DE MONTFORT UNIVERSITY SCHOOL OF NURSING & MIDWIFERY In partnership with UNIVERSITY HOSPITALS OF LEICESTER (UHL)

DE MONTFORT UNIVERSITY SCHOOL OF NURSING & MIDWIFERY In partnership with UNIVERSITY HOSPITALS OF LEICESTER (UHL) GUIDELINES FOR PRE-REGISTRATION MIDWIFERY STUDENTS PARTICIPATING IN THE SAFE PRACTICE OF PREPARING, CHECKING AND ADMINISTERING MEDICINAL THERAPIES IN UHL PLACEMENTS In Relation to the Leicestershire Medicines Code (Current Edition 5.1 (2014)) Issued By: Rowena Doughty Lead Midwife for Education, School of Nursing and Midwifery, DMU Moira McLean, Senior Lecturer for Midwifery, BSc Hons Midwifery Programme Leader, School of Nursing and Midwifery, DMU, Supervisor of Midwives Elaine Broughton, Head of Midwifery, UHL, Supervisor of Midwives. David Harris Principal Pharmacist Womens and Children s Division UHL Karen Mee, Practice Learning Lead, UHL For UHL: Approved By Policy and Guideline Committee Date Originally Approved 17 th February 2012 Trust Reference E1/2012 Version V3 Supersedes V2 (Approved 21 st November 2014) Author / Originator(s) Name of Responsible Committee / Individual Karen Mee, Practice Learning Lead Eleanor Meldrum, Assistant Chief Nurse Karen Mee, Practice Learning Lead Latest Approval Date: 16 th December 2016 Next Review Date: December 2019 Guidelines for Pre-Registration Midwifery Students Page 1 of 11 Version 3 approved by: Rowena Doughty Lead Midwife Education, De Montfort University School of Nursing and Midwifery 01.11.16

CONTENTS Section Page 1. Introduction and Aim 2 2. Extracts from Leicestershire Medicines Code 4 3. Accountability and responsibility of the Registered Midwife 6 4. Role of the pre-registration student midwife 6 Midwifery Exempt List Drugs 6-7 Patient group Directives 7 Oral Drugs 7 Injectable Drugs 8 Intravenous Drugs 8 Syringe Drivers and Volumetric Pumps 8 Blood and Blood Products 9 9 Controlled Drugs 9 Cytotoxic Drugs 5. References 10 Guidelines for Pre-Registration Midwifery Students Page 2 of 11

1. INTRODUCTION AND AIM Standard 17 of the standards for pre-registration midwifery education states that student midwives must be able, at the point of registration, to select, acquire and administer safely, a range of permitted drugs consistent with legislation, applying knowledge and skills to the situation which pertains at the time. Methods of administration include: oral, intravenous, intramuscular, topical and inhalational. Reference: NMC (2009) In order to achieve the standard required for registration, students midwives must be given opportunities to participate in the administration of medicines, but this must always be under the direct supervision of a registered midwife of nurse. Reference: NMC Circular 07/2011 Issue date 17 th June 2011 Medicines management is specifically referred to in the list of essential skills that student midwives must acquire during their education programme. Under the essential skills cluster (ESC) medicinal products management it states: Medicines management in the context of midwifery practice is based on a partnership approach between the woman and the midwife. Its purpose is to provide therapeutic intervention when necessary throughout childbirth to facilitate a positive outcome. Reference: NMC (2009) The Essential Skills required are; ESC 1. Within the parameters of normal childbirth, ensure safe and effective practice through comprehensive knowledge of medicinal products, their actions, risks and benefits including the ability to recognise and respond safely to adverse drug reactions and adverse drug events. ESC 2. Undertake medicinal product calculations correctly and safely. ESC 3. In the course of their professional midwifery practice, supply and administer medicinal products safely and in a timely manner, including controlled drugs. ESC 4. Keep and maintain accurate records, which includes when working within a multi-disciplinary framework and as part of a team. ESC 5. Work within the legal and ethical framework that underpins safe and effective medicinal products management, as well as in conjunction with national guidelines and local policies. ESC 6. Work in partnership with women to share information in assisting them to make safe and informed choices about medicinal products related to themselves, their unborn children or their babies. ESC 7. Work in partnership with women to share information about alternative approaches to using medication where appropriate. ESC 8. Order, receive, store, transport and dispose of medicinal products safely and in accordance with relevant legislation, in any midwifery setting (including controlled drugs) Guidelines for Pre-Registration Midwifery Students Page 3 of 11

