Empowering nurses and midwives: the evidence-base for the Nurses and Midwives Certification Programme of ESHRE†.

Infertility is defined as failure to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce; either as an individual or with his/her partner ( Zegers-Hochschild et al. , 2017 ). It affects one in six heterosexual couples ( ESHRE, 2023 ) with approximately 50% seeking medical help ( Boivin et al. , 2007 ). Reproductive medicine (RM) has evolved during the last decades. Since the birth of Louise Brown, the first baby conceived through IVF, in 1978 ( Steptoe and Edwards, 1978 ), the birth of millions of babies worldwide has resulted from emerging reproductive technologies, including IUI, ICSI, preimplantation genetic testing (PGT), transfers of previously frozen IVF embryos, and gamete donation and surrogacy, among others ( Kamel, 2013 ). IVF clinics employ professionals from different backgrounds, specifically: (i) medical specialists, including gynaecologists, urologists, and endocrinologists, (ii) physicians, (iii) embryologists with at least a Master’s level of education and laboratory technicians, (iv) mental health professionals (i.e. psychologists, counsellors, social workers), (v) administrative staff, and (vi) nurses and/or midwives (depending on the country, i.e. midwives in France, nurses in the Netherlands, and both nurses and midwives in the UK). Many of these professionals gain expertise while working in clinical practice. Given the success of the Embryologist Certification Programme which was implemented in 2008 ( Kovačič et al. , 2020 ), the Executive Committee of the ESHRE assembled the Nurses and Midwives Certification Committee (NMCC) in 2012 to develop a certification programme for nurses and midwives (N&M) working in RM. Identifying a starting point for developing the certification programme for N&M was challenging as, to the best of our knowledge, clinical practice guidelines specifically for nursing/midwifery within RM were (and are) lacking. While the American Society of Reproductive Medicine (ASRM) began offering a nurse certificate course in reproductive endocrinology and infertility in 2010, it consisted of a series of online modules only and did not include a logbook or examination of knowledge. This article aims to report on the development of the Nurses and Midwives Certification Programme (logbook and corresponding curriculum) of ESHRE.

The certification programme aims to provide formal recognition for the knowledge, experience, competence, and capacity for critical reflection of senior N&M working in RM. The pre-requisites for certification are ESHRE membership, minimum 2 years’ experience in medically assisted reproduction (MAR), and bachelor level of education (minimum). The logbook and the corresponding curriculum were developed based on an extensive literature review, expert opinion, and a survey. Since its inception in 2015, the ESHRE Certification Programme for N&M working in RM has been delivered annually, with the exception of 2020, in response to the SARS-CoV-2 pandemic. To date, 200 N&M have obtained ESHRE certification (mean pass rate = 69.08%) and the programme is now accessible to N&M globally, including those with an academic and/or research background, on the proviso that they can evidence sufficient clinical hours to complete the logbook. A total of 49 papers were identified applying the search string (n = 47) and snowball strategy (n = 2). There were 13 papers excluded ( Malin et al. , 2001 ; Allan, 2005 ; Valiani et al. , 2010 ; Warmelink et al. , 2016 ), due to limited information provided in the abstract and/or no access to full-text articles ( D’Andrea, 1984 ; Jennings, 1992 ; Keating, 1992 ; McTavish, 2003 ; Homan, 2006 ; Zakak, 2009 ; Payne et al. , 2011 ; Castells-Ayuso et al. , 2015 ) or being review articles, where primary references were already included ( Allan, 2013 ). Thus, a total of 36 papers were included, spanning 13 countries from across Asia, Oceania, Europe to North America (one country per paper, except publication by Allan et al. (2009) which consolidated findings from 3 countries). The final cohort included 13 non-empirical studies: opinion papers (n = 7), reviews (n = 3), guidelines (n = 2), and an educational paper addressing N&M working in RM (n = 1). The 23 empirical studies included: randomized and non-randomized controlled trials (n = 7), quantitative surveys (n = 4), prospective cohort studies (n = 3), retrospective case–control cohort studies (n = 3), qualitative studies (n = 2), patient surveys (n = 2), and ethnographic studies (n = 2). Overall, 28 of the 36 eligible papers focused on nurses, seven focused on midwives, and one paper focused on both N&M. The literature review showed that the tasks of N&M working in RM differed between and within countries ( Table 2 ). For example, Allan et al. (2009) observed differences in the tasks of fertility nurses in the UK, Australia, and New Zealand. Whereas nurses (and midwives) in the UK independently performed advanced procedures such as oocyte retrieval and embryo transfer, nurses in Australia