Surviving, not thriving: a qualitative study of newly qualified midwives’ experience of their transition to practice

Understanding attrition of early career midwives in Australia

PROBLEM

There is a lack of understanding of the experiences of early career midwives which lead to workforce attrition.

BACKGROUND

In the Australian midwifery setting, workforce attrition in conjunction with the ageing profile of the workforce is of increasing concern. Midwives in the earliest stages of their career are most vulnerable to career attrition, however limited research specifically engages with this cohort.

AIM

To understand the professional and social circumstances that led early career midwives to leave clinical practice, how their midwifery background influenced career trajectories, and what would compel them to return to clinical practice.

METHODS

Semi-structured interviews were conducted with 11 early career midwives who had left the profession within 5 years of qualification. Transcripts underwent thematic analysis.

FINDINGS

Three themes described early career midwives' experiences: transition to professional practice, an untenable workplace culture, mental health impacts of early clinical midwifery practice. Two further themes emerged about experiences post-midwifery careers: influence of midwifery on subsequent career, and conditions for re-entry.

DISCUSSION

Challenges with transitioning to professional midwifery practice in conjunction with untenable workplace culture led to such deterioration in wellbeing that remaining within the profession became unfeasible for early career midwives. Desire to remain within health care was apparent, however re-entry to the profession was deemed by most to be out of the question.

CONCLUSION

Early workforce retention strategies should be the focus of future workforce planning and policy. Larger scale inquiry foregrounding early career midwives is necessary to inform strategies for midwifery workforce retention in Australia.

Early career midwives' job satisfaction, career goals and intention to leave midwifery: A scoping review

OBJECTIVE

To scope and synthesise literature around the job satisfaction of early career midwives - those in their first five years of post-qualification practice - including the effect on their career aspirations and intention to leave the profession.

DESIGN

Scoping review.

METHODS

Relevant databases were searched for published research studies and grey literature. Literature were selected through adherence to pre-set inclusion and exclusion criteria to ensure relevance. Literature was included that was published from 2012. Selected literature were tabled and common themes were mapped to look for similarities and differences in findings.

FINDINGS

Ten papers were included - seven original research studies, a fact sheet, a non peer-reviewed article, and a conference paper. Negative themes - lack of support, workload stress, and job dissatisfaction, and positive themes - passion for midwifery, collegial relationships, and autonomy - were found across many of the included papers.

KEY CONCLUSIONS

Many midwives are considering leaving their profession due to the stress of their work, role dissatisfaction, and a lack of support. This is more common amongst early career midwives. There were some protective factors such as having pride in the midwifery profession. More research is needed to identify and address the needs specific to early career midwives.

"I believe…" - graduating midwifery students' midwifery philosophies and intentions for their graduate year: A longitudinal descriptive study

OBJECTIVE

Midwifery graduates may experience transition shock that makes them question their fit for their workplace and the profession and in extreme cases, may lead to them leaving. Understanding graduate midwives' worldviews, job intentions and work experiences is important to inform retention strategies. Factors such as having a strong professional identity and experiencing strong job satisfaction are important for midwife retention. Conversely, stress, trauma and work-life imbalances are examples of factors that lead to attrition from midwifery. Transition shock experienced by some graduates can exacerbate these factors if not managed effectively. This study aimed to identify causes and impact of any changes in graduate and early career midwives' philosophy, practice, and intention to stay in the profession.

DESIGN, SETTING AND PARTICIPANTS

We invited the 2021 and 2022 cohorts of graduating midwifery students from all educational pathways in Victoria, Australia to participate in a longitudinal descriptive study using a questionnaire with both closed and open -ended questions. This paper reports the findings from 16 participants that completed the first survey of a five-year longitudinal descriptive study.

FINDINGS

The sixteen participants predominantly held a woman centred philosophy and ideally wanted to work in a midwife-led model of care. Although excited about moving into practice, they also disclosed a sense of needing to 'survive' in a maternity care system that their beliefs were not fully in alignment with.

KEY CONCLUSIONS

The hopes, expectations and concerns of midwifery students who are anticipating moving into practice in this study resonate with those previously reported and demonstrate the need to consider personality-job fit in supporting this vulnerable group to transition.

IMPLICATIONS FOR PRACTICE

This study provides insights into graduating midwives' hopes for, expectations of, and concerns about transitioning into practice that may inform the design of transition programs and support expansion of midwifery led models of care.

Newly qualified midwives' experiences of caring for women in the maternity setting: An integrative review

INTRODUCTION

This integrative review aims to explore the experiences of newly qualified midwives (NQMs) when caring for women in the maternity setting.

METHODS

An integrative review (IR) method was chosen based on a systematic approach using Cooper's 1984 framework for transparency and rigorousness. A total of 2428 articles were located, duplicate records were removed, leaving 1428 records. All titles and abstracts were reviewed and 91 articles were then retrieved in full text. After applying inclusion and exclusion criteria, 22 studies were ultimately included in this IR. Appraisal tools were used for each study included in this review according to its research approach.

RESULTS

Literature demonstrated how NQMs' wellbeing is at stake after registration as they go through a tumultuous period full of psychological stress, fear and other surges of negative emotions. The importance for NQMs to form new and trusting relationships with colleagues and women patients is highly evident in the literature.

CONCLUSIONS

Transitioning from a student to a midwife brings about stress and tension especially when NQMs take full responsibility for the women under their care, knowing that their decisions might have a direct impact on the outcome for women, newborns, and families. Literature shows that NQMs are a precious entity to healthcare as they are the future of midwifery and hence more research is recommended.

Experiences of newly qualified midwives during their transition to practice: a systematic review of qualitative research

Objective

To summarize and evaluate the experiences and expectations of newly qualified midwives (NQMs) during their transition from school to clinical practice. One of the main objectives was to provide references for the development of midwifery professional teaching and provide a basis for hospital administrators and instructors of midwifery to develop guidelines and strategies.

