Leadership and management are part of the core foundational skills required for all midwives, as they dictate the ability to provide quality patient care (International Confederation of Midwives, 2023). Leadership in midwifery requires mastery of skills such as critical thinking, delegation, prioritisation, and problem solving. In contrast, management skills require proficiency in resource management, staffing and providing training for newly graduated midwives or midwifery students. These skills not only enhance an individual's professionalism and proficiency in delivering quality patient care but also contribute to better team performance, and improved teamwork, morale and team dynamics (Beiboer et al, 2023). This, in turn, leads to more positive outcomes for patients, including women, children and families.
Graduating midwives are expected to lead healthcare teams in their units. This necessitates strong leadership skills, such as critical thinking, decision making and effective communication. Being a good leader and manager requires extensive exposure and early training in the clinical setting. This prepares students for the dynamic nature of the role. Early exposure fosters familiarity with the ever-changing demands of leadership and management, enabling midwifery students to embrace these roles more adaptively and efficiently upon graduation. However, limited training or experience in the clinical setting can leave midwifery students unprepared, leading to ‘culture shock’, where they feel overwhelmed by unexpected challenges (Mitha et al, 2021). Culture shock is defined as a feeling of disorientation, inadequacy and anxiety caused by the significant differences between the academic environment and the realities of the clinical setting (Mustafa, 2022). This feeling is common among midwifery students, who may be given significant leadership and management responsibilities with little preparation or understanding of their expected roles and responsibilities (Mustafa, 2022).
Midwifery preparation in Brunei vs the UK
In Brunei, midwifery students are trained in both theory and practice. Students are required to spend up to 4 months in clinical placements to enhance their leadership and management skills. In the hospital setting, students are expected to oversee approximately 20 cases each of antenatal and postnatal patients. Students are involved in up to 40 cases of labour and birth, including caesarean sections, vaginal examinations and suturing, among other procedures. In the clinical setting, students are expected to manage around 30 cases each of antenatal bookings, postnatal visits and home visits. Collectively, students are mandated to accumulate an average of 2000 hours in a clinical placement, during which the majority of midwifery skill development occurs. Leadership and management training takes place in the final year of training, where students are exposed to theoretical aspects of leadership and management, including theories, historical perspectives, techniques and responsibilities.
Notably, in Brunei, the regulation of midwifery practice is governed by local health authorities, potentially influenced by Islamic principles and cultural norms. Therefore, midwives in Brunei may need to navigate sensitivities and religious considerations when providing care, respecting local traditions and beliefs. Conversely, UK midwives work in a multicultural society, necessitating sensitivity to a wide range of cultural practices and beliefs. This diversity requires UK midwives to adapt practices and communication styles to effectively meet the needs of culturally diverse patients and their families.
This study aimed to determine the extent to which culture shock impacts midwifery students’ preparation for leadership and management. Additionally, it explored how midwifery students overcome culture shock in the clinical setting to develop their skills.
Methods
This qualitative study assessed final year midwifery students’ involvement in leadership and management modules during their course, and their experiences during clinical placement. The study used a qualitative narrative approach to explore participants’ perspectives, adopting a social constructivism paradigm where the researchers acknowledged the interconnected nature of participants’ experiences during clinical placement, considering the diverse interactions between students, peers, patients and the healthcare team. Recognising that these variables offer unique perspectives, the study aimed to gain a deeper understanding of participants’ experiences.
Participants
Participants were purposively chosen for this study, and were final-year midwifery students from Universiti Brunei Darussalam undertaking a leadership and management module. The university's assistant registrar acted as a gatekeeper for recruiting participants by sharing information about the study with students. Before participating, eligible midwifery students were briefed on the study's purpose.
Data collection
A total of 47 midwifery students met the criteria to participate, although four students declined to take part. The evaluation session took place at the conclusion of the leadership and management modules in May 2023.
The 43 students contributed written evaluation essays reflecting on their overall experiences. The essays had no word limit or restrictions and were written in English. This method was chosen to allow participants to express their thoughts, feelings and experiences in their own words and at length. This provides deeper insights into participants’ perspectives, motivations and reasoning behind their experiences. Through the essay, participants had the freedom to respond in a way that felt comfortable and natural, allowing for a diversity of responses. This flexibility can uncover themes or issues that might not have been anticipated by the researchers (Dahl et al, 2023).
The essay was not part of the students’ assignments, but an optional addition that did not affect academic results or overall performance. Participants were given 1 day to write their essays, which were deposited in a tray outside of the researcher's room at the university. Collection was done at a separate time to avoid unnecessary encounters between the researchers and participants.
