The public enquiry into the failings of the Mid Staffordshire NHS Foundation Trust (Francis, 2013) found that poor leadership, and a focus on targets rather than people, led to health professionals failing to provide patients with safe, high quality and compassionate care. Since then, NHS England has attempted to improve the culture of care by promoting values of respect, dignity, quality of care, compassion, working together for patients, valuing every patient and improving lives (NHS, 2012).
In 2014, Higher Education England, who have the responsibility for supporting the recruitment of the future healthcare workforce, published a values-based strategy (Higher Education England, 2016). The aim of the strategy was to recruit pre-registration students with the values and behaviours that are consistent with those of the NHS. The Royal College of Midwives (RCM) identified professional values based on the delivery of ‘safe, effective, woman-centred, timely and equitable’ evidence- and community-based care (RCM, 2014). The increased awareness of the importance of values-based education has led to providers of midwifery to develop value-based curricula, although there is a paucity of literature that describes the development of a value-based midwifery programme.
The aim of this article is to describe how a values-based midwifery curriculum was conceptualised in one English university and made central to the learning and teaching strategy for a new curriculum.
Background
Midwifery curricula focuses on the acquisition of knowledge, skills, values and experiences are consistent with quality standards laid down by professional bodies and higher education institutions (Nursing and Midwifery Council (NMC), 2009; Quality Assurance Agency for Higher Education, 2015). The Division of Midwifery at the University of Nottingham has a strong history of providing pre-registration education. The team is committed to maximising students' potential to develop the necessary knowledge, skills and values to practise as a midwife. Nevertheless, given the paucity of literature, it was unclear, when development of the new curriculum began, what constituted a values-based education. Values-based education in its broadest terms is defined as helping individuals learn about morals or virtues (Powney et al, 1995).
The purpose of teaching school children about morals or values is said to be to inculcate societal and religious rules or to increase an individual's awareness of what constitutes good character (Leicester et al, 2000). It could be argued that the purpose of teaching in midwifery education is also to inculcate certain rules, as the NMC, which regulates midwifery education, sets out professional codes of behaviour that includes a declaration of good character (NMC, 2009; 2015).
In higher education, the term ‘values-based learning’ is used to emphasise aesthetic values-based knowing; that is, the art rather than the science of caring. The midwife's role is to promote normality and women's feelings of confidence so they can give birth successfully (International Confederation of Midwives, 2014).
The ‘art’ of midwifery is defined as the ability to help ‘women work in harmony with their bodies and open themselves to give birth’ (Kitzinger, 2005:4). The art of midwifery determines the knowledge and skills to be developed in a midwifery model of care (Thomas, 2002). The increase in the numbers of hospital births in recent decades has led to labour wards being ‘steeped in a busyness culture’ (Walsh, 2006:1331). Walsh describes how the culture is ‘fed’ by a processing mentality, similar to what is observed in a factory assembly line. In maternity units, midwives often find that the the needs of the institution is the key priority (Deery and Kirkham, 2006), in contrast to focusing on the needs of women (Kirkham, 1999).
In 1978, Barbara Carper put forward her categorisation of the types of knowledge used by nurses to support professionally-held beliefs and the delivery of care in clinical practice. Carper (1978) also wished to improve the education of nurses and support reflective practice. The typology consists of four fundamental ways of knowing, namely:
In Carper's framework, values are founded on practical action triggered by a nurse's increased awareness of the holistic needs (physical and emotional) of the individual patient (McAllister, 2015). McAllister (2015) argues that if the rise of evidence-based, outcome-driven nursing care is to be challenged, aesthetic (values-based) ways of knowing is key. In midwifery, aesthetic ways of knowing is premised on the creation of meaningful relationships and the use of knowledge and skills that recognise individuality and support humanity (Mander, 2001; Kitzinger, 2005). It was therefore deemed important to develop a midwifery curriculum model that recognised both the aesthetic values of care and compassion, and the values of midwifery educators.
Curriculum model development
The development of the new midwifery curriculum was developed over a 2-year period of iterative discussion with the midwifery academic team and wide consultation with our stakeholders. The process included the following stages:
Midwifery educators' vision and values
A series of staff development sessions, based on appreciative enquiry, took place over a 3-month period. Appreciative inquiry attempts to use ways of asking questions and visualising the future. The aim of the inquiry is to cultivate positive relationships to build on the potential possibilities from an individual, a situational and an organisational perspective (Bushe, 2011). The method requires participants to focus on their role from the perspectives of discovery, dreaming, designing and deploying perspectives (Barrett and Fry, 2005). The sessions with the midwifery team were led by an associate nursing professor, who has an interest in appreciative inquiry. The outcome was a statement of the Division's shared vision and values-based on our existing strengths and what future possibilities were envisioned (Box 1). This shared vision provided a firm foundation on which to develop a values-based midwifery curriculum model.
Stakeholder engagement to consider midwifery ‘ways of knowing’
A number of senior NHS midwifery managers, mentors, supervisors of midwives, midwifery educators and researchers also engaged in a series of consultation events to inform the development of the values-based curriculum model. Participants were asked to take part in an activity based on the pillars of learning framework (UNESCO, 2017).
