The structure of midwifery education in the UK has changed dramatically over the last two decades, moving away from a predominantly practice-based apprenticeship model in a clinical setting, to being firmly established within academia and higher education (Thomas, 2007). The minimum academic level required to be registered as a midwife has also been raised, from a higher diploma to undergraduate degree level (Nursing and Midwifery Council (NMC), 2009). Successful students are awarded a Bachelor of Science (BSc) (Hons) in Midwifery and the professional qualification of Registered Midwife, having been judged by the Lead Midwife for Education to be fit to practise safely and effectively, and having demonstrated sound theoretical knowledge of midwifery.
Post-registration, midwives take control of their own learning and development by engaging in continuing professional development, an ongoing process of reflection and action. The requirement for continued learning post-registration is supported by revalidation, a process that all midwives in the UK must undergo in order to maintain their registration with the NMC. Part of revalidation is the requirement for midwives to undertake 35 hours of continuous professional development relevant to their scope of practice; and as a result, the level of academic study for post-registration postgraduate education has been raised to Master's (MSc) level. As a form of continuous professional development, a Master's degree is described as a second-cycle taught course, commonly taken by individuals who have an Honours degree or equivalent (Judge et al, 2005). Master's level education enables individuals to apply knowledge, to develop an understanding of how boundaries are advanced through research, and to manage complex issues systematically with self-direction, creativity and originality (Rushton and Lindsay, 2008). This article will explore the concept of postgraduate education for post-registration midwives from an individual perspective, as well as from the collective perspective of midwifery as a profession.
Individual perceptions of the post-registration educational journey
Embo and Valke (2017) studied third-year student midwives' perceptions of professional development and found that they were acutely aware of the importance of continuous professional development; particularly in relation to the development of their academic knowledge over didactic clinical skills training. In reality, however, the majority of student midwives tend to consolidate their knowledge by practising as a midwife once they have completed their Bachelor's degree. Their aspirations focus around clinical skill acquisition and progression through a preceptorship programme (Hughes and Fraser, 2011). Once a newly qualified midwife has settled into the routine of the clinical environment, continuous professional development becomes a consideration; however, this tends to be mostly focused on the practicalities of their role and on training courses that will help with their promotion to Band 6, such as mentor preparation and newborn infant physical examination (NIPE) training, as opposed to an academic MSc programme. ‘Training’ and ‘education’ are terms often used interchangeably within midwifery, although, in fact, these terms represent different goals: training is required to develop skills to use a specific tool, whereas education is required to develop cognitive and intellectual skills to analyse situations and inform decision making (Megginson and Whitaker, 2017).
There is a limited debate in the literature around postgraduate Master's level education in midwifery and why midwives do not view this option as part of their career development pathway. It is difficult to ascertain if midwives make a personal decision not to embark on a Master's degree programme or whether this attitude towards personal academic development is about conforming with the norm within the working environment; a way of ‘being part of the club’ (Reynolds et al, 2014). Hobbs (2012) suggests that newly qualified midwives want to believe in the academic philosophy around ideal and reflexive practice promoted at university, but commented that this often conflicts with the day to day tensions of midwifery care. Hunter (2009) found that newly qualified midwives felt that they had to conform to what was expected of them by becoming familiar with the cultural rules. In midwifery, there appears to be a different philosophy of what constitutes knowledge and where this knowledge has originated, with an overwhelming steer towards clinical experience over academic expertise. This is in contrast to a number of other professions, where progression from an undergraduate degree to Master's degree, through to Doctoral studies, is a natural career pathway for many before entering the workplace. Lucas and Tan (2013) found that a person's beliefs about the nature of knowledge and knowing clearly frame how they interpret their educational experience and their approaches to, and perspectives on, learning.
