Coaching and mentoring skills: a complement to the professional midwifery advocate role

It has been 5 years since the removal of the statutory supervision of midwives and over 4 years since the rollout of the employer-led model ‘advocating for education and quality improvement’ (A-EQUIP) (NHS England, 2017a). However, there is still a paucity of evidence recognising the national success or areas for development in relation to the employer-led model, or if the role of the professional midwifery advocate as a quality improvement process and a supportive framework for the midwife and student midwife is effective. A rationale for this lies behind the intensity of managing maternity services during a global pandemic, with time allocation to measure its effectiveness not being accessible (Jardine et al, 2020).

Workload pressures within midwifery have been magnified as a result of the global pandemic, causing anxiety and stress for all healthcare professionals across all settings (Cole et al, 2020). The prediction of the retirement bomb, combined with midwives leaving the profession because of burnout, is having a considerable impact on maternity service provision (Power, 2016). There is additional recognition of stress factors caused by the changing landscape within maternity service provision. One such factor has been identified as the ongoing national implementation of the continuity of care model (NHS England, 2017b).

Both COVID-19 and continuity of care have led to an increase in pressure on midwifery managers and lecturers to deliver a seamless service, combined with supporting midwives and student midwives during these difficult times (Ozga et al, 2021). The latter has not been without its challenges, as self-care and self-compassion for the majority have been side lined, with coping strategies proving to be ineffective (Cole et al, 2020).

Before COVID-19's impact on the UK, research suggested that midwives and student midwives who are self-critical, self-judge and lack self-compassion, can regrettably negatively impact the women and babies that they care for. A survey commissioned in the UK in 2019 stipulated that the midwifery workforce is experiencing high levels of emotional distress, with over 75% reporting personal burnout (Hunter et al, 2019). Lack of self-compassion correlates negatively in care application. Additionally, this negative correlation increases the risk of burnout and compassion fatigue for the caregiver (Beaumont et al, 2015). Therefore, the support framework for midwives and student midwives and the continuous improvement process that the A-EQUIP model is designed to achieve is needed now more than ever, in what have become known as unprecedented times (Radford, 2020).

Restorative clinical supervision

In March 2021, the A-EQUIP professional midwifery advocate model was adopted by the nursing profession. This came at a time when support was, and still is, essential for nurses across all settings (NHS England, 2021). Equally, both nurses and midwives are reporting post-traumatic stress syndrome, with 92% of NHS Trusts raising concerns regarding staff stress levels and burnout, both of which negatively affect wellbeing (House of Commons Health and Social Care Committee, 2021). It is reported that exacerbated staff pressures resulting from the COVID-19 pandemic cause a further strain on service provision intensity. Both the professional nurse advocate and professional midwifery advocate are critical in supporting nurses and midwives with the pandemic recovery process, which has been argued to positively affect NHS services and their patients (NHS England, 2021).

A-EQUIP has four primary functions (Department of Health and Social Care, 2016; National Maternity Review, 2016; NHS England, 2016):

• Education and development
• Personal action for quality and improvement
• Restorative supervision
• Normative (an evaluation of quality control standards within clinical practice).

Restorative ‘clinical supervision’, a support network to boost staff wellbeing, is facilitated by the professional midwifery advocate. The aim of restorative clinical supervision is to guide midwives and student midwives to solve their own problems and find solutions through peer support, increasing critical thinking, combined with the provision of developing personal resilience (NHS England, 2017a; Power and Thomas, 2018). It is further stipulated that adoption of the A-EQUIP model affects staff retention and improves outcomes for women and babies (NHS England, 2017a; Rouse, 2019).

Resilience within the workforce

There is no set universal definition of resilience. However, in recent years, there has been exploration into the relevance of resilience within midwifery practice and how it can be identified (McGowan and Murray, 2016). Its interpretation has been argued to be multifaceted, with complexities in pinpointing what risk factors affect an individual's resilience levels (Williams, 2021). Demonstrating resilience is argued to be fundamental in managing stress and anxiety (Grant and Kinman, 2015) and in an emotionally challenging environment, charged with ever-changing parameters, midwives and student midwives are required to hold the key traits of resilience whatever the situation.

