Midwifery 29 (2013) 7585

Contents lists available at SciVerse ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

Midwives and supervisors of midwives perceptions of the statutory

supervision of midwifery within the United Kingdom: A systematic review
Anne-Marie Henshaw, MMid, PGCAP, RM (Lecturer/Postgraduate Research Student)a,n,
David Clarke, PhD, MSc, BSc, Cert Ed, RGN (Lecturer and Senior Research Fellow)b,
Andrew F. Long, MPhil, MSc, BA (Professor, Health Systems Research)c
a

Academic Unit of Child, Family and Maternal Health, School of Healthcare, University of Leeds, Woodhouse Lane, Leeds LS2 9UT, United Kingdom
Leeds Institute of Health Sciences, School of Healthcare, University of Leeds, Woodhouse Lane, Leeds LS2 9UT, United Kingdom
c
School of Healthcare, University of Leeds, Woodhouse Lane, Leeds LS2 9UT, United Kingdom
b

a r t i c l e i n f o

abstract

Article history:
Received 28 September 2011
Received in revised form
31 October 2011
Accepted 6 November 2011

Within the United Kingdom, the statutory supervision of midwives has a central role in both the
provision of safe, high-quality maternity services and in the regulation of midwifery practice. Despite
its long history, little is currently known about how midwives and their supervisors perceive and
experience the statutory supervisory process.
Objective: to review and synthesise published research on midwives and supervisors of midwives
perceptions of the statutory supervision of midwives within the United Kingdom.
Methods: a systematic review of published, empirical literature was undertaken. This comprised a
systematic search of six electronic databases, supplemented by hand-searching and contact with ve
subject experts. Each of the 19 papers that met the inclusion criteria were critically appraised, thematic
analysis was used to systematically extract key themes and a narrative approach to data synthesis was
adopted, giving greatest weight to studies of higher methodological quality.
Findings: three studies were rated as high quality, 12 good quality and four poor quality. Four
overarching themes were identied; within each theme a range of perspectives were reported. These
encompassed very positive views at one end of the continuum to very negative views at the other.
The four themes reported variable understanding of the statutory supervisory framework and
engagement with supervisory processes; contradictory views regarding the value of supervision and
inconsistent relationships were described across the literature. Supportive relationships and high
quality leadership were described as being empowering and developmental while perceived power
imbalances resulted in supervision being portrayed as punitive and destructive. Resourcing supervision,
by way of protected time and recompense was recognised to be a challenge.
Key conclusions: this review highlighted considerable variability in both midwives and supervisors
understanding of the nature and purpose of supervision as part of the NMC statutory framework.
In particular, the potential for supervision to enhance personal development and midwives practice
varied according to the nature of the relationship between midwife and supervisor. The importance of
supervision being t for purpose and supervisors possessing the requisite knowledge, skills and
attitudes to execute their role and responsibilities effectively cannot be underestimated. More research
is needed to examine ways in which statutory supervision contributes to patient safety and high quality
care and what opportunities there may be for the statutory framework to develop and empower
midwives to work within current, and future, contexts of maternity care.
Implications for practice: as 13 of the 19 studies included within this review were conducted prior to
publication of the current rules and standards underpinning the statutory framework for midwifery
within the UK (NMC, 2004, 2006), it is plausible that the evidence base does not reect contemporary
midwifery and statutory supervisory practice. Notwithstanding, the research included within this
review clearly suggests a need to increase both midwives and supervisors of midwives knowledge and
understanding of the statutory framework.
& 2011 Elsevier Ltd. All rights reserved.

Keywords:
Statutory supervision of midwives
Midwifery supervision
Perceptions
Systematic review

Corresponding author.
E-mail addresses: a.henshaw@leeds.ac.uk, anne-marie.henshaw@yorksandhumber.nhs.uk (A.-M. Henshaw), d.c.clarke@leeds.ac.uk (D. Clarke),
a.f.long@leeds.ac.uk (A.F. Long).
0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2011.11.004

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A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

Introduction
The provision of safe, high quality maternity services is a
complex issue; legislation and robust systems for the regulation
and registration of health professionals are globally recognised as
being crucial for improving standards and assuring public condence in health professionals (Department of Health (DH),
2007a, 2007b; Healthcare Commission, 2008; Kings Fund, 2008;
International Confederation of Midwives, 2010). In the United
Kingdom (UK) regulatory bodies are challenged to provide risk
based mechanisms through which registrants can revalidate, by
way of assessment of evidence, their continued competence and
tness to practice, thereby maintaining professional registration
(DH, 2007b). The proposed revalidation processes will differ
between professions and be proportionate to the potential risk
each profession poses to the public (DH, 2008). Given the
autonomous nature of midwifery practice within the UK and
the risks to women, their babies and families if poor practice
occurs it is important to understand the current framework for
midwifery regulation and how this is perceived and utilised by
the profession.
In the UK the midwifery profession is regulated by the Nursing
and Midwifery Council (NMC), which lays down rules and
standards to determine the preparation and practice of midwives
(NMC, 2004). The statutory function of the NMC is to safeguard
the health and well-being of the public; this is achieved through
maintaining a register of qualied midwives and nurses, establishing and monitoring standards of education, training and
conduct and investigating allegations made against midwives
and nurses who may not have followed the Code and Rules
(NMC, 2004, 2010). In midwifery key parts of this statutory
function, namely assessment of tness to practice and continuing
registration and practice, is devolved via the statutory supervision
of midwives. The aim of midwifery supervision is to protect the
public by promoting best practice and excellence in care; preventing poor practice and intervening in unacceptable practice
(NMC, 2006). Thus, statutory supervision should enable midwives
to provide safe and effective care, and supervisors of midwives to
support midwives to practice with condence (NMC, 2006, 2008).
While in principle the current regulatory position in the UK is
that midwifery supervision should be benecial for women, their
babies and the profession, there has to date been no review of the
evidence to establish whether this is the case. Within this context
a systematic review was undertaken to explore how statutory
supervision is perceived and experienced by midwives and supervisors of midwives. This paper reports that review and draws
attention to what is known, areas of uncertainty, gaps in knowledge and areas for further research.

