This is the final article in a two-part series which explores the experiences of student midwives undertaking the newborn infant physical examination (NIPE). Part one explains the background to the development of this study in detail and explores the use of interpretative phenomenological analysis (IPA) within midwifery education.
Part two presents the study findings, conclusions and recommendations for practice. The aims of the study are detailed in part one, but were broadly to gain insight into student midwives' lived experiences of completing the NIPE requirements of their pre-registration midwifery curriculum.
Literature review
A search of the existing literature was carried out as recommended by Aveyard, Preston and Payne (2016). No papers were retrieved in relation to the specific experiences of pre-registration midwifery students and the NIPE. Therefore, the closest fit for this topic was to examine qualified midwives' experiences of the NIPE; looking for themes that could be transferable to this study. Six, UK-based qualitative studies were selected for review across seven papers. These studies explored the experiences of NIPE-qualified midwives, although the focus of all papers was in relation to the NIPE as an extended role, not as part of routine midwifery practice.
Four main themes emerged when analysing the findings of the literature review. These are explored below, with the themes being presented initially, followed by a critique of each emerging theme.
Midwives' perceptions of the NIPE role
The reviewed papers all demonstrated generalised acceptance of the NIPE role by midwives (Rogers et al, 2003; Mitchell, 2003a and 2003b; Lumsden, 2005; Steele, 2007; McDonald, 2012; Stanyer and Hopper, 2019). The study conducted by Rogers et al (2003) purposively recruited a sample of 10 midwives to explore their attitudes, perceptions and views of extending their role to include the NIPE.
This was a qualitative study design using semi-structured interviews and included a sample of five midwives who were NIPE-trained and five who were not (Rogers et al, 2003). The findings of this study portrayed a sense of job satisfaction from participants, with midwives describing how the NIPE role provided increased autonomy and an ability to provide holistic care (Rogers et al, 2003). Concerns were expressed by participants about the potential for the NIPE to increase workloads with no remuneration, particularly from the participants who were not already NIPE-trained (Rogers et al, 2003) thus suggesting these factors may determine midwives decisions to train as NIPE practitioners.
Mitchell (2003a; 2003b) utilised a grounded theory approach to conduct a qualitative study of 19 midwives to explore their experiences of adopting the NIPE role within practice and examine any constraining factors. Data was collected via semi-structured interviews and the findings of this study, published over two papers (Mitchell, 2003a; 2003b), demonstrate a desire from the participants to develop more holistic care in line with the midwifery ethos. Participants expressed how the NIPE aligned to the remit of midwifery practice and the perception from participants was that they provided a quality NIPE service, using every opportunity to provide health promotion advice to parents during the examination of their baby (Mitchell, 2003a; 2003b).
Lumsden (2005) explored the experiences of 10 midwives to scope their perceptions of the examination of the newborn as an additional part of their role. All participants viewed examination of the newborn as being part of the midwifery role and frequently referred to the examination as being ‘holistic’ (Lumsden, 2005), with many participants working in areas where the ability to provide the NIPE as part of their extended service to the mother-baby dyad was viewed as advantageous. Interestingly, the notion of ‘holism’ was raised by participants who expressed a desire to view the examination as something ‘special’ and to protect the role from becoming ‘mundane’ or task-orientated (Lumsden, 2005).
Stanyer and Hopper (2019) interviewed currently practicing newborn examiner midwives who accepted the need for inclusion of the newborn examination in pre-registration midwifery education, in order to provide high quality care for mothers and babies. These midwives were of the view that the NIPE is an appropriate skill for midwifery practice and that service provision must be sustained by increasing the number of midwives trained to undertake it (Stanyer and Hopper, 2019).
Knowledge development and skill acquisition
An increase in knowledge relating to the baby was identified within several papers (Rogers et al, 2003; Mitchell, 2003a and 2003b; Steele, 2007; McDonald, 2012). Participants from these studies expressed how NIPE training had enhanced their ability to be able to detect issues within the baby and refer appropriately as required, compared to their untrained colleagues.