Resilience is argued to be a process rather than an outcome and mostly derives from experiencing an unexpected event (Bryce et al, 2020). Midwives and student midwives who practice self-care, have self-awareness, are resourceful with their thought processes and have a clear vision of potential threat have a greater capability to cope in a stressful situation (Connolly, 2022). Therefore, NHS organisations have a responsibility of developing resilience within their workforce through both financial resources and strategic planning. Without these, the organisation is argued to be less operationally resilient (Bryce et al, 2020).

Additionally, provision of support mechanisms to instil resilience for both midwives and student midwives is imperative to the decision-making process as it can safeguard midwives and student midwives when they experience challenging or distressing events (Crowther and Hunter, 2016; Williams, 2021). Furthermore, resilience aids with building competence and confidence in practice. This can have a positive impact when dealing with competing demands and enhance positive working relationships (Clohessy et al, 2019). However, Eaves and Payne (2019) debate that midwives and student midwives demonstrating traits of resilience are not protected from high stress levels; they state that this can lead to burnout and additionally, the demonstration of resilience does not reduce a student midwife's intention to quit their midwifery programme.

However, it is argued that interpretation of resilience within the caring professions is drawn from an internal perspective, which views resilience as a positive trait (Matos et al, 2010). It emphasises resilience within the individual rather than reviewing from an ecological perspective. Traynor (2017) argues that flawed systems and staffing issues combined with exposure to challenging situations should be considered when defining resilience. Additionally, resilience is emotive; those not demonstrating the trait can become easily overwhelmed and look for an alternative coping strategy (Bryce et al, 2020).

Student midwives and resilience

To support student midwives with coping strategies with regards to balancing academic and clinical application pressures, resilience should be incorporated into midwifery training programmes early to ensure they are equipped with skills to deal with emergency scenarios (Davies and Coldridge, 2015). Pezaro et al (2016) and Power (2016) support this, stating that the demands of the student midwife role can be challenging. They go on to say that the art of applying theory to practice in a fast-paced, emotional environment combined with flawed team dynamics and academic pressures can cause extreme amounts of pressure for the student midwife, causing stress, anxiety, exhaustion and burnout. Therefore, those accessing the service of the professional midwifery advocate additionally need to be acutely aware of the importance of self-care and the positive outcomes it can bring to not only oneself but to those in their care (Rouse, 2019).

It has been suggested that educators must provide increased support for student midwives in suitable learning environments, ensuring they are equipped with the tools and practical skills to qualify as registered midwives, with wellbeing being a priority (Eaves and Payne, 2019). Power (2016) concurs, stating students should be supported throughout their midwifery training programme as it equips them with the ability to cope positively in practice.

The impact of COVID-19 on those working in the healthcare sector has caused fear, trepidation and anxiety levels to increase considerably (Uytenbogaardt, 2020). Additionally, Ralston and Gorton (2020) have highlighted that young and older females are deemed more at risk of experiencing anxiety than males aged over 25 years. The majority, 89%, of qualified midwives are female (Nursing and Midwifery Council (NMC), 2018a) with 32% being over 50 years old and 3511 midwives reportedly being in their 20s and 30s (Royal College of Midwives (RCM), 2018). This places a high percentage of midwives and student midwives in a high-risk category for increased anxiety levels. Therefore, support mechanisms within higher education institutes and clinical placement areas for midwives and student midwives are paramount.

Supporting strategies for student midwives

The challenges of the global pandemic opened a debate with strong recommendations to address and implement choice for undergraduate nursing and midwifery students (NMC, 2020). The vision was to ensure that students were supported with their learning to enable completion of their studies. In March 2020, emergency standards stipulating COVID-19 emergency legislation provisions were implemented, with a focus on second- and third-year student midwives being granted a choice. The strategy for choice was adopted to reduce significant distress for students experiencing the unfamiliar territory of a global pandemic. The students could opt to either practice for a 12-week period, be supernumerary and salaried or to continue an academic pathway until a recovery strategy had been sought (NMC, 2020). This caused disruption to both academic and practical learning, enhancing anxiety for student midwives because of the uncertainty of the timespan surrounding the pandemic, combined with completing the midwifery training programme within the specified 3-year time allocation.