Knowledge acquisition in midwifery
According to Donley (1986) the foundation of midwifery knowledge is positively constructed and developed by drawing on many different ways of knowing. This was further explored by Hunter (2008), who described three authoritative ways of knowing that guided the midwife: self-knowledge developed from the belief system of the individual, grounded knowledge from personal lived experience, and informed knowledge from objective and scholarly sources. One of the key characteristics of midwifery knowledge is a clear relationship between theory and practice: midwifery cannot be learned solely through theory or practice alone (Papastravrou et al, 2010). The emphasis of a Master's programme is to enable a student to manage the complexity of issues in a systematic and creative way (Quality Assurance Agency for Higher Education, 2001). This provides midwives with the expertise to manage more complex problems in the clinical environment, and gives them the confidence to be an active contributor in the re-creation of midwifery (Hobbs, 2012). A Master's degree promotes the evaluation of midwifery practice by demonstrating advanced levels of problem-solving and clinical expertise in midwifery, thereby raising the standards of midwifery care for women and their families.
‘The skills acquired through undergraduate and postgraduate education are required, more than ever, to challenge the risk-based, medical approach to care, maintain autonomous professional status and regain control’
Why complete a Master's degree?
The benefits for midwives
While a Master's degree may have both personal and professional benefits, engaging in post-registration postgraduate education can be challenging, in terms of the prospect rigorous study and financial and time constraints. In general, undertaking a Master's programme is often influenced by the availability of funding and employer support with study time, rather than the risk of academic failure.
When considering postgraduate education such as a Master's degree or Doctoral studies, the purpose and benefits are usually centred on personal and professional development of the individual graduate midwife. On an individual level, postgraduate education can provide a strong foundation for a future career in research, education, management or consultancy, as well as fulfilling the NMC requirements for continuous professional development. Many higher education institutions and NHS organisations now require prospective applicants to be studying towards, or have completed, a Master's programme when applying for specialist midwifery roles. These roles are, but not limited to, senior clinical and management roles, including consultant and research midwives, and higher education midwifery educators. Postgraduate education is therefore essential for certain career pathways. The personal importance of postgraduate education for career progression notwithstanding, it also is enlightening to reflect on and consider the ways in which graduate midwives, individually and collectively, could contribute to the profession of midwifery by engaging in postgraduate education.
The benefits for midwifery
In the UK, midwives are appropriately trained and legally recognised care providers for women experiencing normal pregnancy and childbirth. The evidence is clear that normal, physiological birth is the optimal and most cost-effective mode of birth for mother and baby (Royal College of Midwives, 2010), and yet there has been a steady decrease in normal physiological birth, and a steady increase in operative birth since 2005 (NHS Digital, 2016). While the reasons for these statistics are arguably multifactorial, it is widely documented that the transition to a risk-based, medicalised approach to health and illness has impacted upon the provision of healthcare in general (Burgess et al, 2016) and maternity care in particular (Scamell and Alaszewski, 2012).
Within contemporary maternity services, it is evident that the professional scope of the midwife is challenged by many social and political factors. Arguably the biggest threat to midwifery, however, is the impact of ‘risk culture’ on role boundaries in maternity services (Scamell, 2011; 2014; 2016; Spendlove, 2017). One study reported that, due to fear of risk, midwives' commitment to preserving the normal physiological process of birth ‘lacked the necessary vitality to curtail the social amplification of risk’ (Scamell, 2016: 19). Now more than ever, the profession requires its members to have the knowledge, skills and vitality to understand and critique risk in maternity care, to clearly define the boundaries of midwifery practice and to preserve midwifery as an autonomous profession. Acquisition of change management, leadership and critical thinking skills through postgraduate education could equip midwives with the necessary skills to preserve their autonomous professional role and be advocates for women in their care.
Key skills
Critical thinking
Analytical skills are the foundation of postgraduate education. In order to successfully complete the educational programme, postgraduate students are required to acquire and demonstrate effective use of critical thinking skills in summative assessments. The Open University (2013) outlines a useful ‘stairway’ (Table 1) to help students understand the skills required to think critically, where the lower steps are the basic competencies that support the higher-level thinking skills that can underpin a critical approach.
