RCN position on registered nurses and nursing associates working in maternity services across the UK
RCN position
The RCN believes that all registered nurses and midwives working in maternity care should be clear about their role, responsibilities, and scope of practice. All registered nurses and midwives should have support to access appropriate continuing professional development (CPD).
The RCN supports a multi professional approach to the provision of care, where skills, knowledge and competence are used effectively to provide high quality evidence-based care.
The RCN also recognises that maternity care is the primary domain of midwifery practice, while acknowledging that registered nurses can and do provide valuable support to elements of that care provided during pregnancy and to postnatal women and their babies.
The RCN recognises that nursing associates are a valuable part of the nursing workforce. The NMC proficiencies established for the nursing associate were developed to support nursing, not midwifery, and the RCN does not believe that there is a role for nursing associates in maternity services.
Background
Maternity care is traditionally the domain of midwives and medical practitioners trained in obstetrics, as well as supported by suitably trained maternity support workers (MSWs)/health care assistants (HCAs). In 2022-3 RCN intelligence confirmed that there were increasing numbers of registered nurses (usually adult trained) working across maternity units, often in postnatal wards, and particularly in England.
In 2019, the RCN carried out a survey and published a report on nurses in maternity care. Our work was four-country focused, but the issues appeared to be more England specific.
Key findings included:
- maternity services were employing nursing associates.
- 26% of the respondents employed registered nurses in maternity services. This was usually in low numbers (1-5) although one respondent said there were more than 20.
- Where registered nurses were employed, the work areas were usually obstetric theatres or high dependency units and on the postnatal ward.
- CPD and career progression for registered nurses was limited, and needed further work, there was also limited role-specific peer support, or clinical supervision.
Nurses are usually employed for high dependency care, theatres (as a scrub nurse, scrubbing for caesarean sections) and related nursing care activities (such as post-operative recovery care). This is particularly relevant in consultant-led units, maternal medicine/maternity centres and maternal medicine centres rather than midwife-led birth units. The most recent MBRRACE (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries) report (2023) identified that many women now have co-morbidities, where registered nurses may have expertise in medical/long-term conditions (such as cardiac care, sepsis, blood clots, epilepsy) and/or mental health issues and can support the role of the midwife in providing the best maternity care required.
Nurses also work in early pregnancy care supporting women in the early stages of pregnancy, as well as termination of pregnancy services, fertility care and sexual reproductive health services. Neonatal units, transitional care units and perinatal mental health care will also employ nurses. In all cases they should have access to relevant post-registration training and continuing professional development (CPD).
Midwives are the accountable lead professional in caring for childbearing women and newborn infants (and providing support for partners) (Standards of Midwifery, NMC 2019). They work across the continuum from pre-pregnancy, pregnancy, labour and birth, postpartum, and the early weeks of newborn infants’ life. It is important to ensure collaborative working, whilst ensuring there is a robust referral system for women to access timely specialist nursing care when required. For example, when there are underlying mental health needs or medical conditions including VTE, sickle cell and diabetes. For some of these referrals the appropriate professional will be a consultant midwife, specialist midwife or a registered nurse or advanced nurse practitioner with a particular skill set and scope of practice.
Registered nurses working in maternity care
The NMC standards are clear about distinctions between post operative care (domain of registered nurses and midwives) and postnatal care (the domain of midwifery), where registered nurses should be providing nursing care, whilst midwives provide the necessary postnatal care to women and babies.
These boundaries of care can become blurred, especially with the current workforce challenges, emerging health care roles and a lack of clarity about scope of practice. This in turn may leave midwives, nurses and NAs, as well as women and their babies vulnerable, and at risk of fragmentation of care into ‘tasks’ and their care not being to the standard required (Standards of Midwifery, NMC 2019). The RCN is clear about inappropriate substitution, as demonstrated in our position on registered nurse substitution.
NHSE published Safe practice principles for adult nurses working as part of multidisciplinary teams (MDT) in maternity services in 2023, which provide useful principles of good practice. NHSE states that:
- Adult nurses should be welcomed and supported into maternity services as part of the multidisciplinary team (MDT).
- A clear governance structure must be in place to support adult nurses working as part of MDTs in maternity services.
- Maternity leaders must be able to clearly articulate and justify how adult nurses are used and contribute within the staffing of their MDTs in maternity services.
- Organisations should support access to the shortened programme to midwifery training for adult nurses with a particular interest.
- Adult nurses working as part of the MDT in maternity services should be given clear information on accessing professional midwife advocates (PMAs).
- Organisations should identify where it is appropriate for adult nurses to be involved in pre-registration education as practice supervisors, as part of the MDT.
The NHSE statement provided guidance to support best practice, and along with this RCN position statement can be used to support registered nurses to practise safely within their scope of practice and without infringing on the protected function of the midwife.
Continuing professional development and revalidation
Continuing professional development (CPD) is a cornerstone of enhancing practice, and it is critically important for all registrants and their managers to ensure and enable appropriate and sufficient education is available and accessible to enable nurses and midwives to continue to practice effectively. The RCN report (Nurses in Maternity Care, 2019) identified that CPD was often not tailored towards nursing needs, and although valuable that nurse and midwives work and learn together for some elements of mandatory and continuing professional education, it is also essential for the nurse to access education appropriate to the needs of nursing.
Appropriate CPD is particularly pertinent for nurses and midwives trained overseas, where culture and adjustment to the local environment also plays a role in understanding the maternity population.
It has been noted that there are limited career progression opportunities for nurses working in maternity services, and CPD may have limited consideration of role-specific needs. Career progression should include registered midwife training, using the shortened midwifery programme. However, this relies on places being available to them (not all HEIs/NHS trusts now support the shortened midwifery programme), and not all nurses employed in maternity care wish to pursue this as an option.
Nurses will also need to demonstrate their competence through the process of revalidation with the NMC every 3 years, and in order to do so, will need support from someone, preferably their named professional midwifery/nursing advocate who understands the specific needs of nurses to revalidate against the NMC nursing standards in the context of their current practice environment. Further information on revalidation can be found here.
Nursing associates (NAs) in maternity care (England only)
A further concern is the role of nursing associates (NAs) in maternity care – their opportunities are very limited, with no career progression available.
In their pre-registration foundation degree education NAs are not educated in maternity care and the RCN does not support employment of or expansion of NA skills in maternity care settings. NHSE are due to publish a letter clarifying that there is no appropriate role for NAs in maternity services, and it is not the best use of their skills and expertise, as it is seen as outside their scope of practice. Should they wish to become a midwife they would need to access the 3-year midwifery programme.
NAs may be employed as part of surgical operating teams, in public health or perinatal mental health and related services, which is not affected by the above statement.
It should also be noted that at the time of publication, the Welsh government is progressing plans to introduce the role of the NA in the Welsh health care system.