McDonald's (2012) paper utilised a grounded theory approach, sampling 17 participants via individual interviews to explore and explain from the midwives' perspectives the motivation to extend their practice and undertake the post-registration examination of the newborn training. Interestingly, all midwives interviewed within this study were under the impression that junior doctors had little training compared to themselves, although they were not actually sure of what their medical colleagues' training comprised of (McDonald, 2012). A further criticism from midwives relates to the quality of the paediatric examination in comparison to their own practice (McDonald, 2012; Stanyer and Hopper, 2019).
The implications for practice
Provision of holistic care to mothers and babies was emphasised by participants within all reviewed papers (Rogers et al, 2003; Mitchell, 2003a and 2003b; Lumsden, 2005; Steele, 2007; McDonald, 2012). The term ‘whole package of care’ related to the ability to undertake the examination without the input of waiting for medical colleagues to come to clinical settings to discharge babies (Mitchell, 2003a). Midwives generally relish the opportunity to take ownership of the NIPE role (Rogers et al, 2003; Lumsden, 2005; McDonald, 2012) with a high level of maternal acceptance (Mitchell, 2003b; Stanyer and Hopper, 2019).
If midwives could undertake the NIPE, it would remove the frustration of waiting for medical colleagues to attend (Steele, 2007; Stanyer and Hopper, 2019). McDonald (2012) observed a change in the culture and working practices of NIPE-trained midwives, with the examination shifting from being holistic to opportunistic as more midwives were rostered to provide the NIPE within clinics, encouraging a task-orientated approach to the examination. This appears to be at odds with the original intention of midwifery role expansion to provide more holistic care (Thompson et al, 2004).
Support
Support for midwives to carry out the NIPE role was explored in detail by Steele (2007) and backing from participants' line managers was found to be a determining factor in the continuation of the NIPE role. The frequency of using the NIPE skills, support for the NIPE trainee and the area of practice the midwife was engaged in were cited as important factors, with midwives working within community settings more likely to delay commencement of the NIPE role after they completed training (Steele, 2007).
Midwives were more likely to conduct the NIPE role where maternity managers collaborated with paediatric services to established agreed working practices and where policies were in place to ensure awareness of work roles and workloads (Steele, 2007; McDonald, 2012). Stanyer and Hopper (2019) highlight within their findings how midwives articulated pre-registration NIPE as a positive step in order to increase the number of midwives trained to undertake this skill, and that the NIPE was something for students to strive for in order to provide holistic care.
Conclusion
Knowledge relating to the NIPE is grounded within the context of qualified midwives who undertake this role as an additional aspect of their practice, emphasising a deficit between the qualified and student NIPE-midwife practitioner. This justifies the empirical inquiry to investigate the experiences of student midwives who are also NIPE practitioners.
Methodology
A qualitative design was utilised due to the alignment with the research aims. IPA is a specific qualitative methodology drawing on hermeneutics and idiography to examine how an experience has been understood from a particular perspective within a specific context (Smith et al, 2009). The use of IPA within the context of this study is explored within part one of this series.
Data was collected via semi-structured interviews. Data analysis was carried out using IPA as a framework to ensure an iterative, inductive approach to cases (Smythe, 2011). Emerging and superordinate themes gave a subjective, detailed view of individual participant's experiences.
Sampling strategy and participants
The study was carried out between March and May 2018 within a large university in the West Midlands where student midwives receive theoretical and practical exposure to the NIPE programme as part of their pre-registration midwifery programme. A purposive sample was gained from a cohort of senior student midwives who had experienced the theoretical and practical components of the NIPE within their final year.
Students were initially notified of the study via a message sent from the researcher on the cohorts' electronic learning environment. The purpose of the study was explained and students who wished to take part were asked to contact the researcher directly. Five students consented to take part in the study. Participants were similar in terms of their shared characteristics such as age and gender, and with comparable levels of experience within midwifery and the NIPE. There were no major differences in terms of academic ability between participants. Maintaining a homogenous sample allowed patterns of divergence and convergence of findings to be closely analysed (Smith et al, 2009).
