In 2018, the Department of Health and Social Care (2018) announced plans to expand the numbers of registered midwives working in the NHS. To facilitate this growth, Health Education England (HEE, 2019) recognised the need to grow clinical placement capacity by 25% across England by 2022. In recent years, clinical placement capacity has been completely filled by students in training, and a range of pressures is being exerted on the system, including staff turnover, the availability of appropriate practice supervisors and practice assessors and variations in the birthrate between services (Markowski et al, 2021).
The work of the Pan London Midwifery Expansion Placement project, led by HEE (London) supported an initiative to introduce a pilot at the Lewisham and Greenwich NHS Trust to organise midwifery students’ learning in practice, known as collaborative learning in practice (CLiP). CLiP originated from the University of East Anglia and was successfully implemented first for nursing students and later for midwifery students at the local partner trust, James Paget University Hospital (JPUH) (Hill et al, 2015; 2020; Tweedie et al, 2019). A visit to JPUH inspired the research team, led by the University of Greenwich, to explore the feasibility of transferring the model to a London maternity unit serving a very different demography and operating a service with a high turnover of women, which was frequently running at full capacity (Tweedie et al, 2019).
There is a growing body of evidence to support the benefits of CLiP, such as effective teamwork, students’ development in confidence and leadership skills in practice, as well as preparing them more effectively for professional practice (Hill et al, 2015; 2020; Harvey and Uren, 2019; Underwood et al, 2019; Williamson et al, 2020a; 2020b; Markowski et al, 2022), while an increase in placement capacity was achieved. In Greater Manchester, the model ‘GM synergy’, which is similarly based on the principles of peer learning and coaching, was trialled and implemented by four universities and their healthcare partners (Leigh et al, 2019). Other trusts, who reported similar models based on peer learning and coaching for student placements, are located around Plymouth, Yeovil, Bedfordshire and Staffordshire but solely concentrate on nursing students (Wareing et al, 2018; Harvey and Uren, 2019; Underwood et al, 2019; Williamson et al, 2020a; 2020b). So far, only JPUH has rolled out CLiP on the maternity ward (Tweedie et al, 2019).
The CLiP model was chosen for a pilot study implemented at the Queen Elizabeth Hospital in Greenwich, London. The first cycle commenced in January 2020 but was curtailed by the COVID-19 pandemic in March 2020 (Markowski et al, 2022). However, this allowed the research team and steering group members to reflect on the pilot and apply changes for the second cycle, which began in October 2020 and is ongoing at the time of writing. This article reports the changes carried out in preparation for, and at the beginning of, the second cycle, and aims to guide to other healthcare education providers for the potential future implementation of CLiP. The findings on the placement experiences of the first cycle of the pilot by students and staff was reported in Markowski et al (2022).
Aims
The aims of the CLiP pilot study were two-fold. First, the pilot aimed to gauge the transferability of the CLiP model to a trust situated in the London region serving a different demographic of women and with a higher turnover of women and staff. Second, the pilot aimed to capture the experiences of the student midwives and staff who participated in the CLiP placement experience. The full details of the study are reported in Markowski et al (2022).
The pilot study
A qualitative research design combined with pragmatic action research was chosen (McNiff, 2013; Creswell and Creswell, 2018). The qualitative approach supported the elicitation of in-depth experiences by participants using semi-structured interviews, and transcripts were analysed using thematic analysis (Braun and Clarke, 2006); these results were reported in Markowski et al (2022). The pragmatic action research approach allowed review of changes in the cycles of implementation by following the steps of planning, acting, observing and reflecting.
A steering group was formed at the start of the pilot comprising 11 members, eight employed by the trust and three members of the research team and not employed by the trust. The steering group met every 4–6 weeks to plan, implement and evaluate the pilot and to address any implementation concerns by finding solutions. Meeting agendas and summarising notes were shared between steering group members to facilitate reflection. Research team members regularly reflected on the activities and communicated these to the steering group membership.