and New Zealand mainly focused on providing patient information and support during (telephone) consultations ( Allan et al. , 2009 ). Five studies, each conducted within one country (New Zealand, the UK, the USA), showed that the tasks of N&M working in RM ranged from technical skills (i.e. performing IUI) to broader skills (i.e. counselling) ( Morris, 2001 ; Oshio et al. , 2002 ; Mitchell et al. , 2005 ; Payne and Goedeke, 2007 ; Peddie et al. , 2011 ). However, according to opinion papers ( Barber, 2002 ; Atri, 2011 ), none of the above studies, addressed the global tasks of N&M working in RM, nor questioned whether N&M working in RM had an assisting or performing role ( Morris, 2001 ; Oshio et al. , 2002 ; Mitchell et al. , 2005 ; Peddie et al. , 2011 ). The logbook was developed following review of the literature, consulting the international expert panel, and analysing data from the survey of Belgian and Dutch N&M working in RM ( Table 2 ). Over time, a total of 76 different tasks have been part of the logbook and they can be sub-divided into eight categories: diagnostic consults (n = 11), information consults (n = 10), treatment consults (n = 11), diagnostic interventions (n = 12), therapeutic interventions (n = 9), laboratory procedures (n = 13), in-treatment (telephone) patient communication (n = 5), and psychosocial support (n = 5). Of these, 43 tasks were performed by N&M working in RM according to the literature review (n = 5), the international expert panel (n = 4), N&M working in RM surveyed (n = 5), both the literature review and expert panel (n = 1), both the expert panel and data from the survey (n = 7), both the survey and literature review (n = 5), or all three (n = 16). The number and composition of tasks included in the logbook were adapted yearly based on novel insights by the NMCC. The original 2015 logbook encompassed 56 tasks. In response to the annual review, the extended role of N&M working in RM is now reflected in the 2024 version by 73 tasks. The global disparity has been identified in tasks and job descriptions of N&M working in RM. For example, despite identical job titles, we only found evidence (from the literature review, international expert panel, and survey of N&M working in RM) for a limited number of tasks included in the logbook (n = 7/76) being performed by N&M from at least five countries. For several other tasks included in the logbook (n = 14/76), we only found evidence that they are performed by N&M working in RM in two countries or less. Moreover, our preparatory research showed that seven specialist tasks were performed independently by N&M working in RM in some countries, while in other countries N&M merely had an ‘assisting’ role (endometrial biopsy, assessment of uterine cavity and tubal patency, hysteroscopy, surgical sperm retrieval, oocyte retrieval, embryo transfer, and communicating the planning of oocyte retrieval). Logbook completion requires applicants to clarify whether they observed, assisted, or performed a task. If this is not possible (within their clinic), the expectation is that applicants request observation at partner clinic or (since 2018) present theoretical understanding of the procedure/s to their colleagues. Candidates are also expected to submit a mature ethical reflection on one clinical case (two before 2020) based on a step-by-step guide created by the Special Interest Group Ethics and Law to facilitate a mature systematic reflection. A curriculum in line with all tasks of N&M working in RM was developed ( Table 3 ). A reading list including book chapters, ESHRE and other professional body publications (i.e. guidelines), and scientific articles supporting the curriculum was established. In addition, text considered ‘essential knowledge’, and not directly linked to the logbook, was incorporated into the final curriculum and reading list. This included background knowledge (i.e. epidemiology of infertility), non-routine aspects of clinical practice (i.e. research), and processes which could not be observed (i.e. implantation of the embryo). The tasks included in the initial and 2024 version of the ESHRE NMCC logbook, grouped per stage of the fertility clinic trajectory, linked to the current curriculum. In logbook 2015. In logbook 2024. NMCC, Nurses and Midwives Certification Committee; WHO, World Health Organization; HSG, hysterosalpingography; HyCoSy, hysterosalpingo contrast sonography. In 2018, an ESHRE campus course was delivered by international experts, with the aim being to promote the professional value of, and enable the preparation of, N&M working in RM for certification. The presentations were uploaded to the ESHRE eLearning platform. In the same year, the NMCC developed a ‘study buddy’, incorporating key components from the curriculum, reading list, and online presentations. In addition to the logbook, the curriculum, reading list, and ‘study buddy’ are reviewed and updated annually by the NMCC. In 2021 and 2022, the NMCC developed a webinar series with attention given to revising presentations in line with current practice/evidence.

