Systematic physical examination of the newborn (SPEN) has been included in the Nursing and Midwifery Council (NMC) Standards for Pre-Registration Midwifery Education since 2019. It is expected to be part of the programme, with students able to undertake SPEN at qualification. Sarah Milnes, and Lucy Bradley, Midwifery Lecturers, University of Leicester, discuss the history of the introduction into the programme and its impact and effectiveness.
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Introduction
The systematic physical examination of the newborn infant (SPEN) is recommended to be performed in the first 72 hours of a baby’s life. Traditionally carried out by a neonatologist or general practitioner, this detailed examination now falls within the scope of midwifery practice. Initially this was taught as a standalone post-qualification module but, following the introduction of the Nursing and Midwifery Council (NMC) Standards for Pre-Registration Midwifery Education (NMC 2019), this has now become integrated within undergraduate midwifery programmes. This article examines the impact and effectiveness of introducing not just the theoretical component to an undergraduate programme but the practical skill simultaneously.
SPEN by midwives
The systematic physical examination of the newborn (SPEN) is a screening tool offered to all babies born in the United Kingdom. The main aims are to identify and refer all neonates born with congenital abnormalities or anomalies of the eye, heart, hips and testes (in male infants) within 72 hours of birth to reduce morbidity and mortality (NHS England 2024). Traditionally this screening examination was performed by a paediatric junior doctor however over the past 30 years, there have been numerous reports and recommendations that this should be an extension to the role of the midwife. The EMREN study (Townsend, Wolke, Hayes et al 2004) evaluated the quality of examinations performed by midwives qualified in SPEN in comparison to the standard procedural examination by a doctor and concluded that in terms of safety, there were no differences in how each profession performed the examination. However, they did find that the quality of the screening offered by midwives was often superior, more thorough and holistic. This may be due to the differences in education and philosophy of care. Doctors often learn practical skills with a “see one do one” approach focussing primarily on the neonate whereas midwives adhered to a much more complete method of education which encompassed the mother/baby dyad.
By 2015 70% of Higher Education Institutes (HEIs) were offering postgraduate education in SPEN, largely as a standalone module for qualified midwives who wished to engage in continuing professional development. The rationale was, that if this extended role resulted in all babies being examined by midwives, this would save the NHS £2.4 million nationally, an amount that would only increase annually (Townsend et al 2004). The main drivers for the implementation of this development were the reduction in junior doctor’s hours resulting in long waits in hospital prior to transfer to the community. However, although the opportunity to train was vast, only 13% of midwives were qualified in SPEN which seemed a poor investment. With ongoing demands of recruitment and retention in NHS Trusts it became difficult to justify releasing staff to undertake an accredited programme. Midwives also experienced a lack of support or protected time to learn (Way, Cescutti-Butler and Irving 2021).
Undergraduate SPEN education
The Lancet Series on Midwifery (Renfrew et al 2014) recognised the importance of high-quality maternity care which must shift away from being fragmented, and that focuses solely on pathology identification and treatment, to a more holistic approach offering skilled, universal care for all. McDonald (2018) discussed that the introduction of SPEN should be incorporated into undergraduate programmes rather than as an advanced specialist role. Some midwives were sceptical and felt that this skill should only be offered to experienced midwives however, increasing enhanced knowledge throughout undergraduate education enables seamless, holistic care at the point of qualification. There is a confidence which comes with being supernumerary and continually developing proficiencies allowing for a more questioning approach to learning for students whilst increasing their awareness of accountability and autonomous practice. Knowledge is expanded along with decision-making skills to enrich and enhance the role of the midwife, offering greater choice for women and families. Undertaking education during a midwifery programme also ensures that students are actively supported to seek learning opportunities and gain proficiencies in order to progress on the course, negating the difficulties experienced by qualified staff.
Midwifery education programmes are regularly required to evolve and adapt in response to changes in evidence and the needs of our service users. They must be fit for purpose, whilst maintaining academic rigour. At the point of registration midwives must be able to demonstrate knowledge, skills and proficiencies that enable them to integrate into the increasingly complex service (Fry, Ketteridge and Marshall 2020).