Ethical approval for the study was granted by the University of Greenwich, including for pre- and postplacement questionnaires and indicative interview questions. Trust collaboration was demonstrated by a letter of support from the head of midwifery, submitted with the ethics application. The letter confirmed that the trust considered the pilot evaluation to be a form of service evaluation and that the trust's clinical effectiveness department had been informed. For the second cycle of the pilot, a modified ethics application was made to request that interviews were conducted online or over the phone, because of COVID-19, which was granted.
The first cycle
Nine midwifery students took part in the first cycle of the pilot on the combined ante- and postnatal ward at Queen Elizabeth Hospital. They worked in groups of three, usually composed of first-, second- and third-year midwifery students. Each trio collaborated in six shifts over 2 weeks, where they had the responsibility of caring for a bay of women, which is usually four women. The students were supervised by the CLiP midwife, who held overall accountability for the care provided by all three students. The CLiP midwife was trained in applying coaching techniques to supervision, which meant asking open questions and eliciting knowledge from the students rather than directly telling and teaching them. These coaching techniques were based on Whitmore's (2017) goals, reality, options and way forward model. For the first cycle, five midwives were trained to be CLiP midwives by the CLiP educator. Figure 1 shows a diagram of the CLiP model as implemented in Queen Elizabeth Hospital.
In cycle one, CLiP training consisted of a 2.5 hour workshop for midwives and students to learn about the CLiP model, applying coaching techniques and to encourage a proactive learning mindset for the students. After this event, all workshop materials were made accessible online and individual one-to-one training was provided by the CLiP educator. It was challenging to engage all midwives in training because of staff shortages during the pandemic, which was why online training was made available.
The CLiP educator was seconded on a 0.4 whole time equivalent position (initially funded by HEE) to prepare students and staff for the CLiP placement experience, to support the midwives initially in structuring the CLiP shift and to facilitate the CLiP hour, which was a dedicated hour per shift for students to reflect on their practice and fill any knowledge gaps.
The steering group met five times in the period from October 2019 to March 2020 and then again in September 2020. The timeline of the key steps in this pilot project is depicted in Figure 2.
Collecting feedback
In March to May 2020, seven of the nine participating students and three CLiP midwives were interviewed after providing consent. The 30–60 minute recorded interviews were transcribed and analysed. The research team further collected written feedback from the CLiP educator, the clinical placement facilitator and the head of midwifery, who were not available to take part in interviews. The latter three participants were also part of the steering group. The research team and steering group members reflected on the collected feedback and discussed and agreed on implementing key changes.
The qualitative findings on the experience of the CLiP placement model were in line with previous CLiP studies conducted in nursing and midwifery in the UK, which emphasised the benefits of peer learning and the coaching model for supervision; namely, peer support, development of new skills such as teamwork, communication and leadership and the autonomy in providing care independently increased their confidence (Hill et al, 2015; 2020; Harvey and Uren, 2019; Tweedie et al, 2019; Underwood et al, 2019; Williamson et al, 2020a). The known challenges of CLiP, as already reported (Harvey and Uren, 2019; Underwood et al, 2019; Hill et al, 2020; Williamson et al, 2020b), were corroborated by this pilot, as there were issues around a lack of awareness of CLiP, which affected the students’ group experience, lack of time for signing off competencies and inconsistency in applying the coaching style supervision.
The CLiP hour was perceived as beneficial to the students’ learning experience, as it provided space for personal assessment and reflection. However, a dedicated space for it was suggested, as it was difficult to hold in the demanding ward environment. It was more difficult to implement CLiP on night shifts, as there were generally fewer staff on shift and the CLiP educator was unable to work full night shifts because of the limited contract. Some of the midwives expressed difficulty in accommodating three students, as it was difficult to facilitate them all working together. This usually resulted in a pair of students working together and one student working alongside the midwife.
