Operational Policy for Powys Teaching Health Board Maternity Services

Powys Teaching Local Health Board Title: Maternity services Operational Policy

Directorate: Women’s and Children’s Code: PtLHB/MAT 034

Author: Cate Langley

Operational Policy for Powys teaching Health Board Maternity Services

Policy Code Date Version Number Planned Review Date PtLHB/MAT Jan 2006 Initial issue Jan 2009 034 Oct 2006 2nd issue – revised Aug 2007 3rd issue – revised

Jan 2009 4th issue – reviewed Jan 2011 – Included chain of command and equipment inventory

Mar 2010 5th issue – addition of Mar 2012 Appendix 4 ‘working hours and handover of care.

March 2012 6th issue – reviewed March 2015 and revised

Document Owner Approved By Date Women’s and Children’s Directorate Women’s and 29/03/12 Children’s Directorate Clinical Effectiveness 16/04/12 committee Document Type Policy

Issue Date: 2009 Page 1 of 25 Review Date: 201

Status: Final Approved by: Clinical Effectiveness committee 16/04/2012 Powys Teaching Local Health Board Title: Maternity services Operational Policy

Operational Policy for Powys teaching Health Board Maternity Services

Contents Page

Validation & Ratification 3 Service Philosophy 5 Service Summary 5 Referrals/exclusion criteria 7 Service Aim 7 Service objectives 7 Maternity service structure 8 Escalation procedure 8 Medical management 11 Multi-disciplinary working 11 Equipment 11 Uniforms 12 Quality and safety 12 Health and safety Supervision of Midwives Clinical risk and incident reporting Concerns/redress Communication Risk assessment Confidentiality Training and education 15 Advocacy 16 Chain of command – jump call procedures 16 Appendices

Maternity services closure record 17 Escalation letter 18 Equipment inventory 19 Midwives working hours and hand over of 22 care For Reviewed / Updated Policies Only:

Relevant Changes – Date

6th issue – reviewed and revised 29/03/12

VALIDATION & RATIFICATION

To be completed by the Author – no policy, procedure or guidance will be accepted without completion of this section which must remain part of the policy

Title: Operational policy Maternity Services Author: Cate Langley Head of Midwifery and Sexual Health Services Directorate: Women and Childrens Reviewed and Updated by: Cate Langley

EVIDENCE BASE Are there national guidelines, policies, legislation or standards relating to this subject area? If yes, please include below:

If No, please provide information on the evidence/expert opinion upon which the policy has been based.

CONSULTATION

Please list the groups, specialists or individuals involved in the development &

Author: Cate Langley consultation process:

Name Date

Powys midwives 26/02/12 Powys supervisors of midwives 26/02/12 Equality Statement l t e e

c a 26/02/12 i v Women and Childrenss services t i a r t i n p e s e v r m o i d

e Comments P f A o f i N

Please insert the name of theD Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol Age √ Name Date Disability √ Women’s and Children’s Directorate 29/03/12 Gender √

IMPLICATIONSRace √ Please state any training implications as a result of implementing Religion/the policy / procedure√ . Belief SexualPlease state √any resource implications associated with the Orientatioimplementation. nNo other implications WelshPlease state √any other implications which may arise from the Languageimplementation of this policy/procedure. HumanNo other implications√ Rights For Completion by Quality & Safety Unit

Checked by: Date:

Submitted to CEC: Date:

Equality Assessment Statement Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have affect at all

Are there any risks arising from the implementation of this policy?

Nil additional risk

Do you believe that they are adequately controlled?

Relevant to: Local guideline for midwives working in Powys Purpose The overall aim is to ensure safe and effective care is provided to mother and baby. Responsibilities All midwives working within Powys hold a recognised midwifery qualification. No additional qualifications are required to carry out this policy. Monitoring This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix system

Process

Service Philosophy

Powys maternity services provide expert, high quality, midwife led care, which promotes and supports the normal physiological processes of childbearing. Midwives are experts in normal midwifery care and are highly skilled in the detection of abnormality with the knowledge of when to refer to a suitably qualified professional. It is recognised that childbirth is a life changing event for families and Powys midwives aim to support families in achieving a birth experience that is both safe and which

Author: Cate Langley satisfies their needs. Women and family members are considered to be equal partners in care planning.