Data collection
Face-to-face, semi-structured interviews were conducted by the researcher. An interview schedule containing topics to be explored was utilised in order to prepare for the likely content of each interview. However, after initial questions, interviews became more participant-led in order to enter the ‘lifeworld’ of each individual (Smith et al, 2009). All interviews took place at the hosting higher educational institute at the convenience of participants.
Written consent was gained prior to each interview commencing, with all participants consenting to interviews being audio recorded for transcription purposes and for interview extracts to be used during write-up and publication of the study. The requirements of the General Data Protection Regulations (2018) and Data Protection Act (2018) were adhered to at every stage of the study. The researcher, as a practising midwife, also adhered to obligations to protect participants in accordance with the code (Nursing and Midwifery Council [NMC], 2018a).
Data analysis
Each interview was immediately transcribed verbatim after data collection and individually analysed in detail. Interview recordings were transcribed verbatim by hand and reviewed by the researcher. To enhance trustworthiness of the research, member checking of transcribed interviews occurred to ensure that resulting transcriptions were an accurate record of conversations.
Individual interview audio recordings were listened to by the researcher several times, while simultaneously reading the accompanying text transcripts. The original transcript text was then analysed in a textual line-by-line fashion, with early annotations made in down one side margin of each page; noting content, linguistics and early interpretative ideas which would later help with the development of themes (Smith et al, 2009).
Transcripts were re-read several times to then enable the development of these early annotations into initial emerging themes (Smythe, 2011). These were listed in chronological order and clustered with other related themes within a separate table (Smith et al, 2009). Using a process of abstraction or pattern identification, these became superordinate themes once they had been named and positioned appropriately within other themes (Smythe, 2011). The process was repeated for all five cases. Cross case analysis was achieved by creating lists of emergent themes across the entire data set, clustering into superordinate themes where common higher order properties were shared.
Quality and validity
The principles described by Yardley (2000) are considered to be of particular importance within IPA and were adopted during this study. IPA, as a methodology, is explored within part one of this series. Consideration of any potential conflict arising between the researcher and study participants, the researcher's role throughout the data collection phase of the project, and all ethical issues were continually reflected on throughout the study.
There was a commitment to ensuring the data remained close to the words of the participants by use of verbatim extracts of participant accounts, allowing for an audit trail of interpretations made by the researcher (Smith et al, 2009).
Findings
Three main superordinate themes emerged following data analysis. To maintain confidentiality, participants were allocated a random identifying number.
1. Learning by doing
The first superordinate theme describes the sense of which the participants made of their development of knowledge and specific skills within the NIPE. There was a struggle to understand the NIPE role while not exposed to it early on within practice:
‘When you can't relate it to something that you're physically doing, I actually found it really difficult, and didn't really enjoy that first year of the neonate.’ -Participant 5
There was consideration given to the differences in learning within university and practice settings by some:
‘You see it in practice and you know what it is, and have more of an idea because it is different doing it on a doll in university…’ -Participant 2
These insights from participants suggest that the theory-practice gap within midwifery education feels real to student midwives. The feeling is magnified within the NIPE, as students require experience in order to firstly determine normality, then deviations from this. Experience of examining babies can only be gained from the practice setting:
‘…Performing the exam. You can read about it, about how to do it but before you do it if you don't understand it.’ -Participant 1
All participants were of the view that the NIPE was predominantly a unique role and the process of learning differed to other aspects of the midwifery course. There was a sense of starting over or taking a step back to the beginning of the course for some:
