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Competence to practise: an unmistakable fact or a holy grail?


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Title: Competence to practise: an unmistakable fact or a holy grail?

Competence to practise an unmistakable fact or a
holy grail?
  • Wednesday 11th February 2015
  • Professor Mary Chiarella

  • Professionalism and professional regulation
  • Elements of professional regulation
  • The question of competence assurance or
    continuing competence.
  • The regulation of midwifery a whistlestop tour

Definition of a profession
  • An occupation whose core element is work based
    upon the mastery of a complex body of knowledge
    and skills. It is a vocation in which knowledge
    of some department of science or learning or the
    practice of an art founded upon it is used in the
    service of others. Its members are governed by
    codes of ethics and profess a commitment to
    competence, integrity and morality, altruism, and
    the promotion of the public good within their
    domain. These commitments form the basis of a
    social contract between a profession and society,
    which in return grants the profession a monopoly
    over the use of its knowledge base, the right to
    considerable autonomy in practice and the
    privilege of self-regulation. Professions and
    their members are accountable to those served and
    to society(Cruess, Johnston Cruess, 2004,

The regulation of health professionals
  • Forms part of a branch of law known as
    administrative law
  • Is described as a protective jurisdiction
  • ICN WHO agree that The purpose of professional
    self-regulation is to safeguard and champion
    patient safety (ICN/WHO, 2005 p.7)
  • Primary objective of the national registration
    and accreditation scheme in Australia under
    Health Practitioner Regulation National Law 2009
    (Qld) Part One, s.3(2)(a)
  • to provide for the protection of the public by
    ensuring that only health practitioners who are
    suitably trained and qualified to practise in a
    competent and ethical manner are registered"
  • In most countries this is achieved by a
    combination of processes
  • 1. Standard setting to ensure the right people
    get into the profession this includes standards
    for courses (accreditation) and standards for
    entry (registration)
  • 2. Advice and guidance to assist practitioners to
    practise in a competent and ethical manner
  • 3. Mechanisms to protect the public when they do
    not practise in a competent and ethical manner,
    for whatever reason

The privilege of self-regulation
  • Professional regulation may be taken to read that
    the profession regulates itself
  • To some extent this is correct, albeit in most
    countries through a statutory framework to give
    teeth to the regulatory processes
  • Professions therefore tend to decide
  • who should enter the profession,
  • what those who enter might look like,
  • how they might properly conduct themselves as
    members of that profession and
  • what criteria would need to be breached in order
    for them to be excluded from the profession

Professional regulation is not favoured by all
  • There is debate as to whether professions should
    self regulate, set their own standards and
    determine who comes in and who leaves ((van Mook
    et al, 2009 Chief Justice of Ontario Advisory
    Committee, 2001)
  • However, there is also concern that our self
    regulation can create monopolies and limit
    market competition - itself an interesting
    debate in a service such as health care (Siebert
    , 2006)
  • "Whereas public regulation was meant to ensure
    public protection, the word is now increasingly
    associated with central control, unreasonable
    bureaucracy and restraint in international trade
    and worker mobility. (ICN, 1998, p.7)
  • Given the global migration of nurses today, and
    the fluctuation between countries in supply of
    nurses, both under and over, there is much debate
    amongst governments and employers alike about how
    influential a profession's hold on regulation
    ought to be (Ameringer, 2008)

Self-regulation or co-regulation?
  • Arguably in most countries the model is not one
    of complete self-regulation, but co-regulation
  • Governments already play a significant role in
    regulation of health professionals
  • Through remuneration systems in both the
    industrial and commercial domains
  • Through legislation that grants access to the use
    of therapeutic drugs and devices
  • Through such structures as admitting and visiting
    rights to hospitals and other health care
    facilities and
  • Through processes such as adverse incident
    reporting and, where serious adverse events
    occur, investigations and recommendations from
    Commissions of Inquiry.

Elements of professional regulation(9) include
  • Registration who should enter the profession and
    what those who enter might look like
  • Accreditation oversight of how those who might
    enter should be prepared
  • Codes and guidelines how they might properly
    conduct themselves as members of that profession
  • and
  • Complaints and notifications what criteria
    would need to be breached in order for them to be
    excluded from the profession

The elements of professional regulation
(Chiarella White, 2013)
Registration deciding who should enter the
Registration standards
  • Deciding who should enter the profession
  • Determining (inter alia)
  • Age of entry
  • Physical and mental well-being
  • Fitness to practise
  • Prior educational experience
  • Educational qualifications (see accreditation
  • The need for proficiency in the relevant language
  • Criminal record checks
  • Professional indemnity insurance
  • Recency of practice.

