Producing competent health professionals is imperative for effective national health outcomes. Similarly, developing a qualified and competent midwifery workforce is claimed to be essential for effective maternal health outcomes (International Confederation of Midwives (ICM), 2010a). The ICM defines a midwife as ‘a person who has successfully completed a midwifery education programme that is duly recognised in the country where it is located’. However, there are global differences and similarities in the way pre-registration midwifery education is delivered. For example, pre-registration midwifery education in the UK is delivered as a 3-year programme (Nursing and Midwifery Council (NMC), 2015), while Brunei has a 4-year programme (Department of Nursing Services, 2014).
The World Health Organization (WHO) has advocated for the development of quality midwives by further strengthening midwifery educational institutions (WHO, 2008). It recommended that institutions develop and monitor their midwifery programme not just to produce quality midwives, but to also build the capacity of midwifery faculties (WHO, 2008). The United Nation's (UN) Sustainable Development Goal Three (ensuring healthy lives and promoting well-being for all at all ages) indicates that reproductive health care and reducing global maternal death rates are particularly important if this goal is to be accomplished by 2030 (UNFPA, 2017).
Brunei is a small South East Asian country with a population of 417 200 (Ministry of Health, 2015). The national birth rate is 16.1 per 1000 people and the total fertility rate is 1.9 (per the female population aged 15-49) (Ministry of Health, 2015). The Maternal Mortality Rate is low at 0.6 per 1000 live births and the percentage of deliveries by trained health personnel is 100%. The Infant Mortality Rate is similarly low at 8.8 per 1000 live births (Ministry of Health, 2015). However, to maintain these maternal health standards, it is still important to promote safe midwifery practice and to reinforce professional autonomy (ICM, 2010b). It is also a fundamental right for women to have competent midwifery care during pregnancy and childbirth (ICM, 2010a).
In this context, schools of midwifery have more responsibility to ensure that they are producing competent and high quality midwives. One way to do this is to enhance the midwifery programme by adhering to the Global Standards for Midwifery Education (ICM, 2010b). In an attempt to reduce dissimilarities and enhance global standards in midwifery care, the ICM published the Essential Competencies for Basic Midwifery Practice (ICM, 2010a) and the framework of the ICM Global Standards for Midwifery Education (2010b). Midwifery institutions around the world were advised to adhere to these standards in order to develop competent midwives. These not only act as framework but also set a benchmark for the institution's aim to provide high quality midwifery education according to the standards (ICM, 2010b). However, little is known about how these standards are met across the world.
Aim
This study aimed to assess the level of adherence to the ICM Global Standards of Midwifery Education in Brunei from the perspectives of student midwives and midwifery faculty members.
Materials and methods
Setting
This cross-sectional study was conducted among pre-registration student midwives (on both diploma and Bachelor's degree programmes) and members of the midwifery faculty at one of the national universities in Brunei that provides pre-registration (undergraduate) level midwifery education.
In 2009, a 4-year Bachelor's degree in health science majoring in midwifery was offered at the university. The programme included a ‘discovery year’ during the third year of study, which gave students an opportunity to study abroad to establish and develop global awareness. The programme is designed for students to attain the necessary core clinical and biomedical expertise with interdisciplinary emphasis. Students have clinical exposure and experience from early on in the programme. All programmes are conducted in English. The programme's entry criteria are: female candidates with a minimum of 220 UCAS points, or equivalent (a diploma in midwifery/nursing with or without post-basic or advanced diploma in midwifery or nursing). All candidates must also pass the ‘multiple mini interview’, in which assessments are conducted at different stations.
Sample
Before inviting participants to take part in the survey, inclusion criteria were established as follows: those who had agreed to take part voluntarily and were either students enrolled on the diploma or Bachelor's degree in midwifery programme, or members of the midwifery faculty within the university. Those who were no longer studying, teaching or working with the midwifery faculty in the university were excluded.
Data collection tool
For data collection purposes, an online questionnaire was devised to gauge the level of adherence to the ICM Global Standards framework. This questionnaire was developed based on the ICM Global Standards for Midwifery Education (2010b) by subject experts, who consisted of three senior lecturers (who were also registered midwives), and three researchers. The senior lecturers were also highly qualified in teaching higher education and possessed postgraduate qualifications in midwifery teaching as well as having worked in the field for more than twenty years.