Methods

A systemic review of qualitative research using meta-aggregation was conducted. We collected studies from 12 databases between inception and February 2023. All qualitative studies published in English and Chinese that reported on the experiences of NQMs during their transition to practice were included. Two independent reviewers assessed the study quality and the credibility of study findings by using the JBI Qualitative Assessment and Review Instrument. The process of searching followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results

A total of 14 studies were included, and 84 findings were extracted. The results were grouped into 8 new categories and synthesized into 3 main themes: multi-dimensional challenges, physical and emotional responses, and demands and expectations. The included studies were identified to be of good quality and the results of the methodological quality appraisal were all B grade or higher.

Conclusion

The transition period is a critical career development for NQMs. However, they faced various stress during the period, which had a negative impact on their physical and mental health. Therefore, it's important to deeply understand their challenges and needs. And effective management strategies should be implemented, such as in-depth cooperation between hospitals and schools, improvement of the clinical transition support system, enhancement of continuing education, and standardization of the management system. This may be beneficial to improve the quality of clinical midwifery and maintain the stability and sustainable development of the midwifery team.

How do new midwives' early workforce experiences influence their career plans? An integrative review of the literature

AIM

To explore how the early workforce experiences of new midwives influence their career plans.

BACKGROUND

Each year, thousands of new midwives graduate from entry-to-practice midwifery courses, gain professional registration, and enter the workforce. Despite this, the world continues to face a shortage of midwives. The first five years of clinical practice, commonly referred to as the early career period, can be highly stressful for new midwives, contributing to early attrition from the profession. Supporting the transition from midwifery student to registered midwife is vital if we are to grow the workforce. Whilst the early career experiences of new midwives have been more broadly explored; little is currently understood about how these can influence their career plans.

METHODS

Following Whittemore and Knafl's (2005) five-stage process, an integrative review was conducted. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Nineteen studies met the criteria for inclusion. Thematic analysis was undertaken to organise and present the findings.

FINDINGS

Thematic analysis, guided by the review question led to the identification of three overarching themes: 'the need for support', 'sustaining health and wellbeing', and 'being able to provide safe and effective midwifery care'.

CONCLUSION

Very little research to date has specifically explored how the early career experiences of new midwives influence their career plans, particularly within the Australian context. Further research is required to better understand how the early workforce experiences of new midwives can either strengthen their commitment to the profession or contribute to the decision to leave midwifery prematurely. This knowledge would provide a basis for the development of appropriate strategies to minimise early attrition from the midwifery profession and promote career longevity.

"I didn't feel like I could trust her and that felt really risky": a phenomenographic exploration of how Australian Midwives describe intrapartum risk

OBJECTIVE

Concepts of intrapartum risk are not well explored in the Australian context. In response to an increasing focus on risk in maternity care, we sought to obtain insight into what Australian midwives conceptualised as intrapartum risk.

DESIGN

The research was conducted using a phenomenographic approach. Following ethical approval, in-depth semi-structured interviews were used to determine the qualitatively different ways midwives conceptualise intrapartum risk.

SETTING

This project was undertaken across different midwifery practice settings in Australia.

PARTICIPANTS

Australian midwives (n=14) with expertise in caring for women in the intrapartum period volunteered to participate in the study.

FINDINGS

When discussing their experience of intrapartum risk, midwives focused on the external horizon of the woman as the risk, that included the internal horizons of being labelled as clinically high risk, working relationships within transdisciplinary risk and institutional risk. Risks were orientated toward the woman as well as to the midwives.

KEY CONCLUSIONS

The midwives in this study conceptualised that intrapartum risk was associated with the woman including being labelled as high risk in addition to certain challenges within the midwife-woman relationship, particularly if there was a lack of reciprocal trust.

IMPLICATIONS FOR PRACTICE

This study supports current evidence that improved collaborative professional relationships are integral to safety in maternity care. It reinforces continuity of midwifery care as important, and particularly as a way of mitigating intrapartum risk. Further research is required to inform what challenges experienced in the midwife-woman relationship contribute to concepts of risk.

Nurturing our new midwives: A qualitative enquiry of mentor's experiences of supporting new graduate midwives working in continuity of care models

PROBLEM

Limited opportunity exists for new graduates in Australia to be employed in continuity of care midwifery models.

AIM

To explore the perspectives of midwifery mentors supporting new graduate midwives employed in continuity of care models.

METHODS

An interpretive, qualitative study was conducted. Semi-structured interviews and focus groups with senior midwifery staff who mentored new graduate midwives during their transition to practice within a continuity of care model were undertaken. Digitally recorded and transcribed verbatim, data were thematically analysed. Data collection ceased once theoretical saturation had been achieved. NVIVO software was used to assist with coding and data management.

FINDINGS

Twelve mentors participated. Mentors provided valuable feedback to optimise the supportive mechanisms to enable the success of the rotation of new graduate midwives in continuity of care models during their transition to practice period. Three key themes were constructed, including: Getting it right in the first place; Nurturing our new midwives; and The cultural void.

DISCUSSION

Consistent with the wider literature, effective implementation, sound support structures and wider acceptance of new graduate midwives transitioning to practice within continuity of care models is crucial to its success and sustainability.

CONCLUSION

Mentors are responsible to nurture, respect and guide new midwives through this crucial period, as they transition from midwifery student to registered midwife. Mentors believe in the transition of new graduate midwives in continuity of care models.

What strategies facilitate & support the successful transition of newly qualified midwives into practice: An integrative literature review

OBJECTIVE

The aim of this review was to identify strategies that facilitate newly qualified midwives to transition successfully from midwifery student to confident, competent practitioner.

