The transition to qualified professional has been reported extensively in the literature, with historic studies highlighting ‘reality shock’ and liking it to ‘flying without a parachute’ (Kramer, 1974; Godinez et al, 1999; Whitehead, 2001). The realisation of increased accountability and meeting the realities of contemporary midwifery practice can be described as a white-water raft ride with perhaps the only option being to ‘sink or swim’ (Hughes and Fraser, 2011).
Preceptorship is defined as ‘a period of structured transition for the newly registered practitioner, during which he or she will be supported to develop their confidence as an autonomous professional’ (Department of Health (DH), 2010a; 2010b:11).
Formal preceptorship programmes were first acknowledged by the UK Central Council (UKCC) (1996) and endorsed by the Nursing and Midwifery Council (NMC) (2006) to facilitate adaptation to new roles and responsibilities. Midwifery students undertake an educational programme to support their development, so that, upon qualification, they have gained the necessary skills to ensure that they are both fit for purpose and fit to practise (NMC, 2009b). To support this, the DH report, A High Quality Workforce (DH, 2008), advocated that a foundation year should be adopted post qualification to allow midwives to develop further skills, especially those relevant to complex midwifery care. This was further endorsed by the Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals (DH, 2010a), and Midwifery 2020 (DH, 2010b). However, new registrants often feel daunted by the responsibilities of their new role, and, upon qualification, lack confidence in their ability to provide effective care (Hobbs and Green, 2003).
Newly qualified midwives at an NHS Trust in the East Midlands undertook a 12-month preceptorship programme, designed to support them to develop their knowledge, competence and confidence under the guidance of an experienced practitioner (Martin, 2013). The programme was facilitated by a specialist preceptorship midwife and the divisional education teams, and included a Trust induction. Midwives were allocated a period of 4 weeks' supernumerary status and were recommended to work with their nominated preceptor for 40% of the time. They should also have received protected time for formal monthly meetings with their preceptor to review progress and set learning objectives.
Literature review
Kramer's pivotal study first coined the phenomena ‘reality shock’, and has been a focal point for many ensuing international studies surrounding the transition of both nurses and midwives (Kramer, 1974). It is apparent that, more than 40 years on from the original research, reality shock remains a current theme (Boon et al, 2005; Van de Putten, 2008; Whitehead and Holmes, 2011; Hobbs, 2012; Avis et al, 2013; Kitson-Reynolds et al, 2014). Kitson-Reynolds et al (2014) depict a notion of ‘fairy-tale midwifery’, with the reality of contemporary practice failing to measure up to the ideals and self-expectations of newly qualified midwives. Reality shock was identified by Van de Putten (2008), with participants expressing feelings of insecurity and fear, similar to the findings of Kramer's research. However, Fenwick et al (2012) suggest that reality shock should be replaced by the term ‘theory-practice gap,’ and found that it was not uncommon for newly qualified midwives to doubt their skills acquisition and decision-making ability following qualification, due to their limited clinical experience. The theory-practice gap links to the concept of confidence and competence, with studies revealing a conflict between the taught philosophy underpinning ‘ideal’ midwifery practice with the stark reality of challenges on contemporary maternity wards (Edwards, 2010; Whitehead, 2011; Licqurish and Seibol, 2013; Mason and Davies, 2013; Barker, 2014; Barry et al, 2014).
The analogy, ‘sink or swim’ is used by Fenwick et al (2012) to describe feelings of confidence and competence. It likened ‘swimming’ with positive interactions and experiences of support from colleagues, and highlighted how this led to increased confidence and competence (Fenwick et al, 2012). However, ‘sinking’ was attributed to poor relationships with other midwives in a working environment that was sometimes harsh. This led to the midwives feeling humiliated, intimidated and foolish, and left them with a sense of increasing incompetence and anxiety (Fenwick et al, 2012).