As a senior lecturer in midwifery and named professional midwifery advocate at the University of Northampton, the author has experienced firsthand the difficulties trying to obtain a postgraduate qualification and applying this to practice during the global pandemic. The feelings experienced by the author echo those that have been voiced in professional midwifery advocate and personal tutor meetings attended by student midwives. The main concerns that were verbally raised by student midwives who chose the academic pathway can be seen in Box 1. Those students who chose the practical pathway additionally verbally raised concerns (Box 2).

Box 1.Concerns voiced by students who chose the academic pathway

• Will we qualify on time?
• Difficulties attending virtual lectures whilet caring for children who were being homeschooled
• Loss of practical application, which affects clinical skills and competencies that are required to be documented within the student midwives' Practice Assessment Document
• What support is the university and practice providers offering?

Box 2.Concerns voiced by students who chose the practical pathway

• At what point during the course will the remainder of the theory be facilitated?
• Will we qualify on time?
• Are we able to care for those women who have been diagnosed with COVID-19?
• Fear of contracting COVID-19
• Am I eligible for the vaccine?
• What support is the university and practice providers offering?

At times, there were no answers to some student midwives' questions, which further exacerbated students' emotions. However, regular meetings were held with student midwives from all cohorts to keep them updated with any change of guidance from the NMC, government and the university. The provision of restorative clinical supervision was facilitated for all sessions by the professional midwifery advocate and the coaching skills acquired further aided in what was a distressing time for student midwives.

The role of the professional midwifery advocate in supporting student midwives with future uncertainty was invaluable at the height of the pandemic. At the time of writing this article (December 2021), the UK was in the middle of the third wave of COVID-19, with scientific predictions being voiced in trepidation. There was an added fear that the omicron variant may bring further disruption to maternity staffing and service provision, combined with a concern for the wellbeing of mothers and babies. This was because almost 75% of pregnant women residing within the UK remain unvaccinated (Blakeway and Smriti, 2022). However, there is hope that the vaccination programme has proven successful (Lacobucci, 2021). So much so that as of March 2022, COVID-19 restrictions were lifted in the UK, with the claim that despite high infection levels of the omicron variant, admission to hospital and death resulting from the disease continues to remain low (Gov.uk, 2022). It is additionally important to note that there is strong evidence supporting the safe use of the COVID-19 vaccination for pregnant women (Blakeway and Smriti, 2022).

Coaching, mentoring and the professional midwifery advocate

The author is passionate regarding support for student midwives and prior to lockdown, commenced a postgraduate course in coaching and mentoring. The rationale for undertaking this qualification was to enhance professional midwifery advocate skills further by complimenting the one-to-one and groups sessions at the university with additional skills acquired from completing the course. This qualification came at a time of great need and the skills attained from completing the course proved to be beneficial to the author, midwives, student midwives and fellow lecturers within the university.

The role of the professional midwifery advocate and restorative clinical supervision is comparable to that of a coach and mentor, as it principally focuses on supporting the individual or attending group attempting to resolve their own issues by responding to open questions or seeking guidance for a resolution through peer support (NHS England, 2017a). This is argued to enhance critical thinking and a platform for developing personal resilience (NHS England, 2017a; Power and Thomas, 2018; Ross; 2018; Rouse, 2019).

In recent years, it has been widely documented that coaching and mentoring has gained momentum (Baek-Kyoo et al, 2012; Price and Fernandes, 2013), with an acknowledgement that the surge within differing organisations has derived from the recognition that coaching and mentoring not only benefits the employee, but also benefits the organisation (Baek-Kyoo et al, 2012; Woo, 2017). Coaching and mentoring has elevated to a point where there is now universal creditability attached to the profession (Chartered Institute of Personnel and Development, 2020). Its growing reputation demonstrates a distinguished positive gain between the dyad of employee and employer. Like the A-EQUIP model, it is centralised around staff development, with the aim of maximising the employee's full potential, thus positively affecting staff wellbeing, retention and productivity for the organisation (Whitmore, 2009; NHS England, 2017a; Ross, 2018).