DESIGN

Integrative literature review.

DATA SOURCES

The following databases were accessed: CINAHL complete, Medline complete, APA PsycINFO, Cochrane Library, Joanna Briggs Institute (JBI), Scopus and Google Scholar.

REVIEW METHODS

A systematic search of key terms across all data sources for the period January 1990 to September 2021 identified 316 papers whose titles/abstracts were screened against our inclusion/exclusion criteria. Thirty-six full texts were screened for eligibility and three papers were identified through ancestral searching. Ten papers were included in our final review.

RESULTS

Mentorship or preceptorship for newly qualified midwives by experienced midwives appears to enhance experiences, either as a standalone strategy, or component of structured programs of transition support. Supernumerary time, designated study days and planned rotations are also valued, particularly when rotating through clinical areas. Smaller teams providing continuity of midwifery care, or organisations that fund mentorship programs appear more able to facilitate support. Mechanisms of online support and learning may also enhance early transition but similarly, require organisational investment to aid success. Whilst most programs were described as helpful none of the studies used validated measures to assess this.

CONCLUSION

Whilst elements of tailored support programs and mentoring/preceptorship from experienced colleagues appear to offer valuable support to transitioning practitioners, it is important to note that the structure of maternity care appears fundamental to the success of many of these strategies. Consequently, maternity care reform which focuses on the adoption of sustainable models of midwifery continuity, alongside urgent investment in midwives, are likely the most promising, over-arching strategies required to support student to midwife transition.

Workplace violence in the Australian and New Zealand midwifery workforce: A scoping review

AIM

The aim of the study is to identify and map what is known about workplace violence involving midwives in Australia and New Zealand.

BACKGROUND

Research from the United Kingdom demonstrates that workplace violence within maternity services is a pervasive issue with significant and wide-ranging clinical, individual and organisational consequences. To date, little is known about this issue within Australian and New Zealand maternity services.

EVALUATION

A scoping review, guided by Arksey and O'Malley's framework, was conducted. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Just one identified study aimed to explore midwives' experiences of workplace violence. A further nine arrived at related results or themes.

KEY ISSUES

Workplace violence is present in a variety of forms across maternity services in Australia and New Zealand. Its prevalence is, however, yet to be understood. Workplace violence causes physical and mental health issues for midwives, premature workforce attrition, and jeopardizes the quality and safety of maternity care.

CONCLUSIONS

Workplace violence has been acknowledged as one of the key contributing factors towards premature attrition from the midwifery profession, with new graduate midwives most likely to leave. With the midwifery workforce ageing and evidence of serious clinical implications emerging, workplace violence needs urgent research and organisational attention.

IMPLICATIONS FOR NURSING MANAGEMENT

Workplace violence is a key contributing factor towards recruitment and retention challenges for managers. To help tackle this, managers have a key role to play in identifying and effectively addressing workplace violence by acting as positive role models, taking a zero-tolerance approach and fostering collegial relationships. Managers, holding key clinical leadership positions, are pivotal to ensuring all complaints raised are handled with transparency and consistency regardless of one's position within the clinical hierarchy and organisational structure.

Challenges experienced by newly qualified nurse-midwives transitioning to practice in selected midwifery settings in northern Malawi

BACKGROUND

Literature shows that newly qualified nurse-midwives face challenges integrating into the workforce during their transition period from education to practice. However, little is known about the needs and challenges of Malawian nurse-midwives during their transition from education to practice. The aim of the study was to explore the transition experiences of newly qualified nurse-midwives working in selected midwifery units in Northern Malawi.

METHODOLOGY

A qualitative descriptive approach was used. Data were collected through in-depth interviews using semi-structured interview guides from a purposive sample of 19 participants (13 newly qualified nurse-midwives and 6 key informants). The researchers developed two interview guides; one for the newly qualified nurse-midwives and another one for the key informants. The interview guides had questions related to newly qualified nurse-midwives experiences of transitioning to practice and the support they received. Participants were from three selected hospitals in the Northern part of Malawi that have maternity units. Data were analysed manually using thematic analysis.

FINDINGS

Five themes related to challenges faced by newly qualified nurse-midwives during their transition to practice in midwifery units emerged from the thematic analysis of the data. These included (1) Theory-practice gap, (2) Lack of confidence and skills, (3) Inadequate resources, (4) Transition support system, and (5) Workplace conflict.

CONCLUSION

Newly qualified nurse-midwives in Malawi encounter many challenges while transitioning from education to practice. The study findings underscore the need to develop a national framework support system that could not only help newly qualified midwives adjust positively to their new role but also create more opportunities for learning and developing and strengthening a collaborative partnership between colleges and hospitals.

Multiple stakeholder perspectives of factors influencing differential outcomes for ethnic minority students on health and social care placements: a qualitative exploration

BACKGROUND

Despite considerable efforts there continues to be a degree awarding gap within the United Kingdom (UK) between the proportion of White British students receiving higher classifications, compared to ethnic minority UK-domiciled students. Practice placement elements constitute approximately 50% of most health and social care programmes, yet surprisingly little research exists related to the factors which may contribute to ethnic minority student placement outcomes or experiences. This study bridges this evidence gap by exploring factors influencing differential placement outcomes of ethnic minority students from the perspectives of key stakeholders.

METHODS

The study followed a descriptive qualitative research design and was multi-disciplinary, with participants drawn from across nursing, midwifery, social work and the allied health professions. Participants from four stakeholder categories (ethnic minority students, academic staff, placement educators and student union advisors) were invited to join separate focus groups. Focus groups were recorded and transcribed and analysed thematically.