All midwives require critical thinking skills to evaluate evidence in the planning and delivery of high quality, evidence-based care to women, to question care models and to be true advocates for women. This includes assessing the impact of challenges such as risk culture on maternity service provision, and identifying opportunities for progressive, evidence-based change.
Research
Postgraduate education also enables students to develop research skills, such as methodically searching for information, to explore and answer questions, which are important providing high quality, evidence-based care. In order for postgraduate students to develop research competence, Master's programmes usually offer and promote the completion of empirical research as part of the dissertation module. Empirical research is not always an essential aspect of some Master's programmes—especially for international students who are not registered and practising in the UK—but engaging in empirical research could provide midwives with the opportunity to research an area of interest and contribute to an existing body of knowledge.
Change management and leadership
Postgraduate education provides the opportunity for students to critique the theory and practice of change management and leadership, and explore the process and practicalities of leading change through classwork and assessment. Leadership and change management skills are essential for all qualified health professionals, from novice to expert, and are essential to manage and deliver everyday care. Leadership and change management skills assist with identifying, leading and managing necessary changes in practice and identifying new ways of working for the care requirements of the future (Gopee and Galloway, 2017). Knowledge of change management and leadership theory and its application to practice would equip midwives and future leaders with the tools to manage and encourage midwives through change in practice. This process can be empowering and exciting, and can stimulate individuals to also achieve their own aspirations (Megginson and Whitaker, 2017). Changing healthcare strategies, modes and models of care are integral to a constantly changing NHS. If midwives are to be true advocates for women and are to reaffirm their unique professional role, they must be adequately educated and equipped to respond to such challenges by managing and implementing change accordingly.
Preserving the future professionalisation of midwifery
To understand how the acquisition of change management, leadership and critical thinking skills can assist midwives with preserving the future professionalisation of midwifery, the concept of professionalism must be explored. Over the decades, scholars and academics have debated the nature of professionalism and what constitutes professional status. Autonomy—‘control over the content and terms of work’ and being ‘self-directing’ (Freidson, 1970: 134)—has subsequently been classified as a central attribute of professionalisation. Analysing the professionalisation of both midwifery and obstretrics, tensions are evident between midwives and doctors over both the ‘control over the content and terms of their professional work’ and for being ‘self-directing’ (Freidson, 1970). These tensions have been described as gendered, discursive, occupational closure strategies, used by both midwives and doctors in the pursuit and maintenance of their professional projects (Larson, 1977; Witz, 1992). In an era of increasing medico-legal pressures and medicalisation (Johanson et al, 2002), childbirth arguably remains subject to the continued control and occupational jurisdiction between these two professional groups. If midwifery is to maintain professionalisation, midwives need to engage with post-registration postgraduate education and develop skills to reassess the midwifery knowledge base, reaffirm their evidence-based professional values, and lead positive and progressive research and change in practice.
The benefit of graduate education for the professional status of midwives, and the professionalisation of midwifery, has been debated in the past (Bower, 2002). It seems apparent; however, that the skills acquired through undergraduate and postgraduate education are required, more than ever, if the profession of midwifery is to challenge the risk-based, medical approach to care, maintain autonomous professional status and regain control over the content and terms of their professional work. Many UK higher education institutions are already promoting graduate entry pre-registration midwifery training at Master's level. Postgraduate studies will assist midwives and future leaders of the profession in developing the necessary change management, leadership and critical thinking skills to respond to contemporary challenges, define and police the professional role boundary of midwives, and preserve the future professionalisation of midwifery. In order to promote the professional recognition of midwifery, the profession of midwifery needs to reaffirm its unique and distinct knowledge base and champion the relationship midwives have with women in their care.
Conclusion
Midwifery has been firmly established as a graduate profession at the point of registration since 2009, and it would seem logical that all post-registration education and professional development should be delivered at Master's level or above. Promoting the professionalisation of midwifery through postgraduate education is not merely an issue of maintaining professional status or gaining academic credibility: it is essential for reclaiming midwifery education for midwives, and for midwives to take the lead in progressive, evidence-based care for women and their newborn infants.