Method
The review protocol, informed by guidelines developed by the
Centre for Reviews and Dissemination (2009), was executed in
four stages (Fig. 1). Stage 1 involved developing the review
question and dening inclusionexclusion criteria (Table 1). The
review question developed was what are midwives and supervisors of midwives perceptions of statutory supervision?
Between January and October 2009 published research, which
explored midwives and supervisors of midwives perceptions of
statutory supervision was sought via a systematic search strategy.
This comprised systematically searching electronic databases
(stage 2) include the following: Maternity and Infant Care, MEDLINE, HMIC, PsychINFO, CINAHL (EBSCO) and Proquest Dissertations and Theses using the key words statutory supervision or
supervision of midwives and perceptionn or experiencen or

viewn or opinionn. Conference proceedings were searched via

websites and the journal Practising Midwife, which is not
available electronically, was hand-searched. Contact was made
with ve selected subject experts including representatives of the
Local Supervising Authority Midwifery Ofcers (UK) Forum,
Association for Improvement in Maternity Services, the Royal
College of Midwives and a Lead Midwife for Education; no
additional published research was identied by these individuals.
The search strategy identied 599 potentially relevant citations. The titles and abstracts were examined to determine their
relevance to the review question. Those citations, which were
clearly of no relevance to the review question, were excluded
(stage 3) (n546). The remaining potentially relevant papers
were obtained in full (n 53) and the review inclusionexclusion
criteria applied (see Table 1). Reference lists were scrutinised to
ensure that any potentially relevant research not already identied was not overlooked (CRD, 2009). Thirty-four papers were
excluded and the methodological quality of the remaining 19 was
assessed using an evaluation tool developed by Long and Godfrey
(2004). This was selected because of the breadth and coverage of
the areas addressed within the tool, its exibility for studies using
both structured and less structured data collection methods and
its requirement for assessors to make explicit the rationale for
their judgement (stage 4). Each study was then rated as high,
good or poor quality according to the quality denitions described
by the National Institute for Health and Clinical Excellence (2009,
p. 75) (Table 2). Quality assessment and data extraction was
undertaken by one researcher (AH); a random sample was
reviewed by DC and AFL and any differences in quality assessment resolved through discussion. Thematic analysis was used to
systematically identify recurrent and important themes reported
within the included studies (Pope et al., 2007). The ndings of
papers rated as being of high quality were reviewed rst and the
main themes identied by reading and rereading each paper until
close familiarity (Hughes et al., 2009) with the content was
established. Greatest weight was given within this review to
ndings from papers of better methodological quality while
ndings of studies rated as poor quality were used only to
conrm the ndings of better quality studies or to raise areas of
uncertainty for further research. 9 key themes were identied.

Findings
Overview of the included studies
Table 3 presents an overview of the nineteen studies included
within this review with the high quality studies presented rst
and poor quality studies last. All the included studies were
published between 1995 and 2009. Data was collected from a
range of different settings including from midwife and supervisor
of midwives participants employed by the NHS and higher
education institutions, as well as self-employed midwives across
England, Wales and Northern Ireland. A variety of research
methods were used; four studies used qualitative interviews;
seven studies collected data via questionnaire survey. The
remaining eight studies used a mixed method approach where
more than one type of data collection method was employed
(Brannen, 2005). For example, Stapleton et al. (1998) used an
ethnographic approach, collecting data via questionnaires and
individual and group interviews. Halksworth et al. (2000) collected data via questionnaire followed by case study research of
ve study areas. Three studies included within the review were
described by their authors as audit (Duerden, 1996, 2000; Paeglis,
2009a, 2009b). As it was apparent from reading each of the
publications that they were actually generating new knowledge

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

Stage 1

Developing the review

question and inclusion
criteria

Stage 2

Potentially relevant
citations identified by the
systematic literature
search

77

n=599

Citations excluded as unrelated or

duplication n=546
Stage 3

Stage 4

Scrutinise identified
research for relevance to
review and apply inclusion
criteria

Assess methodological
quality of n=19 included
studies

Qualitative
n=4

Quantitative
Survey n=7

Inclusion criteria applied remaining

n=53
Research excluded following
application of inclusion criteria n=34

Studies included in review n=19

Mixed Design
n=8

Fig. 1. Stages and results of the systematic review process.

Table 1
Review inclusion and exclusion criteria.
Feature

Inclusion criteria

Exclusion criteria

Participants

Registered midwives (including independent midwives and

midwives employed by the NHS and other employers) and
supervisors of midwives working within the UK
Research that explores, and generates new knowledge
regarding, participants perceptions of the statutory supervision
of midwives
Published primary research using any research method (NRES
2009)
No date restrictions applied

Other health and social care professionals

Midwives not registered to practice within the UK

Focus of study

Type of study
Date of publication

Table 2
Quality denitions used to assess included studies (NICE, 2009).
Quality
assessment

Denition

High Quality

All or most of the evaluation criteria have been fullled,

where they have not been fullled the conclusions are very
unlikely to alter
Some of the evaluation criteria have been fullled, where
they have not been fullled, or not adequately described, the
conclusions are unlikely to alter
Few or no evaluation criteria have been fullled and the
conclusions are likely or very likely to alter

Good Quality

Poor Quality

in the topic area rather than solely seeking to compare practice

with an established standard the decision was taken to include
these studies within this review (National Research Ethics Service,
2009). A further four studies were published in a seminal text
book about statutory supervision (Demilew, 1996; Duerden, 1996;
Shennan, 1996; Williams, 1996). As the level of methodological

