Experiences of newly qualified midwives working in clinical practice during their transition period

It is widely reported in the literature that the transition period from being a student to becoming a newly qualified nurse (NQN) or newly qualified midwife (NQM) is a critical period in the new graduate's working life. It is during this time the newly qualified registrant has to undergo significant learning and adjustments within their preceptorship period, in order to have a successful transition and deliver high quality care (McDonald et al, 2009; Davis et al, 2012; Missen et al, 2015). The Nursing and Midwifery Council (2020) has recently published its guidance document on preceptorship and the principles which underpin transitioning from student to newly qualified practitioner with the expectation that workplaces have in place systems and processes to support and build confidence of NQNs and NQMs.

Studies reveal that NQNs can find the transition period to be a time of anxiety and stress when coupled with increased autonomy, responsibility and accountability (Foster and Ashwin, 2014). A Royal College of Midwives ([RCM], 2016) workforce report indicates that over 40% of midwives in Northern Ireland are aged 50 years and over, which in real terms suggests that there is a major need to train and employ more midwives for the future delivery of maternity services in Northern Ireland. Speaking at the ‘Maternity Transformation Programme: Two years on’, the Health Secretary promised the ‘largest-ever’ increase in NHS midwives, with a plan to train more than 3 000 extra midwives over the next four years (RCM, 2018).

Several studies have explored NQNs' and NQMs' experiences of transition. Themes of disillusionment, anxiety and stress are prevalent across many studies (for example, Ross and Clifford, 2002; Hollywood, 2011, Fenwick et al, 2012). As distress may impair compassion and decision-making abilities (Beaumont et al, 2016) and negatively influence on the strong ideals NQNs have to deliver high quality care (Maben et al, 2007), this has the potential to impact on the care of mothers and babies. A majority of the studies have specifically examined NQN experiences (Mooney, 2007; O'Shea and Kelly, 2007; Marks-Maran et al, 2013; Kumaran and Carney, 2014). While these studies have the potential to illuminate NQMs' experiences, gaining a more specific understanding into this subject is likely to better inform the preparation of student midwives' transition and assist in addressing practice issues in both the academic and clinical settings (van der Putten, 2008; Fenwick et al, 2012).

Context

All NQMs taking up a post within the Health and Social Care (HSC) Trust referred to in this study follow a rotational programme in various ward and department locations across the maternity service, encompassing antenatal, intrapartum and postnatal care environments. To accompany the rotation, all NQMs are introduced to the Midwifery Practice Education team (MPET), which encompasses a consultant midwife and midwifery practice educators, from which they receive a ‘SMARRT Pack’. This pack offers practical guidance that NQMs use to evidence their skills, competencies, mandatory training and learning opportunities that they essentially ‘sign off’ as they progress through their rotation.

Aim

This study aimed to explore NQMs experiences of working clinically during their transition period and how NQMs describe their practice experience; identify any barriers to their development; and explore what factors NQMs believe assisted them in successful transition to registered midwifery practice.

Methods

A qualitative methodological approach using digitally recorded semi-structured interviews was chosen to enable an in-depth narrative exploration (Moser and Kortsjens, 2017). Participants were invited to participate in the study via an email, with a two-week timeframe, ring-fenced for participants to respond. The full list of respondents was reviewed and selected on a ‘first-come-first-serve’ basis. Of the participants' names, eight were placed on a master list and were allocated a numerical value which was used to identify in individual respondents to protect their identity.

Participants

The criteria for determining study participants were NQMs who had attained their midwifery registration in the previous 12 months and had taken up post in this HSC Trust would be eligible to participate in the study. Each year, the number of midwives who take up a post within this HSC Trust varies, dependent on the number of vacant posts and applications. In the 12 months from October 2017 when the study was being planned, there were 16 NQMs employed. The predicted numbers of new recruits were similar to the previous year (n=16). Consequently, to ensure all would have an equal opportunity to participate, the sample were the number of midwives who met the inclusion criteria at the point of data collection. Due to the small-scale nature of this study and time constraints, the aim was to recruit eight participants as it was anticipated that this would provide a fair representation of the target population and would be reflective of sample sizes in similar studies on this subject in which data saturation was achieved.

Data collection

Eight digitally recorded face-to-face, semi-structured interviews were used as the data collection tool. Interviews lasted between 25–39 minutes and were undertaken within work time, so as not to impinge on NQM time off work. Semi-structured interviews were interactive, permitting the midwife researcher/interviewer an opportunity to seek complete, clear answers and probe into emerging topics (Alshenqueeti, 2014). Interviews were undertaken within the hospital environment, in a non-clinical room within the ward or department that the NQM was working. Permission was sought from the midwife in charge before conducting the interview at a time which was both convenient for the participants and the staff of the clinical areas.