Data analysis
The participants’ essays were thematically analysed systematically to identify patterns of similarity or contrasting perspectives, following Braun and Clarke's (2006) guidelines. To ensure reliability and minimise bias, essays were independently coded and categorised by the researchers using a pre-developed coding manual. The manual provided clear guidelines and definitions for each theme, ensuring consistency and inter-coder reliability. Regular inter-coder reliability checks were conducted to verify the accuracy and consistency of the coding process. After coding, the researchers convened to discuss and refine the identified themes, ensuring that they accurately captured the essence of the data. The decision-making process was documented to enhance transparency and allow for replication of the study. Throughout the analysis, meticulous records were kept to provide a detailed audit trail, enabling other researchers to examine the methodology and verify the findings.
Reflexivity and bias
To mitigate power imbalances between the researcher and the students, the researcher used bracketing and limited unnecessary interactions beyond the research scope with the participants. Before the study began, participants were fully briefed regarding the nature of the study, its processes and how the data would be used. This ensured full transparency and consent. During data collection and analysis, the authors acknowledged and validated the voices of the students, their experiences and perspectives. The authors are graduate students of the institute and an assistant professor of the institute engaged in frequent discussions with the authors as a reflexive means to ensure that the results were derived purely from the participants’ feedback, without bias, manipulation or influence from the authors. The essays were anonymous, allowing participants to feel more comfortable sharing sensitive or personal information. This can lead to more honest and candid responses, reducing the potential for social desirability bias.
Ethical considerations
The study was approved by the Institute of Health Sciences Research Ethics Committee (reference: UBD/PAPRSBIHSREC/2022/143). Informed consent was obtained from all participants. Students were invited to join voluntarily, with the assurance that opting out would have no negative repercussions or penalties. Participants were assigned codes to facilitate the data analysis and informed that the data would be anonymous.
Results
Thematic analysis revealed several key themes focused on the factors contributing to culture shock among the participants, along with recommendations for how to mitigate it.
Limited skills and experience
Overall, 35 participants highlighted that they experienced culture shock when placed in clinical settings with leadership and management responsibilities. These roles required skills that felt new and intimidating. Their limited prior exposure and hands-on interaction with the healthcare system left them feeling unqualified and hesitant to take on leadership responsibilities.
‘I faced new challenges like critical thinking, task delegation and prioritisation skills, which felt overwhelming and intimidating. Limited prior experience in healthcare made me feel unprepared and unsure of my abilities’. P2
Lack of time for skill development
Another major reason for culture shock was the limited time to practice leadership and management skills. The time limitations restricted opportunities to fully embrace their roles and receive comprehensive evaluations.
‘Many of us experienced culture shock because we didn't have enough time to practice leadership and management skills during our clinical placements. The short duration of these placements limited our chances to fully learn these roles and get proper feedback. Developing good leadership skills requires more dedicated training and real-world experience in leadership roles, which we often didn't get’.P3
Time management and competing demands
Other responsibilities, including academic assignments and personal matters, further limited time to fully immerse in leadership roles. This highlighted the importance of strong time management skills in preventing culture shock.
‘Balancing academic work and personal obligations leaves little time to fully focus on leadership roles. Good time management is key to avoiding culture shock. It's important to have enough time to learn the clinical environment, understand the team dynamics and get familiar with the facilities for practicing leadership skills. This orientation phase usually takes weeks to feel comfortable delivering patient care and applying what we've learned effectively’. P20
In total, 25 of the participants emphasised the need for time to familiarise themselves with the clinical environment, including understanding team dynamics, familiarising themselves with the facilities and identifying available resources for practicing leadership skills. The extended orientation phase allowed them to build trust with the team and gain a comprehensive understanding of the workflow, ultimately fostering a smoother transition into leadership roles.
Aside from balancing personal obligations and achieving learning objectives during clinical placements, participants also encountered instances where the healthcare team instructed students to participate in routine tasks alongside the team, rather than giving them opportunities to develop leadership and management skills.
‘The focus on routine tasks often overshadowed the opportunities for leadership and management development. While these tasks are essential, I believe a more balanced approach would allow students to gain valuable experience in both areas’. P21
Unfamiliar teams and dynamics
Another factor contributing to culture shock, as highlighted by 10 participants, was navigating unfamiliar healthcare teams.
‘Adapting to new healthcare teams has been a big part of my culture shock. Learning to lead effectively—delegating tasks, communicating well and solving problems—depends on building trust with healthcare professionals. It's crucial to create a strong team bond, feel confident in leading and prioritise everyone's wellbeing’. P30
Effective leadership required a rapport between students and healthcare professionals. Building a strong team dynamic, fostering confidence and understanding the team's wellbeing were the foundation for developing skills.