Research which does not report midwives or supervisors of

midwives perceptions of the statutory supervision of
midwives
Unpublished studies
Opinion papers
Not applicable

detail varied from chapter to chapter attempts were made to

contact the authors to determine whether full research reports
were available elsewhere. One researcher responded: she has
retired and so had no access to archive reports (Duerden, 2009).
Three of the nineteen studies were classied as high quality
(Kirkham and Morgan, 2006; Kirkham et al., 2006; Mead and
Kirby, 2006). Core strengths included comprehensive detail about
each stage of the research process with clear evidence of the steps
taken by the researchers to demonstrate the rigour, trustworthiness and credibility of the research; criteria commonly used to
evaluate the quality of qualitative studies (Duerden, 2000;
Halksworth et al., 2000; Burden and Jones, 2001; Ball et al.,
2002; Holloway and Wheeler, 2010). Eleven papers (Demilew,
1996; Shennan, 1996; Stapleton et al., 1998; Burden and Jones,
1999; McDaid and Stewart Moore, 2006; Smith and Dixon, 2008;
Paeglis, 2009a, 2009b) were rated as good quality. The major
limitation of these papers was that the research methods had
not been adequately described within the research publications.
For example, Stapleton et al. (1998) presented a clear rationale
regarding the conduct and analysis of the in-depth interviews but

78

Table 3
Overview of included studies.
Author

Research aim

Methods

Participants

Synopsis of key ndings (relevant to the

review question)

Smith and Dixon

(2008)

McDaid and Stewart

Moore (2006)

Phase one: Postal questionnaires, In depth

semi-structured, ethnographic interviews.
Grounded theory approach (constant
comparative method) used for interview
analysis. Phase two: Postal Questionnaire

Phase one n 300

midwives,
34% response rate
n 15 midwives
interviewed
Phase two n 910
62% response rate

n 608
Online questionnaire
80% midwives,
Likert scale and open ended questions
(analysed using thematic content analysis) 2% obstetricians
18% GPs, neonatal
nurses, nurses,
paediatricians and
hospital managers
Explore midwives perceptions of the role Semi-structured interviews analysed using Purposeful
n 10 midwives
Glaser and Strauss approach to grounded
of statutory supervision of midwifery in
theory
Northern Ireland
Explore health-care professionals views
about safety in maternity services

Respondents felt that midwifery

supervision was misunderstood and so
undervalued. A lack of time and
remuneration for the role of supervisor of
midwives was identied

Midwives openly acknowledged their lack

of understanding about statutory
supervision and wanted it to be more
transparent, less covert and less formal.

High quality study, which presented

comprehensive detail of each stage in the
research process. Issues related to
distribution of the questionnaires by the
NMC were explained in detail and
subsequent decisions made by the
research team clearly documented

High quality study, which demonstrates

researcher reexivity and describes a
clear audit trail. Problems associated with
administration of the research project
and in particular recruitment of
participants for phase 1 were described in
detail

High quality study, which reports each

stage in the research process in clearly
and in detail

A good quality study, which described the

audit process in some detail. The major
limitation of this research was that the
response rate was approximately 20% of
midwives practising within Yorkshire
and the Humber and so may reect the
views and experiences of midwives at
either end of the continuum or those who
are more enthusiastic about supervision.
Focus group data was collected in groups
facilitated by the Local Supervising
Authority Midwifery Ofcer and so it
would be conceivably difcult for
participants to express negative views of
supervision
Good quality, large scale study, which
reported with a reasonable level of detail
regarding recruitment and study sample.
More detail could have been given about
data analysis but conclusions unlikely to
alter
Overall, rated as a good quality study as
although some of the evaluation criteria
were inadequately described, the
conclusions are unlikely to alter. The

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

36% of midwives agreed or strongly agreed

that their supervisor of midwives kept
them going as a midwife
49% disagreed that their supervisor of
midwives kept them going as a midwife
(p53)
46% felt more support from supervisor/
manager would have the greatest positive
impact on their job
Midwife returners reported varying degrees
Kirkham and Morgan Identify and gather the views of midwife Phase one: Postal questionnaires, In depth Phase one n 18
of support from their supervisor.
midwives, 42.9%
semi-structured interviews. Grounded
(2006)
returners on their reasons for returning
Organisational issues meant that some
response rate
theory approach (constant comparative
and their subsequent midwifery
midwives had not been allocated a
method) used for interview analysis. Phase n 14 midwives
experience
supervisor; some had no contact with their
interviewed
two: postal questionnaire
supervisor; others, despite contact, felt
Phase two
unsupported; some sympathised with the
n 208 midwives
supervisor and seemed to understand their
37% response rate
work pressures and therefore did not
approach them for support
n 758 supervisors Mean time spent on supervisory activities
Mead and Kirby
Determine the amount of time supervisors Postal questionnaire and activity diary
44% response rate
in a week 1 day
(2006)
spent in supervision of midwives in
Two types of supervisor were
England, and whether variations in the
identieda to be supervisor (that is a
activities and time spent on supervision
supervisor who associates supervision as
could be identied
an intrinsic part of their role) and a to do
supervisor (a supervisor who associates
supervision with specic activities)
98% of midwives felt they had a positive
Questionnaires to SOM, midwives, student n 469 midwife
Paeglis (2009a,
Audit supervision of midwives and
relationship with their supervisor (n 460),
2009b)
midwifery practice within Yorkshire and midwives, non-midwives and service users responses (approx
20% response rate) 83% were aware of the proactive work of
(both formal and informal audits), focus
the Humber
groups of student midwives, midwives and n 117 supervisor
their supervisor (n392) however no
midwifery lecturers for formal audits plus of midwives
details were given about the nature of this
responses
self-audit by Trust of progress against
proactive work. Midwives felt that the
(approximately 50% supervisor of midwives was a good role
actions arising as a result of
response rate)
recommendations of last audit visit
model in terms of communication (94%
(Service User and
n 441), evidence based practice (95%
other responses
n 447) record keeping (95% n443)
excluded for the
purpose of this
review)

Kirkham et al. (2006) Obtain a clear picture, of the reasons

midwives give for continuing to practice
midwifery

Synopsis of evaluative summary

Ethnographic interviews data collection

and analysis based upon a grounded theory
approach
Postal survey Statistical Software Package
use to analyse Likert Scale responses;
thematic analysis of free text

Interviews n 28
midwives
Survey sample size
n 1975 midwives
Response rate 52%

Determine the reasons midwives give for

their decision to leave midwifery and, by
asking midwives who have recently left,
to determine what would induce them to
return