‘You feel like a first year student when you're doing [the] NIPE … because it's new, whereas with birth and antenatal check-ups, you've been doing that since first year, but you're only starting to do [the NIPE] in third year.’ -Participant 2
A sense of being watched during the NIPE examination was raised by some within the group. Generally, student midwives are accustomed to being directly observed by a midwifery mentor within their training. However, scrutiny by the baby's parents also occurred within the NIPE:
‘…It's always nerve-wracking because the parents are there watching you.’ -Participant 1
The significance of undertaking the NIPE for the first time was seen as akin to attending a first birth:
‘It's just that extra “thing” that you have a buzz about in your tummy. It's like when you go and see your first birth, and think, “Oh my goodness, I haven't got a clue what I'm doing!” It's the same thing…’ -Participant 5
Exposure to the NIPE within practice was varied, providing an insight into the experiences of participants at different clinical sites. Students are required to perform 20 complete NIPE examinations as a component of their training at the hosting higher educational institution. One participant identified a challenging experience with regards to support in practice and found it difficult to gain the required practical exposure:
‘…You've got all of us lot competing against each other to achieve it; you have the other university, and then you have midwives training as well…’ -Participant 5
Other participants experienced some issues around gaining the required experience but not to the same extent. Time for the NIPE within clinical practice was an issue for some, raising a tension between mentors' availability versus the needs of the service:
‘It's always a bit of a rush when you're in the examination room, and there's how many parents and babies coming through … not lots of time is spent on teaching…’ -Participant 4
Generally, participants stated they were able to overcome challenges in order to pass their course requirements.
2. Mentorship
The second superordinate theme captured the importance of mentorship within the NIPE, as well as participants' experiences of working alongside their mentors for this aspect of their midwifery course.
An insight into the subjective nature of mentorship, as well as the dual role of the mentor – as both the NIPE assessor and with responsibility for grading the overall placement – arose within this theme:
‘I think different mentors are different … then you're doing them in front of parents and a mentor, especially if they're your placement-assessing mentor as well. That can be quite nerve-wracking to know I have got that observation…’ -Participant 3
The availability of specific NIPE-trained mentors proved to be an additional challenge:
‘You don't want to have to be chasing midwives; you don't want to have to be ringing round different departments. Or changing your shift to try and fit with other midwives doing the NIPEs that day…’ -Participant 5
There was a preference for dedicated NIPE-trained mentors:
‘I feel you should be given a specific NIPE-trained practitioner to work with. And by having that practitioner to work with, you know their shifts, you know whether you can do those shifts and when they're going to be on and when you can go work with them…’ -Participant 2
Lack of time within clinical practice had the potential to negatively impact on the NIPE-learning experience:
‘…It has been a real challenge and things like midwives saying, “I'm in a bit of a rush actually” or “Oh, I just need to get these NIPEs done. I don't really have time to spend to teach you!” And you think that's fine, but this is part of my learning, and you think it's not ideal, but okay…’ -Participant 5
Some mentors appeared to lack confidence in supporting students to achieve the NIPE course requirements:
‘The mentors, I feel, are really focused on your postnatals, antenatals and births. And when you bring up NIPEs, it's as if they're not qualified to do that and they kind of brush it under the carpet … I think, especially because it's new, not only is it new for us but the mentors don't really understand it.’ -Participant 5
Participants highlighted variation within practice, attributed to a lack of knowledge from staff regarding NIPE skills by some of the group:
‘…When you go into practice and do it, you've got no clue how to do the other two elements, and you have only got to learn off what the midwives are doing, and some of them have trained a couple of years ago and you know they don't do it the correct way … the hips for example.’ -Participant 1
‘They say, “Oh, it's a clicky hip”, but actually they're doing it wrong. And then is it an unnecessary referral because it's just their method?’ -Participant 2
Some mentors also deviated from the Public Health England ([PHE], 2018) NIPE programme within practice:
