Publication - Advice and guidance

Coronavirus (COVID-19): delivering maternity and neonatal services - update - December 2020

Guidance for NHS Boards for the management of maternity and neonatal services in Scotland in response to levels of COVID-19 infection locally, to aid Boards with local service planning.

Coronavirus (COVID-19): delivering maternity and neonatal services - update - December 2020
Annex A - Guidance for Workforce planning for midwifery services during COVID-19

Annex A - Guidance for Workforce planning for midwifery services during COVID-19

This guidance applies during Covid-19 emergency and should not be used when the emergency is over

Aim

To provide clinical guidance to support decision making using a nationally developed professional judgment decisions making template for midwifery staffing requirements in maternity services during the extreme circumstances of the COVID-19 pandemic.

Driver

During the COVID-19 pandemic it is anticipated that changes will be required in service delivery or clinical models as a result of a number of factors that will vary according to speciality. These include increasing demand, reduction in staff availability due to absence, requirement to implement social distancing measures and the protection of shielded pregnant women and staff. It is therefore highly likely that current staffing models and in particular skill mix may no longer be achievable or appropriate. A planned approach to changing staffing models and skill mix is required to ensure that associated risks can be mitigated in a consistent way and that the best possible care can be provided.

Maternity is an essential acute and community service with no anticipated reduction in need throughout the course of the pandemic. Midwives and the wider maternity workforce will be required to continue care for pregnant women, babies and families and should not be redeployed outwith maternity services.

This clinical guidance has been developed to support clinicians identify where changes may be required to service and clinical models, and the risk mitigating factors which should be considered ring the different phases of the pandemic, taking account of the local context in which the modelling is taking place.

The professional judgement staff modelling template has been developed to provide a consistent approach for clinical and workforce managers to quickly calculate the whole time equivalent (wte) staffing requirement based on the professional judgement of the user in line with the clinical guidance, whilst recognising variation in clinical settings and models of care. The balance must seek to prioritise safe person-centred care that considers the physical and mental wellbeing of women and families within a service where the ability to reduce demand is minimal.

Clinical Guidance for maternity and neonatal care during COVID-19 pandemic.

The Scottish Government has issued guidance to Boards related to maternity care during the pandemic. In addition, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) joint guidance outlines specific advice related to adaptations to services for both midwifery and obstetric care provision.1,2

Midwifery Staffing During COVID-19

Midwifery staffing requirements are normally determined using the Healthcare Staffing Programme workload planning tool as part of the common staffing method. This is accompanied by professional guidance regarding one to one care in labour and a caseload size as outlined in the ‘Best Start Forward Plan for Maternity and Neonatal Services’ (2017). Full implementation of The Best Start was not in place in all Boards prior to the pandemic.

As the coronavirus pandemic is unprecedented, it is recognised to be highly likely that availability of midwifery staff who usually work in specific clinical areas will reduce due to staff absence. Midwifery staffing will therefore require to be altered to ensure staff with relevant experience are utilised in the most effective way. During peak periods it is envisaged that returner midwives, final six month student midwives, year 2 students and redeployed staff will be required to support the delivery midwifery care under the direct or indirect supervision of substantive midwives.

In considering available staff those midwives who are self-isolating or shielding due to Covid-19 that are able to provide care via telehealth or other remote means should also be included in this context.

A flexible pragmatic and staged approach with an emphasis on team-working rather than a ratio approach will need to be considered in order to utilise maternity skilled staff effectively and ensure the most effective care to woman and babies.

Consideration should also be given to the possibility of utilising staff with midwifery registration from other clinical specialties should this be required to sustain maternity services. When considering deployment of staff from other areas a comprehensive risk assessment must be made to ensure that there is a whole system approach to risk assessment and that movement of staff does not have the unintended consequence of disabling other services. In order to ensure a whole systems approach it will be necessary to prioritise access to different staff groups dependent on pressures being experienced across the system whilst ensuring the most effective use of transferrable skills in different clinical settings.

Examples of the type of staff who may be made available are:

  • Health visiting or family nurse practitioners for their skills with safeguarding and infant feeding.
  • Health visiting or family nurse practitioners who have recent experience of midwifery care.
  • Nursery nurses, maternity care assistants and clinical support workers with previous experience in maternity and neonatal care.

Purpose

The professional judgement decision making template will assist Boards to scenario plan and will support a consistent approach as the pandemic progresses. It will provide the operator with the function of calculating the number of staff required on each shift whilst considering the optimum skill mix within the context in which the service is operating at the time. Skill mix will need to alter dependent on availability of staff and changes to workload as a result of changing clinical models as the pandemic progresses. The template will enable to user to alter absence to reflect total absence being experienced at the time or to model based on different assumptions about absence.