It is well reported within midwifery literature that support for midwives and student midwives is essential, as the threat of midwife shortages affects the capacity to provide safe and effective care for women and their babies (RCM, 2018). The role of the professional midwifery advocate in supporting midwives and student midwives to achieve their goals by unleashing their potential to accomplish this will certainly aid with attrition rates for both midwives working within the NHS maternity services and higher education institutes for those students on the pre-registration midwifery training programme (NHS England, 2017a).

It is worth noting that almost 80% of people know how to resolve their issue, but a lack of confidence inhibits them from moving forward towards their end goal (Stoltzfus, 2008). Therefore, the additional qualification of coach and mentor to compliment the role of the professional midwifery advocate, can only enhance the skillset of the facilitator, enabling the advocate to guide those who access the service with problem-solving skills.

The comparable roles of the professional midwifery advocate and the coach/mentor include the advocate primarily supporting the attendees as an individual or in a group, by giving time and space to reflect and explore work environmental experiences. It is performed in a safe, confidential environment with a confidentiality agreement confirmed at the commencement of the session. Additionally, there are distinct activities to shared features between counsellor, mentor and coach (Table 1) and as a midwife/midwifery lecturer and professional midwifery advocate, it is imperative that that sphere of competence is adhered to when supporting others. This is applicable to both the role of the coach and the professional midwifery advocate, where a referral may be necessary to those more suitably equipped to support the midwife/student midwife (Westgaard, 2017). This is pertinent when developing coaching and mentoring skills, as for a novice coach/mentor, lines may become blurred, particularly the line between coaching and counselling (Taylor, 2006).

Consideration should be given to a midwife who holds several key roles and how the overlap of roles and responsibility within that role can be mitigated. For example, a midwife may be a mentor (practice supervisor/assessor), coach and professional midwifery advocate. Clear boundaries and understanding of the purpose are crucial to midwives who are seeking support. Two basic concepts to guide with these boundaries are first, acknowledgement that coaching takes place in the present and focuses on future goals, where counselling concentrates on past events and second, coaching is for driven, functioning people, where counselling is for people who have a degree of dysfunction or chaos (Williams, 2003).

Westgaard (2017) stipulates that there are shared features and distinctions between counsellor, mentor and coach (Table 1).

Professional midwifery advocate and coaching reflective practice

As a midwife and university lecturer, it is vital to have the knowledge base to equip student midwives with the skillset to self-reflect, self-evaluate, recognise and acknowledge what they have done well, combined with identifying gaps and areas for development. This is stipulated in the NMC (2018b) code for professional conduct, which states ‘gather and reflect on feedback from a variety of sources, using it to improve your practice and performance’. This can be achieved by instilling confidence in attendees with open dialogue that provokes reflective conversations (Rouse, 2019).

This reflective practitioner skill set is additionally transferable from the role of the professional midwifery advocate to that of the coach mentor. It is important as a coach to continually develop professionally, reflecting ‘in action’, spontaneous thinking and reflecting ‘on action’, retrospective thinking (Schon, 1987). It is argued to aid with learning by doing, combined with evaluating progress to date and making the necessary adjustments to ensure the facilitation of effective coaching and mentoring sessions.

However, to achieve this, the coach/mentor is required to have a skillset to enable the attendee to maximise their professional and personal potential. It is a necessity for the coach/mentor to have certain attributes and traits to be the enabler for the coachee/mentee to reach their full potential (Clutterbuck and Megginson, 2016). It has particularly been identified that development of trusting relations is key, with Price and Fernadez (2013) stipulating that one-to-one coaching sessions foster professional growth and learning for the coachee, which have evolved from the development of a trusting relationship.

