Improved care for women and babies with Obstetric Theatre Maternity Support Worker development, helps to release time to care for Midwives

Worcestershire Acute Hospitals NHS Trust’s trained Maternity Support Workers to undertake the ‘scrub role’ in obstetric theatres for patients requiring a caesarean section, improving the quality of care for women and babies in the operating theatre. The role of Obstetric Theatre Maternity Support Worker (OTMSW) has allowed midwives to be released from scrub tasks to focus on core midwifery duties – so enhancing care on the delivery suite.

Building on this success – and supported by Skills for Health – a Maternity Exemplar project has also been undertaken. Run by the West Midlands Strategic Health Authority (SHA), the project has tested the transferability of the new role in other maternity units across the region. The Exemplar project demonstrated how the role can help alleviate midwife shortages across the UK.

Maternity care in England is undergoing a period of significant review and change, driven by a national and local shortage of midwives, and escalating demand for maternity services. With a consistently high level of midwifery vacancies in some Trusts, there is a need to take proactive steps to find new ways of working.

The introduction and development of the role of Maternity Support Worker (MSW) at bands 1 to 4, has been nationally identified as one way of modernising maternity services in response to current and future workforce needs. Introduced in 2005, the role is a relatively new addition within maternity health care. Working under the direction of a qualified midwife, MSWs provide care to women and babies before, during and after birth. Their duties typically vary from changing beds and performing routine observations to offering advice on breastfeeding.

The scrub role at a caesarean section had previously fallen within the remit of midwives. It is often not possible for general theatre staff to provide consistent cover due to limited staffing resources within their own departments. With demand for obstetric theatres having risen significantly, it became clear that utilising midwives for scrub duties – was not sustainable.

Whilst the difficulties in recruiting midwives are widely reported, in comparison, recruiting MSWs is much less problematic. It was apparent that there was significant unexploited scope for developing the role of MSWs and providing a structured pathway for their career development.

Worcestershire Acute Hospitals NHS Trust wanted to find a way to release much-needed midwives back onto the delivery suite to concentrate on providing acute care – especially during the intrapartum period. At the same time, the increased demand for scrub cover in the obstetric theatre had to be met.

The Trust also needed to ensure that the scrub role would be consistently undertaken by fully trained and competent personnel in order to ensure the safety and quality of care for mothers and babies. In tandem with this, the Trust wanted to explore the potential for developing the scope of the MSW role.

“This is an excellent opportunity to improve care, develop and supplement the workforce in a significant way and provide development for health care support workers so they have the opportunity to progress their careers”

Jackie Jenkinson, Clinical Midwife Manager at University Hospital North Staffordshire

Prior to settling on a solution, a number of issues and challenges needed to be taken into consideration:

• Existing scrub training had neither been formally developed nor competence-based and was largely delivered on a cascade basis. As a result, there were no recognised programmes or frameworks that could be used or adapted
• Clinical safety is of paramount importance to the Trust, so it was fundamental to ensure that all training would be based on nationally recognised standards and be sufficiently robust to enhance clinical care rather than potentially compromise it
• For the new role to gain acceptance within the maternity unit team and to maximise the contribution of MSWs, the development of the role needed to demonstrate clarity in training, responsibilities, and management
• Initial recruitment to the training programme for a new role was envisaged to be potentially problematic, as the role would not have an established track record or offer any guarantee of success

After analysis of the existing skill mix in maternity services, it was decided to introduce a new tier within the maternity workforce; that of the Obstetric Theatre Maternity Support Worker (OTMSW). The OTMSW would perform the scrub role for a caesarean section and then, if not immediately required in theatre, follow the mother and baby to the post-natal ward to provide continuity of care.

The Trust started from scratch in designing the role and the underpinning training programme, which it based on the nationally recognised Skills for Health competences. The plan was to recruit trainees from within the Trust, as part of the skills escalator for MSWs.

A 12-month package of OTMSW training was developed, leading to an award in preoperative care support. The training is ‘front-loaded’ in the first six months so learners can obtain the knowledge and skills required in order to achieve the competence for the scrub role.