Reflecting on the challenges led to redrawing the model in preparation for the second cycle of the pilot (Figure 3). The modified version of the model involved a dyad of students, preferably one from third year and one from first year. This ensures a more manageable set-up in a demanding environment, because the learning between the students is more clearly defined and allows staff and students, as well as other personnel, to get used to the change from individual mentoring to student group work and coaching. Coaching a dyad rather than a trio also meant that CLiP midwives were able to manage their time more effectively in relation to signing off competencies.
To address the challenges around the lack of CLiP awareness, it was decided to recruit a CLiP educator seconded from the same hospital. This CLiP educator started the role 5 weeks before the first dyad of students commenced in November 2020.
Being seconded from the same hospital meant the CLiP educator had already established working relationships with colleagues and knowledge of the internal processes, while staff already had some understanding of CLiP from the first cycle. Before the first dyad started, the CLiP educator was able to offer more targeted CLiP awareness and introduction courses for staff and students. They further used this preparation time to re-design information posters and compile learning resources, which were made available to all staff in different formats. Online resources and, in particular, videos were useful as they were easily accessible at any time of the day.
To achieve greater consistency in applying the coaching style supervision, the CLiP educator trained at least three CLiP midwives before the first dyad started, and worked with those at the beginning of the first CLiP shifts to support the co-ordination of the shifts. These midwives also agreed to be champions to promote the model further.
In addition, the clinical placement facilitator, a trust-based clinical midwifery educator role to coordinate student placements allocations, made sure that all CLiP midwives were clearly indicated by their role in internal rota planning and communication, so that supervising CLiP midwives were not unexpectedly allocated to other locations in the hospital.
During shifts, CLiP midwives were asked to write the students’ names on the ward board so that colleagues could quickly identify which women were allocated to which students. Other health professionals, such as neonatal nurses and paediatricians who frequently entered the ward, were also more clearly informed about CLiP, so they addressed the students directly concerning the care of their women and babies.
The CLiP educator booked a room for the designated CLiP hour at a regular time and took the students away from the ward to ensure they had space for their reflection and learning.
Reactions to the second cycle to date
The interview data from the second cycle of the pilot is currently being analysed, but so far shows promising improvements. The CLiP midwives and students rated their CLiP experience highly.
‘I really enjoyed CLiP … I'd do it a million times again just because I really felt I gained a lot of confidence, because you were given that extra freedom to go off and create care plans and think of what step you're going to do next, instead of your mentor saying, “have you done this, this and this?” which you would normally experience. Then you have to action it and … report back to them and if you have any struggles or queries, then they're there to help, so it is quite reassuring, it gives you that allowance to actually feel you're controlling the care for the woman, which I loved.’ First year student
‘Now I'm middle of third year, I just wanted … more of the independence to prove to myself, if anything, that I knew what I was doing. And that's exactly what it's done. Being able to look after a bay on my own and know that I've got the support there if I needed it, but ultimately it was up to me. I thought it was going to be quite stressful, but it wasn't … because you're working together as a team.’ Third year student
No students mentioned difficulties having their competencies signed off. All third year students described a confidence boost based on the independence and trust they were given. They felt reassured and better prepared to manage the workload when they graduated. The junior midwifery students expressed feeling more relaxed and were able to ask questions that they might have not asked their practice supervisor. Both student groups rated the CLiP hour highly as time to reflect on their learning and identify any gaps.
‘One of the things I highlighted that I wanted to do in my CLiP hour was improve my medicines management … learning common doses and names… that I use in the postnatal ward, so [the CLiP educator] spoke to one of the pharmacists and she created a chart and updated her chart on loads of common things and then she emailed it over to us, which is a lifesaver.’ First year midwifery student
The CLiP midwives enjoyed coaching the students, since they were facilitating their learning from a distance and could see the students’ professional identity develop.