Scaffolded learning
The latest Standards for Pre-Registration Midwifery Education mandated the education of SPEN to ensure proficiency at the point of registration (NMC 2019). The alignment of required proficiencies for SPEN are now integrated throughout the whole curricula, ensuring a scaffolded approach from the introduction of anatomy and physiology in the first year, including routine neonatal assessment, to the more complex and deeper understanding of the application to the extended role of a SPEN practitioner (NMC 2019). The concept of a spiral curriculum is understood to increase expertise over time resulting in a more advanced application of subject information (Gibbs 2014). An integrated approach to learning requires more than the traditional transfer of knowledge and passive recipient of information. Educators now face the challenge of transforming subject knowledge to enable students to demonstrate increasing mastery of the assessment by point of registration. Integrated undergraduate SPEN learning has a more gradual impartation involving a number of different stages with the building on existing schemata of knowledge to imbed greater appreciation of theoretical knowledge and how this can be skilfully applied. This integrated social constructivist method of teaching is based on the underpinning that learning is a highly social activity where sense is made of the world by constructing learning from various experiences (Pritchard and Woollard 2010).
The progression of learning transfers to real-life, experiential learning where a framework of clinical competencies is assessed in practice through direct observation and the completion of a portfolio of evidence throughout the programme. As with all clinical competencies, student learners are required to progress through the descriptor of accomplishment from participation within the skill, to the higher order of contributing, and demonstrating proficiency on completion of their studies (NMC, 2019).
This meaningful approach to teaching guides students through an appropriate background knowledge, to a systematic skill accumulation where they have the opportunity to turn experience into learning (Fry, Ketteridge & Marshall, 2020) by problem solving, reflection and application to individualised care approaches to midwifery and future service users.
Domain 6.59.2 of the standards (NMC, 2019) details how students must conduct the full SPEN in line with local and national evidence-based protocols. However, this is where discrepancies emerge within individual AEI with the interpretation of which neonates students may examine and exactly how many assessments are required to become competent. With anecdotal ranges from 15 to 70 examinations required prior to graduation, it is no wonder hospital trusts and boards are confused who is competent to utilise this skill at point of registration or if further consolidation is required before a newly qualified midwife becomes a fully-fledged and autonomous practitioner of SPEN.
Conclusion
The impact of assessing the confidence of newly qualified midwives with integrated SPEN practitioner status is yet to be evaluated, due to the slow incorporation of the new NMC standards for education (2019) and emergence of cohorts who had been educated and assessed in this extended role. Future research is required to explore the experiences of NQM to identify how they are supported within a preceptorship year to continue to practice SPEN to ensure competencies and skills are retained through regular practice of the role.
References
Fry, H. Ketteridge, S. & Marshall, S. (2020) A Handbook for Teaching and Learning in Higher Education: Enhancing Academic Practice, Taylor & Francis Group. ProQuest Ebook Central
Gibbs, B.C. (2014) Reconfiguring Bruner: Compressing the spiral curriculum. Phi Delta Kappan, 95 (7) 41-44
McDonald, S. (2018) Integration of the examination of the newborn into holistic midwifery practice: a grounded theory study. Evidence Based Midwifery. 16(4) 128-135
National Health Service (NHS) England (2024) Newborn and Infant Physical Examination: Programme Handbook. www.gov.uk/government/publications/newborn-and-infant-physical-examination-programme-handbook.
Nursing and Midwifery Council (2019) Standards of proficiency for midwives. https://www.nmc.org.uk/globalassets/sitedocuments/standards/standards-of-proficiency-for-midwives.pdf
Pritchard, A. & Woollard, J. (2010) Constructivism and Social Learning. London: Taylor & Francis Group.
Renfrew, M., McFadden, A., Bastos, M. et al (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. The Lancet Series on Midwifery pp 9-25 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/abstract
Townsend, J., Wolke, D., Hayes, J. et al (2004) Routine examination of the newborn: the EMREN study. Evaluation of an extension of the midwife role including a randomised controlled trial of appropriately trained midwives and paediatric sensor house officers. Health Technol Assess 8 (14) https://doi.org/10.3310/hta8140
Way, S., Cescutti-Butler, L., Irving, M., (2021) A study to evaluate the introduction of the Newborn Infant Physical Examination knowledge and skills into an undergraduate pre-registration midwifery education programme, Nurse Education Today, Vol 98, https://www.sciencedirect.com/science/article/abs/pii/S0260691720315069?via%3Dihub
Sarah Milnes, and Lucy Bradley, Midwifery Lecturers, University of Leicester
November 2024