‘I think you see how different midwives do it … obviously, we have been taught a certain way, and I know it is the NIPE standards are the NIPE standards and it should be done the same way … It feels like you're a first year student-midwife as a NIPE, even though you're a third year student-midwife…’ -Participant 2
3. The transition to qualification
Within this final superordinate theme, participants described their feelings in relation to carrying out the NIPE practitioner role. There was a sense of pride voiced by all participants, coupled with trepidation in relation to the NIPE on qualification as a midwife. It was recognised that the experience of the NIPE would differ following qualification:
‘…To do it [the NIPE] as a student … is very different to when you'll be doing it as a qualified midwife, and still have that time where you can do them with another midwife. And as a student midwife, you haven't got that same level of responsibility.’ -Participant 3
There was widespread acceptance of the midwifery NIPE-practitioner role amongst participants:
‘It's just doing what we normally do.’ -Participant 3
‘It's something midwives are capable of, why wouldn't it fall under the midwife's remit?’ -Participant 4
The NIPE was seen as a natural extension of the midwifery role:
‘And it's just like, “Okay, well why not?” We've learnt about babies; we know about babies, we know what's normal, we know what is not. So why can't we do this examination?’ -Participant 2
Participants felt the NIPE would enable them to provide greater continuity of care:
‘If I'm going to be caring for that woman antenatally, hopefully in the intrapartum period and postnatally, I think it is comforting for her for me to be performing the NIPE on her baby as well. And having that complete continuity of care and carer throughout the whole pregnancy, and right through the postnatal period as well, is really great.’ -Participant 5
Maintaining competence within the NIPE following qualification also arose, highlighting how some students could spend nearly a year without clinical experience of the NIPE if completed the course requirements early:
‘So I've got all my numbers now but that doesn't stop me [from] going to the NIPE clinic, like I've booked two more days … I know students have got all their NIPEs in October/November, they're not planning on doing any more, and I think that is such a long time to go without doing the NIPE…’ -Participant 2
Missing something vital dur ing the NIPE examination was a concern:
‘The health implications for the baby, that's a little bit scary: the idea of being completely responsible for that.’ -Participant 4
‘My worry, actually, is that I'm not going to come across something when I have that kind of cushion of a mentor or a team behind me.’ -Participant 5
A huge amount of pride was expressed by participants:
‘…I really enjoy it … It is a good additional qualification to have, especially as you are doing all that work anyway.’ -Participant 3
Increased employability was linked to the ability to undertake the NIPE in practice:
‘…I think it really benefitted me; and I know that other girls from this university have also been offered jobs there. And I would suspect it may be due to our qualifications, which is lovely to think!…’ -Participant 5
‘Employment-wise, it [the NIPE] would probably be a benefit, depending on where you go. I know if you train in a trust where they are training student midwives for the NIPE, they're more likely to see it as a benefit.’ -Participant 4
The findings demonstrated challenges that participants faced with regard to the NIPE aspects of their course. These included application of theory to their NIPE practice, gaining practical experience within the NIPE, as well as the consistency of mentorship and the allocation of a suitably trained mentor. In addition to challenges, participants also attributed benefits to their NIPE training, including increased employability, enhanced knowledge of the baby and the ability to provide holistic care.
Discussion
Much has been said about the experiences of student midwives within various aspects of midwifery practice (Fraser, 2002; Fraser et al, 2013; Coleridge and Davies, 2016). The sense of achievement expressed by participants within this study echoes views of student midwives, generally during their final year of study (Power, 2016).
The NIPE seemed different from other aspects of the programme which may be linked to how the NIPE aspect is assessed, in comparison to other aspects of the midwifery programme. Typically, when students develop their midwifery practice, they are assessed against stringent standards of education issued by the NMC (2009a). Guidance from PHE (2018) does not explicitly stipulate how the NIPE should be assessed, stating that training modules must be university accredited. The duration and content of each NIPE educational programme is governed by the individual higher educational institution, not PHE. The lack of standardisation raises implications for the safety and quality of the NIPE within practice.
