Seminal work (Kramer, 1974) indicated that newly qualified practitioners experience a reality shock on initiation of first post, which is supported by subsequent literature (Maben and Macleod-Clark, 1996; Godinez et al, 1999; Gerrish, 2000; Montgomery et al, 2004; van der Putten, 2008; Kitson-Reynolds 2010; Kitson-Reynolds et al, 2014). Newly qualified midwives (NQM) are expected to be competent novice practitioners who, over the course of a defined preceptorship period, acquire more specialised clinical skills and confidence in practice (Nursing and Midwifery Council [NMC] 2009; Department of Health [DH], 2010). This period of preceptorship is intended to ease the transition from student to midwife, although programmes remain unstandardised and evidence suggests that the level of supernumerary status and exposure to clinical rotations vary between NHS Trusts (Clements et al, 2012; Avis et al, 2013; Mason and Davies, 2013; Bannister, 2014; Foster and Ashwin, 2014; Wain, 2017). Original phenomenological research, upon which this series is based (Kitson-Reynolds, 2010; Kitson-Reynolds et al, 2014), suggested incongruence between new registrants' expectations of practice (their self-imposed ‘fairy tale’ that was perpetuated by peers, lecturers and midwives alike) and the reality of midwifery
Fairy tale midwifery incorporates the idealistic, almost ‘dreamy’, perception (pre-registration) of what the role of a midwife entails and considers this from the participants' experiences of the reality ie fact or fiction (Kitson-Reynolds, 2010). A consensus from the participants indicated that much of what they believed ‘being a midwife’ was like was not accurately reflected in reality, and for some, the reality was somewhat opposing. As students, some perceived that the reality (once qualified) would be utopic, despite experiencing clinical practice realities as a student midwife for three years.
It has been postulated that the midwife-mentor facilitates the birth of a midwife (Morton-Cooper and Palmer, 2000), with the role encompassing responsibilities far greater than teaching and refining clinical skills. Mandeno (2011) described a birth at which she worked alongside a student midwife. She watched the woman's labour song change and situated herself as a teacher of midwifery but was disappointed that the student's focus on task-based activities and clinical skill acquisition left her disorientated and unable to connect with the labouring woman (Mandeno, 2011). The author described how she had failed to identify that the student was falling and recognised her need to facilitate student learning not according to her own definition, but rather by repositioning the student to find merit in experiences beyond ticking off clinical skills (Mandeno, 2011). This highlights the multifaceted role of a mentor as an educator and a motivator, which is underpinned by standards for mentorship (NMC, 2008), and is now superseded by the standards for student supervision and assessment (SSSA) (NMC, 2018).
An area that has not been explored extensively in recent literature is the role of the midwife-mentor in preparing students for initiation of first post as NQM (Ashforth and Kitson-Reynolds, 2019). Exploring the role of the mentor in the transition process may identify ways in which reality shock (Kramer, 1974) may be mitigated against. As such, this literature review aims to consider the role of mentors and preceptors in facilitating the transition from student to NQM. This has never been so pertinent as it is now in terms of the new SSSA (NMC, 2018). The intention of reviewing how learners have, are and will be supported in practice is conducive to the future and retention of the midwifery workforce, as hypothesised by the Royal College of Midwives ([RCM], 2018). It is anticipated that the SSSA will support the transition from learner to NQM much earlier during education, however the SSSA is yet to be fully implemented. Therefore, for the purpose of this literature review the term ‘mentor’ will be used throughout.
‘The intention of reviewing how learners have, are and will be supported in practice is conducive to the future and retention of the midwifery workforce’
Literature searches were conducted to identify primary research pertaining to NQMs' experiences of practice, as discussed in article one, the findings of which are summarised in this piece (Ashforth and Kitson-Reynolds, 2019a), and to identify primary research focusing on student midwives' experiences of mentorship.
Literature review
Five key themes emerged from the chosen literature and are presented below:
The student-mentor relationship
Positive relationships between the student and the mentor increase student confidence and competence (Hughes and Fraser, 2011; Brunstad and Hjälmhult, 2014; Thunes and Sekse, 2015). Being welcomed to the placement environment, mentors who were expecting and prepared for students, and those who clarified student expectations and learning objectives contributed to a sense of wellbeing, motivation and belonging (Hughes and Fraser, 2011; Thunes and Sekse, 2015). A recurring theme in Armstrong's research (2010) was that of battling the hierarchy: students felt powerless to challenge practice, stating they would be more likely to do so once qualified due to greater autonomy. However, whilst this may be the perception of the learner, the reality – as highlighted by Kitson-Reynolds (2010) – was that to ‘fit in’ to existing teams, it is easier to follow the ingrained culture than to challenge aspects of practice. With the re-energised 6Cs (Cummings and Bennett, 2012; Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser, 2012) learners are encouraged to be courageous to make the challenge and hence this may no longer be such an issue in 2019. This is an area worthy of investigation.
