Optimising the continuity experiences of student midwives: an integrative review

'Hope' is the thing with feathers: Student midwifery outside the system

Midwifery in Australia, and across other high-income countries with Westernised care arrangements, is reaching crisis point; an overrun, overworked, and underfunded maternity system causing traumatised and disenfranchised midwives to leave the profession in droves. However, there is also an underreported student midwife retention crisis negatively affecting the profession. Student midwives, becoming disempowered and disillusioned after facing the climate of collective trauma within the system, are leaving their studies at unprecedented rates. The literature explores a number of tangible reasons for this attrition. However, Emily Dickinson's "Hope - the thing with feathers, That perches in the soul, And sings the tune without the words, And never stops - At all." may be a groundbreaking protective element in the retention of student midwives not only through their studies but also for long and prosperous careers. Hope is more pervasive than resilience, more substantial than tenacity, and more empowering than any other incentives. Hope hides in the relational aspects of midwifery, in women transitioning from maidenhood to motherhood in their power. Exposure to midwifery outside the system, may help student midwives find "the thing with feathers" and reinvigorate their egalitarianism, support their professional philosophy, and ultimately retain them through their studies and beyond.

Discovering the invisible: Transformative learning experiences of midwifery students to support physiological birth during continuity of care placements in Québec's freestanding birth centres

BACKGROUND

Despite international consensus advocating a physiological approach to childbirth, there are inconsistent opinions on how to acquire the competencies needed to successfully carry out this approach. While continuity of care experiences (CoCE) within placements is a valued educational strategy, there are limited studies that focus on the learning experiences to support physiological birth.

AIM

To describe and understand the learning experiences related to physiological birth, as well as the transformations required to become a midwife who supports physiological birth, during the CoCE placement process in a birth centre.

METHODS

An interpretive description study design was adopted. Data were collected through audio diaries (n=126) with midwifery students and preceptors (n=14) across four level of placements in birth centres, in Québec, Canada, and discussion groups with students who kept the audio diaries.

RESULTS

Three main themes were identified: 1) appropriating culture: relational autonomy; 2) developing competencies: acknowledging attitude, enabling behaviours and narrative skills; 3) constructing identity: coherence and resistance.

DISCUSSION

The findings demonstrated the importance of CoCE, along with the continuity of preceptorship and a low-tech environment as optimal educational strategies for the acquisition of a culture and competencies that promote physiological childbirth. Resistance is part of identity transformation and represents an opportunity for critical questioning and safe feedback.

CONCLUSION

This study contributes to the understanding of the nature of the competencies developed and the transformations experienced to support physiological childbirth. It recognises the primacy of CoCE within extended placements, embedded in a workplace culture and environment that support relational autonomy.

Development of the essential learning outcomes for the midwifery student continuity of care learning model: A Delphi study

BACKGROUND

In Australia, midwifery students are required to undertake at least ten Continuity of Care Experiences (CoCE) during their education. The learning outcomes of this experience have never been explicit or standardised resulting in inconsistent assessment.

AIM

To develop and identify standardised learning outcomes for the CoCE.

METHODS

A modified Delphi survey was conducted with an expert panel. Intended learning outcome statements were developed, reflecting the learning objectives identified in a previous study. Bloom's taxonomy levels of thinking complexities guided the wording of the outcomes. Participants were asked to rank and rate their level of agreement with each statement over two survey rounds.

FINDINGS

Round one was completed by 32 participants, with 92.5% of the 40 statements reaching consensus. The second round was completed by 23 participants, with 70.7% of the 33 statements reaching consensus. Content analysis of participant comments from each round identified duplicates that were removed and informed refining the wording of some statements. A final set of 15 learning outcomes were agreed upon. The outcomes were broadly grouped within the themes of accountability, advocacy, and autonomy.

DISCUSSION

This study has identified agreed learning outcomes for midwifery students undertaking CoCE. The consensus agreement of experts reinforced the learning model enables the development of woman-centred practice that is underpinned by accountability, advocacy, and autonomy.

CONCLUSION

Purposeful learning outcomes for the CoCE have been developed, informing how the model can be embedded in curricula, guide student learning and assessment to standardise the pedagogy of the model to prepare future midwives.

Advocacy, accountability and autonomy; the learning intention of the midwifery student continuity of care experience

PROBLEM

The Continuity of Care Experience is a mandated inclusion in midwifery education programs leading to registration as a midwife in Australia. The practice-based learning experience has evolved over time, yet there remains no standardised learning intentions, objectives, or outcomes for the model.

