Introduction
From conception to the time of birth and even after birth, women experience difficulties and problems of pregnancy. Most of them do not know what should be done on the different stages of pregnancy and what to do when it comes to caring for the infants (Cormack, 2005). The Australian midwifery takes care of these problems with trained nurses that do take care of the women and the infants. This kind of care does not operate without the code of ethics and specific standards of competencies (Blank, 2004).
A midwife has to have up to standard competencies to provide the care that women need in the respective hospitals in Australia (Barclay et al., 2007). These competencies are provided by the Australian Nursing and Midwifery Council (2006). In the midwifery profession, there are goals or considerations that the midwives have to consider in their work. These are as stated in the International Midwifery Confederation and includes; a midwife has the responsibility of caring for the women during pregnancy, labor, delivery and after delivery too (ICM, 2005).
The confederation indicates that the basic midwifery practice requires a midwife to be responsible and make clinical decisions in the area of practice. The midwives are responsible and accountable for their practice and are suppose to use their current knowledge and skills to perform their functions. The international body also states that women should have equal access to health care services, they are people with human rights and that the midwife should know the health care policies and practice their role based on these policies with the aim of promoting health care to the women and their families (ICM, 2005).
A code of ethics offers important knowledge for the midwives to understand the importance of practicing roles considering the ethical issues and human rights (Fry and Veatch, 2006). It shows that if the human rights and the ethical rights are violated, then the health of the woman and the infant will be affected. The code of ethics plus the standards set for midwifery competencies, help midwives provide the health care that the women and infants deserve. Practicing up to the competent levels according to the National Midwifery Competency Standards (2006), qualifies a nurse to be certified midwife.
Competency standards
As has been indicated earlier, the practice of midwifery has to be evaluated and one has to show some competencies to be regarded as qualified (Cross, 2007). The Australian Nursing and Midwifery Council has formulated standards which have to be met by a nurse in the field of midwifery. These competencies are divided into nine sections with specified elements under each section. The elements describe what actions are suppose to be taken when handling women in a hospital setting (ANMC, 2006).
An example is competency 1 that deals with legislation and common law in midwifery profession. It has four elements under it, the first element (1.1) requires a midwife to act upon knowledge of legislation and common law of midwifery, element two (1.2) states that a midwife should practice midwifery profession while complying to the guidelines and policies of legal implications, element 1.3 describes the competency of a midwife being able to document according to the legal requirements and the last one, 1.4 describes the standard competency of being able to satisfy the requirements of midwifery of care (ANMC, 2006).
Based on the knowledge of the competency standards and what is required of a midwife in the profession of midwifery, this paper will analyze two scenarios with different ethical situations indicating what should be done in the clinical decision making. In the care for women, different situations need appropriate decision making based on the competency of the midwife and use of an assisting model of decision making (Curtis et al., 2007). The scenarios will be analyzed and appropriate decisions using a chosen model of decision making made according to a competent midwife (ANMC, 2006).
The Scenarios
Scenario 1
The case in this scenario is about a primigravida woman of 25 years who had prolonged membrane rupture and was in the labor ward due to labor pain. The gestation period was 40 weeks and was on a synchtoconin infusion. In her birth plan, this woman requested for an epidural. The midwife that was caring for this woman informed the obstetrician so that permission could be granted for this process to be done. An anesthetist was then informed but who was found not to be available at the hospital until after two hours. This woman was left in labor pain for over two hours before the anesthetist arrived.
The Competency Standards at Stake in this Case
According to the National Competency Standards, competency two states that the midwife should be able to take responsibility and be accountable for his/her actions in the midwifery profession. Element 2.1 further indicates that a midwife ought to recognize his/her own knowledge and act based on it considering the scope of midwifery practice. This is identified in scenario one as either ignored or slightly considered.
This is one of the competencies of a midwife that should be made use of in this kind of situation, and for it to be made use of appropriately, a decision has to be made. How an appropriate decision can be made will be indicated later. The midwife is suppose to recognize the role and responsibility of a midwife which is to care for the pregnant women. This needs the midwife to understand, facilitate and support the pregnancy in all the stages (Lan Chang et al., 2008).