Role modelling
All participants (n=125) in Armstrong's study (2010) stated that evidence-based practice (EBP) was taught at university, but 92% (n=115) noted discrepancies between what they were taught in the classroom and what they observed in practice. A total of 49% (n=60) said they did not practise in the same way as their mentor and 54% said they would challenge their mentor's non-EBP. Conversely, 49% (n=60) reported that they would practise according to the status quo as it was easier, and 37% (n=46) felt they would do so to fit in. This has equivalence with the findings from Kitson-Reynolds (2010; 2014).
Hughes and Fraser (2011) found that students believed that midwives modelling EBP were positive role models. Those who were seen to engage in reflective practice and who encouraged students to do the same, were also considered positive role models (Hughes and Fraser, 2011). Practice placements provided a level of connectedness to midwifery that students did not enjoy at university, and mentors modelled verbal and non-verbal communication skills (Finnerty and Collington, 2013). Students expressed frustration, however, that they were unable to emulate the degree of fluency modelled by their mentor (Finnerty and Collington, 2013).
Mentors in hospital settings were more likely to leave students to lead care episodes, under the pretext of providing positive learning experiences, although this meant students missed role-modelling opportunities (Chenery-Morris, 2015). Within the new SSSA (NMC, 2018), some NHS Trusts are implementing the collaborative learning in practice (CLiP) model (NHS Employers, 2018) whereby senior and junior students work in tandem, learning from each other whilst being overseen by a practice supervisor. It will be interesting to observe how this perception changes once the new ways of learning are embedded and normalised into everyday practice.
Fading and role reversal
Mentors are said to have either controlling hands or guiding hands (Hughes and Fraser, 2011); the latter being preferred as they allow students to carry out tasks themselves, while the former did not. Students wanted to be both pushed beyond their perceived comfort zone and capabilities, and supervised by mentors (Hughes and Fraser, 2011). Fading involves removing the supportive scaffolding and enabling students to progress to more active participation in care episodes (Finnerty and Collington, 2013). Without this fading and role reversal, students risk having their confidence and competence undermined (Finnerty and Collington, 2013). Students described their dependence on mentors to teach, show and help them (Thunes and Sekse, 2015), and a lack of continuity of mentors meant limited learning opportunities, as midwives were less likely to allow students to participate fully in care due to a perceived lack of familiarity with student capabilities (Brunstad and Hjälmhult, 2014).
Continuity versus variety of mentors
Continuity of mentor was considered essential to the success of the student, and increased students' sense of belonging and connectedness to practice (Brunstad and Hjälmhult, 2014; Chenery-Morris, 2015). Continuity enabled a trusting and nurturing student-mentor relationship to develop, and meant mentors were more likely to identify individual learning needs (Finnerty and Collington, 2013; Chenery-Morris, 2015). Students felt more secure with continuity of mentor and thus were more likely to engage fully with care (Brunstad and Hjälmhult, 2014).
Furthermore, continuity was thought to increase the student's trust in the mentor to grade their practice fairly, with continuity facilitating the dual role of mentor and assessor (Chenery-Morris, 2015). This could be an issue for the SSSA (NMC, 2018) moving forward as the learner will not be with one midwife-mentor as with the outgoing sign off mentor status (NMC, 2008), but could be working in a larger team of inter-professional members.
Conversely, working with a variety of mentors enabled students to consider different practices and to formulate their own ideas about the type of midwife they aspired to be (Hughes and Fraser, 2011; Brunstad and Hjälmhult, 2014; Chenery-Morris, 2015). Continuity of mentor was considered particularly important for first-year students, while being exposed to different mentors was deemed more important for senior students (Hughes and Fraser, 2011). Students were more likely to experience continuity of mentor in community rather than hospital settings (Chenery-Morris, 2015), although it was not identified whether continuity meant working with one mentor over one placement or working with one mentor across successive placements.
‘Furthermore, continuity was thought to increase the student's trust in the mentor to grade their practice fairly’
NQM-preceptor relationship
Preceptorship is a challenging transition phase from student to newly qualified practitioner in which good support is essential to increase practitioner confidence, competence and job satisfaction by easing the transition from student midwife to midwife (DH, 2010). A preceptor midwife is responsible for overseeing the progression and development of a NQM, including but not limited to acting as a role model, and sharing knowledge and experience (DH, 2010).