Domains of RN standards for practice
  • Professional Practice
  • Critical Thinking and Analysis
  • Provision and Coordination of Care
  • Collaborative and Therapeutic Practice (NMBA,
    2010 under review)
  • Each domain then has a number of elements, and
    each element has a number of behavioural cues to
    assist in assessment.
  • In New Zealand nurses undertaking their
    assessment of continuing competence are expected
    to self- assess against the competency standards
    (Vernon et al, 2010)
  • This use of competency standards is similar to
    developments in America and Canada for medicine
    (WHO, 2005)

Codes and Guidelines and Professionalism
The provision of professional advice and
  • May include
  • Sets of competency standards that a health
    practitioner is required to meet before entry to
    the relevant section of a professional register
  • Codes of conduct and codes of ethics (the
    floors and ceilings of professional
    expectation) (Chiarella, 1995)
  • Professional guidelines, that provide assistance
    and advice to health professionals on a range of
    relevant and often difficult matters. (NMBA,

Examples of how to conduct oneself in a profession
  • The professional Decision-Making Frameworks
    (DMF) for nursing and midwifery (NMBA, 2010)
  • The decision-making frameworks assist nurses and
  • To identify and work within their relevant and
    appropriate scopes of practice
  • To make careful and informed decisions about when
    to delegate work to another health professional
    or health care worker with a more confined scope
    of practice
  • To decide when to take on tasks or assignments
    that might fall outside their normal scope of

Complaints, notifications and professionalism
Managing those who breach the standards set by
the profession
  • This may be due to
  • A lack of competence in the performance of their
    professional role
  • An impairment issue such as a physical or mental
    illness disability or an addiction to drugs or
  • A conduct matter, whereby the individual behaved
    in such a way as to incur a determination of
    unsatisfactory professional conduct or
    professional misconduct.

Consistent with self /professional regulation?
  • Much of the work that is done in terms of
    assessment and decision making in relation to
    complaints and notifications is undertaken by
  • The judicial decision making bodies that hear
    complaints that are prosecuted are also usually
    mainly populated by peers (although they usually
    have at least one legal and one lay member)
  • A number of the changes that have occurred (for
    example, the introduction of the HCCC in NSW)
    came about because the professions did not act
    when they needed to do so
  • For the public to have faith in us as
    professionals, they need to be assured that we
    will act appropriately when there is the
    possibility of public risk
  • From an educational perspective, there is rich
    cautionary material within the professional
    disciplinary case law (Adrian Chiarella, 2010)

Accreditation and professionalism
  • Only just become a separate body for nursing and
    midwifery in Australia, although all other
    registered health professions had separate
    accreditation bodies
  • For nursing and midwifery the task was formerly
    undertaken by the jurisdictional registration
  • However, WHO makes the point that the legal
    framework must secure the autonomy of the
    accreditation system and ensure the independence
    of its quality assessment from government" (p.4).
    (WHO, 2005)
  • The accreditation body sets the standards for the
    courses and programs leading to entry to the
    professions and for post-registration or
    specialisation programs where appropriate
  • These standards are developed and agreed by the
    education providers and key professional
    stakeholders and in this way, can clearly be seen
    to be an arm of professional self-regulation

Issues for todays conversation
  • It is recognised that there are significant
    variations between countries in the extent and
    locus of nurse regulation (Benton Morrison,
  • However, the elements presented above (Chiarella
    White, 2013) are fundamental to any scheme and
    need to be present to fulfil all criteria for a
    professional regulatory process that provides
    public protection.
  • I want to explore continuing professional
    development and its relationship to competence
  • I shall also briefly discuss the regulation of
    midwifery in Australia

