Preceptorship is defined by the Nursing and Midwifery Council (NMC) as a time when a newly qualified registrant is supported and guided to make the transition from student to competent practitioner (NMC, 2006; Department of Health, 2010). New midwives will require support from their colleagues and line managers to complete the preceptorship programme (NMC, 2006).
Although preceptorship remains high on the healthcare agenda, the delivery of programmes remains the responsibility of the local Trust and is variable in terms of time provided and content (Mason and Davies, 2013). The NMC (2006) states that the minimum preceptorship period could be as short as 4 months, but this is arguably insufficient. The Department of Health (2010) does not state the amount of time required to complete a preceptorship programme and simply recommends that it is determined on an individual basis; however, this creates uncertainty and a disparity across the country as to what programmes of support are offered to newly qualified practitioners and how achievable and supportive they are.
In practice, a period of preceptorship will usually be established for a minimum of 18 months and a maximum of 2 years (full-time equivalent) (Feltham, 2014). While most hospital Trusts and organisations recommend that it should last for 18 months, in the north west of England, the leads for preceptorship in each organisation (often practice development midwives) have developed a 2-year long preceptorship programme to allow more time to complete, with the understanding that it may vary according to individual needs.
The transition from student to midwife is a stressful one (Park et al, 2011) and without the correct support and time allowed to achieve competence, newly qualified midwives are at risk of developing anxiety (Whitehead, 2001; Hughes and Fraser, 2011; Foster and Ashwin, 2014) and making mistakes, which may result in them experiencing a state of shock due to the transition from student to midwife (Reynolds et al, 2014). This lack of support contributes to the attrition of newly qualified midwives, with between 5 and 10% leaving the career within 1 year of graduation, according to the Royal College of Midwives (RCM) (2010). As a knock-on effect, this future generation of midwives is left feeling vulnerable, and may not acquire the competence and skills required to become confident practitioners by the end of the programme. In addition, preceptorship has arguably been de-prioritised, due to constraints on budgets, time and resources (Davies and Mason, 2009). Therefore, even in Trusts that seem to have a good package of support for their newly qualified staff, time constraints, staffing and lack of budget for training also affect the quality of the support staff receive (Reynolds et al, 2014).
The rationale for choosing the topic of midwifery preceptorship is to explore if newly qualified midwives are being supported throughout this transitional period. This support is important to their development into a competent and confident practitioner: if a newly qualified midwife is not given the correct support throughout the preceptorship period, this could affect patient safety and the midwife's future career (Feltham, 2014; Foster and Ashwin, 2014).
Methodology
A review of the literature was undertaken using both generic and midwifery-related databases. A search for grey literature was also undertaken with a view to making the analysis of data more robust and reliable. Boolean terms were used to search for the appropriate literature, these included: ‘preceptorship’, ‘band 5 midwives’, ‘newly qualified midwives’, ‘support’, ‘clinical competence’, ‘professional competence’ and ‘confidence’. The inclusion and exclusion criteria for this literature review are illustrated in Table 1.
| Inclusion criteria | Exclusion criteria |
|---|---|
| English language | Nursing preceptorship |
| Sample groups from the UK | Pre-registration education |
| Between the years of 2006–2016 | Fitness-to-practise |
| Full text available | Anecdotal research |
| Newly qualified midwives | Clinical supervision |
| Preceptorship | Posters |
| UK-focused research | Published in 2005 or earlier |
Review of the literature
The Department of Health (2010) recommends a preceptorship package that focuses on reflection and self-directed learning but does not require the new member of staff to be assessed again, as midwives are deemed competent and confident at the point of registration (NMC, 2007). However, the NMC (2009) says that the competence to care for high-risk complex cases comes after initial registration and it is therefore likely that although they are accountable practitioners at this point, newly qualified midwives may not be fully conversant with the wide range of skills required to do their job effectively (Department of Health, 2008). Furthermore, although midwives' knowledge and competence have been assessed at undergraduate level, the transition into a qualified professional requires a new level of competence and confidence that potentially needs to be re-assessed during their preceptorship programme. Skills such as decision-making and leadership are not often acquired at undergraduate level and are imperative to midwifery practice (Avis et al, 2013). A structured preceptorship programme assessing communication, professional values, decision-making skills, leadership and teamwork would help newly qualified midwives to be successful, confident and competent practitioners (NMC, 2014).