RESULTS

Ten separate focus groups [n = 66] yielded three primary themes: 1) recognition, which highlighted stakeholder perceptions of the issues [sub-themes: acknowledging concerns; cultural norms; challenging environments]; 2) the lived experience, which primarily captured ethnic minority student perspectives [sub-themes: problematising language and stereotyping, and being treated differently]; 3) surviving not thriving, which outlines the consequences of the lived experience [sub-themes: withdrawing mentally, feeling like an alien].

CONCLUSION

This study presents a rich exploration of the factors affecting differential outcomes of ethnic minority students on practice placements through the lens of four different stakeholder groups. To our knowledge this is the first study in which this comprehensive approach has been taken to enable multiple viewpoints to be accessed across a wide range of health and social care professions. The issues and challenges raised appear to be common to most if not all of these disciplines. This study highlights the urgent need to value and support our ethnic minority students to remove the barriers they face in their practice learning settings. This is a monumental challenge and requires both individuals and organisations to step up and take collective responsibility.

Newly qualified midwives' perceptions of their level of midwifery clinical competence during community service in KwaZulu-Natal, South Africa

Background

There are links between the inadequate numbers of competent midwives and high maternal mortality ratios and neonatal mortality rates which highlights the significance of job-ready, newly qualified midwives who can display clinical competence. The South African Nursing Council regulated mandatory community service, as a supportive year to develop clinical competence.

Aim

To explore and describe newly qualified midwives’ perceived level of midwifery clinical competence during community service.

Setting

Both the event of the pandemic and the distribution of the potential participants across various geographical settings necessitated planning for data collection in real and online settings convenient to them.

Method

Non-probability purposive sampling was utilized to select and invite the post community service, newly qualified midwives (N = 65), of the select university, who underwent community service in 2018 and experienced exposure to maternity care settings in the eThekwini District (n = 23). Data were collected through five focus groups and analysed through Elo and Kyngas’ content analysis.

Results

Three categories emerged: transitioning from the sheltered education environment to the real practice world, support in practice: disparate realities and interception of mentorship. Six subcategories accompanied the categories.

Conclusion

Newly qualified midwives’ clinical confidence and competence transitioning from the safe academic environment to the authentic accountable clinical setting hinges on mentorship and welcoming, non-stigmatising supportive relationships that facilitate the integration of previous learnings into community service practice.

Contribution

The study allows for audibility and awareness of the transitioning midwives’ perceptions highlighting the significance to maternity staff and policy makers, of supportive relationships and structures.

Midwives Mentoring Midwives: A Review of the Evidence and Best Practice Recommendations

Mentoring involves a reciprocal relationship between a more experienced person (mentor) who offers guidance and counsel to a less experienced person (mentee). Reported benefits of mentoring among students of varying health professions include skill acquisition, understanding of the professional role, acclimation to the culture of the health profession, and personal and professional development. Globally, the midwifery profession has a long-standing history of mentoring students and new graduate midwives. However, only one study has described a formal mentoring program within the US midwifery profession. Therefore, to inform best practice for both formal and informal mentoring programs, current mentoring programs are summarized and a state of the science review on mentoring within midwifery in the United States and internationally was conducted. Three types of mentoring relationships are discussed: (1) student to student (peer), (2) midwife to student, and (3) midwife to new graduate midwife. Effective models and recommended approaches for the development and expansion of mentoring are discussed, to sustain, diversify, and scale up the midwifery workforce. Personal attributes and action steps of effective mentors and mentees are provided.

Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis

OBJECTIVES

This systematic review aimed to offer insight and understanding, through synthesis of findings from studies that report on perspectives of student nurses/midwives, clinical instructors, clinical nurses/midwives on the challenges faced by student nurses/midwives in the clinical learning environment (CLE).

DESIGN

All primary qualitative research studies published in the English language that reported on the views of student nurses/midwives, clinical instructors and clinical nurses/midwives on the challenges faced by student nurses/midwives in the CLE were included.

DATA SOURCES

The electronic databases of Medline EBSCO (1946-), CINAHL (1970), Embase Ovid (1974-), ScielO, WHOLIS (2002-), ASSIA (1985-), Web of Science (1956-), PsycINFO (1800s-) and Maternal and Infant Care (1970-) were searched in November 2019.

REVIEW METHODS

Retrieved papers were reviewed independently by two authors for selection by title, abstract and full text, and two authors agreed for inclusion of the papers. The COREQ criteria checklist was used for assessment of methodological quality of the included studies.

RESULTS

The review included 32 studies published over 22 years between 1997 and 2019 involving 853 nursing/midwifery students, clinical instructors, and clinical nurses/midwives from 14 countries. Three key themes emerged: 'The support structure', 'Personal factors', and 'Planning and organisation - influence of extrinsic factors'.

CONCLUSION

Attitude of clinical staff, instructors, and significant others had a major influence on students' clinical learning. Lack of a sense of belongingness and self-motivation to learn, and perceived fear of doing errors were some of the demotivating factors. Lack of resources to facilitate need-based training, staff shortages, workload and inconsistencies between theory and practice were other key challenges in the CLE. Understanding the challenges faced by students in clinical practice can help overcome the barriers leading to development of competent and confident nurses and midwives.

Learning to be a midwife: Midwifery students' experiences of an extended placement within a midwifery group practice

AIM

To investigate the experiences, perspectives and plans of students who had a six-month placement with the midwifery group practice.

METHODS

Focus groups were conducted with fifteen third - year Bachelor of Midwifery students who had undertaken an extended placement at a midwifery group practice in a large tertiary referral hospital in Queensland, Australia.

RESULTS

Four main themes were identified in the data: Expectations of the Placement; Facilitating learning within a midwifery group practice model; Transitioning between models of care and Philosophy and culture of midwifery group practice.

