwives responsible for the supervision of students take on an additional workload over and above their caseload allotment, with no expectation of financial or other reward for doing so. The demand by universities for additional clinical placements, already stretched to capacity to place students, has challenged maternity services across the state, with employers needing to be cognisant of the consequences of over-burdening staff with student supervision. It became clear that complex problems associated with student placements across the maternity care sector needed to be identified and addressed before opportunities for additional clinical placements could be created in order to meet the needs of the tertiary sector.
Midwifery education in Victoria is offered by seven universities and complicated by the option of three different pathways into midwifery. These pathways include: Graduate Diploma Midwifery, Double Degree (Nursing & Midwifery) and Bachelor of Midwifery. Complexity exists with each maternity service provider being involved with two or more universities involving three to eight different courses, necessitating the need for midwives employed by the service being expected to work with multiple variations in clinical assessment and clinical assessment tools. Instances were reported of some midwives struggling under the burden of working with up to 13 different clinical assessment tools, each with different requirements. The workload associated with the disparate clinical assessments was onerous and identified as a limiting factor in the agreement for services to meet requests for increased numbers of midwifery clinical placements.
A solution to this problem required collaboration between the seven Victorian universities providing midwifery education. This collaboration was facilitated through MIDAC, initially formed in 2007 in response to several threats affecting midwifery education in Victoria. MIDAC was founded on the basis of previous close interpersonal relationships across the university sector. This group had a unified purpose in protecting the future midwifery workforce and, in doing so, improve the experience of women having babies. MIDAC has worked together to promote and enhance midwifery education in Victoria. The concept of midwifery academics across the university sector working together appears to be a fairly unique concept amongst academic institutions. The members of MIDAC realised, however, that in order to increase opportunities for midwifery clinical placements, wider collaborative processes were required.
In 2008, MIDAC approached the Department of Health (DOH) with a request for assistance to increase the number of midwifery clinical places available across the state. The maternity services group within the DOH agreed to facilitate a meeting between MIDAC and the Metropolitan Maternity Managers (MMM). The MMM is a DOH-convened group inclusive of all publicly funded metropolitan maternity services managers in Melbourne. The group have a regular schedule of meetings for the purpose of facilitating collaboration across the services on a range of projects. The meeting between MIDAC and MMM aimed to identify common challenges and explore possible solutions to the interrelated problems of insufficient numbers of midwives in the workforce (MMM) and lack of student clinical places (MIDAC). The first meeting of MIDAC and MMM resulted in agreement to collaborate for the purpose of exploring joint projects designed to resolve these challenges. Several barriers within maternity services to increasing the number of clinical places were discussed, as were the complexity and variance associated with the additional workload midwives supervising students were exposed to, associated with the need to be familiar with multiple variations of clinical assessment tools. Of these varied clinical assessment tools, it was suggested that some were as long as 200 pages and required hours of clinical time to complete. The complexity and time-consuming nature of the varied assessments made this an onerous and often daunting task that was a barrier to being able to free-up additional clinical places.
Agreement on the way forward
A range of possible solutions were explored by the group, with agreement that the development of a Standardised or Common Assessment Tool (CAT) would be the solution most likely to have the largest effect from a single project. The group agreed to collaborate on a project, with MIDAC providing two representatives and Eastern Health (EH) providing the project lead from the MMM group. The collaborative project was supported by a small workforce innovation grant of $12 000 from the Maternity Service Branch (DOH). This money provided for the services of a research assistant to facilitate undertaking the research tasks.
Expanding the collaborative team
It was determined by the group that project collaboration needed to be expanded to include the DOH-convened Rural Midwifery Managers (RMM) group to ensure that every region across the state had the opportunity to participate in the development of the CAT. Each maternity service was then contacted and asked to provide one representative to be the project contact. Email communication was used to link the respective groups, with regular progress reports disseminated throughout the life of the project. Key stakeholders, such as representatives from Nurses Board of Victoria, were included in the project. Additional stakeholders were added where necessary as the project progressed.
