An exploration of midwives' experiences of the transition to practice in the Republic of Ireland

Midwifery recruitment and retention in Ireland is a major challenge (Moore, 2020) as it is globally (World Health Organization, 2020). Graduating from being a student to a registered midwife is a particularly difficult time for some, who may experience stress, strain, low self-confidence and poor job satisfaction (Shatto and Lutz, 2017; Hunter et al, 2019), leading to a high turnover of staff (Bakon et al, 2018). It is reported that most newly qualified midwives experience anxiety because of increased responsibility, professional accountability and clinical decision-making (Fenwick et al, 2012; Clements et al, 2013; Kitson Reynolds et al, 2014). Staff shortages and busy workloads result in an emphasis on task completion, rather than focusing on women-centred care, which increases this anxiety (Fenwick et al, 2012; Hobbs, 2012; Kitson Reynolds et al, 2014).

Studies indicate that well-designed educational programmes can play a positive role in helping newly qualified midwives to successfully embrace their roles as registered midwives and improve their self-confidence, competence and retention rates (Dixon et al, 2015; Pairman et al, 2016; Bakon et al, 2018). While there may be variation in title, such as transition to practice graduate support programmes, mentorship programmes or preceptorship programmes (Edwards et al, 2015), all have a similar purpose to support newly qualified midwives to develop clinical skills, build confidence and become effective team members (Kramer et al, 2013).

Approximately 200 new midwives join the Midwifery Register with the Nursing and Midwifery Board of Ireland (2021) each year, having trained at either undergraduate level leading to a Bachelor of Science in Midwifery or at postgraduate level as a registered nurse, leading to a Higher Diploma in Midwifery. The model of maternity care in Ireland is predominantly medicalised, in which over 99% of births take place in the hospital setting (Department of Health, 2016; Central Statistics Office, 2018).

There are an increasing number of studies worldwide describing midwives' experience of transition to practice (Gray et al, 2019). According to Gray et al (2016), research is needed in countries where there is limited evidence of new practitioners' experiences, as comparing how newly qualified midwives transition to practice shows important differences based on the structure of maternity services. To the best of the authors' knowledge, no research has been published describing midwives' transition to practice in Ireland since 2008. Van der Putten's (2008) study findings highlighted the need for formal preceptorship programmes for newly qualified midwives, yet mandatory programmes to support the transition have yet to be implemented.

The aim of this study was to explore Irish midwives' experiences of their transition to practice. The objectives were to identify the support required by newly qualified midwives during their first year of clinical practice and to explore what factors facilitate or inhibit newly qualified midwives' progress during their transition.

Methods

The study investigated the research question ‘what support is required by newly qualified midwives during their first year of clinical practice?’. A convenience sample of seven midwives from a large teaching maternity hospital, who had commenced their post-registration clinical practice between December 2018 and September 2019 participated. An invitation to take part was advertised via posters in clinical areas and all who volunteered were interviewed. Table 1 outlines each participant's midwifery training, length of postgraduate experience and area of work.

Data collection

An interview guide was designed based on themes emerging from published literature on this topic. This guided the interview process and ensured consistency. Following written consent, the participants discussed their experiences of their transition to practice during individual, face-to-face, voice-recorded interviews that took place in a private room. Interviews were conducted by a midwifery specialist coordinator (a registered tutor) not known to the participants and lasted 15–27 minutes.

Data analysis

Following completion of all interviews, each interview transcript was transcribed verbatim and data transcripts were examined by six tutors independently in order to identify common concepts and themes. The methodology used was essentially interpretative; however, aspects of descriptive phenomenology were included, as participants were allowed to recount their own experiences. This allowed for the collection of richer data as the experience is both described and explained and promotes uncovering of the genuine experience (Rees, 2011). The transcripts were read and re-read in order to acquire a sense of the experience. Significant statements were then extracted and tabulated into an excel spreadsheet and organised into concepts. The initial grouping of concepts is displayed in Box 1. These concepts were examined and arranged to produce the final list of themes (Table 2). To establish methodological rigour, the author chronicled a record of events in order to provide an audit trail.