The ESHRE Nurses and Midwives Certification Programme shadowed the format of the embryologist certification programme ( Kovačič et al. , 2020 ), which included a logbook and theoretical exam. When the ESHRE Executive Committee established the NMCC, it comprised four N&M (H.K., J.P., I.R.J, and E.A.F.D.) as well as a clinical embryologist and gynaecologist with specialist accreditation in RM (A.P.), both in an advisory capacity. The NMCC decided to gather background information by: (i) systematically reviewing the literature on the tasks of N&M working in RM, (ii) consulting and surveying a larger expert panel of international senior N&M, and (iii) surveying Belgian and Dutch N&M working in RM from different clinics. Between 2012 and 2014, the NMCC completed a systematic literature search for opinion and empirical papers to identify all (potential) tasks of N&M working in RM. The Medline database was searched by entering a search string in PubMed combining (MeSH) terms related to RM and nursing or midwifery, more specifically: ‘(Nurse OR Midwife OR Nursing OR Midwifery OR Nurse Midwives OR certified nurse midwife OR certified midwife OR Nurse Clinicians OR Nurse Practitioners OR Advanced Practice Nursing OR Patient Care) AND (Infertility OR Fertility OR fertility clinic OR fertility centre OR Assisted Reproductive Techniques OR assisted reproductive technology OR ART OR medically assisted reproduction OR Fertilization in Vitro OR Insemination OR Artificial Insemination OR Intracytoplasmic Sperm Injections OR Ovulation Induction)’. In addition, the reference lists of the eligible papers were searched in accordance with the snowball strategy ( Polit and Beck, 2012 ). The following data were extracted from the eligible papers: (i) country, (ii) addressed tasks, and (iii) addressed professional status (i.e. nurse or midwife). As a result of asking ESHRE’s national representatives of 30 countries to propose a senior nurse or midwife, nine N&M (one per country) took part in a one-day live international expert panel meeting in September 2013. The following countries were represented: Denmark, Finland, France, Norway, Slovenia, Sweden, Turkey, Ukraine, and the UK. The international expert panel was asked to complete a questionnaire and participate in the discussion about the ESHRE N&M Certification Programme. The questionnaire addressed: (i) the respondent’s background, (ii) the educational background of N&M working in RM in their country, (iii) whether N&M working in RM in their country had no role, an assisting role (i.e. they assist a colleague performing the task), or a performing role (either independently or under supervision) in a subset of 31 tasks identified by the systematic literature review, and (iv) additional tasks in which N&M working in RM participate ( Dancet et al., 2017 ). The characteristics of the international panel are presented in Table 1 . The data on whether the N&M working in RM in their country had an assisting or performing role is included in Table 2 . For items 4.8 and 8.4, the answers to two questions presented to the international expert panel were combined. Logbook items 2.4 and 7.3 could be linked to the same question to the expert panel. Characteristics of the questioned nurses and midwives. N&M: nurses and midwives, RM: reproductive medicine, PhD: Doctor of Philosophy. The tasks included in the initial and 2024 version of the ESHRE NMCC logbook, grouped per stage of the fertility clinic trajectory, linked to the literature, the results of the international expert panel, and the results of the survey in Belgian and Dutch N&M working in RM. ASSISTING K PERFORMED K ASSISTING UK PERFORMED UK ASSISTING D, H, K, L, EE PERFORMED A, K, KK ASSISTING UK, AU, NZ, SW, USA PERFORMED UK ASSISTING D, H, L, EE, GG, LL PERFORMED A, I, J, K, O, KK, UU ASSISTING UK, AU, NZ, SW, USA, KW, IT PERFORMED UK, CH Ukraine, Finland, UK, Norway, Denmark, Slovenia, Turkey, France (yes/no question, no data on assisting or performing role of nurse/midwife) In logbook 2015. In logbook 2024. Refers to the same question in the expert panel. More than one question of the expert panel could be linked to this item in the logbook, all applicable countries were mentioned. Refers to the same question in the