Service Summary

All Antenatal and Postnatal care is provided by 8 Midwifery Teams

South Powys North Powys

1) Ystradgynlais 5) Llanidloes

2) Brecon 6) Machynlleth

3) Llandrindod & Builth Wells 7) Newtown

4) Knighton 8) Welshpool

Intrapartum Care is provided in women’s own homes, one of 6 Powys’ Birth Centres and DOMINO (domiciliary in and out) service into neighbouring district general hospitals.

Births Centres:

1) Brecon 2) Knighton 3) Llandrindod & Builth Wells 4) Llanidloes

5) Newtown 6) Welshpool

Birth Centres have open visiting times and have facilities for fathers or birth partners to stay. The 5 of the 6 birth centres offer en suite facilities. Tea, Coffee and light refreshments are available at all times.

Static Birth Pools are available in Knighton, Llanidloes and Brecon, and a portable pool in Newtown.

Postnatal stay for all women is up to 24 hours

All units have locked security systems and security procedures are followed in line with Policy for Child or Young Person (0-18 Years) abducted or Identified as missing from Powys teaching Health Board premises.

Antenatal Education is provided according to Powys Antenatal Education service specification. There is ongoing evaluation of antenatal classes.

TENS machines, birth mats and Birth Balls are available in Birth Centres

Breastfeeding support is provided by midwives and health visitors. The Bron i’r Babi peer support programmes are available in Machynlleth, Newtown, Welshpool, Llandrindod Wells and Ystradgynlais. Powys is currently working towards Stage 2 of the UNICEF baby friendly initiative.

Referrals/Exclusion Criteria

Women access the service in a variety of ways;

 self referral,

 GP,

 District General Hospital Obstetric team.

Women are risk assessed at booking and where appropriate their care is planned to be midwife led in accordance with the All Wales birth centre guidance (refer to MAT 030 All Wales Birth centre guidelines).

Service Aim

The overall aim of Powys midwifery services holistic approach that places the woman and her child at the centre of care, providing advice, support and care for women and their families during preconception, antenatal, intrapartum and postnatal periods.

Service Objectives

In line with local and national strategies the objectives for Powys maternity services include;

 Place the needs of the mother and family at the centre so that pregnancy and childbirth is a safe and positive experience and women are treated with dignity and respect (Powys Maternity Services strategy 2011).

 Provide a range of high quality choices of care as close to home as is safe and sustainable to do so, from midwife to consultant-led services (Powys Maternity Services strategy 2011).

 Employ highly trained workforce able to deliver high quality, safe and effective services (Powys Maternity Services strategy 2011).

 Provide a service for the population that is constantly reviewed and improved (Powys Maternity Services strategy 2011).

 To ensure that statutory midwifery supervision is in place within Powys to ensure a safe and effective service for all.

 To provide mainstream educational placements for midwifery students.

 To refer to other agencies as necessary including the safeguarding children team, social services, Flying Start, Integrated Family Support Services, physiotherapists, mental health teams, Drugs and alcohol services (Kaleidoscope).

Maternity service Structure

The Midwifery Service operates in two large teams (North and South) each being led by a Lead Midwife. There are 29.14 WTE clinical midwives working for Powys LHB, supported by 3 WTE support workers. The midwifery teams provide clinical support where necessary to colleagues within neighbouring teams across Powys.

Operational management and professional leadership are provided by the Executive Director of Nursing, General Manager of Women and Children’s Services, Head of Midwifery and Sexual Health services, Lead Midwife North (Risk), Lead Midwife South (Public Health) and Practice Development midwife.

All Powys midwives are responsible for planning their own workload, meeting off duty/on call cover to ensure optimum use of resources and providing client centred care within community and birth centre settings. This must be balanced with meeting the unpredictability of a 24 hour midwifery service and maintaining working hours in line with European Working time directives

Duty rotas must be prepared in line with annual/study leave guidelines to enable an even distribution of staff throughout the week and meet the Issue Date: 2009 Page 9 of 25 Review Date: 201

Author: Cate Langley staffing level requirements for the whole midwifery service for Powys. Reporting sickness must follow the maximizing attendance at work policy.

Escalation Procedure

The unpredictable nature of maternity services can lead to peaks in activity, which may on rare occasions exceed staffing capacity. The prime concern must always be the safety of mothers and babies.

However Powys Maternity services will only close or restrict activity as a last resort after a clinical assessment of the risks and full discussion with managers and/or midwifery supervisors .