Continuing Professional Development (CPD)
  • Now an annual mandatory requirement consistent
    across all registered health professions in
  • The Medical Board of Australia defines CPD as
  • the means by which members of the profession
    maintain, improve and broaden their knowledge,
    expertise and competence, and develop the
    personal qualities required in their professional
    lives (MBA, 2010).
  •  CPD is a means of ensuring that health
    professionals keep up to date and hence are more
    likely to be safer,
  • This relates to the first objective of the
    national registration and accreditation scheme in
    Australia under Part One S.3 (2)(a) of the
    National Law, which is
  • to provide for the protection of the public by
    ensuring that only health practitioners who are
    suitably trained and qualified to practise in a
    competent and ethical manner are registered,
  • Health practitioners also believe that CPD is an
    essential component in continuing competence
    (Vernon, Chiarella, Papps Dignam, 2010)

  • It is difficult to ascertain how either CPD or
    indeed recency of practice can assure competence.
  • For example, is there any link between a person
    who attends a lot of lectures and a person who is
  • Clearly there are people who do complete their
    requisite CPD but still are found to be unsafe to
  • Indeed it is difficult to be certain that
    continuing competence can be assured.
  • For example, just because a health practitioner
    performs competently during one assessment of
    competence, they will perform competently the
    next time they undertake the same skill.
  • I might bake a perfect cake today and burn one
    tomorrow. Drive my car well today but have an
    accident tomorrow.
  • Consider the risk matrix below.

Risk matrix for the assessment of competence
(Chiarella White, 2013)
Evidence of sufficient CPD No evidence of sufficient CPD
competent Sufficient CPD Competent No problem No CPD Competent No problem they will be picked up but they are not dangerous
Not competent Sufficient CPD Not competent Problem wont get picked up as will meet renewal requirements but not safe No CPD Not competent Potential problem but we should pick them up through lack of CPD
So is continuing competence just a holy grail?
  • Perhaps the important aspect of CPD is not
    necessarily the assurance of competence, but
    rather a heightened sense of self-awareness of
    risk and the ability to reflect on competence.
  • Reviewing our practice against the competency
    standards or standards for practice cannot
    guarantee that we will always be competent. But
    then nothing can.
  • However, it is perhaps more important that we are
    aware of our limitations and strengths and are
    able to measure these against the requirements of
    a given situation.
  • Perhaps the more important issue is that we are
    aware of our level of competence or incompetence
    in any given situation.

Competence awareness matrix
Competent Incompetent
Aware Aware that they are competent Aware that they are incompetent
Unaware Unaware that they are competent Unaware that they are incompetent
So. back to the current study into competence
  • Aims
  • to explore the interface between professional
    regulation and competence to practise,
    particularly in relation to continuing education
    and performance of competence and
  • to identify whether public safety can be assured
    through performance of competence or awareness of
    either competence or incompetence.

The search for insight
  • Insight has been demonstrated to be the deciding
    factor for adjudicating bodies in relation to
    deregistration (Adrian Chiarella, 2010 Vernon,
    et al., 2010 Vernon, 2013).
  • Thus the questions that we would like to explore
  • can insight be identified, measured and assured,
  • is this measurement preferable to the measurement
    of competence in clinical performance at a given
    point of time or in relation to the current
    requirements for registration, or renewal of
    registration / licensure / certification?

Research design Phase one Review/audit of CPD
and competence notification data
  • Development of CPD review/audit tools
  • Data collection
  • Data collation, thematic and statistical
  • Subject data will be elicited from a review /
    audit of the CPD and recency profiles of a
    convenience de-identified sample of registered
    nurses, drawn from the data bases of the nursing
    regulatory boards/councils who participate in
    this study. The subject sample will be comprised
    of registered nurses from the following two
  • Group A. Registered Nurses who have become the
    subject of competence notifications based on
    performance grounds (previous 3 years).
  • Group B. Registered Nurses who have been assessed
    as part of a recertification / revalidation audit
    process (previous 3 years).

Research design Phase two - Interviews
  • Data collection interviews
  • Transcription and collation
  • Thematic analysis
  • Semi-structured interviews with the performance
    assessors / competence assessors commissioned by
    regulatory authorities, and/or professional
    organisations to review performance competence
    will be undertaken with a view to understanding
    how competence is assessed.
  • Interview questions will include
  • What methods of competence assessment are being
  • Is there a clear evidence-based assessment
    policy, process and guidelines?
  • What are the moderation processes?
  • Are there issues that recur in terms of
    registrants who are required to undertake a
    competence assessment i.e. the behavioural
    traits, history demographics (awareness/insight?)
  • We are also seeking funding to undertake
    observational studies with theses assessors

Research design Phase three Analysis of case
law (5 years)
  • Analysis of five years of case law in each of the
    selected regulatory authorities relating to
    complaints of unsatisfactory performance
    (howsoever defined), that have been prosecuted
    and adjudicated.
  • This analysis will be undertaken to identify what
    factors led to decisions either to retain or
    remove a nurse from the register.
  • In this case law analysis both the ratio
    decidendi and the obiter dicta will be examined
    for any comment relating to awareness/insight,
    history, demographics.
  • In addition, relevant country policies and
    legislation relating to requirements for
    competence assurance and CPD will be analysed,
    themed and reported.