AIM

To identify the key learning intentions of the Continuity of Care Experience by an expert panel to support the development of learning outcomes.

METHODS

A descriptive qualitative study with two focus groups were conducted with an expert panel (n = 15). Participants were midwifery education subject matter experts on the Continuity of Care Experience with backgrounds in academia, policy development, curriculum design, accreditation, or clinical education. The discussions were transcribed and thematically analysed.

FINDINGS

Three main themes and six sub-themes describe the learning intentions of the Continuity of Care Experience. The main themes were: (1) advocacy for women; (2) accountability of care; and (3) autonomy in practice.

DISCUSSION

The education model of continuity of care enables students to develop midwifery practice that involves advocating for women, being accountable for their care and being autonomous in practice. We have established that during the experience students practice in partnership with women and are exposed to the full scope of midwifery care. Importantly students learn holistic woman-centred practice.

CONCLUSION

The learning intentions of the Continuity of Care Experience reflects woman-centred practice. Having identified a common understanding of the learning intention, these can now be used to design learning, and assessment, through the development of measurable learning outcomes.

"It's no ordinary job": Factors that influence learning and working for midwifery students placed in continuity models of care

BACKGROUND

Maternity policy and guidelines increasingly recommend or stipulate the increased provision of midwifery continuity of carer as a priority model of care. The scale up and sustainability of this model will require that student midwives are competent to provide continuity of carer at the point of qualification. Guidance relating to how to optimally prepare student midwives to work within continuity models is lacking.

AIM

To explore perspectives and experiences of working within and learning from student placement within continuity models of care.

METHODS

An online mixed methods survey aimed at midwifery students and qualified midwives with experience of working within or providing education relating to continuity models. Quantitative results were analysed through descriptive statistics while free text responses were brought together in themes.

FINDINGS

Benefits and challenges to placement within continuity models were identified. These provide recommendations that will enhance learning from and skill development within continuity models of care.

CONCLUSION

There is a need for continuity of mentorship and strong relationships between education and practice, and the provision of flexible curriculum content around this to enable students to prioritise appointments with women in their care. System level evaluation and support is needed to guide the optimal provision of continuity models, so that they are effective in improving outcomes and experiences. Foregrounding woman centred care as foundational to education and facilitating the critical deconstruction of dominant discourses that conflict with, and may prevent this form of practice, will promote the provision of care that is integral to these models.

Examining the transformation of midwifery education in Australia to inform future directions: An integrative review

BACKGROUND

Integral to quality midwifery practice is the education of midwives. Like other countries, Australia faces ongoing challenges in delivering midwifery education programs. Reasons include escalating program costs, challenges in securing meaningful clinical experiences, subsumption of midwifery with nursing, and associated loss of identity in some institutions.

AIM

To critically examine the literature exploring the historical and current drivers, supports and impediments for entry-to-practice midwifery programs to identify strategies to strengthen midwifery education in Australia.

METHODS

A structured integrative literature review using Whittemore and Knafl's five-stage framework was undertaken; 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results.

FINDINGS

The literature search identified 50 articles for inclusion. The thematic analysis identified four key themes: i. a commitment to educational reform, ii. building a midwifery workforce, iii. quality maternity care through midwifery education, and iv. progressing excellence in midwifery education.

DISCUSSION

Extensive literature describes the evolution of midwifery education in Australia over the last 30 years. Through collaboration and amidst opposition, quality midwifery education has been established in Australia. Identification of midwifery as a distinct profession and transformative leadership have been integral to this evolution and must be grown and sustained to prevent a decline in standards or quality.

CONCLUSION

There is a need to address priorities in midwifery education and for the evaluation of midwifery programs and pedagogy. The provision and maintenance of quality education and practice require shared responsibility between education providers and health care services.

Learning through relationships: The transformative learning experience of midwifery continuity of care for students: A qualitative study

BACKGROUND

Midwifery curricula in Australia incorporate 'Continuity of care experiences' (CoCE) as an educational strategy based on an assumption that midwifery students will learn skills and knowledge about woman-centred care that they may not learn in the typical fragmented care system. However, exactly what skills and knowledge they are expected to 'learn' and how these can be assessed have never been specifically identified.

AIM

To explore midwifery students' continuity of care learning experiences within pre-registration midwifery education.

METHODS

Focus groups were conducted with first, second and third year Bachelor of Midwifery students (n = 12), who were undertaking CoCE in rural and regional tertiary hospitals in NSW, Australia.

FINDINGS

The overarching theme, 'Learning through relationships', was made up of three interrelated themes: Meeting women and making connections, Being known, and Understanding holistic care.