Burden and Jones

(2001) (see also
Burden and Jones,
1999)

n 80 midwives
Determine the attitudes of midwifery staff Postal Questionnaire
Statistical Software Package use to analyse Response rate 65%
within one maternity unit to midwifery
supervision following a study day aimed Likert scale responses
at raising the prole of supervision

Halksworth et al.
(2000)

To provide descriptive material as to the

practice of supervisors in Wales

Undertake a systematic and independent

Duerden (2000)
Note: This research examination of supervision of midwives
is part of Stapleton
et al. (1998)

Phase one: Postal Questionnaire

Phase two: case study
Semi-structured interviews

Audit questionnaire
Group interviews with supervisors to
examine policies and procedures

n 59 supervisors
93% response rate
n 5 case study
areas and n 38
(midwives and
supervisors of
midwives) semistructured
interviews
n 185 midwives
n 27 supervisors

researcher stated that theoretical

saturation was reached after 10
interviews however the sample
comprised hospital based midwives and
theoretical sampling to include midwives
working in other areas could have been
employed, thereby addressing more fully
the research aim

The results from the England study were

found to be very similar to the North West
study (Duerden, 1996) with recurring
themes related to the appointment and
practice of supervisors; selection and
preparation of supervisors; midwives
choice of, and access to, a supervisor;
statutory requirements including
notication of intention to practice,
arrangements for statutory update (now
PREP) and supervisory reviews; midwives

Good quality study. Development of the

audit tool and the audit process was
described in sufcient detail however
there is no information regarding
strategies to address researcher bias

Good quality study; phase one eldwork

was well described and the problems
encountered accessing the study sample
for reported comprehensively. The main
limitation of this research was that it is
not clear what steps were taken to
account for possible researcher bias and
insufcient detail was presented
regarding thematic analysis of free text
comments in the postal survey

Good quality study although no

demographic information is offered in the
publication regarding the study sample,
which would be useful if wanting to
transfer the ndings to other settings

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

Ball et al. (2002)

They reported experiencing power

imbalance within the supervisory
relationship, which increased the gap
between supervisors and supervisees, 60%
of participants felt that supervisors should
specialise within a particular area of
midwifery practice. Respondents felt that
supervision was given low priority and it
was not recognised by many Trusts but the
majority of them spoke highly of their
supervisors; 100% of participants reported
being grateful or thankful they did not
need supervision as supervision was there
only if you had a problem
Distinction was made between midwives
ability to discuss issues with their
supervisor and the provision of effective
supervisory support (46% felt able to
discuss concerns they had about their work
[40% disagreed or strongly disagreed] yet
48% did not feel their supervisor provided
them with effective support [33% agreed or
strongly agreed that their supervisor
provided effective support). 58% of
midwives in the 3135 age range and/ or
on D/E-grades (band 5/6) did not feel
supervisor provided effective support,
while 48% of respondents over 56 were
more likely to feel that their supervisor did
provide effective support. Regional
variations noted in midwives experiences
of their supervisor providing effective
support.
A change in attitude towards supervision
was reported following study day;
supervisors were more approachable and
less biased.
Midwives reported positive improvements
for items related to restrictive practices and
destructive to self-esteem
Supervisors of midwives valued the role
highly; midwives reported very differing
views but recognised developments in
supervision and reported changing
attitudes (developing the formative aspects
of the role, supporting individuals and
challenging midwives to develop their
practice further).

Good quality study and although limited

detail is presented in the publication
regarding the research process, the
conclusions are unlikely to alter. This
work is widely recognised as being
seminal and the largest study exploring
supervision in Wales.

79

80

Table 3 (continued )
Author

Research aim

Methods

Participants

Synopsis of key ndings (relevant to the

review question)

Good quality study, widely recognised as

being seminal work. Overall, a good level
of detail is presented about most stages
of the research process however while
sufcient detail was presented about the
conduct of the focus group interviews,
little information is given regarding
analysis of focus group interviews.
Research reexivity is well reported as is
steps taken to address possible
researcher bias. This was also an issue
with the audit arm of the study (see
Duerden, 2000)

Good quality study. The questionnaire

was developed from journal articles and
personal experience of the researchers
and so some reference to wider literature
was made. Frequency statistics were used
and although the results offered limited
insight, the aims of the study were met
Good quality study. Sufcient detail is
given regarding the phenomena under
study and the context of the study.
Tensions experienced in the midwifery
profession at the time of the study are
well described. The study sample size and
choice of participants were well justied
but more detail could have been
presented regarding data collection and
analysis. Within the research publication
issues related to researcher reexivity
were not discussed