survey. More than one question of the survey could be linked to this item in the logbook, the prevalence rates of the question with most nurses/midwives performing this task independently were selected. A: Allan and Barber (2005) ; C: Allan (2001) ; D: Allan et al. (2009) ; E: Anderheim et al. (2007) ; F: Arslan‐Özkan et al. (2013) ; G: Atri (2011) ; H: Barber (1994) ; I: Barber et al. (1996) ; J: Barber (2002) ; K: Birch (2001) ; L: Bjuresten et al. (2003) ; M: Carr (2011) ; O: Cheung et al. (2003) ; Q: Gameiro et al. (2015) ; R: Goldman et al. (2014) ; S: Goode and Hahn (1993) ; T: Hahn et al. (1994) ; U: Harris (2000) ; V: Hershberger and Kavanaugh (2008) ; X: Homan et al. (2012) ; AA: Kelly-Weeder (2012) ; BB: Kennedy et al. (1998) ; CC: Mao and Anastasi (2010) ; EE: Mitchell et al. (2005) ; FF: Morris (2001) ; GG: Omu and Omu (2010) ; HH: Oshio et al. (2002) ; II: Payne and Goedeke (2007) ; KK: Peddie et al. (2011) ; LL: Rinaldi et al. (2014) ; MM: Servaes et al. (2014) ; NN: Shu-Hsin (2003) ; PP: Vizheh et al. (2013) ; RR: Weiss (2007) ; SS: Wilson and Leese (2013) . IN: India, UK: United Kingdom, USA: United States of America, AU: Australia, NZ: New Zealand, SW: Sweden, KW: Kuwait, BE: Belgium, IT: Italy, CH: China, TU: Turkey, TW: Taiwan, IR: Ireland, EU: guideline that is used in Europe (not considered as a separate country). The country is based on the residency of the author because it is not mentioned in the article. NMCC, Nurses and Midwives Certification Committee; N&M, nurses and midwives; RM, reproductive medicine; HyCoSy, hysterosalpingo contrast sonography. In 2017, managers of all 21 IVF clinics in the Flemish-speaking region of Belgium and the Netherlands were asked to disseminate a questionnaire among their entire nursing/midwifery staff. Belgium and The Netherlands were studied more in-depth as E.A.F.D. has a research affiliation in both countries and because mainly nurses work in Dutch fertility clinics whereas mainly midwives work in Belgian fertility clinics. Non-responding IVF clinics were sent reminders on two occasions. A total of 48 N&M working in RM participated, including 27 individuals from four Belgian clinics and 21 individuals from nine Dutch clinics (1–14 participants per clinic). The questionnaire addressed: (i) the respondent’s background, (ii) their role (assisting, performing, or no role) in 39 tasks identified by the systematic literature review, and (iii) the educational needs and interests of the respondents. The data were entered and analysed in the Statistical Package for Social Sciences (SPSS; version 28), and descriptive statistics were calculated. The characteristics of the responding N&M working in RM are presented in Table 1 . Table 2 provides information relating to the role of the participants in each task in the logbook. For three logbook items (1.2, 4.8, and 8.1), the answers to more than one question in the survey were verified. In these cases, the data on the most advanced role were given. The background information gathered via the literature review, the international expert panel, and the survey of Belgian and Dutch N&M working in RM influenced the decisions of the NMCC on: (i) pre-requisites for and aims of the certification programme, (ii) the logbook, and (iii) the curriculum. The NMCC decided on the aim of and the pre-requisites for certification after taking into account (i) the current education level of N&M working in RM, (ii) tasks of N&M working in RM in different clinics and countries, and (iii) discussions with the international expert panel on the consensus of opinion with regards to continuing education and professional development of N&M working in RM. A list of tasks in which N&M working in RM have a designated role in at least one country was developed from: (i) the systematic literature review, (ii) insight gathered from the international expert panel, and (iii) the survey of Belgian and Dutch N&M working in RM. The survey among the international expert panel provided insight into the difference in tasks between countries, whereas the survey among Belgian and Dutch N&M working in RM explored the difference in tasks within countries. The NMCC developed a curriculum which would encompass all tasks and roles of N&M working in RM.