DISCUSSION AND CONCLUSION

Third-year midwifery students valued the experience of working one-on-one for an extended placement with a midwife providing continuity of care within a caseload model. The experience was the highlight of their degree and they learned 'how to be a midwife'. Most students found reintegrating back into the hospital system of care challenging, reporting that their developed skills of supporting women holistically and facilitating normal birth were not fully utilised when returning to the task-orientated birth suite. Students valued thoughtful, kind and supportive midwifery preceptors who supported them to transition back into the hospital.

IMPLICATIONS AND RECOMMENDATIONS

Undertaking an extended placement within a midwifery group practice provides students with a rich and holistic learning experience and helps them develop a sense of professional identity. Student placements situated within models of care which provide continuity of midwifery care should be proactively enabled by health services and universities. Research of the longer-term impacts of an extended midwifery group practice clinical placement on midwifery graduates' capabilities and competencies 3-5 years post registration should be conducted.

Understanding workforce experiences in the early career period of Australian midwives: insights into factors which strengthen job satisfaction

OBJECTIVE

The aim of this study was to explore the experiences of early career midwives in Australia and identify the organisational, work environment, personal factors and stressors that influence workforce participation.

DESIGN AND SETTING

A qualitative study, using in-depth semi-structured interviews, was undertaken with midwives 6 - 7 years post-qualification. Qualitative content analysis identified key themes and sub-themes.

PARTICIPANTS

Twenty-eight midwives from one Australian university (graduating years 2007 and 2008) were included. Their pre-registration education was via either a Bachelor of Midwifery (direct-entry) or a Gradate Diploma of Midwifery (post-nursing degree).

FINDINGS

Three themes were generated: (i) 'sinking and swimming'; (ii) 'needing a supportive helping hand'; and (iii) 'being a midwife … but'. The initial transition into midwifery was overwhelming for most participants, particularly when providing intrapartum care. Job satisfaction was strongly related to having a well-developed midwife-woman relationship in clinical care and being able to work to their full scope of practice. Dissatisfaction stemmed from remuneration concerns, inflexibility of rostering, high workloads, and poor managerial approaches. Experiences of bullying were ubiquitous. Factors inducing midwives to stay in their profession were not the absence of those that caused dissatisfaction. The midwife-woman relationship sustained their practice despite those factors that caused dissatisfaction.

KEY CONCLUSIONS

Building strategies that strengthen job satisfaction in midwives is vital. Strategies that provide relational aspects of midwifery practice, ongoing support, rostering flexibility, induce psychological wellbeing, and address workplace bullying, may assist in the early career transition. Access to continuity of midwifery care models as new graduates is warranted.

IMPLICATIONS FOR PRACTICE

Continued professional development and career progression strategies are needed for midwives to cultivate their midwifery skills and work to their potential.

The impact of pre-registration education on the motivation and preparation of midwifery students to work in continuity of midwifery care: An integrative review

Access to continuity of midwifery care (CoMC) models in Australia is increasing but the capacity of the emerging midwifery workforce to provide this care remains largely unknown. The aim of this integrative literature review is to discover how well pre-registration midwifery education prepares and motivates Australian midwifery students to work in CoMC models when they enter practice. Following title review of 432 papers, removal of duplicates and review against the inclusion and exclusion criteria, nine papers were included for review. The results show that access to CoMC is a crucial component of midwifery education, equipping students with knowledge, skills, confidence and motivation to work in this way upon graduation. Existing methods of program delivery and institutional structures often present students with challenges that detract from the value of their CoMC experiences. A focus on CoMC placement - particularly with a continuity of midwifery mentor - may motivate graduates to work in this model of care. This strategy is recommended to better align Australian midwifery education with maternity care reform.

Changing preceptorship to achieve better quality training and less attrition in newly qualified nurses

The preceptorship period is of great importance in the career of a nurse, as he or she moves from being a student to a competent, accountable professional. Problems with the current preceptorship system for preceptors include not receiving adequate training—particularly in providing constructive feedback to preceptees. In addition, when a small number of nurses are repeatedly assigned preceptees to mentor, this can lead to burnout. Preceptees can feel overwhelmed by their first months as a newly qualified nurse (NQN) and can feel unsupported if a preceptor's teaching style or personality is unsuited to them. This can lead to attrition in the nursing workforce, a current problem. This article suggests a new way of organising preceptorship, by allowing preceptors to opt in to the scheme, providing a pool of energised and enthusiastic preceptors. In turn, NQNs could initially work with the pool of nurses before being given the choice of which preceptor to work with individually.

Validation of the MidACE tool - Students' perceptions of the Midwifery Academic role in clinical environments

BACKGROUND

Situating Midwifery Academics in clinical environments can have an important impact on students' clinical learning. Students' perceptions of this support role in the clinical environment using standardised measures has been under-investigated.

AIMS

To develop and test a tool that measures midwifery students' perceptions of the Midwifery Academic role on clinical learning and development of professional knowledge, skills and clinical capability.

METHODS

A staged process for tool development included draft item generation, review by expert panel for face and content validity and pilot testing with a convenience sample of undergraduate midwifery students. Dimensionality, internal consistency and test-retest reliability were evaluated.

RESULTS

Two hundred and seventy-nine midwifery students completed an online survey (74% response rate). Responses on the ten-item tool loaded strongly on one factor, explaining 69.6% of variance. Cronbach's alpha (0.94) and test-retest reliability (intraclass coefficient=.92; 95%CI .89-.95) were good. Most students agreed that the Midwifery Academic role supported the integration of midwifery theory and practice and critical self-reflection. Areas for improvement included working in partnership with preceptors; assessing students' development; and increased presence in the clinical environment.

CONCLUSIONS

This study established reliability and validity of the Midwifery Academic in Clinical Environments (MidACE) tool. Students perceived Midwifery Academics could contribute further to their professional knowledge, skills and clinical capability through a strong collaborative presence in the clinical environment.