Themes
Thematic analysis was used to retrieve the themes and subthemes from the six pieces of literature (Hughes and Fraser, 2011; Morgan et al, 2012; Mason and Davies, 2013; Bannister, 2014; Foster and Ashwin, 2014; Power and Ewing, 2016) used for the purpose of this literature review. The themes are identified in Table 2.
| Theme | n |
|---|---|
| Main theme | |
| Presence of a preceptorship lead and support | 5 |
| Time to complete programme and paperwork | 5 |
| Subthemes | |
| Supernumerary time | 2 |
| Ability of preceptor | 3 |
| Reflection and feedback | 2 |
| Other comments | |
| Simulation and teaching | 1 |
| Planned placements | 1 |
| Bullying | 1 |
Main themes
Programme coordinator and support
The importance of having a lead for preceptorship at a senior level was highlighted as a main theme during the thematic analysis. In five of the six of pieces of literature (Hughes and Fraser, 2011; Morgan et al, 2012; Mason and Davies, 2013; Foster and Ashwin, 2014; Power and Ewing, 2016), newly qualified midwives felt that support via a preceptorship lead or coordinator was important in ensuring that the programme ran smoothly and that they were able to achieve their learning outcomes and competencies appropriately throughout.
The Department of Health (2010) and the NMC (2006) fail to provide any guidance on a preceptorship lead to coordinate the programme, despite its importance. In most studies in this literature review, the responsibility of coordinating the preceptorship programme lay with the practice development midwife (Hughes and Fraser, 2011; Mason and Davies, 2013; Power, 2016). Although this appears to be of benefit, more research is needed to be able to understand the role of practice development midwife across the country (Hughes and Fraser, 2011; Mason and Davies, 2013).
This therefore raises the question as to who should lead the preceptorship programme, and with no guidance from the regulatory bodies like the NMC or Department of Health, the responsibility lies with the employer, adding to existing disparities in the UK. As the literature supports the idea that a lead for the programme is paramount in supporting newly qualified staff to complete it successfully, more time and resources need to be allocated to ensuring that this is achieved in each individual provider organisation.
Now that statutory supervision in midwifery has been abolished (Department of Health and Social Care, 2016), it is more important than ever to support junior staff to become competent and confident practitioners, or risk them leaving the profession (Foster and Ashwin, 2014) or becoming the subject of a fitness-to-practise concern (Smith, 2011; Avis et al, 2013). By having a structured preceptorship programme with a lead or coordinator, staff are less likely to become anxious or depressed, or to make mistakes (Fenwick et al, 2012). However, without guidance or statutory regulation from regulatory bodies such as the NMC and Department of Health, employers will continue to avoid investing focus, time and resources into preceptorship and will therefore provide insufficient support to newly qualified midwives, putting them in an increasingly vulnerable position to be able to succeed.
With a lack of time and resources, online learning could be the way forward to enable junior staff to gain knowledge and use their decision-making skills via set programmes of study. The ‘Flying Start’ programme (Banks et al, 2011), implemented in Scotland, comprised an online web-based learning programme for newly qualified staff and aimed to increase their confidence and competence. It focused on key competencies that often newly qualified staff lack, such as decision-making skills and communication within the multidisciplinary team. The outcome of ‘Flying Start’ package highlighted that staff experienced increased confidence after completion (Banks et al, 2011).
Online learning is becoming more popular as new generations of NHS workers (referred to as ‘digital natives’ (Health Education England, 2015)) are often more familiar with IT services. However, online learning also has its challenges with regards to individual IT skills and taking responsibility for one's own learning. With an ageing workforce in the NHS, some nurses and midwives may find IT skills a difficult daily task. However, the lack of time and staffing in workplaces may mean that online learning may be the way forward to ensure that newly qualified professionals feel supported and able to access continued professional development and learning resources. The role of the preceptorship lead or coordinator would be to support junior staff in its completion and regularly meet with staff to discuss and assess progress.