The regulation of midwifery
  • Midwifery regulation is the set of criteria and
    processes arising from the legislation that
    identifies who is a midwife and who is not, and
    describes the scope of midwifery practice.
  • The scope of practice is those activities which
    midwives are educated, competent and authorised
    to perform.
  • Registration is the legal right to practise and
    to use the title of midwife
  • ICM Framework for midwifery legislation and

Background to the development of professional
midwifery in Australia
  • First Diploma in Midwifery commenced at the
    Womens Hospital in Melbourne in 1888, but only
    available as a P/G program for RNs
  • Midwives Registration Act 1915 (Vic) made
    provision for the education and regulation of
  • Nurses and midwives in all jurisdictions were
    later amalgamated into one regulatory framework,
    usually titled a Nurses Act
  • For many years, it was impossible in Australia to
    practise midwifery unless you were also a
    registered nurse
  • First direct entry midwifery program offered in
    1997 at Flinders University South Australia (now
    10 available)
  • The names of regulatory statutes started changing
    to Nurses and Midwives Acts from the mid-90s
  • Faculties started rebadging as Nursing and
    Midwifery faculties

Background to the development of professional
midwifery regulation in Australia (cont)
  • First Doctor of Midwifery offered from 2000
  • First Chief Nurse changed her office title to the
    Nursing and Midwifery Office in 2003
  • Australian College of Midwives was part of the
    Australia Peak Nursing and Midwifery Forum
    auspiced by then (then) Australian Nursing and
    Midwifery Council
  • APNMF lobbied hard at the negotiations on the
    National Registration and Accreditation Scheme
    (NRAS) to have a separate midwifery register
  • This was achieved and with it the recognition
    that not all midwives were nurses
  • Still regarded as one profession for the purposes
    of much of the organisation of the scheme

What does our midwifery workforce look like
  • Midwifery in Australia has yet to come of age,
    although significant strides have been taken
  • Few midwives work in continuity of care models,
    despite the proven efficacy for mothers (Tracey
    et al, 2013)
  • Many work in only one aspect of midwifery care
    antenatal, labour ward, postnatal, community,
    child and family health even
  • Australia has dreadful statistics on C-section
    rates, especially in the private sector, with
    some hospitals being as high as 50-60 of all
    births (WHO recommended rate is below 15 (WHO,

Our midwifery workforce (cont)
  • Such interventionist practices mean that many
    midwives working in the private hospital sector
    do not get the same opportunity to practise
    continuity of care or even traditional midwifery
  • Yet they identify themselves as midwives and many
    would espouse midwifery, woman centred
    principles of care
  • This unusual situation for our midwifery
    workforce sees us in a time of transition as
  • We need to be mindful of this when considering
    CPD and RoP

Yet our midwifery workforce is changing
  • Continuity of care models are occurring
  • Eligible midwife numbers are growing
  • Access to MBS and PBS facilitates the move
    towards improved maternity care and maternal

Who advises Health Ministers on midwifery matters?
  • Lots of people!!!!!!!!!!!
  • AHMAC Australian Health Ministers Advisory
    Committee (DGs)
  • NRAS sub-committee advises AHMAC mainly
    jurisdictional legal reps but also some workforce
    very influential in the early days of the
    scheme but completely invisible to the Boards
  • AHWPC Australian Health Workforce Principal
  • HPPPC Health Policy Priorities Principal
  • AgManCo Agency Management Committee of AHPRA
    (really the Board of the new NRAS scheme)
  • Why does it matter? Because these committees all
    examine various aspects of the determinations of
    the Health Professional Boards in our case the
    Nursing and Midwifery Board of Australia