How: Recognising the interdependencies of the different aspect of maternity care. The template will allow the user to enter the staffing number required per shift and to identify the minimum number of substantive midwives per shift, the number of registrants who have returned to the NHS during the pandemic and student midwives in the final six months of training and then to identify the number of support staff required. This will allow for scenario planning as the skill mix alters.

Scenario Planning

A phased approach should be taken to introducing skill mix and new staff groups to the relevant clinical environment. Some scenarios are provided below for antenatal, postnatal, labour ward and high dependency categories which are intended to provide guidance on the phasing of implementation for planning purposes. When staffing in each stage is no longer sustainable movement to the next stage is advised The moving through each phase will be dependent on local availability of staff and should be applied taking account of the local context in which the service is delivered. Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to stage one (pre COVID). Boards may be at different stages for antenatal, intrapartum and postnatal care simultaneously at times. It is also essential when considering staffing requirements using these scenarios to consider the clinical leadership required to support staff working out with their normal scope of practice and those who are supervising and delegating to them.

Antenatal Care

Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to stage one (pre COVID)

  • One (pre COVID):
    • Full range antenatal services.
    Staffing
    • Preparation: escalation plans developed, all services still in place, no pressure on transport identified, training and upskilling commenced
    • Maintain numbers and skill mix of registered to unregistered staff
    • Care by midwife
    • Students supernumerary
  • Two:
    • Minimum 6 face to face appointments
    • Consider alternative care delivery methods
    • Consider joining up appointments
    • Stop antenatal group sessions
    Staffing
    • Returner midwife or final 6 month student support midwife with antenatal care, considering continuity of carer
    • Through risk assessment and decision making processes allocate women to returner midwife or final 6 month student matching skills to women’s need
    • Increase capacity by releasing midwives from stepped down or consolidated services
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife has direct or indirect supervision dependant on need
  • Three:
    • Minimum 6 face to face appointments
    • Consider alternative care delivery methods
    • Consider joining up appointments
    • Stop antenatal group sessions
    Staffing
    • Returner midwife, final 6 month or year 2 students support midwife with antenatal care, considering continuity of carer
    • Through risk assessment and decision making processes allocate women to returner midwife or student matching skills to women’s need
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife has direct or indirect supervision dependant on need and level
    • This stage carries risk in ensuring appropriate supervision of students
  • Four:
    • Minimum 6 face to face appointments
    • Consider alternative care delivery methods
    • Consider joining up appointments
    • Stop antenatal group sessions
    Staffing
    • Returner midwife, student midwife or redeployed staff support midwife with antenatal care, considering continuity of carer
    • Through risk assessment and decision making processes allocate women to returner midwife, student or redeployed staff matching skills to women’s need
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife or redeployed staff has direct or indirect supervision dependant on need and level
    • This stage carries risk in ensuring appropriate supervision of students or redeployed staff

Note: students, other than final 6 months, should have normal experience alongside a midwife

Intrapartum Care

Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to stage one (pre COVID). Women will have 1:1 care at all times, however provision may not be by a midwife dependant on the service stage

  • One (pre COVID):
    • Full range of intrapartum options available
    Staffing
    • Preparation: escalation plans developed, all services still in place, no pressure on transport identified, training and upskilling commenced
    • Maintain numbers and skill mix of registered to unregistered staff
    • 1:1 care by midwife
    • Students supernumerary
  • Two:
    • Consider reducing care options ensuring mix of midwifery and obstetric led care
    Staffing
    • Midwife or returner midwife
    • Through risk assessment and decision making processes allocate women to returner midwife matching skills to women’s need
    • Increase capacity by releasing midwives from stepped down or consolidated services
    • Returner midwife has support of midwifery team dependant on need
  • Three:
    • Unable to sustain full range birth options. centralise to AMU/OU
    • BBA covered by community
    Staffing
    • One midwife oversees the care of 2 women, the other woman cared for by final 6 month or year 2 student midwife
    • Through risk assessment and decision making processes allocate women to returner midwife or student matching skills to women’s need
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife has direct or indirect supervision dependant on need
    • This stage carries risk in ensuring appropriate supervision of students
  • Four:
    • Unable to sustain level 3 restricted birth options without deployment of staff from other clinical specialities
    Staffing
    • One midwife oversees the care of 3 women, the other 2 women cared for by final 6 month or year 2 student midwife or staff redeployed from other specialties
    • Through risk assessment and decision making processes allocate women to returner midwife, student or redeployed staff matching skills to women’s need
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife and redeployed staff has direct or indirect supervision dependant on need
    • This stage carries risk in ensuring appropriate supervision of students or redeployed staff
  • Existing HDU
    • Maintain services
    Staffing
    • Maintain numbers and skill mix of registered to unregistered staff
  • Additional HDU
    • Plan for surge capacity as required
    Staffing
    • Maintain numbers and skill mix of registered to unregistered staff
    • Through risk assessment and decision processes upskill proportionate number of staff to ensure skilled staff on every shift