By virtue of being human, researchers are not neutral and objective enquirers in qualitative interviews but are emotionally engaged participants who are sharing an experience with the interviewee (Rosalind and Holland, 2013). With this in mind, the midwife researcher completed a reflexive statement prior to undertaking the data collection in an effort to acknowledge their perceptions, position and bias and the perceived effect it may have on the participants and their responses. During the phase of data collection and analysis, the researcher kept a reflective journal to examine their potential influence on relationships and the openness of interactions with the NQMs participating in the study. Reflections were analysed along with the verbatim transcripts.

Data analysis

Interviews were transcribed verbatim by the researcher, with the resultant transcripts read and then reread several times. During the transcription stage, all identifying markers were removed from the data obtained. The data was analysed using Coliazzi's (1978) framework to determine meanings, identify themes and, ultimately, aim to reduce the amount of data down (Gill et al, 2008) to make some sense of the phenomena under investigation (Parahoo, 2014). In addition, the researchers' academic supervisor examined the anonymised transcripts to discuss their perception of what was emerging from the data. This led to the development of initial broad themes and subthemes which were refined to the final emergent themes.

Results

During data analysis, the researcher detected 30 themes, which led onto the development of 14 subthemes (see Table 1). Following refinement of themes four final themes were identified:

• Expectations and realities of the role
• Creating of conditions for professional growth
• The impact of the care environment
• Limitations to creating a healthful culture.

Discussion

(i) Expectations and realities of the role

One of the predominant factors that the NQMs discussed was expectations of the role and how this affected their adjustment to the realities of the role with the interviewees describing a disconnect between the protective environment they experienced when training and the reality of practice. This is corroborated in the literature by Kumaran and Carney (2014), and Ortiz (2016), who have described the disconnect between the reality of healthcare and the shelter of the registrants' training.

Additionally, the results in this study mirror the findings from Maben et al's (2007) longitudinal interpretative study of NQNs transitioning into practice, which highlights that newly qualified practitioners often emerge from their pre-registration training with a strong set of ideals around delivering high quality, holistic and evidence-based care which are found to be at the opposite end of the scale with the reality of professional and organisational constraints. This links back to the seminal work of Curtis et al (2006) whose study revealed that almost half of the midwives who had left the profession indicated that their inability to provide the type of care that they wanted was a key reason for ceasing to practice.

Under this theme, the subject of competence and confidence emerged, where it appeared that in terms of the NQMs' experiences of transition, the factors of competence and confidence were inextricably linked. Similar findings were reflected in a study by Fenwick et al (2012), who reported participants experienced an increase in confidence levels when they had positive interactions with their colleagues while working in supportive environments. In contrast, it was evident the overpowering message of the reality of clinical practice—that is the difficulties associated with navigating the transition period, were often off-set with challenges and obstacles, such as dealing with the increased responsibility and their expectations of the role versus the reality of clinical practice, which inherently led to feelings of fear, anxiety and worry. These findings are supported by the evidence from studies by both the seminal work undertaken by Kramer (1974), and then much more recently by O'Shea and Kelly (2007), Duchscher (2009), and Kumaran and Carney (2014).

(ii) Creating of conditions for professional growth

The majority of the NQMs described how they found their midwifery colleagues as being an important source of support for them, which is supported by the literature which emphasises the value and importance given to NQMs from the midwifery team (van der Putten, 2008; Wain, 2017). However, not all the NQMs experienced positive relationships which had the effect of eroding any confidence they had developed, further increasing their levels of anxiety and stress. For example, a NQM reflected on her experience of approaching midwifery colleagues for help but the response she received depended very much on which midwife she asked:

‘…most people are so lovely and very understanding of [you being new], but some people just aren't.’

Peer support was also a prominent factor in the NQMs' experience, with support from those who qualified, in and around the same time as they had also seen as a source of extremely valuable support. This has previously been reported by Duchscher (2009) who found that new graduate nurses who no longer had the support that they had during their undergraduate training felt an immense loss. The NQMs reflected in this study that peer support gave them a sense of being able to share experiences—good and bad, with the feeling that ‘we are in this together’.

The findings in this study also revealed the importance NQMs placed on having professional support and guidance external to their placement in place, namely the MPET and using the ‘SMARRT Pack’. As outlined previously, the ‘SMARRT Pack’ is essentially a skills passport to accompany their rotation. When the participants discussed the professional support that was in place, they were in positive terms, with the midwives finding that they were, overall, very beneficial during their transition period.