Powys Maternity Services will work towards the following status

Status GREEN Powys Maternity services will function as listed in this operational policy and have no anticipated concerns that will prohibit admissions or restrict women’s choice of birth place

Status AMBER Powys Maternity services have identified factors which are listed in the criteria for escalation that may precipitate closure and will lead to instigating an operational plan to address the issue.

Status RED Powys Maternity services is unable to manage within the criteria for escalation and after full management review has no choice but to close until advised that the services can once again become fully operational.

The potential closure should be discussed with the Lead Midwife or Head of Midwifery (Mon – Fri 9-5) or the on call supervisor of midwives (Out of Hours). The final decision regarding closure would be taken by the Head of Midwifery or designated deputy. A monthly report on escalation events will be submitted to Women and Children’s General Manager and the Director of Nursing.

Due to existing staffing levels and the impact on neighbouring DGH’s both in increased clinical activity and commissioning costs, the acceptable level of frequency for closure would be kept to unavoidable circumstances only. Powys would continue to work in partnership neighbouring DGH’s to support all maternity services at times of escalation. Issue Date: 2009 Page 10 of 25 Review Date: 201

Reasons for escalation

1. Insufficient staff as a result of

1.1 Staff sickness

1.2 Excessive working hours of existing staff.

Powys midwives work flexibly to meet the unpredictable workload of a 24 hour midwifery service. The teams work as North and Powys teams to ensure that there is a minimum of three on call midwives in both North and South areas.

Specific reasons for escalation

1. On call cover for North or South Powys has reached less than two midwives per area as this would be inadequate and unsafe to cover an intrapartum case (2 midwives to attend a birth in line with British Paediatric recommendations).

2. Insufficient beds. Powys midwives provide one to one care for intrapartum cases in line with WAG (2002 & 2005) Delivering the future and NSF standards. Each of the Powys Birth Centres has a minimum of two beds for labour and postnatal stay, with some centres having the capacity to temporarily set up other private areas in the event of a third bed being required.

3. Increased activity. The birth centres will work in conjunction with each other to enable centralising resources and ensure that one birth centre remains operational in both North & South Powys. In the event of increased activity women in both North and South Powys will be offered homebirth as an option if there are no resident women already in any of the birth centres.

4. Major Incident / Power Failure / Adverse weather conditions in line with tHB Major Incident and Adverse weather policy.

5. Infection control reasons, follow tHB Infection Control Team advice and policy guidance.

Escalation procedure

Where all staffing and environmental measures have been taken and capacity and activity outstrip available resources, the procedure for referral to the neighbouring district general hospitals should be followed.

When a woman contacts the Powys Midwives during the period of closure the Powys midwife should;

 Discuss the closure with a woman to ensure she has a clear understanding of the facts surrounding the matter.

 Discuss with the woman the choice of the neighbouring DGH’s who are accepting referrals, these may also include the option to use their birth centres where appropriate.

 Arrange admission and appropriate transfer to the accepting district general hospital/birth centre. On no account are women to be advised to ring around themselves.

Closure of the maternity unit is to be for the shortest time possible and will be reviewed every 12 hours to asses staffing levels. A maternity closure record form (appendix 1) must be initiated and sent to the Head of Midwifery to complete with an already completed Datix form.

The Head of Midwifery will

 Write to the women effected by the closure using – Escalation Letter (Appendix 2).

 Monitor trends through Datix and escalation log.

 Report all incidents of amber status to General Manager Women’s & Children’s and Director of Nursing on monthly basis.

 Report all closures to General Manager Women’s & Children’s directorate, Head Quality and Safety, LHB at executive level

 Report closure of whole service to Supervising Authority Midwifery Officer (LSAMO).

Medical Management

Powys midwives will directly refer to the appropriate Obstetrician at the neighbouring DGH’s any woman who falls outside the inclusion criteria for midwife led care.

A number of Midwives have been specially trained to undertake the full newborn examination course within 48 hours of birth. All Powys midwives have direct referral to Paediatricians at neighbouring DGH’s or community Paediatrician within Powys.

Midwives will liaise with General Practitioners regarding women receiving midwife led care and will refer to the GP for all medical related conditions not associated with pregnancy.