Consolidation of skills and knowledge forms an integral part of the transitional journey. The NMC define competence as having the knowledge, skills and judgement to demonstrate fitness to practise (NMC, 2014), and advocate that the newly qualified should have protected learning time during their first year in order to develop confidence in their practice (NMC, 2006; 2009b; 2015). However, variation in the quality of preceptor programmes provided by the NHS has led the NMC to consider incorporating preceptorship into undergraduate programmes from 2020 (NMC, 2016). Integrating preceptorship into the final year of midwifery programmes could see midwifery educators playing a greater role in clinical placements to prepare and support students as they make their transition to qualified practitioner.
A supportive environment is vital to ensuring a successful transition to graduate practice (Boon et al, 2005; Skirton et al 2012). Fenwick et al (2012) found that positive midwife-to-midwife relationships within a supportive working framework empowered the newly qualified (Fenwick et al, 2012). The evidence suggests that effective support during preceptorship is essential and a crucial indicator for the retention of staff (Hughes and Fraser, 2011; Mason and Davies, 2013; Feltham, 2014). This is further substantiated through the findings of the Royal College of Midwives' (RCM) seminal review, Why Midwives Leave: Revisited (RCM, 2016), which revealed insufficient support as one of the main drivers for midwives leaving the profession.
The findings of the review reveal preceptorship has been subjected to limited research in the UK before 2011. Recently, however, the Health Education England report Mind the Gap (2015), initiated in response to regional concerns from employers about the recruitment and retention of nurses and midwives, revealed how employers and education providers need to consider models of supervision, mentorship and preceptorship that meet the needs of the differing generation profiles of newly qualified health professionals. In consideration of the findings from the literature review, the author endorses a fundamental need for further research into preceptorship to help midwives adapt to their new role as they continue their evolution to competent, confident practitioners.
Methodology
The research formed part of a Master's degree, therefore ethical approval was gained from both the University Ethics Committee and the NHS Trust Directorate of Research Innovation. A purposive sample of eight midwives, who had completed their preceptorship between 2012 and 2015, received written information about the study with an invitation to participate. With their consent, the midwives discussed their experiences of preceptorship during voice recorded, semi-structured interviews.
An interpretative phenomenology analysis (IPA) approach was used to conduct the study. IPA explores the lived experience and examines how people apportion meanings to understand their experiences (Quinn and Clare, 2008). As a methodology, IPA is derived from Heidegger's phenomenological hermeneutics, and entails a subjective examination of the participants' experiences of a certain phenomenon (Roberts, 2013). The methodology is principally interpretative, but also includes aspects of descriptive phenomenology by enabling participants to recount their own experiences, therefore allowing for both a description and an explanation of an experience.
Data analysis
IPA involves a meticulous examination of the data transcripts in order to identify common themes. It aims to explore the subjective experience and proposes that the same event may be experienced differently by participants, due to the varying meanings that are attributed to the situation (Quinn and Clare, 2008).
To begin the analysis process, the participants were first given a unique code for identification (Quinn and Clare, 2008). These codes were allocated according to their individual backgrounds (Table 1).
Table 1. Participant codes
| Direct entry midwife | DE1 | DE2 | DE3 |
| International midwife | IM1 | IM2 | IM3 |
| Nurse trained midwife | NT1 | NT2 |
Each interview transcript was transcribed verbatim. Margin notes were made about particular thoughts or feelings which were arranged to produce an initial grouping of themes (Table 2).
Table 2. Initial grouping of themes
| Feelings during the transitional period |
| Thoughts about the preceptorship package offered by the local NHS Trust |
| Gaining confidence |
| Seeking support |
| Time |
| Supernumerary period |
| Positive and negative experiences of preceptorship |
| Support from their supervisor of midwives |
| Support from the preceptorship midwives |
| Changes to preceptorship package |
These concepts were grouped together to produce the final list of themes:
- Confidence and competence
- Support
- Feelings during the transitional period
- Time
- Perceptions of the preceptorship programme
- Changes to the preceptorship programme.