Good quality study with a reasonable

level of detail presented at each stage of
the research process

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

knowledge of the function of the

supervisor, the need for supervision and
the need for support; supervision of
midwife lecturers and midwives working in
neonatal units
Ethnographic study comprising of six study Questionnaire audit Findings were extensive and
Examine the impact of statutory
Stapleton et al.
comprehensively reported upon
n 212 midwives
sites. Research methods included
supervision upon midwives and their
(1998)
Supervision was recognised to be a
Interviews
questionnaire (closed questions, verbally
practice; make comparative analysis of
Note: Findings
professional characteristic of midwifery.
n 168
from this research the range of models of supervision in use; administered)
Midwives knowledge and understanding of
value grids used
assess the relationship between effective In-depth interviews, construct of Kelly
were also
supervision varied from very poor to more
with 80 midwives
repertory grids
supervision and the achievement of the
published in
knowledgeable. Issues related to
over 3 sites
Focus groups
objectives of changing childbirth (DH
Stapleton and
condentiality and condence within
following
1993); identify the educational
Kirkham (2000)
supervisory relationships was described
interviews
and Stapleton et al. implications of the study for student
and the implications of supervisors
Focus groups
midwives, midwives and supervisors
(2000)
multiple roles were discussed
(n 15 groups on
(management, leadership). Supervision was
6 sites)
perceived by some to be a mechanism of
control with the disciplinary aspects of
supervision being problematic for
midwives and supervisors. A culture of
intimidation, learned helplessness, guilt
and blame was reported by midwives and
supervisors working within the NHS but
opportunities to reformulate negative
experiences of supervision were recognised
n 80 midwives
Midwives were confused about the roles of
Burden and Jones
Determine whether midwives within one Postal Questionnaire
Statistical Software Package use to analyse Response rate 68% supervisor and manager and so often
(1999)
maternity unit could differentiate
referred issues to both supervisor and
Likert Scale responses
between the role of supervisor and the
manager. Midwives perceived view of the
role of manager
managerial and supervisory roles was
compounded by supervisors being in
managerial posts
Semi-structured interviews analysed using n 32 independent 2/3 of participants had been through an
Demilew (1996)
Explore independent midwives
midwives
investigatory process. 1/4 more than once
perspectives of their professional practice, thematic analysis
and 5 midwives had been through a
the midwife/supervisor relationship and
supervisory investigation on 3 occasions.
the relationships of the midwife with
32 separate investigations were reported,
other health-care professionals
1/2 of these concerned differences in
clinical practice and decision making as
measured by local policy. 1:5 investigations
were appropriate retrospective enquiries
reviewing adverse pregnancy outcomes
such as intrauterine death, neonatal death
or babies who were initially ill (p. 192).
Midwives critical of process of
supervisionthe investigations
experienced as being unsupportive,
punitive and negative; demonstrable lack
of trust by the supervisor of midwives;
process seemed to be blame labelling until
proven otherwise
n 12 midwives
Supervisory support described as a
Shennan (1996)
Explore the experiences midwives had
Semi-structured interviews with
continuum from midwives being very well
with supervisors
continuous data analysis (theoretical
supported to midwives being poorly
approach to data analysis not stated)
supported being identied

Synopsis of evaluative summary

Poor quality. While the intervention and

The study day increased midwives
issues related to the distribution of the
knowledge of supervision and midwives
did increase their access to, and seemed to questionnaire were described in some
detail, evaluation criteria related to
be using supervision more effectively
sample, data analysis and results were
following the study day
not met and the reporting of the study
makes it difcult to assess whether the
conclusions would change.
Questionnaire
n 8 midwifery
All respondents expressed a need to have a Poor quality with insufcient detail given
Evaluate the midwifery lecturers
lecturers
named supervisor and were concerned that regarding sample characteristics, data
understanding and experience of
their supervisor would be able to act as an collection and data analysis. The
supervision and to identify their
questionnaire was distributed by a
advocate within the educational
requirements from the statutory
supervisor of midwives/senior lecturer to
institution; the most frequently reported
framework of supervision.
support need was to maintain and facilitate her colleagues; researcher bias and
the lecturers personal clinical practice. 6 of reexivity were not considered nor the
possible implications of researching a
the 8 respondents did not have a named
group of 8 colleagues.
supervisor
Poor quality. A small scale survey
62.5% of respondents only contacted a
Postal questionnaire using open and closed n 32 midwives
Elicit information about how midwives
supervisor if an incident required it. 50% of comprising of nine questions, which
88%
questions. No information regarding data
currently experience supervision;
fulls few evaluation criteria. Very
respondents felt supervision was more
Response rate
strengths and weaknesses of supervision; analysis of qualitative comments
limited details about the research
necessary for protecting their clinical
how supervision should change
practice compared with 31% who felt it was participants are provided (team
midwives), free text comments were
more necessary for protecting the public
and their clinical practice and professional invited and one comment per question is
published for questions 18. It is not
update
70% felt that supervision in their area was known how representative these are of
the sample nor how they were selected.
not adequate
The researcher suggests possible
explanations for the participants
responses but again it is not known how
these are drawn and whether they reect
the personal views of the researcher
Poor quality. Such limited
Participants were reported to be very
Unclear details of
Audit
Undertake a systematic examination of
methodological detail is presented and so
positive about supervision within the
nal participants
Structured interviews with mainly closed
supervision of midwives in one area
only few evaluation criteria have been
region and that supervision is alive and
n 385 midwives
questions. Three interview schedules:
within the UK
well (p. 139). Safeguarding the public was fullled. It is not known if the conclusions
and n60
group interview with supervisors of
would change. The author was contacted
midwifery teachers deemed to be most important role of
midwives, supervisor of midwives and
supervisor, 4% of midwives saw supervisors to determine whether the report could be
interviewed
midwives
as disciplinarians but the role of supervisor accessed via another route but the author
no longer had in her possession a copy of
as a supporter was felt to be the most
important role. 27% of supervisors reported the report and the body to whom she
reported is now dissolved
directly observing midwives clinical
practice. Midwives expressed difculties
determining between role of supervisor
and the role of manager
Poor quality. Few of the evaluation
Explore clinicians knowledge, opinions
Semi-structured interviews
n 12 midwives
Midwives reported little input about
criteria were addressed. Specic
and experiences of supervision
Analysed using latent content analysis
supervision in their pre registration
programmes or post registration education limitations include the study sample
comprised of midwives working in one
Knowledge and understanding of
supervision and the legislatory framework maternity unit; it is unclear whether data
saturation was considered and while it is
was inaccurate and incomplete;
stated that content analysis was used to
supervision was perceived to be a safety
generate themes the process is not
net for midwives; midwives spoke with
transparent and it is not clear how the
positive regard for their own supervisors
but recognised challenges associated with themes were identied and which were
more important to the participants
combining the roles of supervisor and
manager

Hughes and Richards Determine whether a study day on

(2002)
supervision would facilitate midwives to
obtain greater access to their supervisor

Rogers (2002)

Gaffney (1998)

Williams (1996)

n 219 midwives
60% response rate

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

Duerden (1996)