The Nurses and Midwives Certification Programme of ESHRE was developed scientifically. The logbook was created based on an extensive literature review (36 papers spanning 13 countries worldwide), an international expert panel of nine N&M, a survey of 48 N&M working in RM in Belgium (4 clinics) or the Netherlands (9 clinics), and input from the NMCC. A total of 76 tasks performed by N&M working in RM were listed and categorized according to the N&M working in RM role (assisting/performing). The findings illustrated global variation, including disparity within Europe, and within countries. Since 2015, the logbook, which originally encompassed 56 tasks, has been reviewed and updated on an annual basis. The revised 2024 version now comprises 73 tasks across eight categories. A curriculum and reading list in line with the tasks of N&M working in RM was developed. Since N&M working in RM are not only performing tasks, applicants are also evaluated on their ability to reflect on an ethical case. While several papers have surveyed N&M working in RM on specific tasks and roles, to our knowledge, this is the first to study all tasks and roles of N&M working in RM across different countries. A strength of the methodology was the mixed method approach of this study including: (i) an extensive literature review, (ii) consultation of an international expert panel, and (iii) a survey of Belgian and Dutch N&M working in RM. While only nine countries were represented in the initial international expert panel meeting, geographic spread was reached. Future expert panel meetings will allow digital participation in the hope of reaching experts from more countries. Nevertheless, the participation rate (n = 62%) of surveyed Belgian and Dutch N&M working in RM could have been improved had we pursued a more personal approach, such as reminder telephone calls. Additionally, while this article discusses the development of the logbook and curriculum (and by extension the ethical case, and reading list) it does not include the development of the educational material created by the NMCC to help participants prepare for the theoretical exam of the N&M Certification Programme. ESHRE recognizes the need to articulate the different tasks and roles of N&M working in RM, in particular, the education and training required to enhance and develop quality standards in clinical practice. In summary, global diversity exists in relation to tasks and roles of N&M working in RM, therefore universal collaboration is required to reach consensus regarding knowledge, experience, competence, and job title associated with the extended role. Shifting tasks from those currently assumed by physicians or other healthcare professionals have several benefits. Firstly, it might offer economic benefits, however, the cost-benefit analyses remain limited ( Barber, 2002 ; Rinaldi et al. , 2014 ). Nevertheless, consideration of the Royal College of Nursing (RCN) education and career progression framework for fertility nursing ( Royal College of Nursing, 2021 ) may be appropriate in this regard. Secondly, extending the tasks and roles of N&M working in RM has been attributed to increased job satisfaction, although this has yet to be examined empirically ( Cheung et al. , 2003 ). Thirdly, the findings of a small-scale ethnographic interview study in the UK suggested that role extension increased continuity of care ( Allan and Barber, 2005 ). Fourthly, opinion leaders hypothesize that expanding tasks and roles of N&M working in RM could improve patient satisfaction ( Morris, 2001 ), yet this has been disputed by studies gathering empirical data ( Malin et al. , 2001 ; Bjuresten et al. , 2003 ). Nevertheless, the American Nurses Credentialing Centre’s Magnet Recognition Model ® challenges this, evidenced through infrastructure for exemplary professional nursing practice, innovation, and quality patient care (and satisfaction), in addition to staff satisfaction and retention ( Abuzied et al. , 2022 ). Interestingly, the development of the ESHRE Certification Programme has established an advanced curriculum for N&M working in RM, and continues to function as a central body creating and maintaining minimum standards in both theory and clinical practice, regardless of origin or geographical location. The ESHRE logbook can be completed by applicants from all over the world, irrespective of global cultural differences in the context of permitted procedures within their clinic and national legislation, as they can indicate for certain tasks that they assisted, observed, or presented (demonstrating knowledge of process and procedure) the task rather than performing it independently. There is