Box 1.Initial grouping of concepts

• Challenged/overwhelmed
• Accountability
• Responsibility
• Being judged
• Supernumerary period
• Familiar environment
• Support
• Approachable supportive staff
• Unapproachable staff
• Short staffing
• Too busy
• Just completing tasks
• Learning by doing
• Learn from mistakes
• Gaining confidence
• Seeking support
• Time
• Support from midwifery managers

Ethical considerations

Ethical approval was granted by the hospital research ethics committee, study number 13 – 2019. Written consent was obtained from all participants, and at the outset of the process, participants were given a pseudonym for identification, to maintain anonymity (Rees, 2011).

Results

Feeling challenged

All seven midwives interviewed described the early days of transition to practice as challenging or overwhelming.

‘I think the first word that comes to my head is “overwhelming”’.

(Pippa)

Four of the seven participants recounted how they felt overburdened by the immense sense of responsibility and accountability of working under their own registration.

‘You wanted someone to double-check everything you were doing even though you knew you could do it…I found that I questioned myself a lot more than when I was a student…because you knew it was your registration now’.

(Roisin)

Findings from this study suggest that there was no difference in the experience of transition between those who were direct entry to the profession and postgraduate entrants. Both groups reported that they found the process challenging once the enormity of being registered became apparent.

‘I worked as a nurse earlier on but it's completely different because you're more independent as a midwife because you have to make more choices you have to have more clinical judgment…more pressure, more responsibility and being more accountable for what I do’.

(Avril)

‘You have to be on the ball…there is no time to learn on your own pace you just have to know everything… that adrenaline rush and you just need to know everything’.

(Emily)

The majority of respondents made reference to their own expectations of their performance, which appeared to heighten their anxiety, using terminology such as needing to be: ‘on the ball’, ’safe’, ‘double check everything’, ‘prove yourself’. Some recounted feelings of fear.

‘It is the fear of the unknown, and I remember someone saying to me you will feel sick every day until you have 5 months', 6 months' experience. I remember thinking “I can't do this for that amount of time”’.

(Noelle)

‘I was straight on to nights…I was just put in a room by myself and I found it was terrifying’.

(Sheila)

Newly qualified midwives felt that they needed to prove themselves and not make mistakes. They felt that more senior midwives were constantly judging their performance, which reduced their self-confidence.

‘I think they judge you if you don't get it right the first time…sometimes you're afraid to ask because you're a midwife now’.

(Avril)

‘Everything is a test, everyone is “all eyes on you”… you feel like, if I get one thing wrong…I'm the snake in the nest’.

(Pippa)

Five of the seven participants described the hospital environment as ‘too busy’ and ‘understaffed’ which contributed to their sense of being challenged. Newly qualified midwives were the first to be moved to other departments to cover staff shortages, making them feel undervalued and ‘just a number’.

‘Our workload is so much that my main priority in the day is managing my workload…there's too much work and not enough support’.

(Laura)

‘When there is a staff shortage, the junior staff are always moved around a lot…I feel we are just like a number’.

(Emily)

There was also a sense of disappointment that the reality of clinical practice did not live up to their ideal midwifery philosophy.

‘For me, being with the woman is just a part of my soul…but I don't get a lot of time to do that…I have to do a lot of things rather than actually being with woman…I suppose the environment that we work in…doesn't really value…the real side of the care that we give…you're just permanently in survival mode’.

(Laura)

Learning from experience

All seven midwives acknowledged that clinical experience was key to improving their confidence and developing competence during their transition to practice.

Some of the midwives described how their proficiency improved over time.

‘Within 3 months I was a lot more confident, there was a lot of things I was a lot more confident about’.

(Sheila)

‘I've been around longer and I'm seeing other people make the decisions or I've just gained confidence in my own ability to make those decisions’.

(Pippa)

Midwives acknowledged how being immersed in practice, although daunting, pushed them to grow in skill, confidence and competence.

‘We learn in college but really you learn the most by actually doing it’.

(Noelle)

‘It is through trial and error that you learn…just to put myself in there and just learn how to swim’.

(Emily)

‘There's no tool or anything that you can put in place that's going to replace the experience that you get from just being in there and doing what you need to do and seeing how the team operates and how the wards operate’.