Postal questionnaire
Pre and post study day

81

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A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

limited methodological detail for other parts of the study, specically the audit and focus groups. These were common issues
across the research reviewed (Demilew, 1996; Shennan, 1996;
Duerden, 2000; Smith and Dixon, 2008; Paeglis, 2009a, 2009b).
Ball et al. (2002) presented supercial details regarding steps
taken to account for potential researcher bias during data analysis
and there was a lack of methodological description regarding data
collection and analysis by Burden and Jones (1999, 2001),
Halksworth et al. (2000) and Ball et al. (2002). The remaining
ve papers (Duerden, 1996; Williams, 1996; Gaffney, 1998;
Hughes and Richards, 2002; Rogers, 2002) were rated as poor
quality; they offered inadequate methodological description and
thus omitted the detail required to assess their credibility. A
synopsis of each studys aims, methods, key ndings and quality
assessment can be found in Table 3.
Themes
Four overarching themes were identied across the literature
and this section presents an overview of each theme.
The signicance of statutory supervision for midwives and
supervisors of midwives
Knowledge and understanding of the statutory supervision of
midwives and the role of supervisor of midwives. Midwives
apparent lack of knowledge and understanding regarding the
statutory supervisory framework was reported across studies
and time (McDaid and Stewart Moore, 2006; Williams, 1996;
Stapleton et al., 1998), with fundamental differences noted
between midwives and supervisors understanding of the
primary purpose of midwifery supervision. Midwives expressed
a need for supervision to protect them from increasing levels of
complaints and litigation (Stapleton et al., 1998) and were more
likely to consider that the protection of their own clinical practice
was more necessary than public protection (Gaffney, 1998).
Supervisors regarded public protection to be the most important
element of their role but recognised the tensions between
protecting the public by monitoring standard of practice at the
same time as supporting midwives (Halksworth et al., 2000).
Midwives who were knowledgeable about supervision were more
likely to have been involved in a supervisory investigation, or to
be working outside the National Health Service (Stapleton et al.,
1998).
Midwives also reported feeling uncertain about the differences
between the statutory role and responsibilities of supervisor of
midwives and the role and responsibilities of their midwifery
managers (Williams, 1996; Burden and Jones, 1999; Duerden,
2000; Halksworth et al., 2000; Stapleton and Kirkham, 2000).
Uncertainty was not limited to midwives; approximately 19% of
the supervisors in one study described difculties in discerning
between their statutory and employment roles (Duerden, 2000).
Some midwives preferred their supervisor to not be their
manager. They believed that non-manager supervisors were more
trustworthy and so they felt more able to discuss issues in
condence, which they may not want to disclose to their manager
(Stapleton and Kirkham, 2000). However they identied that nonmanager supervisors may lack power within the organisation to
act as an advocate for midwives and reported wanting their
supervisors to have clout within the wider organisation
(Stapleton and Kirkham, 2000, p. 82). These tensions were greater
for midwives who had been involved in clinical incidents and who
felt unable to draw upon their supervisor for support because
their supervisor was also a manager.
Statutory supervision was problematic for midwives not
working in clinical environments as employers did not always

understand or support midwives to meet their statutory requirements within their workload. In particular midwifery lecturers
reported needing assurance that they would be able to maintain
midwifery skills while working in higher education (Rogers,
2002).
Leading or in the background and hidden?. Raising the prole of
midwifery supervision with both midwives and the public was
considered to be crucial by midwives; some felt that supervision
was in the background, hidden and invisible (McDaid and
Stewart Moore, 2006, p. 185). Stapleton and Kirkham (2000)
however found that not all supervisors possessed the ability to
lead midwives and the midwifery service, nor awareness of their
own limitations.
The value of supervision. One of the larger, good quality studies
included within this review established that the vast majority of
midwives participating in the study wanted to retain statutory
supervision (Stapleton et al., 1998). Looking across the studies,
wide-ranging views about the value of supervision were reported.
Both Halksworth et al. (2000) and Demilew (1996) found that
some midwives expressed a lack of regard and respect for
supervision, describing it as being demoralising and degrading
(Demilew, 1996, p. 196), while the majority of the midwives
interviewed by Stapleton and Kirkham (2000) felt privileged to
have statutory supervision (2000:63). Notwithstanding, the
review ndings suggested that supervision is undervalued and
under resourced by many NHS Trusts (McDaid and Stewart
Moore, 2006; Smith and Dixon, 2008).
Statutory supervision as a means of supporting high quality practice
Support. Midwives varying experiences of supervisory support
were explored across a number of studies; poor supervisory
support resulted in midwives being unable to talk through their
feelings and having no one to turn to in a crisis (Stapleton et al.,
1998, p. 143). Midwives in Shennans (1996) study described
supervisors undermining their condence to practise, being
oppressive and using their power destructively by apportioning
blame without establishing the facts while in some Trusts
organisational issues meant that a few midwives had no
supervisory support because they had not been allocated a
named supervisor (Kirkham and Morgan, 2006).
Other midwives reported observing their supervisors being
stressed out (Stapleton et al., 1998, p. 143). Midwives were
sympathetic towards the supervisors and recognised the workload associated with the role and therefore chose to not approach
them for support (Kirkham and Morgan, 2006). Midwives
described how essential it was for supervisors to be able to
balance complex pressures associated with the role of supervisor
(Stapleton et al., 1998). This was conrmed by Williams (1996)
who identied that midwives who were well supported acknowledged their supervisors strength of personality and felt that they
had the capacity to take their concerns seriously.
Stressors for the supervisors of midwives included trying to cope
with and manage the competing demands of their supervisory and
substantive roles (Stapleton and Kirkham, 2000). Supervisors who
were managers reporting institutional loyalties, which regularly
clashed with their personal and professional objectives as a supervisor while supervisors who were not managers reported having no
direct access to resources and so considered that their authority as
a supervisor was compromised at times by non-midwife managers
(Stapleton and Kirkham, 2000). Supervisors were also concerned
that there were times when midwives seemed reluctant to discuss
issues with their supervisor as a result of their supervisors
additional managerial role and the implications this may have

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

83

upon practice (Halksworth et al., 2000). This nding conrms

earlier work by Shennan (1996) who reported instances of midwives feeling that their supervisors managerial responsibilities
took priority over their need for support and that, at a time when
they needed the most support, they received very little.

these as being negative and damaging, inciting feelings of blame

and stigma (Stapleton and Kirkham, 2000, p. 86; Stapleton et al.,
2000). When dealing with an admitted error, differences were
identied in the way individual supervisors and supervisory teams
addressed issues (Stapleton et al., 1998, p. 188)

The supervisory review meeting. Midwives recognised that meeting

once a year, as required by the NMC (2004), may not offer the
support they need to facilitate practice and personal development.
Moreover, some felt that the formality of the meeting widened the
gap between supervisor and supervisee (McDaid and Stewart
Moore, 2006). Midwives who commented more positively about
their supervisory review meeting spoke in terms of the meeting
being a source of inspiration and encouragement (Kirkham and
Morgan, 2006; Stapleton et al., 1998).