The regulation of midwifery in the new national
regulation scheme
  • Two registers, one for nursing, one for midwifery
  • Option to be non-practising
  • Option to be on either or both
  • Registration standards
  • Criminal record check
  • PII
  • CPD
  • RoP
  • ELS

Matters specific to midwifery already contained
in the legislation
  • Midwife practitioners
  • S.284 exemption for PII for homebirth midwifery

Matters specific to midwifery that we addressed
after the legislation was introduced
  • Notation for eligible midwives these 2
  • Endorsement for eligible midwives now joined
  • The safety and quality guideline (related to
  • All currently under review

What is an eligible midwife?
  • Not a creation of the national regulatory scheme
    provision for registering midwives and midwife
  • Developed by MSAG during the maternity reforms
    following the Maternity Services Review
  • MSAG determined that only eligible midwives
    would be eligible for access to MBS and PBS
  • It was agreed that NMBA should take ownership of
    this as there were clearly regulatory issues
  • MSAG had deemed there had to be a set of criteria
    for eligibility
  • These were being negotiated by other key
    stakeholders in Canberra

So MORE key stakeholders to advise our health
  • Consumer groups
  • Midwifery groups
  • Obstetricians and GPs
  • Insurers
  • Industrial bodies
  • PLUS
  • All the other people who were already advising
    them earlier

Regulation of eligible midwives
  • Three NMBA regulatory elements to the
    registration provisions
  • Endorsement as an eligible midwife
  • Professional indemnity insurance arrangements in
    place or midwife meets the requirements for
  • Safety and Quality Guideline for privately
    practising midwives
  • PLUS
  • Cth requirements for collaborative arrangements

Requirements to be able to provide a Medicare
midwifery service
  • To provide a Medicare midwifery service, an
    eligible midwife is required to be working in
    private practice and have
  • A Medicare Provider Number
  • Professional indemnity insurance, and
  • Collaborative arrangements in place with a
    specified medical practitioner and/or
    credentialed at a hospital or with an entity
    other than a hospital (such as a community health
    centre or a medical practice) that employs or
    engages at least one obstetric specified medical

  • Endorsement for scheduled medicines allows a
    midwife to legally prescribe medicines in
    accordance with the respective state and/or
    territory drugs and poisons legislation and other
    associated requirements, and is gained through
    meeting the requirements of the Registration
    standard for endorsement for scheduled medicines
    for eligible midwives developed under the
    National Law.

Endorsement as an eligible midwife
  • To be endorsed for scheduled medicines as an
    eligible midwife, a midwife must be able to
    demonstrate, at a minimum, all of the following
  • Current general registration as a midwife in
    Australia with no conditions on registration
    relating to unsatisfactory professional
    performance or unprofessional conduct.
  • Registration as a midwife constituting the
    equivalent of 3 years full time / 5000 hours
    within the past 6 years across the continuum of
    care or specified context of practice.
  • Successful completion of
  • A Board approved program of study leading to
    endorsement for scheduled medicines, or
  • A program that is substantially equivalent to
    such an approved program of study as determined
    by the National Board.

The PII Exemption under S.284
  • The National Law provides an exemption for PII to
    PPMs providing intrapartum services in the home
    providing the following conditions described in
    section 284 of the National Law are met
  • (1) During the transition period, a midwife does
    not contravene section 129(1) merely because the
    midwife practises private midwifery if
  • (a) the practice occurs in a participating
    jurisdiction in which, immediately before the
    participation day for that jurisdiction, a person
    was not prohibited from attending homebirths in
    the course of practising midwifery unless
    professional indemnity insurance arrangements
    were in place and  

S.284 (1) cont
  • b) informed consent has been given by the woman
    in relation to whom the midwife is practising
    private midwifery and
  • (c) the midwife complies with any requirements
    set out in a code or guideline approved by the
    National Board under section 39 about the
    practice of private midwifery, including
  • (i) any requirement in a code or guideline about
    reports to be provided by midwives practising
    private midwifery and
  • (ii) any requirement in a code or guideline
    relating to the safety and quality of the
    practice of private midwifery.

S.284 (2) (3)
  • (2) A midwife who practises private midwifery
    under this section is not required to include in
    an annual statement under section 109 a
    declaration required by subsection (1)(a)(iv) and
    (v) of that section in relation to the midwifes
    practise of private midwifery during a period of
    registration that is within the transition
  • (3) For the purposes of this section, the
    transition period
  • (a) starts on 1 July 2010 and
  • (b) ends on the prescribed day.