Another subtheme was that of supernumerary time within the clinical area and while all participants in this study had an awareness that they were entitled to have supernumerary time, it was apparent from the interviews that there was great variability with many experiencing little or no opportunity for having supernumerary status. Indeed, when the participants did receive supernumerary time in a new clinical area, they found it was beneficial to their development, but conversely when they didn't receive it, they encountered difficulties with navigating around a new environment, a new work routine, and with a new team of people.

‘Asking for help’ was a finding that emerged from the data that impacted on the NQMs' transition. Their experiences of ‘asking for help’ were, on the whole, very positive, and the majority of participants reflecting that, their midwifery colleagues were approachable and helpful. However, it appeared that the poor staffing levels had an impact on the responses that the NQMs had received when asking for help. In a commentary around this subject, Darbyshire et al (2019) describes the rite of passage that some nurses (and midwives) impose on the newly qualified registrants as justification for the ‘in our day’ we had to suffer and endure, so why should these ‘new nurses’ enjoy anything different or better?

(iii) The impact of the care environment

In terms of workload, busyness of the clinical areas and feelings of being a ‘burden’, the participants spent a significant amount of time discussing these factors and their impact on their overall experience. Participants recounted how both the busyness of the clinical areas and low-staffing levels impacted on their workload, causing them a degree of stress and anxiety as they essentially ‘had to get on with it’.

The NQMs also reflected that due to the busyness of the clinical environment, and their workload, they would refrain from asking for help from their midwifery colleagues due to the sense of burden that they felt they were imposing on them. It would appear the findings of this study revealed how the NQMs were sensitive to the pressures within the care environment, and wishing to be seen as a team player, they, at times, rather than burden their ‘over-worked’ colleagues, simply got on with the task in hand, staying on long past their shift in order to finish their work. This was similar to the experiences recounted in a similar study where participants recounted feeling like being newly qualified was a ‘baptism of fire’ to be endured, and a sense of their experiences being a rite of passage (Norris, 2018). However, from the interviews, the overall sense was that staying on well past their shift ended and having a fair share of the workload was important for their sense of being an important component of the team.

(iv) Limitations to creating a healthful culture

The subject of time management was a subtheme that was discussed by every NQM, with many of them stressing the point that they were so busy ‘carrying out tasks’ that they were actually prevented from spending time with the women in their care. For some, working for long periods without a break was a regular occurrence, with the busyness of the clinical area often the reason. In addition, the subtheme of ‘finishing work on time’ appeared to be linked with the busyness of the clinical areas, as the midwives described how they tried to balance their workload with the time available to them in order to finish their shift on time.

Hobbs (2012) recounted many situations where midwives were expected to have very short breaks, go without them altogether or stay long after their shift had finished. While these actions were linked to the busyness of the working environment, there is also the notion that midwives will be respected for doing so.

These subthemes were also evidenced by Reynolds et al (2014) in their work with NQMs which discussed the notion that NQMs have to go ‘above and beyond’ to ensure that they were not perceived as lazy, despite their own perceptions of some of their more experienced (midwifery) colleagues as being so. These issues are concerning and require to be addressed if the culture for NQMs is to change.

Discussion

The findings from this study reveal that while the NQMs shared similarities with other studies (van der Putten, 2008; Hobbs, 2012; Reynolds et al, 2014) in relation to the realities of clinical practice, support was key to moving forward and creating a more empowering culture. It was apparent that the sense of increased responsibility and expectation of the role were a huge challenge for the NQMs. Data obtained from this cohort of NQM participants revealed that their competence and confidence were very much interdependent and, in general, the longer they were working in a particular clinical environment, the better able they were to consolidate their knowledge and skills. Consequently, their competence and confidence inevitably increased.

In this study, the fears and anxieties manifested themselves both physically and emotionally, and proved to be barriers to the NQMs development. Support was a key factor, with participants describing the invaluable source of peer support they gained from others who commenced post at the same time as them. The support they had from both their midwifery colleagues and also professional support from the professional development team was also seen as important, which is mirrored in the literature relating to transition of NQMs (Hughes and Fraser, 2011; Foster and Ashwin, 2014). The participants also made frequent references to the value of the MPET support and the ‘SMARRT Pack’, which are support mechanisms that were specific to the HSC Trust and may offer a value for other healthcare settings to consider.