A mixed-methods methodology was identified as the most appropriate research design for the conduct of this project. It was determined that the first step was to collect baseline data from key stakeholders with experience using the various clinical assessment tools on a regular basis, to confirm the desirability or need for the development of a common assessment tool. A survey of midwifery students, midwives supervising students during placement and clinical supervisors was undertaken using Survey Monkey. The survey was developed to gather information on what worked and what did not work across the range of existing clinical assessment tools, for use as a guide in the development of the CAT. The survey link was then distributed through the electronic collaborative group email list to MMM and RMM for local distribution to midwives engaged in student supervision. Clinical midwifery educators working with all seven universities were identified by MIDAC and invited to participate in the survey by email. A group of 90 midwifery students attending a popular workshop on new graduate programs convened by the Australian College of Midwives Victorian branch (ACM VIC) were also invited to participate by email. This cohort of final semester midwifery students were considered to be a representative group from all universities, courses and pathways.
Key findings from the preliminary survey were used to guide facilitated activity in two subsequent workshops in an attempt to retain elements from existing clinical assessment tools considered to work well, and to eliminate those elements identified as not working well during the clinical assessment process.
A total of 39 midwives and 48 midwifery students, out of a possible 90, participated in the preliminary survey. It has not been possible to quantify the total number of midwives who received an email inviting them to participate in the study as a snowball method was used, inclusive of all midwives supervising students from each of the seven universities and the three student pathways. Emails were disseminated through university and service networks, a process that involved some duplication.
The following were the main findings derived from the survey data. In response to the question ‘do the clinical assessment tools you use in the supervision of students allow you to assess the student’s clinical skill or be assessed?’, only 50.8% (n = 31 of 61) of the midwives and 54.2% (n = 26 of 48) of the students agreed. In response to the question ‘what type of clinical assessment tool would you prefer to use when assessing a student’s performance or being assessed?’, 84.6% of midwives (n = 33 of 39) and 93.8% of students (n = 46 of 48) were strongly in favour of having a standardised assessment tool that combined both competency- and skills-based assessment, rather than a reliance on one or the other. In response to the question ‘how important would using a common assessment tool be for you’, 87.2% (n = 34 of 39) of midwives and 93.8% (n = 46 of 48) of students indicated that it was important or very important, confirming the need for and the direction of the project.
The full results of the preliminary survey were presented to representatives from MMM and RMM, midwifery academics and key stakeholders at the first of two facilitated workshops convened at the DOH for the purpose of developing the CAT for statewide use. These workshops brought together all the key stakeholders for the purpose of achieving consensus agreement on the key elements to be included in the CAT and those to be excluded.
Two separate facilitated workshops convened at the DOH 2 months apart were used as the second source of data guiding CAT development. A full attendance was achieved at both workshops, due in part to the influence of the DOH in encouraging attendance at senior management level.
The first facilitated workshop identified the aims and potential benefits of the project using the findings of the preliminary survey as a starting point. The workshop provided an opportunity for frank and robust discussion on the issues and difficulties faced, including the availability of skilled clinical educators and concern regarding the burden that additional clinical placements would have on midwives working in the services. The special circumstances that exist in small rural and regional maternity services were recognised in this process. There were many stories of staff doing clinical assessments in their own time, as they did not have sufficient time to spend during a clinical shift when they were delivering care and supervising students.
Using the findings of the preliminary survey as a guide, the group determined the essential elements to be included in the CAT. First, that a competency-based assessment needed to remain using the Australian Nursing and Midwifery Council (ANMC) Competency Standards for Midwives (2006) for the purpose of assessing the student’s overall clinical competence. This assessment, however, would be completed less frequently than current requirements for some programs. A second set of skills-based assessments incorporating the ANMC competencies were developed in the clinical practice domains of pregnancy, labour and birth, following birth and care of the baby. The purpose of the skills-based assessments were to allow for more structured formative assessment to take place as part of the one-to-one supervision arrangement between student and midwife working a case allotment together. The responsibility for determining the proposed number and content of the skills was deferred to MIDAC, with volunteers from service representatives attending the workshop assisting in the development of the content breakdown within each skill.
A second workshop allowed the presentation of the agreed 24 skills assessments to be included in the CAT and the formation of working groups to refine these assessments further. The measurements to be used in the assessment of competency, competencies and clinical skills were debated at length in the workshop, resulting in agreement that the Bondy scale was the best option as it came with proven validity in measurement.11 The second workshop concluded with consensus agreement that the design and core elements of the draft CAT reflected the requirements articulated by midwives, academics and students, and had the potential to reduce workload involved in clinical assessment of midwifery students.