Where to from there?
  • The Australian Workforce Ministerial Council has
    extended the transitional period to end 2015.
  • The exemption to PII does not extend to any
    antenatal and postnatal care provided by the
    midwife. PII for antenatal and postnatal care
    remains the responsibility of the privately
    practising midwife and is included in the
    approved registration standard for PII.
  • A working group under the Health Ministers is
    currently reviewing what will happen post 2015

Other elements of the SQG
  Midwifery competency standards
 Scope of Practice
 Code of professional conduct for midwives and Code of ethics for midwives
 Professional boundaries for midwives  
 Recency of practice
 Continuing professional development
 Decision making framework
 Co-regulatory requirements between Medicare and the National Board
 Prescribing authority and compliance with state and territory legislation
 Collaborative arrangements
 NMBA Guidelines for advertising of regulated health services
 Notification and management of performance, conduct or health matters
Collaborative arrangements
  • Were introduced by the Federal government to
    ensure midwives are able to transfer care to a
    doctor when necessary
  • However they are not optional, they are
  • As the AMA explain "requirement for a
    collaborative arrangement with a medical
    practitioner puts in place an overarching quality
    framework to preserve patient safety and ensure
    that medical practitioners are not left out of
    the loop"
  • The legislation regarding collaborative
    arrangements includes
  • The National Health (Collaborative arrangements
    for midwives) Determination 2010, and
  • The Health Insurance Amendment Regulations 2010
    (No. 1).

Collaborative arrangements
  • Collaborative arrangements make for an
    interesting concept
  • There is an absolute requirement for a midwife to
    collaborate with a doctor but no reciprocal
    requirement for a doctor to collaborate with a
  • Thus collaboration doesn't necessarily describe
    the situation accurately
  • It seems more like an arranged and very one-sided
    marriage whereby if the midwife promises to
    "love, honour and obey" then the doctor promises
    (we hope) to love and honour but happily agrees
    to be obeyed
  • It seems odd that what is a completely
    professional expectation - namely that a midwife
    would refer to or work with a doctor if (s)he
    believed the patient to be high risk becomes a
    matter of coercion that goes to the heart of
    access to MBS

Add to the already complex mix the question of
  • a valid and mainstream choice for women in many
  • It provides many women with a satisfying and
    rewarding birth experience
  • The right to have access to homebirth is now
    considered to be a fundamental human right,
    according to the European Court of Human Rights
    in Strasbourg (Ternovszky v. Hungary (Application
    no. 67545/09) 14th December 2010)
  • In Australia PPMs cannot obtain PII to cover them
    for homebirth but all HCPs are required to have
    PII in order to practise their profession.
  • S.284 (discussed above in relation to the SQF)
    provides an exemption for PPMs to be able to
    conduct homebirths without PII providing (inter
    alia) there is a SQF in place
  • However PPMs do have to have PII to cover ante
    and post partum care, which means that, in order
    to access the government sponsored PII scheme,
    they have to meet the same criteria to be notated
    as eligible midwives

How do we plan for the regulation of midwifery?
  • My maxims
  • Good decisions are made on good information
    (Charlesworth M. 1989 Boyer Lectures)
  • Hard cases make bad law (Rolfe J. Winterbottom v
    Wright 1842) and we have had our share of hard
    homebirth cases
  • Thus we need evidence
  • Evidence of what works here, evidence of what can
    work elsewhere, evidence of what is safe

NMBA strategic planning
  • PII - study commissioned by NMBA, completed by
  • SQG revised and out for consultation
  • Supervision of PPM study commissioned by NMBA,
    undertaken by PwC
  • Midwifery Standards for Practice deferred due
    to consultation overload
  • Registration standard for eligible midwives
    almost completed

The evidence what is safe, what works
elsewhere, what might work here
  • National Institute for Clinical Excellence (UK)
  • Intrapartum care care of healthy women and their
    babies during childbirth
  • http//

Two key recommendations (p.10)
  • Advise low-risk multiparous women to plan to give
    birth at home or in a midwifery-led unit
    (freestanding or alongside). Explain that this is
    because the rate of interventions is lower and
    the outcome for the baby is no different compared
    with an obstetric unit.
  • Advise low-risk nulliparous women to plan to give
    birth in a midwifery-led unit (freestanding or
    alongside). Explain that this is because the rate
    of interventions is lower and the outcome for the
    baby is no different compared with an obstetric
    unit, but if they plan birth at home there is a
    small increase in the risk of an adverse outcome
    for the baby.