DISCUSSION

The findings from this study contribute to understanding the educational effects of CoCE. The CoCE relationship provided safety and freedom to learn which was seen as foundational for midwifery students' vision of their future practice and can be seen as a self-determined transformational approach to learning.

CONCLUSION

This study adds insight into midwifery students' experience of CoCE, and demonstrates that transformative learning occurs through developing a relationship with both the woman and the midwife. For midwifery to develop as a profession and maintain its focus on woman-centredness, it is important that this aspect of midwifery education remains embedded within midwifery program philosophies and learning outcomes.

The lived experience of being an undergraduate midwifery student in the neonatal unit

OBJECTIVE

The objective of this study is to examine the experience of undergraduate student midwives in the neonatal unit.

BACKGROUND

Clinical experience is an essential component of education for the development of competent midwives. Literature has highlighted the pivotal effects of precepting and how it contributes to student experience. Although there is a plethora of research examining undergraduate student midwives' experience, to our knowledge this is the first study exploring their experience in the neonatal unit.

DESIGN

Based in phenomenology, eight semi-structured interviews were conducted producing rich data.

METHODS

Following informed consent and ethical approval, post transcription, the data were coded using Colaizzi's (1978) framework.

RESULTS

Significant themes and sub-themes emerged such as course design, environmental experience, sources of stress and preceptor experience. The student experience very much depends on the preceptor, how busy the environment is and if appropriately staffed.

CONCLUSIONS

Based on these findings there are suggested recommendations including adjusting the timing and length of the placement and how to improve the environment based on the preceptor-student relationship. Also, suggestions on how consistency and communication can be improved are proposed.

Continuity of care experiences: A national cross-sectional survey exploring the views and experiences of Australian students and academics

BACKGROUND

Continuity of Care Experiences (CoCEs) are a component of all entry-to-practice midwifery programs in Australia and facilitate an understanding of the central midwifery philosophy of woman-centred care and continuity of the therapeutic relationship. The aim of this research was to explore how CoCEs are viewed and experienced by students and academics across Australia.

METHODS

Students enrolled in Australian midwifery programs and academics who teach into these programs were invited to participate in a cross sectional, web-based survey. Data were analysed using descriptive statistics and free text responses were analysed using content analysis.

FINDINGS

Four hundred and five students and 61 academics responded to the survey. The CoCE was viewed as a positive and unique learning experience, preparing students to work in midwifery-led continuity models and developing confidence in their midwifery role. Challenges in recruitment, participation in care, and balancing the workload with other course requirements were evident in reports from students, but less understood by academics. Significant personal impact on finances, health and wellbeing of students were also reported.

DISCUSSION

The value of CoCEs as an experiential learning opportunity is clear, however, many students report being challenged by elements of the CoCE within current models as they try to maintain study-work-life balance.

CONCLUSION

Innovative course structure that considers and embeds the CoCE requirements within the curricula, in addition to a collective commitment from regulatory bodies, the maternity care sector and Universities to facilitate CoCEs for students may address some of the significant student impacts that are reported by this research.

Prepared and motivated to work in midwifery continuity of care? A descriptive analysis of midwifery students' perspectives

BACKGROUND

Internationally, midwifery education and maternity services are evolving to promote midwifery continuity of care. It is unclear whether current Australian midwifery education programs are graduating a midwifery workforce prepared and motivated to work in this way.

AIM

To discover how well midwifery students in Australia feel they have been prepared and motivated to work in midwifery continuity of care when they enter practice.

METHODS

A pragmatist approach was used. Participants were final year midwifery students at one Australian university participating in the Midwifery Student Evaluation of Practice (MidSTEP) project over three consecutive years. Descriptive analysis of selected scaled and free text responses was undertaken to ascertain how students' clinical practice experiences had influenced their learning, development and career aspirations.

RESULTS

Exposure to midwifery continuity of care had profound impact on students' learning, enabling them to provide woman-centred midwifery care whilst increasing confidence and preparedness for practice. The majority were motivated to work in midwifery continuity of care upon graduation. A small minority of participants felt unprepared to work in midwifery continuity of care, attributing this to their family commitments, a sense of needing more experience or unsupportive workplace cultures.

SUMMARY

Midwifery continuity of care experiences are highly valued by midwifery students and positively influence confidence, preparation and motivation for beginning practice. It is necessary to review education standards to ensure quality, consistency, and adequacy of these experiences throughout pre-registration midwifery education. This will assist in generating a midwifery workforce prepared and motivated to deliver the goals of maternity service reform.