Findings and discussion
Confidence and competence
At the point of registration, midwifery students must demonstrate that they have met the criteria decribed in the Standards for Pre-Registration Midwifery Education, to ensure they are fit to practice and gain entry onto the NMC Register (NMC, 2009). Although this validates a level of competence at qualification, the midwives described some lack of confidence in adapting to their new responsibilities.
‘I feel like I've only really got my confidence since I've gained my competencies and have been able to consolidate.’
(NT2)
‘You feel quite under pressure to be quick. When you are a student, you have that midwife who is working alongside you, so one of you is taking the lead with the care or writing the notes; you're never doing both together.’
(DE2)
This midwife also reflected on her new found responsibility and accountability:
‘It's your PIN number, and it's your name, and they are your notes.’
(DE2)
Support
The participants were asked to describe how well they felt they were supported by the preceptor midwife.
‘She was great, really helpful, and even though she didn't work on site she always sent emails and said “if there is anything I can help you with I'll come and help you.” She was a really good support.’
(IM1)
‘I'd like to see her about more to support suturing and other competencies. Most of the time it's really busy and you can't have someone to supervise you.’
(DE3)
The Trust preceptorship programme states that the newly qualified midwives should have formal meetings with the preceptor midwives to review their progress. The midwives were asked whether this was a reality in practice.
‘I think you should meet her at the first, third, sixth and twelfth month, but I only saw her once.’
(DE2)
The midwives all reported that, apart from their initial induction period, they had little interaction with the preceptorship midwife; none of the midwives reported formal meetings to support their transition. The preceptees reported that the largest amount of support was provided from the midwifery staff on the unit, although they quickly realised who they could turn to—and those who were perhaps less helpful.
‘The majority of people were really supportive, but you found yourself looking to see who else was there because you knew which midwives you can pinpoint for help.’
(IM1)
The results reflect the literature, which recommends that newly qualified midwives thrive in a working environment in which they are encouraged to develop in their role by seeking guidance and support from their peers (Avis et al, 2013). One such avenue of support is from a supervisor of midwives. Through their role to support and empower midwives in their practice by providing leadership and guidance, they protect childbearing women and their babies by promoting safe midwifery care (NMC, 2009a). At the time of the study, the unit had five supervisors based on the labour ward, so there was often a supervisor working clinically to support staff. In the UK, midwifery students are educated about supervision of midwives (NMC, 2009a); however, supervision was a new concept to the international or nurse-trained midwives.
‘I think it's something I'm still getting used to.’
(IM1)
‘I just feel that coming from a nursing background where's there's nothing, it's brilliant. It's really invaluable because it does give you that extra support.’
(NT1)
Supervision can substantiate a formal preceptorship programme. However, with the proposed changes to the statutory function of supervision set to be implemented in 2017, it is vital that any new model for supervision continues to support newly qualified midwives, during and beyond their transition.
Feelings during the transitional period
The participants' responses demonstrated feelings of overwhelming vulnerability during their preceptorship.
‘There aren't any words for it. You do feel vulnerable and you feel like, you know, I'm asking for help, please help me…’
(DE1)
Another midwife said of her experience:
‘I felt sick most days but I didn't have any choice. I just had to get on with it.’
(DE3)
These feelings of insecurity and fear are consistent with the theory of reality shock (Kramer, 1974). Evans and Choucri (2012) expressed the transition as a process of change where nothing would ever be the same again. Crossing over from the protective stance of being a student to being an accountable midwife was deemed highly stressful and frightening by the participants:
‘Stressed, petrified, horrendous every day. Yes, I felt awful, like a first year student. I had days where I thought, “Oh God.” It's really quite overwhelming’
(IM1).
The sample included two nurse trained participants, who compared their own experiences as newly qualified nurses with being newly qualified midwives.
‘I'd been there as a student nurse, so I was half prepared for it, but midwifery was quite a shock because as a midwife you're so much more autonomous.’
(NT2)
Time
The participants all reported varying periods of supernumerary time from the four weeks advocated at the Trust. For one midwife, her experiences were positive:
‘Well, when I talk to other people about their preceptor, they never got to work all the time with theirs, and I think thank goodness that I did, because she taught me everything.’