The Birthplace UK study, 2011 (cohort of 65,000
  • There were 250 primary outcome events and an
    overall weighted incidence of 4.3 per 1000 births
    (95 CI 3.3 to 5.5).
  • Overall, there were no significant differences in
    the adjusted odds of the primary outcome for any
    of the non-obstetric unit settings compared with
    obstetric units.
  • For nulliparous women, the odds of the primary
    outcome were higher for planned home births
    (adjusted odds ratio 1.75, 95 CI 1.07 to 2.86)
    but not for either midwifery unit setting.
  • For multiparous women, there were no significant
    differences in the incidence of the primary
    outcome by planned place of birth.

Continuity of care midwifery models
  • Caseload midwifery care versus standard maternity
    care for women of any risk M_at_NGO, a randomised
    controlled trial
  • The Lancet, Volume 382, Issue 9906, Pages 1723 -
    1732, 23 November 2013
  • Prof Sally K Tracy DMid, Donna Hartz PhD, Mark B
    Tracy FRACP, Jyai Allen BMid, Amanda Forti RM,
    Bev Hall MIPH, Jan White RM, Anne Lainchbury
    MMid, Helen Stapleton PhD, Michael Beckmann
    FRANZCOG, Andrew Bisits FRANZCOG, Prof Caroline
    Homer PhD, Prof Maralyn Foureur PhD, Prof Alec
    Welsh FRANZCOG, Prof Sue Kildea PhD

Findings M_at_NGO study
  • Publicly insured women were screened at the
    participating hospitals between Dec 8, 2008, and
    May 31, 2011.
  • 1748 pregnant women were randomly assigned, 871
    to caseload and 877 to standard care. The
    proportion of caesarean sections did not differ
    between the groups (183 21 in the caseload
    group vs 204 23 in the standard care group
  • The proportion of women who had elective
    caesarean sections (before onset of labour)
    differed significantly between caseload and
    standard care (69 8 vs 94 11

Findings (M_at_NGO study cont)
  • Proportions of instrumental birth were similar
    (172 20 vs 171 19 as were the proportions
    of unassisted vaginal births (487 56 vs 454
    52 and epidural use (314 36 vs 304 35.
  • Neonatal outcomes did not differ between the
    groups. T
  • Total cost of care per woman was AUS56674 (95
    10617102730 less for caseload midwifery than
    for standard maternity care.
  • The results show that for women of any risk,
    caseload midwifery is safe and cost effective.

PII Study
  • The report was commissioned by NMBA to obtain
    information on the uptake and provision of PII
    internationally, the claims and complaints
    environment in relation to privately practising
    midwives (PPMs) providing homebirth and the
    potential barriers and enablers to PII for PPMs
    in Australia
  • They were specifically requested to model the
    issues and to identify considerations

PII considerations
  • Specific registration of PPMs
  • PPM Practice models group practice, support,
  • Nationally consistent risk assessment models and
    frameworks for care
  • Improved data collection
  • Strengthened ties between industry and insurers
  • Alternate insurance models
  • Enhanced collaborative models to improve referral

The supervision project
  • The scope of the project includes
  • International literature review on models of
    supervision for midwives other health
  • Conduct interviews focus groups with
  • Analyse and assess models of supervision suitable
    for implementation in Australia
  • Recommendation of suitable innovative models
    including cost and implementation strategy

Where to from here?
  • We believe we are proposing a robust framework
    for the protection of the public for PPMs wishing
    to provide antepartum care in the home.
  • The results of the midwifery supervision project
    will inform our next step.
  • We hope the work we are doing and the evidence
    emerging about homebirth will assist insurers to
    feel confident to provide PII and to obviate the
    need for S.284

Regulation of scope of practice
  • What we cannot currently do is to protect the
    public against unregulated health workers who
    choose to assist with birth
  • Some jurisdictions (such as SA) have implemented
    restricted birthing practices legislation
  • We would prefer a regulated scope of practice in
    relation to ante-natal, intrapartum and post
    partum care to midwives, obstetricians and
    appropriately qualified General Practitioners
  • I personally would prefer it to be nationally