'The rollercoaster': A qualitative study of midwifery students' experiences affecting their mental wellbeing

OBJECTIVE

Midwifery student mental wellbeing is an important consideration for the sustainability of the profession, however it has seldom been the subject of empirical research. Previous studies of the lived experience of midwifery students have focused on the impact of transition experiences and student satisfaction, rather than specifically on mental health and students' views on support for their mental wellbeing.

DESIGN

A qualitative descriptive study using semi-structured interviews.

SETTING

A midwifery undergraduate programme in one university in the South of England.

PARTICIPANTS

20 BSc midwifery students.

FINDINGS

Two inductive themes were developed from our analysis. The theme of 'the rollercoaster' encapsulated students' experience over the length of the course, characterised by multiple culture shocks of being in different worlds, from one clinical placement to the next, from university to clinical placement. This experience was emotionally taxing. The theme of 'being noticed, feeling connected' encapsulated midwifery students' views on what could help them enjoy their training. They wanted to be seen as individuals by at least one educator, they wanted opportunities to connect with their peers and they wanted the support available to them to be consistent.

CONCLUSIONS

Listening to students' insights into the lived experience of being a midwifery student can enable midwifery educators to improve the way courses are designed and support structures are put in place. The importance of having consistent contact with peers and educators cannot be underestimated.

IMPLICATIONS FOR PRACTICE

The emotional demands of midwifery training must be acknowledged. Educators should identify ways in which they can provide students with consistent individualised support and regular opportunities to meet with their peers.

The initiation of Dutch newly qualified hospital-based midwives in practice, a qualitative study

In the Netherlands, a percentage of newly qualified midwives start work in maternity care as a hospital-based midwife, although prepared particularly for working autonomously in the community.

AIM

This study aimed to explore newly qualified Dutch midwives' perceptions of their job demands and resources during their initiation to hospital-based practice.

DESIGN

We conducted a qualitative study with semi structured interviews using the Job Demands-Resources model as theoretical framework.

METHODS

Twenty-one newly qualified midwives working as hospital-based midwives in the Netherlands were interviewed individually between January and July 2018. Transcripts were analyzed using thematic content analysis.

FINDINGS

High workload, becoming a team member, learning additional medical procedures and job insecurity were perceived demands. Participants experienced the variety of the work, the teamwork, social support, working with women, and employment conditions as job resources. Openness for new experiences, sociability, calmness and accuracy were experienced as personal resources, and perfectionism, self-criticism, and fear of failure as personal demands.

CONCLUSION

Initiation to hospital-based practice requires from newly qualified midwives adaptation to new tasks: working with women in medium and high-risk care, managing tasks, as well as often receiving training in additional medical skills. Sociability helps newly qualified midwives in becoming a member of a multidisciplinary team; neuroticism and perfectionism hinders them in their work. Clear expectations and a settling-in period may help newly qualified midwives to adapt to practice. The initiation phase could be better supported by preparing student midwives for working in a hospital setting and helping manage expectations about the settling-in period.

Connecting Status and Professional Learning: An Analysis of Midwives Career Using the Place© Model

This paper seeks to deconstruct the place of midwives as professionals using the novel interdisciplinary lens of the Place Model—an innovative analytical device which originated in education and has been previously applied to both teachers and teacher educators. The Place Model allows us to map the metaphorical professional landscape of the midwife and to consider how and where midwives are located in the combined context of two senses of place: in the sociological sense of public esteem and also the humanistic geography tradition of place as a cumulative process of professional learning. A range of exemplars will bring this map to life uncovering both the dystopias and potentially utopian places in which midwives find their various professional places in the world. The Model can be used to help student midwives to consider and take charge of their learning and status trajectories within the profession.

Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors

OBJECTIVE

The overall study aim was to explore the relationship between the emotional wellbeing of UK midwives and their work environment. Specific research questions were to: assess levels of burnout, depression, anxiety and stress experienced by UK midwives; compare levels of burnout, depression, anxiety and stress identified in this sample of UK midwives, with levels reported in Australia, New Zealand and Sweden; identify demographic and work-related factors associated with elevated levels of burnout, depression, anxiety and stress.

DESIGN

Cross sectional research design using an online survey. The WHELM survey tool was developed within the Australian maternity context and includes a number of validated measures: The Copenhagen Burnout Inventory (CBI), Depression, Anxiety and Stress Scale (DASS-21), as well as items from the Royal College of Midwives (RCM) 'Why Midwives Leave' study (Ball et al., 2002).

SETTING

United Kingdom.

PARTICIPANTS

An on-line survey was distributed via the RCM to all full midwife members in 2017 (n = 31,898).

DATA ANALYSIS

The demographic and work-related characteristics of the sample were analysed using descriptive analyses. Levels of depression, anxiety, stress and burnout, measured by the CBI and DASS scores, were analysed using non-parametric statistical tests. Comparisons were made between groups based on demographic and work characteristics. Mann-Whitney U tests were used for two group comparisons, and Kruskal Wallis tests were used for groups with 2+ groups. Given the large number of analyses undertaken, statistically significant comparisons were identified with a conservative alpha level (p < .01).