The initial six months include 123 hours of classroom-based learning, followed by a placement rotation in both theatre and ward environments. Thereafter, OTMSWs receive on-the-job training in skills such as taking blood samples, basic observations during the post-operative period, support during breastfeeding and baby care. Critical to the on-the-job training, are the learners’ partnerships with their assessors, who provide mentoring and encouragement as well as formally assessing their skills against the required competences.

Basing the OTMSW role on Skills for Health competences facilitates a clear and universal

understanding of the position, its responsibilities, and its competence level. For instance, OTMSWs and their colleagues are aware of the limits of their competences, and, if presented with a case outside their field of expertise, will immediately escalate it to the main theatre team.

Aware of the early success of the pilot in Worcestershire Acute Hospitals NHS Trust, the West Midlands SHA saw the opportunity to work with Skills for Health to test the transferability of the role to other hospitals within the region. Two additional sites – Walsall and North Staffordshire – were chosen to join a ‘Maternity Exemplar Project’ and trial the role of OTMSW. The project aimed to train, deliver and measure the success of five new OTMSWs in each pilot site.

A Stakeholder Group was created with representatives from each pilot, the West Midlands SHA, Skills for Health and the Royal College of Midwifery, to provide ongoing advice and support. Skills for Health also worked directly with the pilot sites to assist in setting up the training and support the preparation of competence-based job descriptions, ensuring clarity and accountability for the new role. The aim was to ensure that there had been thorough evaluation and realisation of the benefits of OTMSWs in order to roll-out the post and inform the future maternity workforce UK wide.

Benefits

• Quality and safety of patient care in the obstetric theatre is enhanced as the aim of the new OTMSW role is to ensure scrub cover can be consistently provided by specifically trained staff who have completed a 12-month structured programme of competency-based training and assessment
• Delivery suites have greater midwifery capacity to provide acute clinical care when required. In the Worcestershire Acute Hospital NHS Trust, the removal of midwives from the scrub role is expected to release a minimum of 75 hours of midwife time per week – the equivalent to two additional full-time midwifery posts
• New mothers can enjoy continuity of care post-caesarean, as the OTMSW can follow the mother on the care pathway to the post-natal ward, ensuring a smooth handover to the post-natal team.
• Assurance that those performing the obstetric theatre scrub role are competent practitioners who have been trained and assessed against nationally recognised standards
• Patient safety is promoted as only specifically trained personnel – with the underpinning knowledge to implement current evidence-based best practice – will undertake the obstetric theatre scrub role. A further spin-off of the programme is that continual contact with course facilitators and assessors whose job it is to stay abreast of latest best practice creates a knowledge-flow that enables improvements to be made as appropriate
• Financial savings at Trust level, as the introduction of highly skilled OTMSWs at employment bands 3 or 4 mean theatre nurses (band 5) and midwives (band 5 to 7) can be more appropriately utilised
• Staff retention is expected to improve as the changes improve the working lives of midwives and support compliance with the European Working Time Directive, and MSWs are offered structured career development opportunities.
• Midwives are released from non-midwifery tasks to focus on performing more technical and specialised midwifery tasks, especially during the intrapartum period of care – resulting in improved job satisfaction.
• A structured career development pathway is now in place for MSWs, giving them the option of a further step on the skills escalator.
• The programme has brought about a positive shift in midwives’ attitudes towards the MSW role, with most citing benefits such as better patient care.
• Feedback from clinicians who have experienced the OTMSW pilot has been overwhelmingly positive. They have complimented both the knowledge and skills of their new scrub team members

The programme exposed significant potential for the new OTMSW role to transform maternity services across the UK. Trusts outside the West Midlands quickly expressed interest in the role, and the final report from the Maternity Exemplar Project included key recommendations about the transferability of the OTMSW role and training programme.

West Midlands SHA also developed a bid to explore the viability of introducing the core surgical elements of the OTMSW training programme to general theatres as well as other areas in which surgery is performed, such as day centre units and some GP surgeries.

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