This activity aimed to identify their core educational midwifery values. The four pillars of learning are recognised as the fundamental principles for reshaping education, namely:
Within the model, the overarching pillar of learning is ‘to know,’ as this provides ‘the cognitive tools required to better comprehend the world and its complexities, and to provide an appropriate and adequate foundation for future learning’ (UNESCO, 2017). Participants were given 30 cards containing topics and themes from the midwifery curriculum and some additional blank cards to add their own ideas. The groups were asked to choose the areas that they felt were most important for learning how to become a qualified midwife, which were then placed under the four pillars of learning. The next stage was for each group to agree on a primary value for each pillar. The lead author noted the final responses and the most frequent values were included in the final ‘ways of knowing’ framework (Figure 1). It became clear that the supporting pillars of midwifery education values developed in our Division were consistent with the Department of Health's Compassion in Practice (Commissioning Board Chief Nursing Officer and Department of Health Chief Nursing Adviser, 2012). The final framework was sent to participants for validation before being used to guide the development of the new pre-registration midwifery curriculum.
The curriculum model
During the workshops, it became clear that student learning was viewed as developmental and central to the values identified by the stakeholders. A spiral curriculum (Figure 2), which revisits material and concepts at different levels and depths, was chosen because it supports a developmental constructivist process that allows learning to take place over a long period and to be repeatedly revisited (Bruner, 1960). An essential aspect of the model is the use of distinct key areas of study to organise the content and assessment of learning. Through consultation with student midwives, midwifery mentors and service users, key areas of study were also identified from policy documents and discussion of social, environmental and public health issues pertinent to midwifery (NMC, 2009; Commissioning Board Chief Nursing Officer and Department of Health Chief Nursing Adviser, 2012; Francis, 2013; RCM, 2014). Another important consideration was how the curriculum could provide ‘globally excellent and internationally relevant teaching’ (University of Nottingham, 2015: 26). For this reason, globalisation was chosen as the seventh strand, to ensure that world views, concepts of midwifery knowledge and practice and other aspects of culture were addressed within the pre-registration curriculum. It was also important to design learning and teaching strategies to support the values-based curriculum model.
The learning and teaching strategy
In the changing context of global healthcare, the role of the registered midwife needs to be dynamic. A midwife needs to be able to think critically, reflecting on (and in) practice to integrate relevant evidence from a range of sources (Nicholls and Webb, 2016). Midwives are also expected to adopt a compassionate and caring approach to professional practice with commitment to working within a multi-dimensional healthcare setting. The curriculum model therefore provides a structure that supports students to acquire, demonstrate and apply midwifery knowledge and skills in a supportive learning and teaching environment. Furthermore, the curriculum promotes the development of professional values, emotional intelligence and the skills needed to engage in life-long learning, as well as supporting evidence-based practice.
Midwifery undergraduate students need to be equipped with higher level, critical appraising skills to be effective practitioners (Nicholls and Webb, 2006). A high proportion of midwifery students are from the so-called ‘Generation Z’, born in 1995 or later. Homan (2015) describes Generation Z as digital natives and self-directed learners, who proficiently use up-to-date technologies, and it is therefore vital that midwifery educationalists acknowledge these characteristics when designing curricula. The use of a spiral curriculum and the adoption of a blended learning philosophy, which combines online digital activites as well as classroom methods, ensures that individual learning needs can be accommodated. The use of virtual teaching platforms and an ePractice portfolio enables a range of appropriate and clinically based activities. Flipped learning has only more recently been used in higher education and the literature seems to suggest that it has not been used in midwifery education. It is proposed that flipped learning offers a model that better suits the philosophy of the adult learner (Williams, 2016).
Flipped learning can be defined as:
‘A pedagogical approach in which direct instruction moves from the group learning space to the individual learning space, and the resulting group space is transformed into a dynamic, interactive learning environment where the educator guides students as they apply concepts and engage creatively in the subject matter.’
The flipped learning approach to module delivery was chosen to increase the content delivered outside of the classroom and to enhance the learning within. A curriculum model, entitled FLAME (Flipped Learning and Midwifery Education), was developed, based on a modified version of Bloom's Taxonomy (Anderson et al, 2000) (Figure 3). The model is depicted as an inverted pyramid to represent the increase in knowledge of a student midwife as they progresses through the curriculum. The change in colour through the model is analogous to the increase in ‘thirst’ and depth of knowledge that is fostered in the student changing from an ‘ember’ to a ‘flame’. In the FLAME model, students are advised what is to be studied in advance of any session, in order to be prepared to participate in a range of facilitated lecturer-and student-led activities. The approach is different from blended learning in that it is important for students to study the topic in advance of any face-to-face sessions so they are adequately prepared for the next phase of learning (Williams, 2016).
Midwifery lecturers worked closely with learning technologists and academics to design and put in place the learning and teaching strategy. This FLAME model was based on the premise that if students come prepared for face-to-face sessions, the time spent with midwifery academics can be used to better effect, to promote the development of the higher-level education skills required by midwifery students. If students can come to the theoretical sessions, having already gained some understanding and foundation in the subject or topic area, time is released to focus on discussion, critical appraisal and synthesis, rather than simply checking understanding (Williams, 2016). The flipped learning model has been embedded into our new midwifery curriculum, with the aim of enhancing both students' learning experience and their theoretical knowledge and application to midwifery practice. The Division of Midwifery's commitment to the FLAME model also reflects the values-based curriculum.
Conclusion
It is believed that this curriculum model supports the delivery of transformative, values-based educational experience in the midwifery undergraduate programme. It is proposed that it will equip midwifery students with the knowledge and skills necessary to deliver compassionate, high-quality midwifery care in a globalised healthcare arena. The model illustrates a pragmatic approach to designing and developing values-based learning opportunities in midwifery undergraduate programmes. The Division recognises that students as partners in learning, and evaluation of the curriculum in ongoing. As a result, there are a number of ongoing activities focusing on engaging students in module development to ensure that their ‘voice’ is truly heard within the values-based curriculum.