Theory vs. reality: the gap between the classroom and clinical setting
Half of the participants reported a significant discrepancy between the skills and knowledge learned at the university and what they encountered in the clinical setting.
‘There's a big difference between what we learn in class and what we experience in clinical settings. The clinical environment is always changing due to things like ward rules, policies, how leaders manage, team dynamics and the types of patients we have to take care [of]’. P27
The clinical environment was dynamic and influenced by a multitude of factors, including the specific needs and routines of each ward, established policies and protocols that may differ from classroom learning, leadership styles that can vary depending on individual midwives, existing team dynamics that required students to integrate themselves effectively and the diverse range of patient types encountered. Each of these elements presented unique challenges for students to understand and navigate effectively.
Recommendations for bridging the gap: gradual introduction and enhanced training
Despite theoretical and practical preparation, the participants struggled to translate skills into real-life settings, for a variety of reasons.
‘Even though I've been prepared well in theory and practice, I find it hard to use my skills in real clinical settings. The limited time, resource differences and diverse work cultures add to the challenge’. P8
Many participants suggested a gradual introduction to leadership and management roles and recommended focusing on improving preparation to translate skills and knowledge into clinical practice.
‘I think starting with leadership and management roles gradually could help us understand the clinical environment better and adapt more effectively. This could also prepare us for challenges and lessen the culture shock’. P8
The role of simulation in building confidence
Simulations were recognised as a positive teaching method for improving practical skills, including leadership and management.
‘Simulations are helpful for learning practical skills like leadership and management, but they need to be more realistic to prepare us better for real clinical work. They give us a chance to practice these skills before we start in clinical settings. I think more frequent simulation sessions would really improve our readiness and give us more practice in a safe environment’. P16
Almost all of the participants emphasised the need for more realistic simulations to effectively translate learned skills into clinical practice. The majority appreciated the positive impact of simulations and expressed a desire for more frequent sessions to provide opportunities for practice in a safe environment.
Discussion
This study explored midwifery students’ experiences of clinical placement, highlighting the range of factors that contributed to culture shock among students experiencing practice for the first time. The students noted that their limited experience of leadership and management responsibilities, a lack of time and their unfamiliarity with the healthcare teams significantly contributed to feeling unprepared and overwhelmed. They expressed a desire for more simultion-based training, to prepare them for practice, and a more gradual introduction to the practice environment, to allow them time to adapt to the new setting.
Factors contributing to culture shock
Existing research highlights the challenges of transitioning from theoretical knowledge to practical application in healthcare settings (Fauzia Masroorianissa et al, 2024). Factors contributing to culture shock among midwifery students included feeling unready to adapt to the clinical setting, where they faced challenges related to patients, healthcare teams, resources and the working environment. Students facing culture shock may feel conflicted as they struggle to balance their idealised expectations of midwifery practice with the challenging realities of fast-paced and resource-limited clinical settings (Shamoradifar et al, 2022). This can cause feelings of inadequacy, self-doubt and confusion about their role in the healthcare team.
A lack of awareness makes it difficult for students to navigate the clinical environment and requires them to spend more time familiarising themselves with their surroundings. The initial struggle to familiarise themselves with the setting, routines and team dynamics can lead to information overload. This subsequently adds challenges to processing new information effectively and retaining essential knowledge related to patient care (Lovin et al, 2023). Furthermore, the challenges of navigating an unfamiliar environment can impair student confidence and hinder their ability to actively participate in learning opportunities in the clinical setting. The process of becoming familiar with the environment consumes time and energy, diverting their focus from achieving their learning objectives and potentially leading to poor time management (Amoo and Enyan, 2022).
The initial adjustment period can exacerbate time management difficulties for students. This may lead to prioritising immediate tasks at the expense of critical reflection, independent learning and in-depth analysis, which are essential for fostering clinical development (Arundell et al, 2024). Poor time management can also lead to confusion and miscommunication between the student and healthcare team, causing additional stress and challenges related to poor communication (Shamoradifar et al, 2022). This can intensify feelings of inadequacy and impede comprehension of complex concepts.
Midwifery students may be faced with unclear roles and responsibilities. Misaligned expectations between the student, mentor or healthcare team can create misunderstandings, as students may end up performing tasks unrelated to their learning objectives (Reime et al, 2022). This can limit a student's sense of agency and leave them feeling unsure of their expected contributions. As a result, they may feel hesitant to take the initiative or struggle to identify opportunities to apply their theoretical knowledge to real-world situations (Amoo and Enyan, 2022).