Muiti-disciplinary Working

Midwives work closely with Health Visitors, Physiotherapists, Obstetric teams, General Practice, Safeguarding children’s team, Social Services, Kaleidoscope, Flying Start, Powys Domestic Abuse Forum and Police.

Equipment

Midwives are responsible for ensuring that equipment is appropriate, in good working condition, fit for purpose and meets current health and safety legislation (NMC Midwives Rule 2004). All Powys Midwives carry their own equipment in line with agreed Equipment Inventory (Appendix 3)

Midwives should record the weekly checking of their equipment in their work diary. It is the responsibility of all staff to ensure that any equipment that they use is serviced regularly.

All mobile phones under contract are monitored monthly for call activity.

Midwives are responsible for ensuring the safe keeping of RSA secureID tokens, keeping them in a safe place, ensuring they are not stored with their password and reported if lost.

Uniforms

Midwives should dress in accordance with tHB Uniform policy

Quality and safety

Quality and safety initiatives are an integral part of the midwifery service. Performance will be regularly reviewed and audited by the Lead midwives, Practice development midwife and supervisors of midwives and reported to Quality and safety committee and within the Women’s & Children’s directorate.

Health and Safety

The Head of Midwifery has overall managerial responsibility for the health and safety of the maternity services. Lead midwives and midwives will fulfill their health and safety responsibilities in line with the tHB Health and Safety procedure and job description.

All personnel that identify risks must make reports to the tHB Risk register via the Datix system.

Supervision of Midwives

Statutory Supervision of midwives provides a sound professional mechanism to:-

 Ensure midwives are competent practitioners thus promoting the safety and wellbeing of mothers and babies  Influence and monitor the development of optimum standards of midwifery practice in order to promote the wellbeing and individual interests of women and their babies  Provide support and guidance to all practising midwives.

Within Powys tHB Supervisor of Midwives work to the following standards

Midwives have 24 hour access to a Supervisor of Midwives; Powys supervisors provide an on call rota

The ratio of Supervisors to Midwives in Powys is 1:8 thus facilitating a named supervisor for each Midwife (LSA Standard not to exceed 1:15 and ratio to reflect local needs and circumstances)

Powys Midwives can choose their own supervisor, and can access a Supervisor who has no management responsibility

Supervisory support is encouraged on a day to day basis, but each midwife should arrange to meet with her supervisor at least once a year for the purpose of statutory supervision. (Rule 12, NMC Midwives Rules and Standards 2004)

Confidential supervisory activities are undertaken in a room that ensures privacy. Each Birth centre or Powys Midwifery team base offer these facilities

Standards of Record keeping are audited through the individual annual supervisory review.

Powys Supervisors support practice development with Tool Box talks on relevant issues and their relation to practice.

Powys Supervisors of Midwives meet six weekly to discuss local supervisory issues and respond to Clinical Risk Management reports (Datix) and disseminate lesson learning through clinical risk newsletters.

Powys Supervisors of Midwives endeavour to meet annually with supervisory teams in a joining Health Boards and NHS trusts.

Powys Supervisor of Midwives participate in annual audit of Statutory Midwifery Supervision with the Local Supervising authority midwifery officer (Rule 13, NMC Midwives Rules and Standards 2004)

Clinical Risk and Incident Reporting

All clinical incidents, near misses, and complaints are registered and reported via the tHB DATIX system. All recorded incidents are reviewed by the Lead midwife (risk), where concerns regarding clinical practice are

Author: Cate Langley identified a supervisor of midwives will review the case and identify any specific learning requirements for the individual midwife and/or service. There may be instances where the investigator is from outside of maternity or outside of the organisation.

Serious untoward incidents are discussed at Risk management meetings and where appropriate escalated to the Quality and Safety meetings.

Feedback to staff is via the Lead midwives, named supervisor of midwives or clinical risk newsletter highlighting lessons learnt through reporting and where appropriate arranging any system changes to prevent the likelihood of the event re-occurring

Concerns/redress

Any complaints received regarding any aspect of the service should be directed through the line management system and an investigation will be undertaken according to the LHB Concerns Procedure.

Guidance on this is provided for families via the Concerns Information Leaflet.

Communication

A Communication Inventory will be available within each midwifery team. There will be open communication between all disciplines. Pregnancy Hand Records and Unified Child Health Record will be completed by all involved in clinical care.

There will be quarterly joint shire meetings (North & South) for feedback of relevant clinical/management issues and sharing of Clinical Alerts on complex cases.