Supervisory relationships

Challenges associated with resourcing the statutory supervision of

midwives. Midwives expressed sympathy with supervisors about
the limited time allocated for supervision and the associated
workload pressures (Halksworth et al., 2000; Kirkham and
Morgan, 2006; McDaid and Stewart Moore, 2006; Smith and
Dixon, 2008). The Healthcare Commission (2008) state that 86%
of Trusts allocate 12 days a month for supervisors to undertake
supervisory activities; however, Mead and Kirby (2006) found
that in reality twice this amount of time is required.
Supervising the supervisors. Midwives and supervisors expressed
concern regarding the perceived vulnerability of supervisors of
midwives (Stapleton et al., 2000). This was particularly challenging
for midwives making the transition to being a supervisor where
they lacked role models for their own supervision (Stapleton et al.,
2000). Furthermore, few supervisors had the experience of being
well supervised before they became supervisors (Stapleton and
Kirkham, 2000) thus compounding the situation.
Statutory supervision as a means of controlling midwives and
midwifery practice
Control and the statutory framework. Monitoring of the quality and
standard of a midwifes practice by supervisors of midwives
was described by some midwives as being controlling and
undermining, inhibiting development of a supportive, facilitative
relationship between supervisee and supervisor (Stapleton and
Kirkham, 2000). Other midwives felt that the monitoring aspects
of supervision offered them protection from low standards
of practice from their colleagues and as such was comforting
(Stapleton and Kirkham, 2000, p. 69). Stapleton et al. (2000)
suggested that while many supervisors have moved away from
this inspectoral role, the extent to which they did so was associated
with their personal style and philosophy of supervision. Some
supervisors continue to use monitoring, in particular monitoring
record keeping, as a tool to assess the standard of a midwifes
practice (Duerden, 2000; Halksworth et al., 2000) while others
sought to distance supervision from the monitoring elements of the
statutory function.
Intimidation of midwives by supervisors was reported in three
studies where the supervisee and supervisor disagreed about a
course of action (Shennan, 1996; Williams, 1996; Stapleton and
Kirkham, 2000). Midwives described occasions when they felt
intimidated by supervisors, but they also suggested that supervisors were intimidated by their managers (Shennan, 1996) or
inuenced by medical staff when they complied with the medical
staffs self-ascribed superiority (Williams, 1996, p. 151).
The studies repeatedly focused upon investigations into a midwifes tness to practice. Some midwives felt that the disciplinary
aspects of supervision were important while others perceived

Supervisory relationships and power. This review found that both

midwives and supervisors of midwives recognise the benets of
establishing and developing positive, constructive relationships,
where midwives were able to openly discuss and debate issues
and seek advice (Demilew, 1996; Williams, 1996; Halksworth
et al., 2000; Stapleton and Kirkham, 2000; Stapleton et al., 2000).
Where the supervisor and supervisee shared a similar philosophy
and understanding of midwifery the relationship was more likely
to be positive; when they possessed different belief systems
midwives experienced tension, conict and obstructive practices
(Demilew, 1995). Midwives who had not established a
relationship with their supervisor reported being reluctant to
call upon a supervisor of midwives in an emergency situation and
inhibited from discussing and debating practice and development
issues (Halksworth et al., 2000).
Four studies highlighted the personal attributes and skills the
supervisors should possess to establish and develop an effective
supervisory relationship, in particular approachability, availability and a good attitude towards fellow midwives (Halksworth
et al., 2000). The supervisor should be a good listener (Kirkham
and Morgan, 2006); able to hold condences, trustworthy and to
put herself in the midwifes shoes (Halksworth et al., 2000;
Stapleton and Kirkham, 2000, p. 71). Midwives also thought that
supervisors of midwives should be advocates, change agents and
adjudicators (Stapleton and Kirkham, 2000); with a mature
approach and good interpersonal and assertiveness skills
(Williams, 1996). Furthermore, they should be motivational,
visionary, objective, kind, humble and caring with extensive
knowledge in a wide range of areas and recent clinical experience
(Williams, 1996; Stapleton and Kirkham, 2000).
Condentiality was perceived as being fundamental within
supervisory relationships and midwives who had experienced a
breach of condentiality felt that their relationships broke down
as they could no longer trust supervisors with information they
considered to be of value (Stapleton and Kirkham, 2000). However maintaining condentiality during a supervisory investigation resulted in midwives feeling anxious, threatened and
undermined on one study site (Stapleton and Kirkham, 2000).
Feeling valued was found to be crucial if midwives were to safely
explore previous difcult experiences and provide the opportunity to empower the midwife to understand the past and to look
to the future (Stapleton and Kirkham, 2000).
While the capacity of the supervisory relationship to empower
midwives was widely reported (Shennan, 1996; Williams, 1996;
Halksworth et al., 2000; Stapleton and Kirkham, 2000; McDaid and
Stewart Moore, 2006), some midwives felt that supervision could
never be empowering as currently midwives could not appeal
against local supervisory decisions (Stapleton and Kirkham, 2000).
Some supervisors acknowledged the powerful nature of statutory
supervision and longer term implications of inappropriate
appointments to the role (Stapleton and Kirkham, 2000).