The literature search in the first article (Ashforth and Kitson-Reynolds, 2019a) identified that the NQM-preceptor relationship is important in developing NQM confidence and progression, and enabling the NQM to feel supported (Avis et al 2013; Foster and Ashwin, 2014). While it was considered beneficial to reflect and debrief with peers (Clements et al, 2012; Mason and Davies, 2013; Barry et al, 2014), the relationship between the NQM and preceptor, and a shared philosophy of care, were also important (Barry et al, 2014; Kensington et al, 2016).
Some NQMs were able to work supernumerary shifts with their preceptor (Mason and Davies, 2013), although others were not and believed they would have benefited from a greater preceptor presence to supervise such clinical skills as suturing (Wain, 2017). The broader circle of midwives working clinically were felt to have a positive impact on the NQMs' confidence levels when they were supportive, friendly and encouraging (Fenwick et al, 2012; Clements et al, 2012; Wain, 2017), although support was found to depend on service demands and staffing levels (Avis et al, 2013). A collective sense of responsibility was felt by midwives towards NQMs (Kensington et al, 2016).
Crucial roles inhabited by preceptors included that of setting goals, debriefing and reflecting, and preceptors were evaluated positively when they were supportive and approachable, whilst still enabling NQMs to practise autonomously (Hughes and Fraser, 2011; Kensington et al, 2016). Preceptors were believed to quell NQM enthusiasm if they sought to challenge the status quo (Hobbs, 2012). This calls into question the delineation of roles between the NQM and preceptor, and the level of dependence and independence experienced. NQMs are autonomous practitioners who nevertheless rely on more experienced midwives to facilitate the acquisition of more advanced clinical skills, such as cannulation and perineal suturing, which are required for career progression.
Discussion
The transition process begins at the inception of pre-registration training, with student midwives progressing from non-midwife to midwife, developing confidence and competence throughout the course. Fading was thought to provide students with the opportunity to engage more fully in care episodes, moving students from peripheral to central participation, which prepares students for autonomous practice as NQMs (Finnerty and Collington, 2013). Literature suggests that pre-registration training does not adequately prepare students for the realities of this first post, which causes reality shock and disappointment as their expectations of fairy tale midwifery are not met (Kramer, 1974; Kitson-Reynolds 2010, 2014).
University teaching was considered unrealistic, which served to heighten the theory-practice gap (Armstrong, 2010), although it could be postulated that academic teaching aims to instil gold standard midwifery care, while practice placements should aim to marry the gold standard care with the realities of practice. If NQMs' experiences are falling short of their fairy tale midwifery, it is perhaps necessary to consider the reality that students are presented with during their training. It could be that the SSSA (NMC, 2018) will address some of these aspects with a re-invigorated focus on developing the learner for first post in a more realistic way and from an earlier point in the pre-registration education programme.
The literature identified does not explore the role of the mentor in preparing students for the realities of practice as a qualified midwife, although this is reflected upon by the lead author in Vignette 1 (below) and in Kitson-Reynolds and Trenerry (2019). Mentors were considered important in integrating students into clinical areas, increasing student confidence and competence, exposing students to learning opportunities, encouraging reflection, and acting as role models for students (Hughes and Fraser, 2011; Finnerty and Collington, 2013; Brunstad and Hjälmhult, 2014; Chenery-Morris, 2015; Thunes and Sekse, 2015). Preceptors were also considered important as role models and in developing NQM confidence (Fenwick et al, 2012; Avis et al, 2013; Mason and Davies, 2013; Kensington et al, 2016).
‘The literature identified does not explore the role of the mentor in preparing students for the realities of practice as a qualified midwife’
The NQM-preceptor relationship may be considered an extension of the student-mentor one, but there is a distance as the NQM is an autonomous practitioner and must practise as such. The student-mentor relationship should be a positive one that facilitates transition from non-midwife to midwife and, as midwifery care is becoming increasingly complex, it may be appropriate to introduce a model of midwifery education more closely akin to an apprenticeship model that prepares NQMs for the real world of midwifery practice. This may mitigate against Kramer's reality shock (1974) and Kitson-Reynolds’ ‘fairy tale’ midwifery (2014).
Continuity from student-mentor to NQM-preceptor was not explored, and while NQMs are expected to be competent in providing low-risk care at the point of commencing their first post, the preceptorship period is aimed at developing competence in more advanced clinical skills and confidence in practice (DH, 2010). Continuity of mentor is important in identifying individualised learning needs (Finnerty and Collington, 2013; Chenery-Morris, 2015), so it could be considered that the transition to NQM could be further facilitated by the continuation of a positive and nurturing relationship from student-mentor to NQM-preceptor.