Under competency standard 2, the midwife is suppose to determine the strengths and weaknesses in her knowledge and skills, and know how to address the weaknesses. As indicated in element 2.1, a competent midwife should be accountable for own practice as well as be able to accept the responsibility under midwifery profession. The midwife should contact other people that are qualified to offer other health care services beyond the midwifery practice (ANMC, 2006). If a midwife has this competencies, then the ability ti make decisions is enhanced. According to the ethical code of midwifery, the ethical principles in midwifery states that the women are people with human rights, the midwife should act according to the policies and standards of midwifery care provision to improve the quality of care given to the women and the infants and that the women should have equal access to health care she deserves (ANMC Ethics, 2006).
Elements 5.2, 6.1 and 7.2 of the National Nursing and Midwifery Council competencies are also of importance in this case, yet revealed to be stake. Element 5.2 states that the midwife should assess the health of the woman and her baby by carrying out a comprehensive assessment and taking appropriate actions based on the findings of the assessment (2006). This is not done in the case of the 25 year old woman whose state had been determined but appropriate action not taken.
Element 6.1 states that a midwife should be able to make use of the knowledge and skills to provide care to the infant and the mother even with complex needs as part of the team work of midwifery. Scenario 1 is a case of a primigravida lady with complicated situation and in labor pain, yet the action taken is just to leave her in pain for more than two hours waiting for an anesthetist. 7.2 of the competency standards involve issues on the rights of the patient being taken care of. The woman has rights that have to be respected. The right of the woman who made a decision to be offered an epidural was not respected. She had made a decision as part of her birth plan but was left in pain for long without being attended to (ANMC, 2006).
Important Principles of Ethics
The major principles of ethical of concern in this case in midwifery practice therefore are, accountability, beneficence and status of the fetus and value of life (Jones, 2004). Based on these ethics and the competency standards, decision making can therefore be made by the midwife. In the process of decision making, there are theories that are used to assist the midwife in making the decisions. The one appropriate in this case is the Utilitarian framework (Jones, 2004). Before discussing how a decision can be made using this model, it is appropriate to know what this Utilitarian model is. There is a different framework that can be used in decision making known as deontological ethical decision-making framework (Jones, 2004), but decisions have to be made based on the midwife’s choice of framework, which she feels is appropriate (Curtis et al., 2007). This deontological framework will not be discussed as it will not be used in this case.
Utilitarian Framework
Utilitarian model according to Baron is a decision making model base on “the best option holds the most expected good” (Carson, 2006). In this theory, actions to be taken are analyzed in terms of what consequence will result. The objective of this kind of decision making is to create great benefits to the largest number of people, that is for so many people to benefit from the action taken (Jones, 2004). The theory of utilitarianism has two forms, the act-utilitarianism and the rule utilitarianism. The act of utilitarianism is a form that does not consider how the benefits are achieved in the long run, but only expects the benefits to be great and benefit so many people. The rule utilitarianism considers the benefit to be achieved as well as the means through which the benefit can be obtained (Jones, 2004).
The Appropriate Decision for Scenario 1
The principles of ethics that should guide the midwife have been noted earlier as accountability, beneficence and status of the fetus. The competency standards already show what competencies a midwife should have. Based on these, the midwife should make decisions on the lack of knowledge on offering epidural care to the patient, be accountable for the actions on midwifery practice in such a situation and act with the aim of providing benefits (Bluff et al, 2005).
“The best will always offer the good solution” (Carson, 2006), the best would have been to find out the weakness of knowledge and skills which is the inability to offer epidural or the lack of knowledge about which anesthetic to give. The midwife should have decided on a next step which was to call another obstetrician to inform about the absence of an anesthetist or ask for the anesthetic. The midwife should act according to provided assessment information about the patient to be taken care of as midwifery competency standards require.
Who should benefit in that hospital where the woman in pain was left for long? If the utilitarian model is used in making decision, then the midwife, the hospital staff and reputation of the hospital would be considered. Identifying the weakness of not knowing anesthetics and contacting the obstetrician could be an appropriate action that could have benefited the patient, the obstetrician, the midwife, the absent anesthetic, and the hospital. The greatest accomplishment would have been relieve of pain and conduction of what the patient desired.