FINDINGS

A total of 1997 midwives responded to the survey, representing 16% of the RCM membership. The key results indicate that the UK's midwifery workforce is experiencing significant levels of emotional distress. 83% (n = 1464) of participants scored moderate and above for personal burnout and 67% (n = 1167) recorded moderate and above for work-related burnout. Client-related burnout was low at 15.5% (n = 268). Over one third of participants scored in the moderate/severe/extreme range for stress (36.7%), anxiety (38%) and depression (33%). Personal and work-related burnout scores, and stress, anxiety and depression scores were well above results from other countries in which the WHELM study has been conducted to date. Midwives were more likely to record high levels of burnout, depression, anxiety and stress if they were aged 40 and below; reported having a disability; had less than 10 years' experience; worked in a clinical midwifery setting, particularly if they worked in rotation in hospital and in integrated hospital/community settings.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Many UK midwives are experiencing high levels of stress, burnout, anxiety and depression, which should be of serious concern to the profession and its leaders. NHS employed clinical midwives are at much greater risk of emotional distress than others surveyed, which has serious implications for the delivery of high quality, safe maternity care. It is also of serious concern that younger, more recently qualified midwives recorded some of the highest burnout, stress, anxiety and depression scores, as did midwives who self-reported a disability. There is considerable scope for change across the service. Proactive support needs to be offered to younger, recently qualified midwives and midwives with a disability to help sustain their emotional wellbeing. The profession needs to lobby for systems level changes in how UK maternity care is resourced and provided. Making this happen will require support and commitment from a range of relevant stakeholders, at regional and national levels.

Six months qualified

Student midwives need not fear life as a qualified midwife. Claire Axcell talks about becoming more independent, building your confidence, and finding your ‘midwifery crush’

Developing a community-based nursing and midwifery career pathway - A narrative systematic review

INTRODUCTION

Community nursing and midwifery is changing in response to a shift in care from hospital to home, brought about by increasing costs to care because of an aging population and increasing chronicity. Until now, community nursing positions and scope of practice has been dependent on service focus and location, which has led to the role being unclearly defined. Lack of appeal for a career in community practice and a looming workforce shortage necessitates a review into how community nursing and midwifery transition to practice is supported.

METHODS

This review sought to identify, assess and summarize available evidence relating to transitioning into community nursing and midwifery practice as a speciality. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach. A narrative synthesis was then undertaken on papers that examined community nursing and midwifery pathway perspectives which define, and enable or inhibit a contemporary pathway. Thematic analysis used a theoretical framework developed for early career and rapid transition to nursing specialty practice.

RESULTS

There is a paucity of research that identifies community nursing and midwifery as a discreet scope of practice. Twelve papers were eventually included in the review. Verbatim findings were extracted from the papers and clustered into categories based on the chosen theoretical framework. Major themes were 'the self' (professional and personal); 'transition processes'; and, a 'sense of belonging'. Sub themes included narrative identifying inhibitors and enablers in each theme.

DISCUSSION

No definition of community practice or pathway was identified in nursing, although midwifery was clearly defined. Community nursing practice was described as generalist in nature although specialist knowledge is required. Being part of the community in the professional sense and personal sense was considered important. The importance of transition was identified where pre-entry exposure to community practice was seen as important. Stages in transition to practice were recognised as pre-entry; incomer; insider; and, a sense of belonging. The process of transition should be planned and individualised acknowledging past experience whilst acknowledging the specialist nature of community-based practice.

Relationships between working conditions and emotional wellbeing in midwives

BACKGROUND

Emotional distress in midwives contributes to high attrition. To safeguard midwives' wellbeing, there is a need to identify the impact of workplace variables.

AIM

To review the existing evidence on the relationships between working conditions and emotional wellbeing in midwives, and construct an analytic framework for understanding these relationships.

METHODS

Systematic search and selection procedures using a range of databases. Results of included studies were synthesised into a thematic literature review of qualitative and quantitative research.

FINDINGS

Various types of poor emotional wellbeing in midwives correlate with a variety of interrelated working conditions, including low staffing/high workload, low support from colleagues, lack of continuity of carer, challenging clinical situations and low clinical autonomy. Staffing levels seem to be able to modify the effects of many other variables, and the impact of challenging clinical situations is affected by several other variables.

DISCUSSION

These workplace variables can be categorised as modifiable and non-modifiable risk indicators.

CONCLUSION

While certain conditions that correlate with midwives' wellbeing are non-modifiable, several crucial variables, such as staffing levels and continuity of carer, are within the control of organisational leadership. Future research and interventions should focus on these modifiable risks. Research design should maximise the chance of establishing causation, while any innovations in this area should anticipate the interrelatedness of these risk factors to avoid unintended negative consequences.

The future in their hands: Graduating student midwives' plans, job satisfaction and the desire to work in midwifery continuity of care

BACKGROUND

Midwife-led continuity of care models benefit women and the midwives who work in them. Australian graduate midwives are familiar with, and educated to provide, continuity of care to women although the opportunity to work exclusively in positions providing continuity of care on graduation is uncommon.

AIM

To explore the immediate and aspirational employment plans and workforce choices, reasons for staying in midwifery and perceptions around factors likely to influence job satisfaction of midwives about to graduate from one Australian university during the years 2012-2016.

METHODS

This longitudinal study draws on survey responses from five cohorts of midwifery students in their final year of study.

FINDINGS

Ninety five out of 137 midwifery students responded to the survey. Almost nine out of ten respondents either aspired to work in a continuity of care model or recognised that they would gain job satisfaction by providing continuity of care to women. Factors leading to job satisfaction identified included making a difference to the women for whom they care, working in models of care which enabled them to provide women with 'the care I want to give', and having the ability to make autonomous midwifery decisions.

CONCLUSION

Aligning early graduate work experiences with continuity of care models may have a positive impact on the confidence and professional development of graduate midwives, which in turn may lead to greater satisfaction and retention among a workforce already committed to supporting the maternity healthcare reform agenda.

Expected clinical competence from midwifery graduates during community service placement in Limpopo province, South Africa

Background

Community service nurses are placed in a hospital within the first year after qualifying to obtain clinical experience under the supervision of experienced professional nurses. When placed in clinical environments, new midwifery graduates are expected to be job ready, demonstrate competence in the provision of evidence-based care, practise independently and assume accountability and responsibility for their own actions.