Time
The of lack of protected time to spend with the preceptorship lead and/or preceptor or to complete paperwork was highlighted in five out of six of the pieces of literature (Hughes and Fraser, 2011; Mason and Davies, 2013; Bannister, 2014; Foster and Ashwin, 2014; Power and Ewing, 2016), and emerged as a main theme during analysis. This was also described as ‘organisational constraints’, which included low staffing levels, lack of break times and tired staff (Mason and Davies, 2013). The literature suggests that, due to the increasing amount of pressure being placed on maternity services—including rising birth rates, increasing complex needs and financial constraints—the time for preceptorship support and coordination is limited (Hughes and Fraser, 2011). This lack of time, coupled with the added pressures of becoming a newly registered professional may cause much anxiety and uncertainty among new staff (Foster and Ashwin, 2014).
Additional organisational constraints such as excessive workload and low staff morale (Mason and Davies, 2013) also added to the pressure that newly qualified midwives faced on a daily basis. A lack of time to complete the preceptorship package effectively (Hughes and Fraser, 2011) therefore had a damaging impact on the confidence and competence of newly qualified staff. These organisational constraints could also make it near impossible to ensure that adequate support is in place for newly qualified midwives (Hughes and Fraser, 2011).
Subthemes
Supernumerary time
The time allocated for a supernumerary period was highlighted as an issue among newly qualified midwives and managers. The midwives felt that this time allowed them to settle into their new role and become familiar with their new environment without the increased pressure of being expected to take on the same workload as other more experienced colleagues (Foster and Ashwin, 2014; Hughes and Fraser, 2011). The supernumerary period is therefore an important aspect of the preceptorship period and unfortunately (again due to organisational constraints), the length of time allocated to new staff for a supernumerary period varies greatly between employers and even between wards, depending on staffing numbers, sickness and unit workload (Hughes and Fraser, 2011). The NMC (2006) and Department of Health (2010) do not specify a recommended length of time to be classed as supernumerary, leaving the responsibility with the employer.
The guidance that most Trusts in the region employ as an appropriate period of supernumerary time is approximately 75 hours in each area (Foster and Ashwin, 2014), which equates to six 12-hour shifts, possibly including mandatory training and Trust induction days. Despite being allocated as supernumerary on the rota, staff shortages may mean that a midwife has to become part of the team and is expected to take on an increased workload (Bannister, 2014). Newly qualified staff should stay where they are allocated during the supernumerary period however, it was also reported that staff are sometimes pulled to work on other wards or in other areas during busy periods or to cover sickness (Mason and Davies, 2013). This results in new staff becoming increasingly vulnerable and unsupported, with the potential to make mistakes. Midwives may also feel unable to ask for help (Fenwick et al, 2012), especially during busy periods, for fear of irritating other more senior colleagues. A lead for preceptorship would therefore be beneficial to ensure that time is allocated appropriately for training.
Due to the lack of recommendations from regulatory bodies, the disparity between employers is likely to remain an ongoing problem until set guidance is implemented. More research is needed to identify the extent to which the supernumerary period differs between employers of midwives in the UK in order for the NMC and Department of Health to take note of the issue and establish some clear guidance as to what is reasonable.
The articles used for this literature review failed to discuss or mention the financial impact that supernumerary staff have on the organisation. This could potentially be one of the reasons why supernumerary status is often shortened or discontinued earlier than expected (Mason and Davies, 2013).
Ability of preceptor
The Department of Health (2010) has a detailed definition of what is required of a preceptor, including attributes such as:
It is clear to see that expectations of the role are very high. Due to the ageing midwifery workforce (Merrifield, 2017) and early retirement of senior staff, a widening gap between junior and senior staff has been created. The staff that usually fill this gap are ideal preceptors due to their experience and expertise, but loss of senior midwives means that newly qualified midwives are being partnered with other inexperienced midwives.