Again, there are shared characteristics that a coach, counsellor, mentor and professional midwifery advocate hold (NHS England, 2017a; Westgaard, 2017). These characteristics have been argued to compliment the four disciplines and in particular, mentoring is argued to moderate the positive relationship between employee and coach, which determines organisational commitment (Woo, 2017). To be an effective coach, mentor and professional midwifery advocate, it is imperative that the attributes/characteristics listed in Box 3 are recognisable traits in the coach/mentor/professional midwifery advocate facilitator.

Box 3.Shared characteristics for coaching, mentoring, professional midwifery advocate and counselling

• Building transparent confidential, safe and trusting relationships with attendees
• Using effective strategies and guiding to acquire skills to engage with issues presented by the client/midwife/student midwife
• Using supportive helping skills to look ahead and move forwards to achieve positive change
• A demonstration of a non-judgemental approach
• Being authentic, compassionate and empathic in the relationship

Source: NHS England, 2017; Westgard, 2017

It is understandable when reviewing the distinctions shown in Table 1 and the shared characteristics of the coach, mentor, counsellor and PMA in Box 3 why the novice coach/mentor/professional midwifery advocate can potentially deviate from the structure of the models used in one-to-one coaching sessions.

It is also important for the coach/mentor/professional midwifery advocate to have an increased awareness with regards to their client's body language. Body cues aid with identification of the client's psychological stance and levels of authenticity that are normally triggered by noticeable changes (McLeod and Thomas, 2010). These triggers can be viewed in Table 2.

Leadership is also a significant factor within coaching and mentoring and that of the role of the professional midwifery advocate. For learning and development to be successful, the coach/mentor/professional midwifery advocate facilitates empowerment of the attendee, supporting them to consider options and reflecting on actions and thought processes (Wallbank, 2013), combined with addressing barriers to learning (Bradshaw, et al 2018). In particular, the transformational leadership style (Burns, 1978) creates enthusiasm, is led by example, instils vision and values and inspires the individual and workforce to meet a common goal through effective communication (Govier and Nash, 2009). The four components of transformational leadership, namely, intellectual stimulation, individualised consideration, inspirational motivation and idealised influence, are argued to best suit leaders from caring professions and enhance the leadership practical application within the profession (Huang et al, 2016). However, Meskelis and Whittington (2020) additionally acknowledge that not one definitive leadership style is suitable for all situations and that the client's personality trait must be taken into consideration.

Following recommendations of many coaching and mentoring experts, it is important to recognise that the coaching/mentoring relationship is built on respect rather than friendship (Deiorio and Carney, 2016). This minimises the risk of client dependency and makes it easier to end the coaching/mentoring relationship (David et al, 2016). This is also apparent in the role of the professional midwifery advocate, as accessing an advocate who was not the line manager of the employee reduces barriers and the risk of conflict of interest, enabling the employee to feel safe to express themselves (McCalmont, 2018).

Conclusions

The risk of stress, anxiety and burnout for midwives and student midwives has been increased by the complexities of the pandemic, combined with the changing landscape of maternity services, resulting from implementation of the continuity of care model. Now more than ever, support offered by the professional midwifery advocate is a critical component to aid the sustainability of the midwifery workforce. The additional coaching skills acquired by the author to complement the professional midwifery advocate role have proved beneficial and undoubtedly made a positive impact on student midwives and midwives who have accessed the service.

Key points

• Before COVID-19's impact on the UK, research suggested that midwives and student midwives who are self-critical, self-judge and lack self-compassion can unfortunately negatively affect the women and babies that they care for.
• The support framework and the continuous improvement process that the A-EQUIP model is designed to achieve is needed now more than ever in what have become known as unprecedented times.
• Provision of support mechanisms to instil resilience for midwives and student midwives is imperative to the decision-making process, as it can safeguard when midwives or student midwives experience challenging or distressing events.
• The role of the professional midwifery advocate and restorative clinical supervision is comparable to that of a coach and mentor, as it principally focuses on supporting the individual or attending group attempting to resolve their own issues by responding to open questions or seeking guidance for a resolution through peer support.
• The reflective practitioner skillset is transferable from the role of the professional midwifery advocate to that of the coach mentor. It is important as a coach to continually develop professionally, reflecting ‘in action’, spontaneous thinking and reflecting ‘on action’, retrospective thinking.