Note: students, other than final 6 months, should have normal experience alongside a midwife

Postnatal Care

Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to stage one (pre COVID).

  • One (pre COVID):
    • Full range of postnatal services.
    Staffing
    • Preparation: escalation plans developed, all services still in place no pressure on transport identified, training and upskilling commenced
    • Maintain numbers and skill mix of registered to unregistered staff
    • Care by midwife,
    • Students supernumerary
  • Two:
    • Home visiting based on need
    • Minimum contacts day 1,5,10
    • Prioritise face to face contact based on need
    • Consider other care delivery methods
    • Stop postnatal group sessions
    Staffing
    • Returner midwife or final 6 month student support midwife with postnatal care, considering continuity of carer
    • Through risk assessment and decision making processes allocate women to returner midwife or final 6 month student matching skills to women’s need
    • Increase capacity by releasing midwives from stepped down or consolidated services
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife has direct or indirect supervision dependant on need
  • Three:
    • Home visiting based on need
    • Minimum contacts day 1,5,10
    • Prioritise face to face contact based on need
    • Consider other care delivery methods
    • Stop postnatal group sessions
    Staffing
    • Returner midwife, final 6 month or year 2 students support midwife with postnatal care, considering continuity of carer
    • Through risk assessment and decision making processes allocate women to returner midwife or student matching skills to women’s need
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife has direct or indirect supervision dependant on need and level
    • This stage carries risk in ensuring appropriate supervision of students
  • Four:
    • Home visiting based on need
    • Minimum contacts day 1,5,10
    • Prioritise face to face contact based on need
    • Consider other care delivery methods
    • Stop postnatal group sessions
    Staffing
    • Returner midwife, student midwife or redeployed staff support midwife with postnatal care, considering continuity of carer
    • Through risk assessment and decision making processes allocate women to returner midwife, student or redeployed staff matching skills to women’s need
    • Returner midwife has support of midwifery team dependant on need
    • Student midwife or redeployed staff has direct or indirect supervision dependant on need and level
    • This stage carries risk in ensuring appropriate supervision of students or redeployed staff

Note: students, other than final 6 months, should have normal experience alongside a midwife

Clinical Supervision and leadership

At a time of significant pressure it is essential that roles, responsibilities and accountability is clear. Clinical supervision will be particularly important at this time for all staff to support their health and wellbeing.

All registered midwives can delegate tasks to others in accordance with the NMC code. Further support for decision making in relation to delegation can also be found in the decision support framework produced by the Northern Ireland Practice and Education Council which has been adopted for use in the 4 countries of the UK. This may be helpful to midwives when delegating or supervising staff who have been deployed to maternity services as a result of Covid-19.

https://nipec.hscni.net/download/projects/current_work/provide_adviceguidanceinformation/delegation_in_nursing_and_midwifery/documents/NIPEC-Delegation-Decision-Framework-Jan-2019.pdf

https://learn.nes.nhs.scot/28973/coronavirus-covid-19/delegation

Applying scenarios to professional judgement decision making template

The template requires local information on numbers of patients or beds, the length of shifts, the percentage absence and the skill mix required per shift. Using professional judgement, this enables the user to calculate the minimum number of locally experienced NHS substantive staff to ensure a midwife with local knowledge and expertise per shift. This also allows for variation to the skill mix dependent on availability of staff. The ultimate aim is to clearly identify the number of staff required to provide care whilst giving consideration to a significantly altered skill mix and associated risks as the pandemic progresses.

Within the template there is step by step guidance and definitions of key terms. There are pop-up explanatory notes throughout the template. The output will highlight if there is a shortfall in the current wte which indicates that more staff may be required or alternatively if there is capacity for staff to be deployed to another area.

It should be noted that the calculation does not include time for clinical leadership and management.

The professional judgement decision making template and associated guidance for use is attached as a separate supporting document.


Contact

Email: Amy.Brown@gov.scot