Some students highlighted that they spent the majority of their clinical placement time performing routine tasks rather than focusing on the leadership and management aspects of patient care. The emphasis on routine tasks suggests a gap between student expectations and practical experiences. This may hinder the development of essential leadership and management skills, potentially leading to feelings of dissatisfaction and discouragement.
A common issue among students and healthcare teams is a poor understanding of the purpose of clinical placement, often stemming from miscommunication (Almukdad and Karadag, 2024). Students may not fully comprehend what they need to achieve during their clinical placement (Almukdad and Karadag, 2024). When both students and the healthcare team lack a clear understanding of the goals and expectations, it can lead to unrealistic expectations and ultimately hinder the learning experience. Students may enter their placements unprepared for the realities of the clinical environment, while the healthcare team may have unrealistic expectations of student capabilities. This miscommunication can create confusion, frustration and contribute to feelings of culture shock.
Having the right attitude and taking clinical placement seriously can play a crucial role in shaping a positive and resilient mentality for students (Dugué et al, 2021). Students who approach their placements with a positive mindset, seeing challenges as chances to learn and develop, are more capable of handling unexpected situations. This attitude helps them build self-confidence, believing in their capacity to learn and adjust (Haywood et al, 2021). Cultivating a growth-oriented mentality enables students to perceive setbacks as temporary obstacles on their journey to professional growth. These optimistic perspectives empower students to develop effective strategies for managing stress and difficulties in clinical settings (Kuipers and Mestdagh, 2023). Ultimately, a resilient mindset enables students to recover quickly from setbacks and maintain a constructive outlook throughout their placements, facilitating a smoother transition and minimising the effects of cultural adjustment.
Countering shock with familiarity
Cultivating familiarity with the practice setting can mitigate feelings of culture shock during placement, enabling students to adapt and become more versatile in different working conditions (Arundell et al, 2024). It is important to provide students with enough time to adjust and orient themselves to the specific workplace culture. This allows students to properly adapt and transition into the working environment (Sweet, 2019). By becoming attuned to the available resources, facilities and staff beforehand, students experience a sense of comfort and reduced anxiety when they formally begin their placements. This allows them to focus on learning and actively participating in clinical experiences (Haririan et al, 2022).
The opportunity to familiarise themselves with the environment and the people in it allows students to establish trust and rapport with the healthcare team. This facilitates communication, which is essential when students need to develop leadership and management skills that require strong interpersonal communication, such as delegation, liaising with the multidisciplinary team and problem solving (Mustafa, 2022). Allowing students time to familiarise themselves with the new working environment also enables the healthcare team or mentors to adjust to the addition of the student (Lovin et al, 2023). This allows the student to contribute to the best of their abilities and provides opportunities for task delegation and adjustments to leadership styles, facilitating the development of leadership skills. Time for adjustment allows mentors to effectively assess student needs and tailor their guidance and support to individual learning styles. This adaptable approach allows students to develop their leadership skills while still maintaining the team's overall effectiveness (Kuipers and Mestdagh, 2023).
Grounded reality-based simulation
In addition to clear communication and early exposure during clinical placement, another effective approach to promoting familiarity for midwifery students is simulation. Simulation involves practical, hands-on training, allowing students to practice and refine their skills, including leadership and management, in a safe, supervised and informative environment (Folkvord et al, 2023). It serves as a means to assess competency and prepare students before clinical placement.
During simulation sessions, midwifery students can develop leadership skills at their own pace and receive valuable feedback from supervisors, lecturers or peers on the skills they perform. This feedback enables students to learn from each other, understand different approaches and receive insights on the effectiveness of their methods (Koukourikos et al, 2021). Simulations provide students the opportunity to apply knowledge and skills they have learned in a practical context, preparing them for their placement in clinical settings where they may encounter similar issues as those in simulation scenarios (Moloney et al, 2022). It is crucial for simulations to be realistic and applicable to the student's context. Dramatic or unrealistic scenarios may fail to prepare students effectively, as they may not reflect the scenarios or events that they are likely to encounter in the clinical environment (Changuiti et al, 2021). Simulations should be designed to be relevant and realistic, ensuring that students can effectively translate the skills they learn to real-life settings. This enhances their readiness and ability to handle situations they may face during clinical placement (Pajohideh et al, 2023).
The more simulations that students participate in, the more likely they are to familiarise themselves with the skills they need to develop (Changuiti et al, 2021). This can reduce culture shock once students are placed in clinical settings, as they will already be accustomed to the skills they are expected to demonstrate. During simulations, equal opportunities must be provided to all students to ensure equal learning opportunities and understanding (Moloney et al, 2022) and avoid bias, unfairness or unpreparedness. Simulations improve students’ readiness and adaptability to perform well in clinical settings, ultimately reducing culture shock (Baayd et al, 2023).