Scenario 2
This is a case of a Muslim woman who could not speak English but was in a hospital where the care takers spoke English. She had given birth through spontaneous delivery and since then had attempted to breast feed her baby with no success. This Muslim was not able to breast feed her baby due to blistered nipples. Her attempts to breast feed the baby failed and therefore resorted to artificial means of feeding. The midwife that was responsible for her care did not even look for an translator to help her know the problem with the Muslim woman. The midwife did not even assist the Muslim woman care for her baby or her breast.
The Competency Standards at Stake in this Case
Competency standard two, specifically element 2.1 is shown to be at stake in this case. A competent midwife is suppose to recognize her roles in understanding, giving support and facilitating the care of the pregnant woman from the initial stages of pregnancy to birth and after birth too. The midwife in this scenario as indicated in this case did not even bother to know what assistance the Muslim woman needed (ANMC, 2006).
Another competency standard that the midwife did not meet is element 3.1 which requires the midwife to communicate effectively to the woman (ANMC, 2006). This is done by active listening, using a language that can be understood by the woman and engaging the assistance of an interpretor in cases where the woman’s language is foreign to the midwife and the midwife’s language is not known to the woman too (Andre and Heartfield, 2007).
Element 3.3 is another standard not taken care of. It indicates that a competent midwife should plan her care to a patient and be able to evaluate it while partnering with the patient (ANMC, 2006). This midwife that was in charge of the Muslim woman did not even ask the woman about her problem. The midwife should have communicated to the woman, asking about what assistance the woman needs and offering solutions, of which the woman had to participate and the two come to an agreement of what care or assistance to be offered.
The next competency standard ignored is competency 5, element 5.2. This states that a competent midwife should assess the health of the woman and the baby, after which she should make necessary steps to assist the woman (ANMC, 2006). Scenario two indicates that the woman had blisters in her breasts which the midwife did not even know. It means that the midwife did not assess the health status of the woman and so revealed her incompetency in performing her work as a midwife.
Other elements also noted to be at stake are; elements 10.1, which states that a midwife should plan on the strategies to use to provide care services ensuring that the practices are culturally safe, done by incorporating the knowledge on culture into midwifery practice, element 12.2 that requires the midwife to make use of the power she has in her roles and element 7.2, which deals with issues about the human rights of the woman that need to be respected. Cultural needs should be considered (ANMC, 2006). A Muslim who do not understand English should as well receive the same care irrespective of her religion and culture. A translator that could assist the midwife to provide the care needed should have been brought to assist. The midwife could have made use of her power to perform her duties (Thomson, 2003).
The Appropriate Decision for Scenario 2
Just as in the case of scenario 1, decision making will be based on the utilitarian framework. When making a decision in a clinical setting, the midwife or nurse needs to consider certain ethical issues in the midwifery or the nursing profession (Ament, 2006). As had been indicated earlier, the ethical issues to be considered in this case are the well being of the infant, the beneficence and the accountability.
It is as well important to act according to the code of ethics of midwifery (ANMC Ethics, 2006). These guide the decision making too. Competency standards also assist the midwife since the practice should be of a given standard which she has to meet. According to the utilitarian model, the best decision to a problem will always offer a good solution (Williamson, 2006). Both the rule and the act apply in this decision making, though in a hospital setting, the rule would be more appropriate considering the ethical issues.
The rights of a woman must be respected, and for them to be respected, the process of attaining the aims of the midwife which is to provide care and help the woman in cases of problem, have to be safe (Brown, 2004). The health of the child has also to be of concern to the midwife. The outcome of a decision made by a midwife in this case, according to utilitarian model should benefit the woman, the child, the hospital reputation and the midwife (Riley, 2007).
The correct decision that would be appropriate for such a case would be to look for a translator for the midwife to understand what the Muslim woman needs, and act according to the competency standards of midwifery practice which have been shown earlier. This will benefit all of the involved parties (Riley, 2007). The woman if had been assessed to have blisters in her breasts, would have been helped out of the situation to breast feed the baby and not resorting to artificial means.
Conclusion
Decision making is the very important issue in midwifery practice since different situations do occur. There are different ethical issues that need to be considered when providing care to the women and their infants. For all these to be done, a nurse has to be competent. Competency helps one make appropriate decisions since the ability to identify ethical issues at stake in a situation is already built and the correct skills and knowledge to be applied are known too. Midwifery, in this paper is shown to depend so much on the ethical issues in midwifery and the competency of a midwife.
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