(Pippa)

Support

The theme of support (or lack of support) permeated every interview. It was evident in the data that supportive practices facilitated newly qualified midwives' progress during their transition to practice.

Six of the seven midwives interviewed had completed student clinical placements in the hospital prior to qualifying. Transitioning to practice in a familiar environment eased their transition.

‘You see, I'm lucky in a way that I trained here, so I…know where everything is and how everything works’.

(Noelle)

‘Well as I trained here…I think I know the hospital and I know how everything works’.

(Avril)

Some midwives received a 2-week supernumerary period at the beginning of their placement with support from a clinical skills facilitator.

‘I had clinical skills support for a week or two. And that was good for the more practical side to things’.

(Noelle)

However, this level of support was sporadic and not offered to all newly qualified midwives. Each midwife interviewed highlighted the need for support from an approachable colleague in the clinical area, such as clinical skills facilitators or a buddy/mentorship system.

‘It probably would have been nice at the beginning to have maybe a linked midwife, kind of like a buddy type of system. I think that probably would be nice just someone that you could ask questions to’.

(Noelle)

‘There's not really a [transition to practice] programme, there's just like 2 weeks supernumerary and you're kind of thrown in’.

(Sheila)

Newly qualified midwives considered clinical skills training important, with particular reference to emergency ‘skills and drills’ training, as many dreaded their first emergency.

‘The clinical skills were brilliant, if there was any quiet moments, we'd run through postpartum haemorrhage drills and emergency bleeps and that was helpful because at least then you know you won't be caught out in emergency situations’.

(Pippa)

‘If you experience a baby that comes out flat… you have to do your neonatal resuscitation programme. Things you dread that you will have to do one day’.

(Noelle)

Friendly, approachable colleagues assisted newly qualified midwives during their transition to practice and in particular they valued the support from their line manager.

‘The manager on the ward was excellent, she was always checking in with you making sure that you were doing okay’.

(Roisin)

‘We have a really good manager/leader, she's good clinically she can meet us emotionally and she was just…approachable’.

(Laura)

‘If you got a really good, friendly, supportive person, that day you felt great’.

(Noelle)

Interestingly, newly qualified direct entry midwives appear to have additional training needs, because they are not registered general nurses.

‘[We need] more training, maybe high dependency… practical…especially because we are direct entry, I mean you kind of know “diddly squat” about gynae cases’.

(Sheila)

‘I think the direct entry students might benefit with just basic skills like even cannulation and all those things’.

(Emily)

One midwife suggested that team-building events would be beneficial, whereas others highlighted the importance of debriefing/reflection sessions.

‘[Following an emergency], your manager would debrief you on that [situation] - she may say “well done”…“this is what you can do the next time” or “you need to work on this or that”’.

(Noelle)

‘Some kind of protected time…to be able to reflect with my colleagues would be incredible’.

(Laura)

‘We don't really do anything together ever as a group, so that's why it probably takes a bit longer to feel like you're part of the team’.

(Sheila)

Unsupportive practices and attitudes

Participants described how unsupportive practices and attitudes inhibited their transition to practice. These included the expectations of others (being judged), expectations of self (questioning self, responsibility/accountability/proving yourself), lack of clinical skills facilitator support, busy hospital environment and unsupportive colleagues.

A supportive relationship between newly qualified midwives and their colleagues was a significant feature of a positive transition to practice, whereas unsupportive colleagues potentially inhibited their confidence and safety.

‘If someone isn't approachable, it can be scary having to ask them things’.

(Sheila)

‘I was afraid to ask because they may be judging you…to be safe I got the manager to double-check something for me’.

(Avril)

One participant acknowledged how the busy environment affected other midwives approachability.

‘Understaffed people are put under pressure and they become less approachable, not necessarily because they are unapproachable people, but because they are swamped with work’.

(Pippa)

Newly qualified midwives acknowledged that being accepted and valued as a member of the team was important and this sometimes took time.

‘I think it takes a while before you feel like you're part of the team, I don't know if that's just here’.

(Sheila)

‘I wanted to establish myself and to be part of the team and to feel…supported and valued as part of that team…it was really important to me. At the beginning it's hard because you're still a junior’.