(IM3)
For another participant, however, her experience was not as positive:
‘I had two supernumerary shifts and after that I was overseen by the Band 7 and allocated my own women, so not really supernumerary.’
(DE2)
One midwife highlighted the problem of her preceptor also having to mentor a student.
‘I didn't have many shifts with her because she's a sign-off mentor and always had a student as well, which was a massive issue.’
(IM1).
This raises the matter of adequate staffing and insufficient numbers of sign-off mentors, and highlights the problems faced when one midwife has to meet the demands of dual roles of both preceptor and mentor. Staffing levels were also perceived by one midwife as a major problem when it came to receiving protected time with her preceptor:
‘Obviously it's short staffed and these midwives get pulled elsewhere. You might be working with someone else, or you're not on the same shifts as them.’
(IM2).
The issue of protected time to support professional learning is construed as a barrier to preceptorship by Morgan et al (2012). Despite the Trust offering a robust preceptorship programme to support these midwives, this study has found that the challenges of staffing and inadequate skill mixes appeared to create a barrier to preceptorship. The reality of practice meant that most preceptors could not be released from the clinical area and take protected time to support their preceptee.
One midwife felt strongly that having time to consolidate in one clinical area was really important in order to gain knowledge and experience:
‘You need that time to consolidate properly. You are not going to become competent if you are just going from one area to another.’
(NT2)
One midwife highlighted the issue of midwife to women ratios on the wards:
‘I spent a year on delivery suite […] I struggled when I went to the ward with the 1 [midwife] to 11 [women] plus babies. I didn't have any supernumerary preceptorship time there, which I felt would be beneficial because it is very different.’
(NT1)
It appears from these findings that the issue of time is just one of the many organisational constraints on modern practice, and—given the challenges within the NHS—providing sufficient time to meet the needs of a preceptorship programme remains problematic.
Perceptions of the programme
Receiving a structured preceptorship programme was significant for those midwives who had either trained overseas or at a different NHS Trust. For the international midwives, it appears that the promise of a structured preceptorship period was important to help them successfully integrate into a new country.
‘It was the fact that they said you'd get a supernumerary period with a preceptor midwife which sounded appealing to us.’
(IM1)
Preceptorship should be seen as a supportive foundation period to further develop confidence to practice (Foster and Ashwin, 2014). The accounts from the interviews suggest that the promise of preceptorship was influential in their decision for commencing employment with the Trust.
Changes to the programme
The participants were asked to identify potential areas of the programme which could have enhanced their transition.
‘I think it should be individually tailored to midwives because it was a bit of a tick box exercise.’
(DE2)
For others, the main change would simply be having more protected time with their preceptor:
‘It would be your preceptor being available for you, but it's like asking the impossible. It's staffing, isn't it?’
(IM1)
The findings from the data recapture varying perceptions of the experiences and echo previous studies, which highlight that further investigation is necessary to evaluate ways to improve the transition for novice midwives.
Inequalities of the preceptorship programme
The findings have identified that aspects of the Trust programme were not implemented. One of the main areas highlighted was that the midwives did not receive adequate supernumerary time in the clinical areas, or protected time to meet with their preceptors. This led the researcher to question not just why, when such a systematic pathway was in place, it was not being executed, but more notably, what quality and assurance governance the Trust had in place to monitor its operation to ensure equity and conformity with national guidance (DH 2010a). The Standards for Preceptorship (DH 2010a:16) specifically state that preceptorship should ‘meet and satisfy professional regulatory bodies', and that it operates ‘within a governance framework’.
Staffing
Adequate staffing were aspects identified as an impediment for receiving appropriate support during preceptorship. The RCM advocates the need for almost 3000 more fulltime equivalent midwives in the UK to meet the demands of current maternity services (RCM, 2015), with statistics predicting that, by 2020, the number of births in the UK will rise to approximately 700 000 (National Maternity Review, 2016).