ESC 9. Use and evaluate up-to-date information on medicinal products management and work within national and local policies and guidelines using appropriate reference. ESC 10. Recognise and correctly respond to obstetric emergencies in the context of medicines management. Reference: NMC (2009) This document provides guidelines for students and midwives, so that students can achieve the essential skills required in medicinal products management. It clarifies the students role and participation in relation to the Leicestershire Medicines Code (LMC) Administration Sections 6 and 16. This document applies to all student midwives (including those undertaking a shortened programme following adult nurse registration). 2. EXTRACTS FROM LEICESTERSHIRE MEDICINES CODE The following is taken directly from the Leicestershire Medicines Code. Responsibility The practitioner in charge of the clinical area is responsible for ensuring that standards for medicines administration fall within the requirements of this code. Medicines must only be administered by: A Registered Midwife or Nurse, not including student midwives. The NMC state that student midwives who are registered nurses, cannot administer medications. Although they are registered nurses, they are not practising as such, and the principles which apply to students on the three year programmes will also apply to those on shortened programmes (Caroline Woolrich, Nursing and Midwifery Policy and Standards, 20 th May 2011) A pre-registration student nurse or pre-registration student midwife as part of their training, but only under direct supervision of a registered midwife/nurse who must accept full responsibility for the correct administration and recording of the medicines prescribed. It is acknowledged that in the majority of circumstances, single person medicines administration is acceptable by a Registered Midwife providing that the person has demonstrated the necessary level of knowledge and competence. Exceptions include where: a practitioner is instructing a learner a patient s condition makes it necessary to have a second check a controlled drug is involved Guidelines for Pre-Registration Midwifery Students Page 4 of 11

an injection/infusion is involved a complex calculation is required (*see below); local circumstances make the involvement of a second person desirable, in the interests of minimising the potential for error (** see below) * The use of calculators to determine the volume or quantity of medication should not act as a substitute for arithmetical knowledge and skill (NMC 2008 section 8) ** Single person administration by a Registered Midwife or Registered Nurse is acceptable for all aspects of medicines administration (apart from the exceptions, as stipulated). However, should a practitioner choose to have his/her practice checked; it must be realised that full accountability for the correct administration of the medicine lies wholly with the administering practitioner. Anyone checking is individually accountable for his/her part in the process. Where a second midwife/health professional checks the administration of medicine the identity of the checking person should also be recorded; however the ultimate responsibility remains with the administering health professional. Administration of Medicines to Babies; Midwives Exempt Medicines List Midwives can check and administer medicines on the authorised (See LMC) list to babies in their care on the postnatal wards. A student midwife may fully participate in the process of preparing, checking and administration of drugs on the midwifery exempt list under the direct supervision of a sign off midwife mentor. Medicines prescribed by a doctor or authorised prescriber All medicines must be checked by two registered midwives/nurses, one midwife and one nurse or one nurse/midwife and one doctor/pharmacist. Student midwives can act as a third checker to facilitate their learning. Reference: UHL Procedure for the independent checking of medication in babies, children and young people (under 18 years Administration of Medicines to Clients Under 16 Years Old; For patients under 16 years of age who are being treated in an adult or maternity environment the patient should be assessed by a doctor or a pharmacist regarding the suitability of adult doses. If adult doses are suitable, two registered midwives may administer medication. Student midwives can act as a third checker to facilitate their learning. Student Midwives can be involved in the checking and administration of medicines to under 16 year olds including those on the Midwifery Exempt Authorised List as a third practitioner. Guidelines for Pre-Registration Midwifery Students Page 5 of 11