‘It was nice watching them like grow and develop and change throughout the shifts … It was more like we were colleagues rather than a midwife and students, which I think was good.’ Midwife 3
Next steps and implications for the future
The CLiP model demonstrates a sustainable means to expand clinical placement capacity and grow the future midwifery workforce to ensure provision of a dynamic profession that meets the needs of every mother and her family. Of equal importance, CLiP has demonstrated several qualitative benefits of a coaching model as an innovative means of supervising and supporting students to learn and work together in practice. This new approach requires a mindset shift away from the legacy of the traditional one-to-one mentor–mentee model where a student's learning is directed, work is allocated and practice supervisors do the same work as before, but with a student. In contrast, a coaching model, such as CLiP, operates as a micro-team, where the coach steps back, allowing the two (or three) students under their supervision to learn by providing care to an allocated group of mothers and babies, asking questions and observing students’ practice (Hellström-Hyson et al, 2012). It is hoped that this model can be rolled out to other areas of maternity services in the next phase of the project, such as community, although there is little experience of this elsewhere.
The publication and adoption of the new standards for student supervision and assessment (Nursing and Midwifery Council, 2018) are timely and align with the principles of CLiP, as students are no longer restricted to working with a ‘sign off’ mentor for 40% of their practice time. With CLiP, the new standards enable students to be supervised by a CLiP midwife who acts as a practice supervisor within the clinical area, which is used as a complete learning environment. This includes students working and learning alongside each other, demonstrating the value of peer learning (Markowski et al, 2021). By the nature of their professional roles, midwives are natural coaches, adapting easily to the coaching aspect of CLiP. Thus, the CLiP midwife becomes a role model, demonstrating coaching skills to students who develop these as learners.
Tweedie et al (2019) report that engaging with CLiP as a student enables a more seamless adaptation to becoming a newly qualified midwife, as it helps to develop confidence and leadership skills and enhances effective teamwork. This has also been borne out by the authors’ own research. In a demanding and fast-paced practice environment, an initiative that facilitates greater preparedness for working after registration is a vital factor in the retention of the newly qualified workforce in the early stages of their careers, as described in the HEE (2018) RePair project.
Conclusions
The authors’ research has limitations as it was a pilot study with a small sample, and data collection was affected by the pandemic (lack of time by staff and students, who were interviewed via video call). However, this CLiP pilot has contributed to an evidence base demonstrating the benefits of CLiP and the model's transferability. The experiences gained and lessons learned provide assurance that it is feasible to implement CLiP into a demanding London maternity unit. Ongoing research is required to evaluate the long-term impacts of a consistent coaching model of supervision on the next generation of midwives.
Key points
- Collaborative learning in practice is an approach to increasing placement capacity while providing an enriching learning experience for students.
- This research contributes to growing evidence of the benefits of collaborative learning in practice, including effective teamwork, students developing confidence and leadership skills and being better prepared for professional practice.
- A modified version of the collaborative learning in practice model was developed, involving a dyad of third and first year students to enable a manageable set-up in a demanding environment and support learning between students.
- To address a lack of collaborative learning in practice awareness in the hospital, a collaborative learning in practice educator seconded from the same hospital was used to develop a variety of training materials and to offer bespoke training.
- All collaborative learning in practice midwives need to be clearly identified by their role in internal rota planning and on shift so that supervising midwives are not unexpectedly allocated to other clinical areas, to ensure consistency in supervision can be offered.
- The collaborative learning in practice hour (students’ protected learning time) needs to take place at a regular time in a dedicated room away from the clinical area, so students have space for learning and reflection.
CPD reflective questions
- If you were to adopt a phased introduction of the collaborative learning in practice coaching model in your trust, which clinical area(s) might enable a smooth initial introduction of the model?
- What factors enable or inhibit a smooth transition from a traditional ‘one-to-one’ mentor–mentee model to one where learning is student directed?
- What existing resources does your trust have to implement the collaborative learning in practice coaching model?
- How will the demands of maternity services ensure that students are able to participate in peer learning without compromising the needs of the service?
- What advantages/disadvantages might exist for students/educators working in a peer-to-peer learning environment compared to the traditional model?