Following a one semester pilot of the CAT and associated revisions, the CAT has been implemented across all pre-registration midwifery courses in Victoria in 2011. The pilot evaluation that followed the development of the CAT, the implementation process and full evaluation of the CAT project will be reported following completion of the 1 year statewide trial.
Using a collaborative partnership workshop approach enabled the development of a clear project focus where all participants agreed on the outcome required; that is, a CAT that could be used across all clinical placements regardless of the academic program or maternity service. This collaboration occurred at multiple levels enhanced by DOH support and can be credited as the key to the success of the project. The ability of the project team to meet the needs of the academic, professional and registering authority, as well as deliver a tool that enabled clinicians to more effectively assess student clinical competency and competence to practice, represents a breakthrough in complex collaboration across key stakeholder groups in solving difficult problems. The challenge to develop a tool for use in all clinical settings that met all of the requirements of such diverse services straddling rural and metropolitan regions meant that the project team needed to work closely and respect the differing perspectives. The workshops enabled a facilitative approach to develop the broad concepts and themes of the tool. These workshops were then followed up with electronically linked expert groups made up of a mix of academics and clinicians, who worked through the individual domains of practices and skill sets to ensure they met the requirements of both groups. All team members had multiple opportunities to provide feedback and comment on the various components of the tools, with regular due dates provided using email.
This project highlights the success that was achieved through a collaborative framework in solving the issues created through increased demand for midwifery student clinical placements. The unique collaboration involving academics, students, industry and government facilitated success and is a blueprint for future projects. Through this collaboration, a CAT was developed for use across all pre-registration midwifery courses in Victoria and was implemented in 2011. A full evaluation of the CAT is currently in progress, to be reported when the evaluation is complete. The collaboration on this project provided a range of benefits and challenges, as well as unique opportunities for further collaborations involving industry, government, regulators and the tertiary sector.
The authors declare that no conflicts of interest exist.
We acknowledge the substantial and dedicated contribution of all members of the collaborative partnership team in the development of the CAT for pre-registration midwifery courses. These include maternity policy branch DOH Victoria, rural and metropolitan maternity managers groups, midwife participants in the workshops and all the midwifery educators and students who took the time to complete the preliminary project surveys, Eastern Health and the full membership of MIDAC (Australian Catholic University, Ballarat University, Deakin University, LaTrobe University, Monash University, RMIT University, Victoria University).
 Australia’s health workforce. Canberra: Productivity Commission; 2005.
 Health workforce submission from ADIA, Canberra: Productivity Commission; 2005.
 Nursing and midwifery labour force 2007. Canberra: Australian Institute of Health and Welfare; 2009.
 Loy CS, Warton RB, Dunbar JA. Workforce trends in specialist and GP obstetric practice in Victoria. Med J Aust 2007; 186: 26–30.
| PubMed |
 Laws P, Sullivan EA. Australia’s mothers and babies 2007. Canberra: Australian Institute of Health and Welfare; 2009. Perinatal statistics series no. 23. Cat. no. PER 48.
 Laws P, Li Z, Sullivan E. Australia’s mothers and babies 2008. Canberra: Australian Institute of Health and Welfare; 2010. Perinatal statistic series no. 24. Cat. no. PER 50.
 COAG’s meeting 29 Nov. Attachment A – Health and ageing. Canberra: Australian Government; 2008.
 Improving maternity services in Australia; the report of the maternity services review. Canberra: Commonwealth of Australia; 2009.
 More clinical placements needed as demand in undergraduate university nursing courses increases. Australian Nursing Federation; 2009. Available at http://www.anfvic.asn.au/news/14549.html [verified 10 January 2012].
 The standards and criteria for the accreditation of nursing and midwifery courses leading to registration, enrolment, endorsement and authorisation in Australia – with evidence guide. Canberra: Australian Nursing and Midwifery Council; 2010.
 Bondy KN. Criterion-referenced definitions for rating scales in clinical evaluation. J Nurs Educ 1983; 22: 376–82.
| CAS | PubMed |