Variation within the NIPE practice was evident from the analysis of students' accounts within this study. The most common variation reported by participants related to the conduct of the hip examination. Interestingly, this aspect of the examination is known to be a source of anxiety amongst qualified practitioners (Bloomfield et al, 2003; Thompson et al, 2004). The phenomenon of being watched during the NIPE was noted by several participants within this study, although observation is not unusual for student midwives as they are required to work alongside midwifery mentors within clinical practice by the NMC (2009a; 2009b) standards.
The experience of being watched and trusted to undertake the NIPE examination was magnified for participants if the mentor was also assessing the overall midwifery placement. Although failure to achieve can occur within other aspects of midwifery training, the ability to undertake the NIPE as a midwife is not a core requirement currently within the NMC (2009a) standards for pre-registration midwifery. The integration of the NIPE within pre-registration courses is at the discretion of educational providers, meaning student midwives have the potential to be disadvantaged if it is not possible to pass the midwifery programme without the NIPE aspect. The impact of this on pre-registration midwifery course completion rates has not been evaluated.
All study participants expressed satisfaction as being able to provide holistic care to women and their babies within their accounts, mirroring how qualified midwives generally embrace the enhanced autonomy the NIPE role provides them with, and increased job satisfaction (Rogers et al, 2003; Mitchell, 2003b; Lumsden, 2005).
Strengths and limitations of the study
The themes generated by the analysis of the research are only one of many possible accounts of how student midwives may experience the NIPE and how they make sense of this experience.
To promote reflexivity, a reflective diary was utilised during data collection and analysis to ensure that boundaries between the researcher and participants did not become blurred as a result of any potential conflict of power or familiarity, due to the researcher's position as a NIPE-qualified midwife and midwifery lecturer.
Conclusion
This study has provided a unique account of how student midwives experience the NIPE component of their pre-registration midwifery training, with participants' accounts presenting how it feels to undertake the NIPE role as a preregistration midwifery student. These perspectives contribute to the feeling that the NIPE is different in some way, compared to other aspects of the midwifery programme.
The new NMC proficiencies for midwives do not explicitly name the NIPE as a mandatory component of the midwifery role, but do state the requirement for midwives to conduct the systematic physical assessments of the newborn within 72 hours of birth (NMC 2019). There is a continuing discussion within the literature, relating to the appropriateness of student midwives to take on the NIPE role within their pre-registration training (Blake, 2012; Jones and Furber, 2017). It is hoped that the findings from the study will be useful to other higher educational institutions, considering the inclusion of the NIPE within their pre-registration programmes and that the insights shared by participants will aid in the resource planning and structure of future programmes.
Recommendations for practice
Higher educational institutions must ensure that mentors are familiar with the most up-to-date recommendations from PHE. Targeted mentor update sessions and the provision of the NIPE refresher sessions for qualified staff could support staff to develop their own confidence and knowledge within the NIPE and the pre-registration course requirements. A designated NIPE student coordinator role should be developed within each clinical area in order to provide consistency of mentorship within the NIPE for student midwives.
Consideration should be given to how future pre-registration midwifery curriculums incorporate the NIPE as there could be a result in increased student attrition, on the basis of what is still perceived to be an extended midwifery skill (Royal College of Midwives, 2016). Greater clarity from PHE to specify the numbers of the NIPE course contact hours would facilitate the standardisation of the NIPE practice amongst higher educational institutions.
Future research exploring the experiences of newly qualified midwives should be conducted in order to capture how their insights and perspectives around the NIPE alter following qualification and whether the NIPE role is retained. Further evaluation is required to determine how effectively current preceptorship programmes support newly qualified midwives to be able to take on the NIPE role in practice following their midwifery training, and to prevent the loss of competence associated with a lack of practice within the NIPE (Steele, 2007; Lanlehin et al, 2011).
Newly qualified midwives should be encouraged to be immersed within the NIPE immediately following qualification to ensure they retain the skills and confidence to continue the NIPE role within practice; delaying their role of practice supervisors of student midwives (NMC, 2018b), until the full consolidation of their own clinical practice has occurred.