The student-mentor relationship undergoes transition from its inception: as students gain and refine their skills, fading enables role reversal and greater participation in care episodes. Mentors that inhibit student participation in decision-making and care planning risk undermining student confidence, which may negatively impact their ability to practise autonomously upon qualification. While it is important that students learn from role modelling, clinical reasoning and decision-making need to be developed within a safe and supportive environment that promotes independent thinking and criticality. This is supported locally by the autonomous practice module that incorporates student case loading and decision-making (Kitson-Reynolds et al 2015; Ashforth and Kitson-Reynolds, 2018; 2019). Research into this area, with the introduction of the SSSA (NMC, 2018), changes with the practice supervisors/assessors and the CLiP (NHS Employers, 2018) model is recommended once time has permitted implementation and normalisation of change.
Both mentors and preceptors were identified as playing a role in facilitating reflection on practice, and a shared philosophy of care was important between the NQM and preceptor, although this was not explored in the student-mentor relationship (Hughes and Fraser, 2011; Barry et al, 2014; Kensington et al, 2016). Mandeno (2011) described facilitating a birth with a student midwife whose focus on task-based activities prohibited her from engaging with the labouring woman. This may call into question the focus of midwifery education and clinical placements, and the juxtaposition of clinical skill acquisition and ticking off competencies, and learning the art of midwifery, which focuses on a woman-centred philosophy of care. Again, changes in terms of pre-registration midwifery education in 2020 will need to be reviewed against this aspect of care.
While one study identified that midwives felt a collective responsibility for NQMs (Kensington et al, 2016), this was not reiterated in studies focusing on the experiences of students, which described students feeling vulnerable and marginalised from learning opportunities when they were not working with their allocated mentors (Brunstad and Hjälmhult, 2014). This calls into question midwives' perceived responsibilities towards their peers, colleagues and students in terms of nurturing and teaching, and is perhaps increasingly pertinent considering the move from mentors to practice assessors and supervisors. This is about developing the future workforce and minimising attrition as highlighted by the RCM (2018).
Conclusion
The role of mentors and preceptors is multifaceted and incorporates support, teaching, role modelling, signposting opportunities, and guidance. Mentors must encourage reflective practice, criticality and decision making, which are important in the transition from student to NQM. While the role of the preceptor in supporting NQMs has been explored in the literature, the role of the mentor in facilitating the transition to NQM has not been explored. The third and final article in this series will consider the ways in which student midwives are prepared for autonomous practice as NQMs, particularly with the recent move from mentors to assessors and supervisors. It will consider implications and make recommendations for practice to attempt to mitigate against the so-called fairy tale midwifery.
Vignette 1: from student-mentor to NQM-preceptor
Jaki was my first mentor and as a first year, I was at least 10 paces behind her and completely in awe. My peers loved midwifery yet I felt as though I was missing something. One night, Jaki and I walked into a woman's birth space. I stood back as she locked eyes with the woman, making a connection so instant that my heart felt as though it had skipped a beat. That was my ‘wow’ moment; the moment I felt a connection to midwifery and to the midwife that I wanted to become.
I worked with Jaki at various points across each of my three years of training, including for my student caseload. She opened up my eyes to the complexities and operational challenges of midwifery, and thanks to her, I was exposed to care in a variety of settings. She shared her self-doubt and frustrations, included me in her reflections and made me question practice. Although I worked with other mentors and selected various practices to take forward into my own practice, Jaki was always my mentor and I was always her student. She welcomed me into her world and whisked me along with her, regaling me with stories of her midwife adventures.
I fell in love with midwifery under her guidance and progressed from terrified first-year running to keep up, to third-year ready to fly the nest. Jaki was the obvious choice to be my preceptor; she offered a mixture of support and tough love that I needed. We share a philosophy of care and she never doubts my ability to do something. I trust her implicitly: she will catch me if I fall, but I know that she will not let me fall in the first place.
Jaki has not supervised any of my clinical skills since I qualified and I did not work any of my supernumerary shifts with her, which was good as we were no longer student-mentor. I was a midwife and needed to spread my wings, albeit tentatively. She may not have taught me to suture or cannulate, but the things she taught me were far more valuable and have carried me through the darkest days of preceptorship. She taught me the art of midwifery and when I have questioned who I am as a midwife, she is the anchor that keeps me grounded. Last week, I was called into a birth room to be extra support for a midwife and her student. My role was minimal but as the woman transitioned, I cupped her face in my hands and we had a moment—just the two of us. The world stopped spinning and we stepped over the brink together. Later that shift, the student midwife told me she would be taking that moment forward into her own practice. I saw how the art and love of midwifery is transmitted from one generation to the next, and how I have taken my place in that cycle. Jaki has spent four years teaching, guiding, cajoling and supporting me to be the midwife I wanted to become and the one she always knew I would be—that has been invaluable.