Guideline for Endorsed Midwife Scope of Clinical Practice

Guideline number: QH-HSDGDL-034-4

Effective Date: 18 August 2025

Review Date: 18 August 2028

Supersedes: New HSD Guideline

On this page:

1. Purpose
2. Scope
3. Guideline for Endorsed midwife (EM) Scope of Clinical Practice (SoCP)
   3.2 SoCP recognition and approval
   3.3 Endorsed midwife prescribing, pathology and diagnostic imaging process
4. Human Rights
5. Aboriginal and Torres Strait Islander considerations
6. Supporting and related documents
7. Glossary of terms
8. Approval and implementation
9. Version control

1. Purpose

This guideline provides recommendations for Hospitals and Health Services (HHS) regarding best practice for documentation and utilisation of Endorsed Midwife (EM) Scope of Clinical Practice (SoCP). It also outlines the governance, Nursing and Midwifery Board of Australia (NMBA) registration standard, and scope for Endorsement for schedule Medicines for midwives including EM prescribing, pathology, and diagnostic imaging.

The provision of this guideline and proposed governance ensures:

• processes are in place that enable EMs to work to their full scope of practice
• the EM is responsive to the needs of the population across the full continuum of the health journey
• the EM delivers quality, effective and efficient clinical outcomes
• the associated effects on the interdisciplinary team and approach to the woman’s care is communicated when advancing an EM’s scope of practice; and
• the EM will be enabled to deliver the best quality care, first time, every time.

The provision of this guideline:

• meets the needs of the HHS and EMs regarding supporting advanced scope of practice models of care throughout Queensland public health services
• supports the movement of EMs internally between other facilities within and external to the HHS.
• addresses the requirements for legislative compliance in relation to EM’s scope of practice roles
• addresses the accreditation requirements for recognising and authorising advanced scope of clinical practice for EMs utilising the NMBA Registration Standard.

2. Scope

This Guideline applies to all Hospital and Health Services.

This Guideline applies to midwives registered with the Australian Health Practitioner Agency (AHPRA) with endorsement for scheduled medicines that are employed by QH.

This may also apply to midwives required to have documentation and authorisation of advanced clinical practices or activities that demand specific training or qualifications.

3. Guideline for Endorsed midwife (EM) Scope of Clinical Practice (SoCP)

3.1 Governance

The Nursing and Midwifery Board of Australia (NMBA) develops registration standards, professional codes, guidelines, and standards for practice which together establish the requirements for the professional and safe practice of nurses and midwives in Australia.

The midwife, as registered by the NMBA, is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care, and advice before conception, during pregnancy, labour, birth, and the postpartum period, and to provide care for the newborn, and the infant. This includes consultation with, and referral to, medical care or other appropriate assistance; and implement emergency measures where necessary.

Midwives who have NMBA endorsement for scheduled medicines are recognised under the Health Practitioner Regulation National Law (Queensland), section 94 as being qualified to administer, obtain, possess, prescribe, sell/supply or use a medicine for midwifery practice.  EMs can also apply for and receive a Medicare provider number to access the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS).

The registration standard: Endorsement for schedule medicines for midwives requirement includes:

1. Completion of an approved prescribing course.
2. Three years full time (5000 hours) experience in the past six years that is either across the continuum of care, or in a specified context of practice.
3. Successful completion of an NMBA-approved program of study leading to endorsement for scheduled medicines, or a program that is substantially equivalent to an NMBA-approved program of study leading to endorsement for scheduled medicines as determined by the NMBA (NMBA, 2017).

EMs use extended skills, experience and knowledge in assessment, planning, implementation, diagnosis, and evaluation of care delivered. The Fact sheet: Endorsement for scheduled medicines for midwives outlines EM core activities and include:

• provision of screening that includes ordering and interpreting diagnostic tests (pathology and medical imaging) relevant to the care of women and babies during pregnancy, labour and newborn period
• prescribe, administer and supply scheduled pharmacological and non-pharmacological interventions
• comprehensive antenatal, intrapartum and postnatal care, including the ability to admit women into hospital and provide care on their own authority
• referral to obstetricians and paediatricians.

An EM can only perform these activities to the extent necessary to practice Midwifery. The maintenance of competency and registration status at the level of endorsement is reviewed upon engagement and annually.

3.2 SoCP recognition and approval

The Queensland Health Service Directive, Credentialing and defining the scope of clinical practice (QH-HSD-034), states HHSs shall ensure:

• Midwives undertaking specific procedures or practices that require specific training or qualifications have a current documented Scope of Clinical Practice.