Risk Assessment

A risk assessment is completed at booking for all women and recorded within the handheld records. The assessment will be re-visited at 28 weeks and 36 weeks of pregnancy, and as indicated throughout the pregnancy, onset of labour and first postnatal home visit. Plans of care will be recorded in the clinical record along with documented lead clinician.

Environmental risk factors will be identified using the Home risk assessment as part of the unified child health records.

Confidentiality

All women will be asked whether their personal information can be shared and with whom this may be likely to be shared. Her response will be respected at all times unless otherwise indicated such as in cases of child protection.

All information disclosed by or discussed with patients is kept strictly confidential within the multi-disciplinary team.

Training/Education

There is an on-going comprehensive training programme for the midwifery team, which incorporates and satisfies statutory and essential requirements and is reflective of personal appraisals.

Midwifery updates will provide opportunities to update in IV cannulation, perineal suturing, obstetric emergencies, neonatal & adult resuscitation and fetal monitoring skills.

All midwives will record activity relating to the care of high risk women, this can include;

 Supporting high risk antenatal cases at consultant clinic.

 Attending elective caesarean section for a Powys woman.

 Safeguarding.

Midwives will review their activity with their Lead midwives and practice development midwife. Where this falls below 90 hours per annum or where a skill or knowledge deficit is identified a period of planned sessions within a District General Hospital will be facilitated.

Study Leave will be agreed with Lead Midwife, in line with personal development plans and service requirement.

Student midwives will be allocated a mentor who will help them meet agreed learning objectives/goals.

Advocacy

There is an independent Patient Advocacy Service accessible to all patients.

CHAIN OF COMMAND – JUMP CALL PROCEDURE

If any midwife has any cause for concern about mother or baby’s wellbeing, she can contact the relevant consultant directly for advice. In an emergency the consultant may be in transit and not immediately available at DGH the midwife can always refer to the duty registrar in the first instance who can then seek advice from the consultant in the usual way.

Appendices

MATERNITY SERVICE CLOSURE RECORD

1. Summary

2. Women Referred To Other Units

Incident Form Completed……………………..

Signed…………………………………………. Midwife

Date & Time…………………………………...

Escalation letter

Merlin’s House

Llandrindod Wells Hospital Temple Street Llandrindod Wells Powys LD1 5HF Date Dear I am writing to apologise that you had to be referred to another maternity unit, on Date here, due to staffing issues in the maternity services provided by Powys (t) Health Board. This was due to reason here.

The safety of you and your baby was our prime concern when the decision to refer you to another hospital was made. A decision to close the service to admissions is always made as a last resort and I can only apologise again for this change in plan at such short notice.

If you do have any outstanding concerns regarding your care name, Lead Midwife or I would be pleased to meet with you to discuss them. If you wish to take up this offer please contact my secretary Miss Elin Evans on 01597 828755. She will be happy to make any necessary arrangements. Yours Sincerely Cate Langley: Acting Head of Midwifery & Sexual Health Cc Name, Lead Midwife Equipment Inventory Suture Pack - Yellow

Suture Kit

Vicryl Rapide x2

Sterile Gloves SROM Pack - Blue Sterile Tampon Issue Date: 2009 Page 20 of Speculum25 Review Date: 201 Wound care pack Status:10ml Final Syringe x2 Approved by: Clinical Effectiveness Aqua Gel committee 16/04/2012 Lignocaine 1% 100mg in 10mls Sterile Gloves M C & S Swab 21g Needle x4

Sterile Gauze Powys Teaching Local Health Board Title: Maternity services Operational Policy

Intrapartum Pack - Green Sterile Gloves Non Sterile Gloves IVI Pack - Long Black Apron IV Administration Set x2 Urinary Catheter X2 Sodium Chloride 1000mls Amnihook X2 Sodium Chloride 500mls Goggles Sodium Chloride 0.9% Maternity Pads 10mls x2 Clinical Waste Bag 16g IV catheter x2 Red Linen Bag (Grey) Blood bottles 18g IV catheter x2 10ml Syringe (Green) 2ml syringe IV Dressing x2 25g needle x2 Alcoswabs 21g needle x2 Luer adaptor Alcohol swabs Micropore Cord Clamp Non Sterile Gloves Vit K oral Syringe Blood Bottles Drugs Additive label Syntometrine1ml x2 Syntocinon 10i/u in 1ml x5 Ergometrine 500mcg in 1ml Vitamin K Ranitidine 150mgs Venepuncture - Red Adrenaline 1:1000 2 amps Community Sharps Box Blood Bottles Blood Forms Issue Date: 2009 PageVacutainers 21 of 25 Review Date: 201 Status: Final Needles Approved by: Clinical Effectiveness Alcoswabs committee 16/04/2012 Cotton Wool Butterfly 20mm Powys Teaching Local Health Board Title: Maternity services Operational Policy