(Noelle)

Discussion

The findings of this study add to the international literature on the topic of transition to practice by describing midwives' experiences of this transition in the Republic of Ireland. Findings share commonalities with much of the published literature (Van der Putten, 2008; Hughes and Fraser, 2011; Fenwick et al, 2012; Clements et al, 2013; Kitson-Reynolds et al, 2014; Gray et al, 2019). Midwives in Ireland described transition to practice as a time when they felt challenged because of increased responsibility and accountability. It was a period of growth as a result of learning by doing and a supportive working environment was paramount. However, this study highlights how postgraduate midwives, who have previously transitioned from student nurse to qualified nurse, and direct entry undergraduate midwives, who are experiencing this transition for the first time, are equally challenged by their autonomous role as newly qualified midwives. Darra and Clark (2017) concur with these findings, as they reported that postgraduate student midwives struggled to undertake the decision-making aspects of the midwife's role. The findings also imply that undergraduate midwives may have additional training needs post qualification, compared to peers trained at postgraduate level.

Participants' experiences of transition to practice were described under three themes. The first theme, ‘feeling challenged’, draws similarities to Kramer's (1974) seminal work, which described reactions of shock as newly qualified staff reported feeling not ready for clinical practice following years of education. As a result, new graduates experienced feelings of anxiety, fear and self-doubt, as also described by Duchscher (2009) and Gray et al (2019). The majority of respondents in this study made reference to feelings of doubt and fear when they realised the enormity of the responsibility/accountability a midwifery registration confers. This is in keeping with the findings of Van der Putten (2008) and Gerrish (2000), who reported that increased responsibility and accountability increased anxiety.

The impact of the busy hospital environment and low staff levels pervaded each interview. This is in accordance with findings from a study examining the work, health and emotional lives of midwives in the UK (Hunter et al, 2019), which indicated that perceptions of low staff levels was the strongest predictor of work-related anxiety, stress and burnout. Midwives in the present study felt their time in clinical practice was spent completing tasks rather than providing women-centred care. This did not match their idealistic view of midwifery care. In the Republic of Ireland, the majority of maternity care is still provided in the hospital setting. As recommended by the National Maternity Strategy (Department of Health, 2016), community-based services are increasing, but they remain sporadic. In comparison, in the UK, community midwifery is widely available including along-side and free-standing midwifery units. Research suggests that models of maternity care can affect midwives' experience of transition to practice. Griffiths et al (2019), Fenwick et al (2012), Hobbs (2012) and Kitson-Reynolds et al (2014) reported that providing hospital-based care caused frustration for newly qualified midwives, as their experience did not live up to their ideal midwifery philosophy.

The Irish National Maternity Strategy, published in 2016, maps out the future for maternity services in Ireland. The model of care proposed is based on the principle that childbirth is a natural, physiological process, with plans to offer a better experience and more choice for service users, including more choice of birth setting. It will also provide a better and more appropriate environment for transition to practice as building relationships with both women and midwifery colleagues can ease the transition (Fenwick et al, 2012).

The theme ‘learning from experience’, is discussed in other transition to practice literature (Gray et al, 2019). This study outlines how newly qualified midwives with the acquisition of experience were more comfortable making clinical decisions, and over time, increased their confidence and competence as a midwife, as described in the seminal work of Patricia Benner (1984). As the participants' confidence improved, the sense of being challenged abated and they began to grow as professionals.

The third theme ‘support’ emerged in every interview. Support in midwifery practice is a common theme, not only relating to newly qualified midwives, but has also emerged as an important theme while exploring midwives' experiences of undertaking a return to midwifery practice programme (Cowman et al, 2020). The present study demonstrates how the actions of midwifery colleagues can enable or hinder newly qualified midwives progress during their transition to practice.

