In clinical practice, how often do midwives stop and think about the evidence behind the care provided? Do midwives routinely discuss research findings with colleagues, or challenge the validity of new recommendations? How do midwives ensure their practice is always contemporary and evidence-based, not simply founded on the practice that has come before?
Healthcare is continually shifting in response to new knowledge and understanding. The expectation is that clinicians will work within a contemporary research-base, with students developing evidence-based practice through theory and placement learning. For this to succeed, students need to be supported by midwives who role model evidence-based practice and research, and with learning that facilitates the conceptual leap towards embedding evidence-based practice and research in their emerging midwifery practice (Reid et al, 2017).
Supporting evidence-based practice and research learning
Whether in clinical or academic settings, all midwives are educators, with a responsibility to nurture student confidence in evidence-based practice and research; partnership working between practice and approved education institutions is key (Holland and Lauder, 2012). However, teaching evidence-based practice and research presents a challenge for students and educators alike. It is widely acknowledged that nursing and midwifery students find evidence-based practice and research a challenging subject (Newton et al, 2010; Sidebotham et al, 2014). The Nursing and Midwifery Council (2019) standards of proficiency for midwives, state that new registrants should be prepared to critically appraise and interpret research evidence to inform decision-making and develop practice, including being able to evaluate and discuss practice implications where there is conflicting or absent research evidence. This relationship with research evidence must begin during pre-registration training and be maintained in the years beyond qualification.
With evidence comprising a core component in assessment and learning activities, student midwives have a level platform to explore research and critically challenge their peers, without the hierarchical concerns that may be present in clinical environments. Curricula that ensure student midwives view evidence as integral to midwifery practice are key to laying this analytical foundation, while acknowledging that the degree of evidence-based learning in placement is often mixed and dependent on the practice witnessed (Spencer and Yuill, 2018). When students learn the theory of evidence-based practice and this contrasts to their clinical experiences, there is potential tension with their ability to maintain evidence driven focus during their placement learning (Allen and Anderson, 2019). When evidence-based practice is marginalised in the context of other competing workplace demands, a different mode of professional function emerges, which could be termed ‘practice-based-practice’: midwifery that becomes entrenched without criticality or questioning of care provision (Toolhill et al, 2017; Bayes et al, 2019). Translating evidence into practice is a complex process and often the best available evidence takes time to become common practice, creating a challenge for midwifery students and educators (De Leo et al, 2019). This tension between evidence-based practice and research and practice-based practice increases at registration, when the newly qualified midwife moves away from a learning environment that focuses on the teaching of evidence-based practice and research, potentially finding themselves with less opportunity to engage meaningfully with the evidence-base (Kerr and Rainey, 2021).
The enquiry into maternity care at Shrewsbury and Telford NHS Trust revealed a lack of scrutiny, criticality and application of evidence alongside minimal professional challenge among clinicians in a teaching hospital environment (Ockenden, 2022). It cannot be assumed that students and newly qualified midwives learn within services where evidence-based practice is modelled. Even when reviewing the implementation of measures designed to avoid a repetition of these maternity care failings, a critical eye must be maintained, with maternity professionals adopting a thoughtful and considered view of the evidence underpinning proposed practice changes (Renfrew et al, 2022).
It seems that simply embedding elements of evidence-based practice and research in undergraduate midwifery curricula may not be enough to ensure that midwives implement evidence-based practice (Corr, 2018; De Leo et al, 2019). Educators need to facilitate evidence-based practice and research learning in such a way that newly qualified midwives continue with evidence-based practice post-registration, gaining confidence to implement best available evidence (Leach et al, 2015) and themselves becoming role models for evidence-based practice and research.
Practice-based-practice vs evidence-based practice
Aspiring student midwives may be drawn to the profession because of the practical nature of the core midwifery skills inherent in the role. In the authors' experiences, students will profess to be less skilled at aspects of their training such as academic writing and research-related activities. These evidence-based practice and research skills are also challenging to master, but why more so than abdominal palpation or active fetal heart auscultation? The skill of critiquing and challenging evidence should be approached with a commitment akin to these ‘hands on’ midwifery skills.
Practical and physically based skills appear more meaningful to students than the desire to learn research, with students seeing less value in taught research skills (McIntosh et al, 2013; Corr, 2018). There is a dissonance between what is taught in the classroom and the skills performed in the clinical setting, which can cause frustration and confusion in students (McIntosh et al, 2013). Ultimately, is this because seeing and enacting skills is favoured over understanding the foundation of practice through academic engagement with literature?
Learning environments impact the processes of knowledge acquisition, with students experiencing lower confidence and competence levels where there is a recognised theory-practice gap, where the skills taught in the classroom are not effectively applied in clinical situations (Ball et al, 2022). It is widely acknowledged that research skills increase students' ability to analyse, evaluate and become effective autonomous practitioners (Power and Ridge, 2017), but students can fail to see the application of evidence-based practice and research in their everyday experiences of clinical practice. The ‘hands on’ or overt skills of midwifery are emulated in clinical environments through the observation and duplication of practice supervisor's actions, whereas applying evidence into practice is much more subtle, more abstract, and students can struggle to grasp the application of this despite acknowledging its importance (Corr, 2018).
Students not seeing evidence-based practice and research skills in action, alongside a perception that these midwifery skills are less accessible than others, presents educators with a challenge that needs to be addressed by clinical and academic midwives alike. Finding ways to support students to confidently develop evidence-based practice and research skills, and ultimately maintain them in the workplace, requires alternative ways of working and collegial approaches, which will be explored in a forthcoming birthwrite article.