Discussion
The NMC requires midwives, at the point of registration and
beyond, to be procient at making effective use of the statutory
supervisory framework to review, develop and enhance their

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A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

knowledge and skills (NMC, 2009). The evidence within this

review suggests that midwives and supervisors of midwives
recognised that statutory supervision can contribute to public
protection by facilitating midwives to reect upon their standards
of practice, but at the same time, tensions were evident between
what the LSAMO National (UK) Forum (2009) describe as the
administrative, interactive and developmental aspects of the role.
Lack of knowledge and understanding about midwifery supervision and the role of supervisor of midwives was a theme, which
cut across the research reviewed but it was not possible to
determine whether midwives decient knowledge and understanding of the statutory framework reected a lack of engagement with statutory processes, perhaps because they saw no
value in supervision. On the contrary, Williams (1996) found that
midwives were knowledgeable about the historical context of
supervision, yet it was unclear how this inuenced their current
perceptions. What was clear from these studies was a marked
difference in the interpretation and implementation of the statutory framework across the UK, and across time.
Lack of clarity regarding boundaries between supervisory and
management functions cut across a number of themes. This was
made more complex by inconsistencies between individual
supervisors approaches (Stapleton and Kirkham, 2000). Supervisors who were also midwifery managers reported clashes
between institutional loyalties and supervisory responsibilities
(Stapleton and Kirkham, 2000, p. 85) and thus the juxtaposition
between statutory role and employment role is portrayed as
being problematic. Despite the ndings of the Mead and Kirby
(2006) study, which indicated that supervisors spent a mean time
of one day per week on supervisory activities, 14% of NHS Trusts
continue to allocate no protected time for supervision (Healthcare
Commission, 2008). The impact that a lack of time has upon a
midwifes motivation to undertake the supervisory role should be
established, especially as nationally problems in recruiting
and retaining supervisors of midwives have been recognised
(Healthcare Commission, 2008).
Midwives expressed a range of views about the supervisory
review meeting and while some found the meeting inspirational
and encouraging other midwives report little benet. Despite
every registered midwife having to meet with their supervisor at
least annually, no research was located, which explores the scope
of the supervisory review meeting, whether it has any impact
upon midwifery practice and what that impact may be. This is a
particularly important area to research as public assurance
regarding safety and quality within maternity services is intrinsically linked to midwives ongoing registration with the NMC.
The review ndings suggest that complex relationships have
developed between some midwives and supervisors of midwives,
in particular with regard to power and trust within the supervisory relationship. This review identied the importance of the
nature and quality of the supervisory relationship in facilitating
midwives to develop their practice and it is not inconceivable that
motivations for becoming a supervisor may affect these relationships. The importance of trust within midwifery relationships was
also acknowledged by Hunter et al. (2008) who found that
midwives sometimes tried to appear to be knowledgeable when
actually they lacked trust and the condence to openly discuss
issues related to competence with their colleagues. These issues
reect the ndings of this review; supervisory relationships
have the capacity to empower, inspire and motivate midwives.
Conversely poor relationships can result in a lack of trust and
openness, which in turn could impact upon standards of clinical
practice and safety of women and their babies. More research is
required in this area.
Looking across the limited research evidence base reviewed,
in general, midwives perceived their involvement in supervisory

investigations as being punitive, unsupportive and having a profound effect upon self-efcacy (Demilew, 1996, p. 192; Stapleton
and Kirkham, 2000, p. 88). Inconsistencies regarding how issues
related to tness to practice are addressed and variations from one
practice area to another were also identied. One study, however,
reported midwives indicating personal growth as a result of such
involvement (Stapleton et al., 2000, p. 118), but it is not clear
whether this was a retrospective view nor how this may have
changed during the process of the investigation or following
acceptance of the investigating supervisors recommendations.

Strengths and limitations of the review

This review has employed systematic methods to identify and
quality appraise published research, that reports midwives and
supervisors of midwives perceptions of the statutory supervision
of midwives. Thematic analysis was utilised to identify the main,
recurrent themes arising across the literature (Pope et al., 2007).
Our intention was to be provide insight into the possible multiple
thematic strands in existing evidence, with a view to aid understanding of perceptions for current midwifery supervision processes in the UK. It thus may provide the foundation for a future
integrative review approach aimed at providing a synthetic overview of the research evidence (Whittlemore and Kna, 2005).

Recommendations for practice

As 13 of the 19 studies reviewed were conducted prior to
publication of the current rules and standards underpinning the
statutory framework for midwifery within the UK (NMC, 2004,
2006) it is plausible that the evidence base does not reect
contemporary midwifery and statutory supervisory practice. This
must be taken into account when considering the ndings of this
review and highlights the need for further research into this area.
Specically, further research needs to be undertaken into the core
functions of the current statutory framework to inform the
development of proportionate revalidation mechanisms. Notwithstanding, the research included within this review strongly
suggests a need to increase both midwives and supervisors of
midwives knowledge and understanding of the statutory framework. A review of the supervisorymanagerial interface and ways
in which effective statutory supervision can underpin public
safety by enhancing high quality practice is overdue. The importance of supervisors of midwives being t for practice cannot be
underestimated; this includes preparing and appointing midwives who possess the knowledge, skills and attitudes required
to execute the role and responsibilities effectively within the
changing and challenging context of midwifery practice.

Conclusion
The Department of Health emphasises the importance of
assuring the public that services are delivering high quality, safe
and effective care, which is intelligently regulated and measured
(Department of Health, 2007b). Within midwifery the NMC
discharges this element of its regulatory responsibilities through
the statutory framework for the supervision of midwives. The
important contribution of statutory supervision to patient safety
and quality of care is recognised within the policy and practice
literature (Kings Fund, 2008; Midwifery 2020, 2010). More
research is needed to examine ways in which statutory supervision contributes to patient safety and high quality care and
what opportunities there may be for the statutory framework to
develop and empower midwives to work within current, and

A.-M. Henshaw et al. / Midwifery 29 (2013) 7585

future, contexts of maternity care. Moreover, there is a need to

update the current evidence base in respect of the real world
engagement of midwives and their supervisors with the current
rules and standards as these relate to statutory supervision. It is
to this end that the current research of the lead author is directed,
in particular, to explore the extent and ways in which the
midwifery statutory supervisory review meeting is t for purpose.
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