Supportive relationships with colleagues had a beneficial effect on newly qualified midwives confidence and competence, as highlighted in other studies (Fenwick et al, 2012; Clements et al, 2013; Cummins et al, 2015). All participants identified the importance of clinical support during their transition to practice and the need for a mentorship or buddy system. Similarly, while exploring what other supports may assist a smooth transition to practice, newly qualified midwives suggested that debriefing/reflection sessions, emergency skills and drills training and team building events would be beneficial. The provision of transition to practice and mentorship programmes to newly qualified midwives worldwide has been identified as playing a positive role in helping the transition to the role as registered midwives (Pairman et al, 2016; Gray et al, 2019). A recent UK study by Watson and Brown (2021) highlighted that newly qualified midwives require a named ‘buddy’ or preceptor in each clinical area and a forum to allow the newly qualified midwives to discuss and share experiences. In the Republic of Ireland, it is acknowledged that transition to practice begins at the inception of midwifery training and formal preceptorship support is mandatory for student midwives (Nursing and Midwifery Board of Ireland, 2016). However, this is not replicated for newly qualified midwives, resulting in a sporadic or absence of support structures in place for midwives transitioning to practice in the Republic of Ireland. This is in contrast to the UK, where preceptorship programmes are routinely provided for newly qualified midwives. These programmes are reported as being important in providing support and developing newly qualified midwives confidence and competence. However, a lack of programme standardisation across trusts (Ashforth and Kitson-Reynolds, 2019) has resulted in the UK Nursing and Midwifery Council (2020) developing common principles to help employers build an effective model of preceptorship for all newly qualified midwives in the UK.

The findings from this study outline how unsupportive behaviours hindered newly qualified midwives progress during their transition to practice. Participants in this study described being undervalued as midwives, with similarities to Begley's (2002) study where some newly qualified midwives felt ‘just like a number’, suggesting little has changed since 2002. Some of the more senior midwives were perceived as judgemental. This resulted in newly qualified midwives feeling uncomfortable and in some instances, were afraid to ask questions or seek help. This is consistent with other studies where others' perceptions and expectations of newly qualified midwives increased their anxiety (Van der Putten, 2008; Fenwick et al, 2012; Netshisaulu and Maputle, 2018).

Strengths and limitations

In keeping with qualitative studies, the goal of this study was not statistical representation, but a rich understanding of the behaviour and experiences of participants. Therefore, the findings may not be representative of all newly qualified midwives. However, the authors believe the selected population was representative of the target population and data saturation was reached. While this is a small-scale study, it is the first to have been undertaken on this topic in the Republic of Ireland since 2008, and thus has the potential to contribute to the published literature.

Conclusions

The conclusions from this study are based on data from seven participants from one cohort of newly qualified midwives in the Republic of Ireland. However, the findings are in keeping with much of the published literature on this topic. The findings indicate that the most important aspects of transition to practice for newly qualified midwives are receiving support and experience in the clinical area. This study underlines the importance of support from approachable colleagues on newly qualified midwives' transition to practice. Staff shortages and a busy hospital environment can affect these relationships, as colleagues may appear unapproachable. This can lead to situations where newly qualified midwives may not ask questions for fear of being judged, which potentially could place the newly qualified midwives and women and babies at risk.

Support during the transition period is necessary to ensure high standards of care. To date, mentorship/preceptorship programmes have not been widely implemented for newly qualified midwives in the Republic of Ireland, and international literature indicates that these programmes prove successful in supporting midwives during the transition period. Therefore, the authors propose that there is a need for the introduction of a formal mentorship programme for newly qualified midwives in the Republic of Ireland. This study also illustrates that direct entry newly qualified midwives may have additional training needs, as they are not registered general nurses. Additionally, registered general nurses who become registered midwives are challenged, despite previous experience of transition to practice, because of the autonomy of the midwifery profession and the authors suggest that further research is needed in these areas.

Key points

• Newly qualified midwives feel challenged and sometimes overwhelmed during their first year of clinical practice.
• Learning from experience is key to transitioning from student to staff midwife.
• Newly qualified midwives require extra interpersonal support indicating that there is a need for the introduction of a formal mentorship programme in the Republic of Ireland.

CPD reflective questions

• Reflect on your own experience of transition to practice and how it relates to these findings.
• Consider what strategies can be implemented to facilitate newly qualified midwives adapt to their new role.
• Reflect on the support newly qualified midwives may need and how clinical staff can provide this support.
• What actions/attitudes can hinder a newly qualified midwife's transition to practice and how can we eradicate them?