It is vital that there are sufficient numbers of midwives to support novice midwives and to meet current agenda to ensure that safe, personalised maternity care is available to all women (National Maternity Review, 2016). Following the aftermath of events at the Mid Staffordshire NHS Trust, there have been several leading reports which have been influential in making recommendations to address the managerial and organisational factors necessary to support safe staffing, and make recommendations for monitoring the numbers of midwives needed to promote safe maternity care (Berwick, 2013; Francis, 2013; Keogh, 2013).
Support
Maternity services are under immense pressure to provide quality care to women, and midwives are increasingly facing challenges to their role to meet these additional requirements (Hughes and Fraser, 2011). The literature reveals that the reality of contemporary midwifery practice means that novice midwives are expected to ‘hit the ground running’ in an environment where often the added pressures on staff means a lack of time and motivation to support junior midwives (Davies and Mason, 2009). It is therefore crucial for the safe care of all women that newly qualified midwives receive sufficient support.
Recommendations for practice
In consideration of the issues raised during this study, the researcher proposed the subsequent recommendations for practice.
Personalised preceptorship programme
The requirement for an individualised preceptorship programme, tailored to specific needs, was identified during the study, to support newly qualified midwives during their transition.
Effective monitoring of the programme
For the successful implementation of a preceptorship pathway, there needs to be robust Trust governance to evaluate and audit the quality and assurance of the programme, in collaboration with effective communication between the preceptorship and education team, senior management and clinical co-ordinators. The researcher recommends that there should be a specific Trust guideline for the preceptorship of newly qualified midwives, with regular review to allow for continued evaluation and development of the preceptorship programme.
Time for consolidation
In addition to the 4 weeks' supernumerary time provided at the Trust, an additional period of 1 week's supernumerary time should be scheduled at the start of each clinical rotation during the preceptorship, to allow for orientation into the new clinical area. There should also be provision made for regular protected time to review individual progress.
Limitations
This study was conducted to meet the requirements for the Degree of Master of Science, and was therefore a small scale project to meet the University prerequisites. Consequently, this only allowed for the use of one sample of midwives, thus limiting the research findings to those from one NHS Trust's preceptorship programme. The literature review recognised research from other areas within the region (Hughes and Fraser, 2011; Avis et al, 2013; Foster and Ashwin, 2014). It could therefore be beneficial to undertake a systematic review of the literature to provide a comparison of both regional and national preceptorship programmes within the UK.
At the time of the study, the researcher was a supervisor of midwives, a part-time lecturer and also a work colleague to the interviewees. This could be perceived as both a strength and a limitation for the study in regards to how the participants perceived their relationship with the interviewer (Oakley, 2015). On reflection, the relationship between the researcher and the participants did not appear to affect how the questions were answered during the interviews.
Conclusion
A robust preceptorship supports newly qualified midwives to make their transition into a confident, safe autonomous midwife (DH, 2010a). Our novice midwives are embarking on a professional journey where they will inevitably encounter the challenges and realities of contemporary midwifery practice within the NHS. If the future of the midwifery profession is to be protected, is essential that midwives are supported and empowered during and beyond their preceptorship. This will give them the confidence and inspiration to become innovative role models and champions, to lead future generations of midwives.
Key Points
- Preceptorship is defined as a period of structured transition for the newly registered practitioner
- Research demonstrates that robust preceptorship supports newly qualified midwives to make their transition to a confident, safe autonomous midwife
- Participants of the study reported both positive and negative experiences during their preceptorship
- Preceptorship has been subjected to limited research in the UK before 2011, demonstrating a fundamental need for further exploration
- Newly qualified midwives must be supported and empowered during and beyond their preceptorship, to give them the confidence and inspiration to become innovative role models and champions to lead future generations of midwives
CPD reflective questions
- What measures does your Trust have in place to support newly qualified midwives?
- In your experience, which support measures in your organisation are the most successful and which could be improved?
- How might newly qualified midwives be further encouraged and supported to become competent and autonomous practictioners?