One of the major factors that emerged from the findings of this study that both enabled and were a barrier to transition, was that of supernumerary time. Linked to supernumerary status was the issue of asking for help with the majority of the NQMs feeling able to ask questions or ask for help from their midwifery colleagues. However, some had a sense that, depending on the situation, they were a burden on others, who were already overworked, or that some of their colleagues were not particularly helpful.

The findings in this study brought to the surface the factors of time management, not getting a tea break and not finishing work on time as significant issues for some of the participant midwives. These findings are in direct contrast from what the policy documents distinctly identify as the drivers towards high quality maternity care workplace cultures that facilitate good teamwork, innovation and time to care (RCM, 2014). While the factors identified in this study are all somewhat connected, it would appear that these issues, like the others discussed, are not unique to the NQMs in this HSC Trust and these are factors that have been documented frequently in the literature with regard to how new registrants adapt and cope within their new roles.

Limitations and strengths

There were eight participants in the study, and while qualitative research favours smaller sample sizes in order to obtain a rich and detailed narrative from the data, it therefore means that transferability of the findings is somewhat limited due to the small numbers involved. In addition, the midwife participants knew the researcher in the capacity as a senior midwife within their HSC Trust. While this had the potential to influence participants to provide responses they thought the researcher wanted to hear, reflection suggested this was not so. The researcher also made efforts to mitigate this risk by taking the time at the beginning of each interview to explain the role of researcher, and also by changing out of uniform for the purposes of conducting the interviews. Reflexivity revealed that these actions helped to ‘set the scene’ as NQMs considered they ‘weren't at work now’ so they could be as open and honest as they wanted without fear of repercussions or fear that they would offend the researcher with their viewpoints.

One of the major strengths of this study is the participants, through open and honest dialogue, during their interviews allowed for a substantial amount of rich data to be collected and subsequently analysed. While this has been a small-scale study, it is the first to have been undertaken in this HSC Trust setting and has the potential to contribute to the wider body of literature.

Conclusion

This study achieved what it set out to explore, which was the experiences of NQMs in clinical practice during their transition period in a HSC Trust. This has been evidenced by the rich narrative that the participants clearly and honestly communicated, alongside the themes that emerged from the findings, which were interwoven with the literature that currently exists around this subject. The clearly articulated journey that has been described by the NQMs who participated in this study demonstrated that there is both a need and desire to change, improve and develop the transition period for all new midwives who take up post in this HSC Trust. Consideration needs to be given to more robust guidance which articulates what support looks like for NQM in the clinical environment, with some ideas for development:

• Develop the current preceptorship programme within this HSC Trust in line with the new NMC (2020) Pr inciples of Preceptorship recommendations for NHS Trusts
• Development of a Band 5 forum for NQMs to meet up on a regular basis with the Head of Midwifery and other senior midwives to discuss their transition and enhance their support networks
• Advanced planned rotation with flexibility to vary the length of time spent in particular areas depending on the needs of the NQMs
• A named preceptor/‘buddy’ in each clinical area that each NQM will be assigned to when they rotate to a new clinical area
• A shared social media site to allow the NQMs to discuss and share experiences, with the support of the MPET to facilitate the discussions or to signpost to any useful information or learning opportunities.

It is hoped that some of what has been learnt through this study can be applied in practice to aid successful transitions from student to registered midwife in the future and consider additional approaches to aid in the retention of midwifery staff within both the profession and employed within the HSC Trust.

Key points

• After seeking ethical approval, the newly qualified midwives (NQMs) were interviewed using semi-structured interviews, and the data analysed using Colaizzi's (1978) framework
• The themes that emerged from the data were (i) expectations and realities of the role; (ii) creating of conditions for professional growth; (iii) the impact of the care environment; (iv) limitations to creating a healthful culture
• Comparing these findings with the wider literature around the topic, the findings would suggest that the NQMs in this study shared similarities with those in other studies. In particular, that the realities of clinical practice were all too different from the expectations that they had starting their post as new midwives
• The NQMs who participated in this study articulated that there is both a need and a desire to change, improve and develop the transition period for all new midwives who take up their first post
• The findings from this study offer insight into approaches that may be applied in practice to aid in the successful transitions from students to registered midwives in the future

CPD reflective questions

• What type of preceptorship programme is in place in your work setting and what impact, if any, has this had on your midwifery teams?
• Do newly qualified midwives where you work have a ‘SMARRT Pack’ or an equivalent document that helps guide newly qualified midwives (NQMs) through their preceptorship period?
• If you had participated in this research, what issues would you have raised from your time as a NQM?
• On reflection of the issues that have been raised in this research, do you anticipate any change to how you work with and support NQM colleagues in clinical practice?