Student midwives can be involved in the checking, and administration of medicines to 16-18 year olds on adult doses including those on the Midwifery Exempt Authorised List as a second practitioner. Reference: Leicestershire Medicines Code 3 ACCOUNTABILITY AND RESPONSIBILITY OF THE REGISTERED MIDWIFE The registered midwife is accountable in all instances. S/he has the responsibility to make a professional judgement that they are satisfied that students participating in the procedure of administration of medicines have reasonable knowledge (including side effects, indications/contra indications, dosages) of the drugs they are checking and administering. Definition of direct supervision; Direct supervision means in direct visual contact during which time the sign off midwife observes the act of administration of medicines by a student midwife. This includes the preparation, including any calculations required, checking the patient, administering medication, disposal of equipment and completion of relevant documentation. Reference: NMC Circular 07/2011 Issue date 17 th June 2011 4 THE ROLE OF THE PRE-REGISTRATION STUDENT MIDWIFE 4.1 MIDWIFERY EXEMPT MEDICINES LIST Exemptions from the general rules pertaining to the prescription only medicines legislation are permitted for midwives. The UHL Policy for the Supply and Administration of Medicines by Midwives (C70/2007) includes the current list of local exemptions agreed for administration by midwives employed at University Hospitals of Leicester. This list differs from the current NMC midwives exempt list; therefore it is important that midwives and student midwives are aware of the need to comply with local trust policy in relation to medicines administration. The UHL Policy for the Supply and Administration of Medicines by Midwives (C70/2007) which includes the list of current permitted exemptions, can be located on the UHL intranet document management system. Reference: Medicines Act 1968; NMC Circular 07/2011 Issue date 17 th June 2011; UHL Policy for the Supply and Administration of Medicines by Midwives From July 1 st 2011 an amendment to medicines legislation allowed student midwives to administer medicines on the midwives exemption list, with the exception of controlled drugs, under the direct supervision of a midwife. The midwife supervising the administration of all exempt list medicines by a student midwife must have undertaken an approved mentorship programme and be a sign off mentor. A student midwife may fully participate in the process of preparing, checking and administration of drugs on the midwifery exempt list (with the exception of controlled drugs) under the direct supervision of a sign off midwife mentor. More detailed information regarding administration of controlled drugs can be found in section 4.4. Reference: NMC Circular 07/2011 Issue date 17 th June 2011 Guidelines for Pre-Registration Midwifery Students Page 6 of 11

Both the midwife sign off mentor and the student must sign the patients medication chart or document in the notes. The sign off midwife mentor remains responsible for the delegation of any aspects of the administration of medicinal products, and they are accountable to ensure that the student midwife is competent to carry out the task. Reference: NMC 2008 As the list of midwifery exempt drugs may be amended from time to time, the midwife remains accountable for ensuring that any drug administered under the exempt list is still included on the UHL list at the time of administration. 4.2 PATIENT GROUP DIRECTIVES (PGD): Student midwives must not administer or supply medicines under a PGD under any circumstances. Responsibility for the administration/supply of a medicine under a PGD, lies with the registered midwife who has been assessed as competent to do so, and that responsibility cannot be delegated. Student midwives should know their responsibilities under law and the application of medicines legislation to practice in relation to PGD s. Reference: NMC circular 05/2009 Issue date 24 September 2009 If, in the interests of learning, the midwife mentor wishes a student midwife to participate in the administration of a medicine which is included on a PGD, the medicine must first be prescribed by a doctor on a prescription sheet, and administration signed for by the supervising midwife. 4.3 PRESCRIBED DRUGS: This section covers all medications (with the exception of those on the midwives exempt list and any PGD s) which have been prescribed as per the Leicestershire Medicines Code. ORAL DRUGS, and those administered via Inhalation, Rectal, Vaginal, and Topical routes and Eye Medications (Excluding Controlled Drugs) The student midwife may fully participate in the process of preparing, checking and administration of the above under the direct supervision of the registered midwife mentor. Signatures are required from both the registered sign off mentor and the student midwife. 4.4 INJECTABLE DRUGS; SUBCUTANEOUS INJECTIONS The student midwife may fully participate in preparing, checking and administering these drugs under the direct supervision of the registered sign off midwife, providing that both participants in the procedure have satisfied the requirements of the LMC. Signatures are required from both the registered midwife and the student midwife. Guidelines for Pre-Registration Midwifery Students Page 7 of 11