In conclusion
  • Professional regulation is more than registration
    of health professionals
  • It consists of four key elements that together
    are designed to protect the public from unsafe
    practitioners (in whatever field)
  • There is a strong interface between professional
    education and professional regulation
  • The question of the extent to which this ought to
    be self regulation by the health profession or
    not is vexed, particularly when a practitioner
    makes a series of public and significant mistakes
    or behaves in a way that is completely contrary
    to professional standards
  • However, it is fair to say that professional
    regulation is a key element of professionalism as
    it is one of the ways in which the public bestows
    its trust and confidence in us as health
  • There is always work to be done ?

The dilemma of the regulator
  • Regulation touches the point between the public
    and the personal. Over regulation is seen as an
    interference in personal conduct under
    regulation is seen as an abdication of public
    responsibility. When harm happens we blame
    ineffective regulation but when we are stopped
    from doing something risky we say regulation is
    excessive. The public, media and politicians
    often face both ways wanting more or less
    regulation depending on the moment and the
    mood. Harry Cayton, Chief Executive, Commission
    for Health Care Regulatory Excellence. Address to
    AHPRA Conference September 2010

Thank you -
  • Adrian A Chiarella M (2010) Professional
    Conduct a casebook of disciplinary decisions
    relating to professional conduct matters (2nd Ed)
    Nurses and Midwives Board of New South Wales
  • AHPRA Forum of Health Professions Council (2011)
    Accreditation under the Health Practitioner
    Regulation National Law Act1 (the National
    Law)Online Accessed on 13th August 2012 at
  • AHPRA (2012) http//
  • Ameringer, CF (2008) The health care revolution
    from medical monopoly to market competition
    University of California Press, Ltd. London,
  • Australian Nursing and Midwifery Accreditation
    Council (2012)National accreditation guidelines
    Online Accessed on 13th August 2012 at
  • Benton D Morrison A (2009) The role and
    identity of the regulator an international
    comparative study ICN Geneva
  • Chiarella EM, (1995) Regulatory standards
    nurses' friend or foe? In Gray G. Pratt R.
    (Eds) Issues in Australian Nursing 4 Pearson
    Press Melbourne
  • Chiarella M White J (2013) which tail wags
    which dog? Exploring the interface between health
    professional regulation and health professional
    education. Nurse Education Today
  • Chief Justice of Ontario Advisory Committee
    (2001) Elements of Professionalism Ontario
  • Cruess SR, Johnston S Cruess RL (2004)
    Profession a working definition for medical
    educators Teaching and Learning in Medicine an
    International Journal 16 (1), 74-76, p.74

References (2)
  • DBA (2010) http//
  • NMBA (2010) http//
  • Health Practitioner Regulation National Law 2009
  • International Council of Nurses and World Health
    Organisation (2005). Nursing Regulation A
    Futures Perspective, Geneva.,
    o_regulation.pdf. (Last accessed 24 February
  • Medical Board of Australia (2010) Medical CPD
    Registration Standard p.2 http//www.medicalboard.
  • NMBA (2010) http//
  • NMBA (adopted 2010) National framework for the
    development of decision making tools for nursing
    and midwifery practice (original publication ANMC
    2007) Online Accessed 13th August 2012 at
  • NMBA (adopted 2010) A nurses guide to
    professional boundaries (original publication
    ANMC and NZCN, 2010) Online Accessed 13th
    August 2012 at http//www.nursingmidwiferyboard.go
  • NMBA (2012) Code of professional conduct for
    nurses in Australia Online Accessed 13th August
    2012 at http//

References (3)
  • PBA (2012) http//
  • Professions Australia (2012) AccreditationOnline
  • Siebert K (2006) Time is right to break monopoly
    of regulators Online Opinion Accessed on 23.6.12
    at http//
  • Styles M Affara F (1998) ICN on regulation
    Towards 21st century models ICN Geneva
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    CPM, (2009) The concepts of professionalism and
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  • Vernon, R., Chiarella, M., Papps, E., Dignam,
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    Council of New Zealand Continuing Competence
    Framework. Confidential Report. Napier, Author.
    ISBN 978-0-908662-33-3 Vernon, R., Chiarella,
    M., Papps, E., Dignam, D. (2010, October).
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    Education, Geneva/Copenhagen