Postnatal Pack - Black Gloves Sterile Stitch Miscellaneous Cutter White Sterile Dressing Spare Gloves Towel Blood Bottles M C & S Swab Etc. Neonatal Screening Card Lancets Alcohol Swabs Bilirubin bottle Vitamin K 2ml Syringes 25g needles Plasters

Birth Pack, towels, inco pads – front pocket.

Paperwork – back pocket

GUIDELINES FOR MIDWIVES WORKING HOURS AND HAND OVER OF CARE

All midwives should be aware of their own limitations e.g. tiredness, illness, stress, that can affect judgement and practice in relation to their own and the women’s safety.(NMC 2008)

Midwives should be aware of the provision of the European working time directive (EU, 1993; EU, 2000) when planning off duty rotas.

· 11 hours’ continuous rest in every 24 hour period

· Minimum 20 minute break when shift exceeds 6 hours

· Minimum 24 hour rest in every 7 days or

· Minimum 48 hour rest in every 14 days

· Minimum 4 weeks’ annual leave

· Maximum 8 hours work in 24 for night workers (if applicable).

On call hours from home do not equate to working hours (SiMap 2000). However midwives should take into consideration the likelihood of being called to care for a woman during their on call period and plan work accordingly. In accordance with our medical colleagues who are on call but not resident the following applies ‘”work begins when a doctor is disturbed from rest and ends when rest is resumed’’ (DoH 2002).

However it is recognised that whilst all midwives have specified contractual hours there are often occasions when they will need to be exceeded. On such occasions midwives should consider the following local guidance.

· After 8 hours on duty, without a break, midwives must question their fitness to continue.

· After 12 hours on duty without a break, midwives must request to be relieved by a rostered colleague.

· If a woman is transferred from midwife managed care to a DGH during labour it may be possible for the transferring midwife to remain with the woman until she delivers. However, this will depend on staffing levels and

Author: Cate Langley internal contract arrangements and must be negotiated with team colleagues.

· A midwife who is on duty, but away from base, (e.g. DGH or home delivery) must ensure they use the agreed measures in relation to the use of lone working devices.

· The lead midwife will be responsible for monitoring the hour’s midwives work on a monthly basis. Assessment of compliance regarding total hours worked should normally be taken over a 17 week period.

Hand over of care:

Antenatal and postnatal care hand over for women in the community will be written in the woman’s case notes. Verbal communication when necessary may be by telephone.

Intrapartum:

When hand over in labour is necessary this must be hand written and verbal between midwives, person to person.

All entries in notes must have date, time, signature and printed name and position (e.g. Midwife X). When hand over has been completed the midwife must ensure entries in the notes and on the partogram reflect the handover.

Where the All Wales clinical pathway for normal labour is used midwives must ensure that all meal breaks and handover of care are documented on the front sheet of the appropriate documentation, including date and time of commencement of care and when care discontinued.

References

· DoH (2002)Guidance on Working Patterns for Junior Doctors.A document produced jointly by the Department of Health, the National Assembly for Wales, the NHS Confederation & the British Medical Association. DoH: London.

· European Union (1993) The Organisation of Working Time EC Directive =93/104/EC. http://europa.eu.int/comm/employment_social/labour_law/documentatio n_en.htm#

Eurpean Union (2000) European Directive 2000/34/EC. http://europa.eu.int/comm/employment_social/labour_law/documentatio n_en.htm#

· Nursing and Midwifery Council (2008)The Code. Standards of conduct, performance and ethics for nurses and midwives. NMC, London

· Sindicato de Médicos de Asistencia Pública (Simap) v Conselleria de · Sanidad y Consumo de la Generalidad Valenciana C-303/98 EC (2000)

Status: Final Approved by: Clinical Effectiveness committee 16/04/2012