INTRAMUSCULAR INJECTIONS (Excluding Controlled Drugs) The student midwife may fully participate in checking and administering these drugs under the direct supervision of the registered sign off midwife, providing that both participants in the procedure have satisfied the requirements of the LMC. Signatures are required from both the registered midwife and the student midwife. 4.5 INTRAVENOUS INJECTIONS CLEAR INTRAVENOUS FLUIDS (no additives) Under direct supervision of a registered midwife, the student midwife may act as a third checker for clear intravenous fluids, set up the infusion, connect the infusion and set the rate, the registered midwife must remain present throughout the process. Signatures are required from both the registered midwife and the student midwife (LMC) INTRAVENOUS BOLUS DRUGS AND INTRAVENOUS ADDITIVES (Including Preprepared Metronidazole or Potassium) The student midwife must not administer or act as second checker or participate in any preparation of IV medicines or add any additives under any circumstances. The student midwife should, however, be given every opportunity to be involved and act as a third checker in preparation for their future role as a registered midwife. SYRINGE DRIVERS AND VOLUMETRIC PUMPS The student midwife must not administer, act as second checker or participate in any preparation of any drug for administration via a syringe driver or volumetric pump under any circumstances. To facilitate learning, the student midwife should have the opportunity to closely observe the entire process of setting up, connecting and operating syringe drivers and volumetric pumps. Under the direct supervision of a sign off mentor the student midwife may act as third checker. BLOOD AND BLOOD PRODUCTS The same rules apply as for Intravenous Bolus drugs and Intravenous additives (see 4.3.2) The student should participate as often as possible as the third checker. Anti-D is a blood product, however this is included in the midwives exempt list. Under the direct supervision of a sign off midwife mentor, student midwives may participate in the administration of Anti-D. 4.6 CONTROLLED DRUGS Guidelines for Pre-Registration Midwifery Students Page 8 of 11

In all situations the responsibility for checking and administering all Controlled Drugs lies with the registered midwife. Midwifery Exempt List: If a controlled drug is to be administered under the midwifery exempt list, the student midwife must not administer the drug. However they can be involved in the checking and preparation process under the direct supervision of a registered midwife sign off mentor. The student midwife then signs as a witness. The student midwife must be aware of their role and legal responsibility when acting as a witness. (LMC). Reference: NMC Circular 07/2011 Issue date 17 th June 2011 Controlled Drugs Prescribed on a paper or electronic drug chart: If a controlled drug has been prescribed by an authorised prescriber, and is not being administered under the midwifery exempt list, the student midwife may check and administer oral, subcutaneous or intramuscular drugs under the direct supervision of a sign off mentor. The student midwife then signs as the person administering the medication. The sign off mentor supervising acts as the witness. The student midwife must be aware of their role and legal responsibility when administering a controlled drug. (LMC). Under no circumstances may a student midwife administer a controlled drug via the intravenous route. 4.7 CYTOTOXIC DRUGS It is unlikely that a registered midwife will be required to administer a cytotoxic drug. However should this occur, LMC requirements apply to student midwives. The student midwife must not administer or act as second checker, or participate in any preparation of any cytotoxic drugs under any circumstances. 4.8 EPIDURAL ROUTE OF ADMINISTRATION Under no circumstances may a student midwife check or administer any medication via an epidural route. Guidelines for Pre-Registration Midwifery Students Page 9 of 11