The demands of becoming a preceptor for newly qualified staff should not be undermined or misconstrued. As it is important to have the eligible skills and knowledge to be a named preceptor, it could be argued that preceptors need training to fulfil the role effectively (Foster and Ashwin, 2014). Mason and Davies (2013) found that, during their focus groups with newly qualified midwives, some staff lacked confidence in their preceptor. Participants reported that if they had a preceptor who was not confident, this affected their own self-confidence as practitioners (Foster and Ashwin, 2013). This could have been due to organisational constraints, resulting in junior staff being allocated to other junior staff as preceptors. The overall aim of the programme is to support the newly qualified practitioner's growth and development and therefore a senior midwife with such attributes would make an ideal preceptor. Department of Health (2010) guidance suggests that a preceptor should be considerably more experienced than the newly qualified midwife and be considered a role model within the profession. Midwives who take early retirement and return to the profession part time would be ideal to support newly qualified staff as preceptors. In addition, a training package could be developed between employers and higher education institutions to ensure that competence is achieved among preceptors, who are given the demanding task of nurturing, teaching, assessing and supporting newly qualified staff. The package would ideally include guidance on giving constructive feedback and challenging behaviours, simple teaching techniques, leadership and communication.
Reflection and feedback
The literature (Mason and Davies, 2013; Bannister, 2014) identified reflection and feedback as important to the preceptorship programme. Nurses and midwives undertake reflection every day, sometimes unknowingly. The Department of Health (2010) states that reflective practice is an important component of a preceptorship programme, and allows the midwife to effectively self-assess and discuss with the preceptorship lead or preceptor. Even though an experience may have been mostly positive, it is natural to focus on any negatives identified during the process (Velo and Smedley, 2014) and therefore constructive feedback to newly qualified staff is important to re-enforce the positive aspects of the situation and advise on how to enhance practice. Discussion time is again affected by organisational constraints but a focus on allocated time with preceptors could improve the learning experience.
Implications for future practice and research
This literature review has discussed the need for more primary research into the role of the practice development midwife, who is often responsible for coordinating preceptorship programmes. In order to address some of the highlighted themes, research into the role of the practice development midwife will be needed. This will allow policymakers and preceptors to understand the role in more detail and to lead organisational and cultural change, embedding new practices and advocating to protect and support junior midwives effectively.
Higher education institutions play an important role in ensuring that newly qualified staff are competent and confident at the point of registration. By embedding these elements in the undergraduate curriculum, the transition from student to midwife will be smoother and more effective. This could be done by encouraging teamwork within the interprofessional team, working on communication and decision-making skills, and managing obstetric emergencies through simulation. Higher education institutions could also offer a module/training programme for continued professional development, with the support of the local Trusts, that focuses on these key skills and supports the preceptorship package that maternity providers offer. With the additional support from universities, junior staff would have more support and opportunity to develop and enhance their skills during the first 12 months of qualification.
Conclusion
This literature review has highlighted the lack of primary research around the competence and confidence of newly qualified midwives during their preceptorship period. It has discussed some key areas that can be developed for the future, such as training programmes for preceptors and the need to conduct further primary research. Two main themes (lead for preceptorship and time) and three subthemes (ability of preceptor, supernumerary time and reflection and feedback) were derived by thematic analysis. Theses themes are not surprising as most health professionals are aware of the increasing pressures in UK hospitals. However, some of them can be lessened or improved by better service management and a robust preceptorship programme coordinated by a named lead for preceptorship.
Time to complete the preceptorship period should be a priority to ensure the retention, support and nurturing of newly qualified staff. To achieve this, more time and money needs to be dedicated to research and to more support and training for staff. The Department of Health and NMC need to provide more guidance on what is required of a preceptorship package, including the preceptorship lead. Preceptorship needs to be made mandatory in all maternity providers and consistency around the UK is crucial to ensure that all newly qualified staff receive the support they require to succeed, and can move between employers, transferring their preceptorship package with them.