scope, therefore, for ESHRE certification to achieve global recognition in advanced fertility practice which recognizes the ‘legitimacy of nurses to practice at an advanced level through assessing their qualifications, experience, and competence’, which is known as ‘Credentialing’ in the UK (Royal College of Nursing, n.d.). Advanced Nursing Practice (ANP) is associated with a level of practice as opposed to type of practice, with the Nursing and Midwifery Council (NMC) in the UK ‘committed to carrying out a comprehensive review of advanced nursing and midwifery practice, including consideration of whether regulation is needed’, as part of their 2020–2025 corporate strategy ( Nursing and Midwifery Council, 2022 ), and would qualify for a separate entry (in line with Credentialing) on the professional register. Pulcini et al. (2010) evaluated the global status of ANP, concluding that despite gaining interest, many nations perceived a lack of support from physician organizations. As a consequence, the combined absence of clarity among stakeholders regarding role descriptors for ANP and integration within the multidisciplinary teams, including formal advanced practice credential, may limit renumeration for a highly skilled professional group ( Fothergill et al. , 2022 ). Lack of formal recognition for ANP has been evidenced in Norway, for example (Norwegian Nurses Union, n.d.); the role was most recently introduced through a pilot study of nurse practioners’ and clinical nurse specialists ( Holm Hansen et al. , 2020 ). However, without a formal advanced practice credential, such as is the case for nurse sedationists or critical care nurses, fertility nurses are not formally recognized or financially rewarded for their knowledge, experience, and competence in specialist and often advanced practice; the ANP curriculum is awaiting national regulation ( International Advanced Practice Nursing, 2022 ). In 2020, the World Health Organization (WHO), called for ‘expansion and greater recognition of all nursing roles, including advanced nursing practice’ to meet patient need for quality, holistic based care ( Kilpatrick et al. , 2023 ). However, in the absence of global implementation, N&M working in RM are being denied the opportunity of career progression. Our findings highlight a problematic consequence, unique to the European Union, where despite the free movement of individuals, member states were not previously required to recognize professional qualifications ( WHO, 2009 ). This resulted in disparity in education and role recognition and development of N&M across member states in accordance with state ‘designated authority’. This has since been rectified, with the EU introducing a system of ‘automatic recognition’ of professional qualifications, subject to minimum training requirements under the EU directive on the recognition of professional qualifications (Directive 2005/36/EC). Nevertheless, disparity exists on a global scale; Peddie et al. (2011) highlighted not only the significant difference in tasks and roles of N&M working in RM in the UK, but also job title. The findings applying general principles to nursing and midwifery qualifications, leaving scope for standardizing professional practice for specialist and advanced practice N&M (including N&M working in RM). Further research is required to evaluate ESHRE certification and its impact on professional and personal development. Advances in MAR are ever-increasing, which creates an opportunity for greater accountability, responsibility, and autonomy of practice for investigation and procedures traditionally performed by medical colleagues. Therefore a scoping study is required to analyse, combine, and evaluate the barriers and facilitators of implementation, in addition to cost-benefit analysis. A deeper understanding of tasks and roles before and after achieving ESHRE N&M certification, in addition to its impact on professional and personal development, may strengthen the argument for global recognition of advanced fertility nursing practice. Thereafter, retrospective evaluation of job satisfaction resulting from autonomy of practice can be explored, in addition to evaluation of patient satisfaction derived from a holistic approach which encompasses continuity of care throughout their fertility journey. Perhaps a global model built on a combination of ESHRE and ASRM certification, national training and/or certification programs (i.e. the UK and the Netherlands), and the US Magnet Recognition Program ® will ‘support greater role harmonization, and inform global priorities for advanced practice (fertility) nursing education, research, and policy reform’ ( Luzinski, 2011 ).