Midwifery Students Administration Summary Page Medication Administration Route Level of Student Participation Signatory Medicines to include inhaled, vaginal, Students can check and administer under Registered midwife and student signing as rectal and topical routes and eye direct supervision of a registered midwife second checker. If patient is under 16 medications (Excluding Controlled Drugs) years old 2 midwives must administer medication, student to sign as third checker. Oxygen Therapy Student may set up and set rate under direct supervision of a registered midwife. Registered midwife. Student to sign as second checker Subcutaneous injections (Excluding Controlled Drugs) Intramuscular Injections (Excluding Controlled Drugs) Clear intravenous fluids (No Additives) Midwives Exempt Medicines List (Excluding Controlled Drugs) Prescribed Controlled Drugs: Oral (Excludes Any Controlled Drugs On Midwives Exempt List ) Prescribed Controlled Drugs: Subcutaneous and Intramuscular Injection (Excludes Any Controlled Drugs On Midwives Exempt List ) Midwives Exempt Medicines List: Controlled Drugs Controlled Drugs: Intravenous Drugs: Epidural top ups Intravenous Bolus Drugs and Intravenous Additives (Including pre-prepared infusion bags) Blood and Blood Products Patient Group Directions Students can check and administer under direct supervision of a registered sign off midwife mentor Students can check and administer under direct supervision of a registered sign off midwife mentor Students may set up, connect and set rate under direct supervision of a registered midwife. (Students not allowed to connect infusion to a cannula if patient is under 16 years old) Students can check and administer medicines on the midwifery exempt list under the direct supervision of a registered sign off midwife mentor. Students can check and administer under direct supervision of a registered sign off midwife mentor (2 qualified midwives present throughout) Students can check and administer under direct supervision of a registered sign off midwife mentor (2 qualified midwives present throughout) Student must not administer or add additives or act as a second checker under any circumstances Student must not administer or add additives or act as a second checker under any circumstances Student must not administer or add additives or act as a second checker under any circumstances Student must not administer or add additives or act as a second checker under any circumstances Student must not administer or add additives or act as a second checker under any circumstances Registered sign off midwife and student signing as second checker. If patient is receiving Dalteparin 5000 units or less OR is under 16 years old 2 midwives must administer medication, student to sign as third checker. 2 Registered midwives, student to sign as third checker. 2 Registered midwives, student to sign as third checker. Registered sign off midwife mentor and student. The midwife is accountable for ensuring drugs are on approved, current UHL midwives exempt list. Registered sign off midwife mentor. Student midwife signs as a witness. Sign off mentor responsible for ensuring student midwife is aware of their role and legal responsibility when acting as a witness Registered sign off midwife mentor. Student midwife signs as a witness. Sign off mentor responsible for ensuring student midwife is aware of their role and legal responsibility when acting as a witness Checked by 2 qualified midwives. Student midwife to act as third checker only Checked by 2 qualified midwives. Student midwife to act as third checker only Checked by 2 qualified midwives. Student midwife to act as third checker only Checked by 2 qualified midwives. Student midwife to act as third checker only Checked by 2 qualified midwives. Student midwife to act as third checker only Direct Supervision: The student is observed by a registered midwife throughout the preparation, calculation, checking of patient, administration, disposal of medication and equipment and completion of documentation Third Checker: Students should be involved in the process in preparation for future role. PGD Student midwives must not supply or administer medicines under a PGD under any circumstances. Midwife Exempt Student midwives can administer all UHL approved midwife exempt medications under the direct supervision of a mentor except for controlled drugs Accountability and responsibility: The Registered Midwife is accountable in all instances. They have the responsibility to make a professional judgement that the student participating in the procedure of medicines has reasonable knowledge of the drugs they are checking and administering. References: Leicestershire Medicines Code UHL Controlled Drugs Policy UHL Policy for the Supply and Administration of Medicines by Midwives UHL Procedure for the independent checking of medication in babies, children and young people(under 18 years) Guidelines for Pre-Registration Midwifery Students Page 10 of 11

REFERENCES Leicestershire Medicines Code Current Edition. http://insite.xuhltr.nhs.uk/homepage/clinical/medicines-information/leicestershire-medicines-code Nursing and Midwifery Council (2007, 2010 Edition) Standards For Medicines Management Nursing and Midwifery Council: London Nursing and Midwifery Council (February 2009) Standards for Pre-Registration Midwifery Education Nursing and Midwifery Council: London Nursing and Midwifery Council (2008) Standards for medicines management full content / summary booklet and DVD Nursing and Midwifery Council: London Nursing and Midwifery Council (2009 b) Supply and/or administration of medicine by student nurses and student midwives in relation to Patient Group Directions (PGDs) NMC circular 05/2009 Issue date 24 September 2009 Nursing and midwifery Council (2011) Changes to Midwives Exemptions Administration of medicines on midwives exemptions list by student midwives NMC circular 07/2011 Issue Date 17 th June 2011 Medicines Act 1968 www.legislation.gov.uk/ukpga/1968/67/pdfs/ukpga_19680067_en.pdf (Accessed July 11th 2011) UHL Policy for the Supply and Administration of Medicines by Midwives (Approved by Maternity Governance Group August 2007) Trust ref: C70/2007 Originator: Jan Qualie UHL Procedure for the independent checking of medication in babies, children and young people(under 18 years) (2015 and subsequent versions) Trust ref: B21/2015 Guidelines for Pre-Registration Midwifery Students Page 11 of 11