It is recommended a governance process be established for recognition and approval of SoCP for Endorsed midwives, for example:

Executive Director of Nursing and Midwifery (EDNM)

• Accountable for the governance of nurses and midwives’ scope of clinical practice and must ensure nurses and midwives have completed a currently accredited course

Nursing Director (ND)/Midwifery Director (MD)

• Responsible for the management of the midwife’s application process and clinical performance.

Line Managers

• Responsible for reviewing the midwife’s application process, professional registration and recency of practice, and maintaining the corporately approved register to record a staff’s evidence of currency and approved SoCP.

3.2.1 SoCP application process

1. The midwife submits completed application form (Appendix 1) and certified copy/copies of successful completion of an NMBA-approved program of study leading to endorsement for scheduled medicines to the Line Manager for review and endorsement.
2. The Line Manager reviews the EM’s SoCP Application Form, including:

• Certified documents/qualifications
• Professional registration number and status (including endorsement, conditions, notations or restrictions) via the Australian Health Practitioner Regulation Agency (AHPRA) on-line national register
• Recency of practice relevant to the advanced practice position

If approved, complete the Line Manager endorsement section on SoCP Application Form (Appendix 1) and forward to the relevant Nursing/Midwifery Director. If not approved, return application form to the Endorsed midwife and discuss reason(s) for non-approval.

3. The Nursing/Midwifery Director to review EM’s application. If approved, complete the Nursing/Midwifery Director endorsement section and forward to the Executive Director Nursing and Midwifery (EDNM). If not approved, return application form to Line Manager and discuss reason(s) for non-approval.
4. The Executive Director Nursing and Midwifery (EDNM) will review EM’s application and if approved, complete the Executive Director Nursing and Midwifery (EDNM) final endorsement section and notify the Nursing/Midwifery Director, who will notify the Line Manager.

If not willing to approve, return the application form to Nursing/Midwifery Director and discuss reason(s) for non-approval.

3.2.2 Notification of Application Approval

Once the application is fully approved, the line manager will forward a copy to the local workforce management team and will notify EM.

Line Managers should register the successful EM’s details on a corporately approved register to record a staff’s evidence of currency and approved SoCP.

Monitoring

Line Managers will maintain all advanced practice records in the employee’s personal staff file. Scope of Clinical Practice status is:

• Granted for the period of time that the Endorsed midwife is working in the approved context
• Reviewed in tandem with the annual Performance Assessment and Development Plan (PADP) and in accordance with the NMBA Continuing professional development Registration Standard and Recency of Practice Standard.

3.3 Endorsed midwife prescribing, pathology and diagnostic imaging processes

3.3.1 Endorsed Midwife Prescribing

Midwives who hold the endorsement for scheduled medicines are considered by the NMBA to:

• Be able to administer, obtain, possess, prescribe, or supply specified schedule 2, 3, 4 and 8 medicines to the extent authorised under the relevant legislation that applies to the state or territory in which they practice. In the case of Queensland, this includes the Medicines and Poisons Act 2019 and the Poisons (Medicines) Regulation 2021.

The EM SoCP applies to the authority to prescribe for women from commencement of pregnancy care throughout the antenatal, intrapartum, and postnatal periods including prescribing for the neonate and infant. While there is no specific formulary required, the EM is required to ensure prescribing within their SoCP and the relevant legislation for the state of Queensland.

EMs will, wherever possible, prescribe by the Pharmaceutical Benefits Scheme (PBS) | Midwife Items which subsidises the cost for clients and the organisation. Any medication prescribed outside of this may incur an additional cost to the client and/or health service.

Monitoring

If there is any doubt about an EM’s competence in prescribing, their Midwifery Manager and/or Midwifery Director shall consider any or all of the following:

• Request a specific evaluation of the EM’s performance by an external or internal professional peer.
• Recommend a SoCP for a limited period followed by review.
• Define conditions or limitations on the SoCP requested.
• Require the relevant clinical services, procedures, or other interventions to be performed under supervision or monitoring.
• Hold over the decision and request further information.
• Refuse the new/renewal of the application.

3.3.2 Endorsed midwife ordering and interpreting pathology and diagnostic imaging

The EM SoCP includes provision of screening that includes ordering and interpreting diagnostic tests (pathology and medical imaging) relevant to the care of women and babies during pregnancy, labour and newborn period.