Emotional and psychological preparation
It is crucial to provide students with opportunities to express themselves emotionally and psychologically. It is well-established that midwifery education can be challenging, often involving crucial moments in patients’ lives when emotions are heightened (Bingham et al, 2023). It is important that students have a channel where they can professionally express their feelings and concerns and seek guidance. This allows students to overcome challenges in the clinical setting, maximising learning opportunities without jeopardising their placement. Providing emotional and psychological support is essential for students’ wellbeing and resilience as they navigate education and training (Kuipers and Mestdagh, 2023).
Emotional intelligence revolves around self-awareness, particularly regarding one's own emotions and their impact on interactions with others, especially patients. It emphasises the ability to remain calm under pressure, understand the emotional state of patients and collaborate effectively with the healthcare team to deliver optimal care (Dou et al, 2022). Being emotionally intelligent is highly beneficial for students, as it encourages the motivation to strive for continuous development of leadership and management traits (Haririan et al, 2022). This emotional awareness prevents feelings of helplessness or hopelessness when they are not supervised or guided by a mentor, healthcare team or supervisor. Emotional intelligence also enhances an individual's sense of empathy and understanding, which is crucial in providing care to patients and communicating effectively with the healthcare team (Haywood et al, 2021). This development shapes the individual to be a better leader with a strong sense of awareness and an understanding of the needs and welfare of both individuals and the team (Dou et al, 2022).
Having a platform where students can discuss their thoughts and reflect would significantly reduce the burden, stress and academic workload typically associated with high workloads, personal responsibilities and the pressures of clinical experiences (Yu et al, 2021). Allowing students to feel and express themselves provides a cathartic release (Haywood et al, 2021). This platform is especially useful when students feel intimidated, confused or experience culture shock in an unfamiliar environment with little preparation. It promotes a supportive environment where students can openly discuss their feelings and concerns, ultimately fostering a healthier and more productive learning experience (Dugué et al, 2021).
Implications for practice
Academic educators should prioritise lesson plans that better prepare students to face the challenges of clinical placements. Collaborating with clinical supervisors or mentors in the clinical setting could help establish mutual understanding and consensus on expected learning outcomes for midwifery students. Policymakers in clinical settings should also be mindful of factors that hinder student learning experiences, such as issues related to resources, staff training, communication and orientation. Addressing these issues will enhance student learning experiences and readiness, enabling both students and healthcare teams to maximise leadership and management skill development.
Given that cultivating the right attitude can enhance students’ learning experiences during clinical placements, academic educators should prioritise training students to be mentally and emotionally prepared. Practices such as reflection, critical thinking and feedback sessions are effective pedagogical methods to help students mentally prepare for anticipated challenges in clinical settings. Policymakers should invest in training mentors and healthcare workers to ensure that they have the necessary tools and resources to effectively educate students during their clinical placements. This training should encompass effective communication and the ability to manage student training and supervision simultaneously, ensuring efficiency in clinical practice.
Academic educators play a significant role in improving the delivery of simulations to enhance midwifery students’ competency in leadership and management before clinical placement (Moloney et al, 2022). There should be a greater emphasis on curating simulation scenarios that reflect real-life settings and increasing the frequency of simulation sessions. This maximises learning opportunities for students and ensures equitable learning outcomes as they prepare for leadership roles in clinical settings.
Limitations
The study's main limitation is its small sample size, which may not accurately reflect the learning needs and opinions of the entire midwifery student population, especially those from other institutions. Students at different institutions may have received different training and had varying exposure in clinical placement.
While all participants emphasised the need for better preparation to combat culture shock, gathering feedback from other stakeholders could add significant value to the findings. This could include healthcare workers, educators, mentors and students from other institutions. A wider range of perspectives would enhance the generalisability of the research.
Recommendations
Further research is recommended to gain a more in-depth understanding of the culture shock experienced by midwifery students. Studies exploring the perspectives of healthcare workers, educators and students from other institutions could be beneficial. This broader approach would help identify optimal strategies to prepare midwifery students for clinical placement.
Conclusions
Although midwifery students understand the importance of leadership and management as part of their preparation to become competent and flexible midwives, they still reported the need for more learning opportunities and exposure, guided by mentors, to ensure comprehensive and productive clinical learning. The students also highlighted the importance of having mentors who are capable of addressing learning needs and are trained to lead and manage, allowing students to replicate and apply their knowledge and skills competently.