Aim

The study aimed at exploring the expectations of experienced midwives of clinical competence of newly graduated midwives during transition.

Setting

The study was conducted at the training hospitals of the five districts in Limpopo province.

Method

The researcher used a qualitative approach which is explorative and descriptive in nature. The population comprised all the professional midwives with experience of 5 years and above working at the selected hospitals in Vhembe, Mopani, Capricorn, Waterberg and Sekhukhune districts of Limpopo province, South Africa. From each selected hospital, five experienced midwives were selected using non-probability, purposive sampling method. An in-depth individual face-to-face interview was used to collect data from the participants, until saturation was reached. The open-coding, Tesch’s eight-step process was used to analyse data.

Results

Results revealed that newly graduated midwives failed to meet the perceived expectations by experienced midwives; this was reflected in sub-themes: limited sense of independence, limited participation in task sharing and commitment and competence versus incompetence to patient care.

Conclusion

The experienced midwives expected newly graduated midwives to function as professionals; unfortunately, they expressed disappointment as graduates did not meet their expectations. Newly graduated midwives lacked sense of independence, commitment to patient care and did not display ability in task sharing.

Perceived job demands and resources of newly qualified midwives working in primary care settings in The Netherlands

OBJECTIVE

The objective of this study is to identify perceived job demands and job resources of newly qualified midwives (NQMs), working in primary midwifery care during their first years in practice.

DESIGN/SETTING

A qualitative study, with semi-structured group interviews was conducted. Midwives working less than three years in primary midwifery care in the Netherlands were invited to join a focus group interview.

MEASUREMENTS AND FINDINGS

Five focus group interviews were with 31 participants. Interviews were transcribed and analyzed. Data were analyzed thematically by using the different characteristics of the Job Demands Resources model. Working as a locum midwife is demanding for Dutch NQMs, due to a large number of working hours in different practices and a lack of job security. Decision-making and adapting to local guidelines and collaborations demand a high cognitive load. These aspects of the work context negatively impact NQMs' work and private life. Working with clients and working autonomously motivates the newly graduates. Support from colleagues and peers are important job resources, although colleagues are also experienced as a job demand, due to their role as employer. Strictness in boundaries, flexibility and sense of perspective are NQMs' personal resources. On the other hand, NQMs perceived perfectionism and the urge to prove oneself as personal demands.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Dutch NQMs' first years in primary midwifery care are perceived as highly demanding. In primary care, NQMs usually work as locum midwives, self-employed and in different practices. Working in different practices requires not only working with different client populations and autonomous decision-making, but also requires adaptation to different local working arrangements. Building adequate support systems might help NQMs finding a balance between work and private life by having experienced midwives available as mentors. Furthermore, training and coaching of NQMs help them to become aware of their personal resources and demands and to help them strengthen their personal resources. Improving NQMs' working position through secure employments require changes in the organization of maternity care in the Netherlands.

Becoming a midwife: A survey study of midwifery alumni

BACKGROUND

Becoming a competent midwife is a complex process. The aim of midwifery education is to support the development of competence in midwifery skills, knowledge and to prepare graduates to meet the responsibilities inherent in the midwifery role.

AIM

To explore the experiences of our alumni midwives, ask how well they perceived their midwifery programme had prepared them for beginning midwifery practice and to identify any curriculum changes, or postgraduate study topics, that would support the transition to midwifery practice.

METHODS

An online survey was conducted with alumni of a Bachelor of Midwifery programme (New Zealand) who graduated between 2011 and 2014. The quantitative data were analysed using descriptive statistics, and a general inductive approach was used to develop themes from the qualitative data in the comment boxes.

FINDINGS

Forty-two alumni viewed becoming a midwife as a blend/combination of: (1) gaining the knowledge and practical skills required for the profession; (2) management skills in areas of running a business, working with other people, navigating local procedures and processes effectively, and balancing work with personal life; (3) gaining confidence in one's competence, and (4) having support along the way.

DISCUSSION

Competence in current evidence-based midwifery knowledge and practice is important in educating midwifery students. However, to transition to practice, a supportive environment is needed to assist midwives to develop self-management, business skills, and the confidence to negotiate and collaborate with colleagues and other health professionals.

CONCLUSIONS

Not only did midwifery knowledge and practice skills matter for alumni, but also the acquisition of management skills, strategies for building confidence, and ongoing support. Content that facilitates these requirements should be included in midwifery programmes to support the transition from student to practitioner.

Personal, professional and workplace factors that contribute to burnout in Australian midwives

AIM

This study aimed to identify personal, professional and workplace factors that contribute to burnout in midwives.

BACKGROUND

Burnout is prevalent in the midwifery workforce. Burnout adversely affects the well-being of midwives, diminishes the quality of care they provide and can shorten career duration.

DESIGN

Self-administered online survey. The survey included the Copenhagen Burnout Inventory and personal and professional variables related to age, children, years of experience, role, model of care and satisfaction with work life. Midwives were invited to participate via an email sent from the Australian College of Midwives and through professional networks between June and July 2014. Variables associated with burnout were entered in a multinomial logistic regression.

RESULTS

A total of 1,037 responses were received and 990 analysed. The prevalence of moderate to severe personal (N = 643; 64.9%) and work-related burnout (N = 428; 43.8%) were high. Having children, providing caseload midwifery care and working in a regional area were associated with low burnout. However, midwives registered for 5-10 years were more likely to report work and client-related burnout. Similarly, midwives reporting a lack of satisfaction with work-life balance were also more likely to report personal and work-related burnout.

CONCLUSIONS

Family-friendly work environments that facilitate work-life balance can help to reduce the personal and organizational costs of burnout. Similarly, providing continuity of midwifery care in a caseload model can facilitate work-life balance and provide significant mental health benefits to participating midwives.