Pathology

The EM requesting a pathology service for a woman or baby must determine the service is necessary. The service may only be provided in response to a request from the treating practitioner (i.e. the EM must be providing direct care to the patient the request is for) and the request must be in writing.

The EM must ensure laboratory tests requested are correct abbreviations as per Pathology Queensland Standard Profiles for General Chemical Pathology

• For digital sites refer to local ieMR Ordering pathology reference guides. For non-digital sites, follow local procedures.

Endorsed Midwife pathology services eligible for MBS are listed on Note MN.13.19 | Medicare Benefits Schedule

Diagnostic imaging

The EM requesting a diagnostic imaging service for a woman or baby must determine the diagnostic imaging service is necessary for the appropriate professional care of the patient. The service may only be provided in response to a request from the treating practitioner (i.e. the EM must be providing direct care to the patient the request is for), and the request must be in writing, signed and dated.

For all medical imaging orders, the minimum standards must be met as per Radiation Safety Regulation 2021 (QLD).

The request must contain sufficient information to clearly identify the item/s of service requested, for example:

• Patient’s name, date of birth, unique record number (URN)
• Patient’s location
• Date of request
• Name of authorised requestor and contact number
• Examination requested
• Applicable clinical information:
  • Relevant clinical history – including expected day of delivery (EDD), gestational age and obstetric history
  • Signs and symptoms (if applicable)
  • Clinical question that requires answering

For digital sites, refer to local ieMR Placing Medical Imaging Orders Reference Guides. For non-digital sites, follow local procedures.

Endorsed Midwife diagnostic imaging services eligible for MBS are listed on Note MN.13.19 | Medicare Benefits Schedule

3.3.3 Management of pathology and diagnostic imaging requests

EMs are to regularly check ieMR messenger or pathology results through their specific hospital's pathology reporting processes, and action results received within 7 working days, as per established protocols.

Where possible, ring the woman to discuss any abnormal results received, document as per hospital protocol, and follow up with an appointment if appropriate as per unit protocol. Ensure a retrospective service of occasion happens for both the phone call and the follow up.

Risk Management Process for Clinician Absence/ Leave Periods

• If the EM is unable to check the results of tests ordered due to absence (e.g., EM temporarily or permanently unavailable as leaving unit or going on leave), then the following is to occur:
• Nominate a colleague to be proxy. NOTE: proxy must also be an EM.
• Arrange for the results to be sent to the proxy to be checked in the responsible EM’s absence.

4. Human Rights

Queensland Health must act and make decisions compatible with human rights, in accordance with The Human Rights Act 2019  (the Act). This includes conducting the documentation of scope of clinical practice process and making decisions with regards to the authorising SoCP of individuals in accordance with the Act.

5. Aboriginal and Torres Strait Islander considerations

In adhering to this guideline, HHSs must consider the impact this guideline may have on Aboriginal and Torres Strait Islander stakeholders, particularly cultural impacts.

6. Supporting and related documents

• Credentialing and defining the scope of clinical practice QH-HSD-034
• Credentialing and defining the scope of clinical practice Department of Health Policy QH-POL-390
• Department of Health strategic plan | Queensland Health
• Fact Sheet: Endorsement for scheduled medicines midwives
• MBS Online
• Medicare Benefits Schedule Requesting Requirements for Participating Midwives.
• Medicines and Poisons Act 2019 - Queensland Legislation - Queensland Government
• Midwife PBS Prescribing
• NMBA Midwife standards for practice
• Unleashing the potential: An open and equitable health system
• Women Centred care: Strategic directions for Australian maternity services

Authorising Health Service Directive

• Credentialing and defining the scope of clinical practice Health Service Directive (QH-HSD-034)

Forms and templates

• Endorsed Midwife SoCP application template (DOCX 56 kB) for HHSs to use

Related National Safety and Quality Standards

1. Clinical Governance Standard
2. Partnering with Consumers Standard
3. Medication Safety Standard
4. Comprehensive Care Standard
5. Communicating for Safety Standard
6. Recognising and Responding to Acute Deterioration Standard

7. Glossary of terms

8. Approval and implementation

Guideline custodian

The Chief Midwife Officer

Approving officer

Deputy Director General, Health Workforce Division, Department of Health

Approval date: 18/08/2025

Effective from: 18/08/2025

9. Version control

PRINTED COPIES ARE UNCONTROLLED

CLASSIFICATION – OFFICIAL – PUBLIC