The self-rated questionnaire evaluated the adherence of the ICM Global Standards based on participant's perceptions. There are six different categories of the ICM Global Standards, which were all included in this questionnaire. These are: organisation and administration; midwifery faculty; student body; curriculum; resources, facilities and services; and assessment strategies. Scoring was dependent on the type of response scale that each item represented. In this study, only the rating scale and multiple choice scoring are used.
For the rating scale, some questions are scored on a five-point Likert scale (1=strongly agree, 2=agree, 3=neutral, 4=disagree and 5=strongly disagree) to measure participants' perception of their institution based on the ICM Global Standards. Only one question was scored on a graphic ten-level rating scale (0=worst, 1=very poor, 2=poor, 3=significantly below average, 4=below average, 5=average, 6=above average, 7=significantly above average, 8=good, 9=very good, and 10=excellent) to discover the overall rating given by participants at the end of the questionnaire. This rating scale was calculated as a median as it used ordinal data (where the ordering of the label matters due to the rank) (Allen and Seaman, 2007), whereas the multiple choice type was scored by giving a score of 1 for each statement selected and 0 for any that are not selected. In terms of the calculation, the mean was calculated as it was considered nominal data and a dichotomous result (University of California, Los Angeles, 2017).
For ordinal data, the result was classified according to the rating, i.e. 2.00 denoted a majority ‘Agree’ with the particular question. For the nominal data, the result was categorised according to the mean result, with 0.50 taken as the midpoint. Scores below this indicated that the result was below average and scores above indicated that the result was above average. Results closer to both extremities (0 or 1.00) denoted either lowest or highest agreement with the question respectively. The link for the survey questions was distributed to participants via the website Qualtrics.
A pilot study was carried out to identify any possible issues that may have arisen with the questionnaire. If any were present, these could be rectified at an early stage. The pilot study was carried out among ten respondents who were recruited through convenience sampling within the university's midwifery faculty. To simulate the data collection, respondents consisted of five students and five faculty members. The pilot study data obtained is not included in this study. During the pilot study, a panel of three expert analysts, consisting of senior midwifery lecturers, were given the questionnaire to ensure face validity (Shuttleworth, 2017).
Data from the pilot study were also used to carry out the Cronbach's alpha test in order to test the instrument's reliability. This was imperative, as the instrument was not validated, and was developed by the research team based on the ICM (2010b) Global Standards of Midwifery Education. Following the test, the internal consistency of the whole questionnaire was found to have a Cronbach's alpha coefficient (a) of 0.85. This result indicates a high degree of internal consistency for this study's instrument (Tavakol and Dennick, 2011).
Data analysis
The data gathered were then analysed using SPSS v21. Respondent demographics (Table 1) were assessed according to their own variables, which were all categorical. The variables were: gender, age group, position, programme level, country's name, education level and knowledge on ICM. For the questionnaire scores, descriptive statistics were carried out to calculate both mean and the median. To compare the total mean score between students and faculty members, an independent t test was conducted as normality assumption was satisfied.
| Variable | n (%) | n (%) |
|---|---|---|
| Students (n=29) | Faculty Members (n=10) | |
| Age group (years) | ||
| <20 | 3 (10.3) | 0 (0) |
| 20–30 | 20 (69.0) | 0 (0) |
| 31–40 | 4 (13.8) | 0 (0) |
| 41–50 | 2 (6.90) | 6 (60.0) |
| >51 | 0 (0) | 4 (40.0) |
| Gender | ||
| Male | 0 (0) | 0 (0) |
| Female | 29 (100) | 10 (100) |
| Position | ||
| Student | 29 (100) | 0 (0) |
| Midwifery lecturer/teacher | 0 (0) | 9 (90.0) |
| Administrator | 0 (0) | 1 (10.0) |
| Programme level | ||
| Diploma | 20 (69.0) | 3 (30.0) |
| Bachelor | 9 (31.0) | 4 (40.0) |
| Master | 0 (0) | 3 (30.0) |
| Highest education attainment | ||
| Higher secondary | 16 (55.2) | 0 (0) |
| College | 11 (37.9) | 0 (0) |
| Bachelor's degree | 2 (6.90) | 3 (30.0) |
| Master's degree | 0 (0) | 7 (70.0) |
| Higher education | 0 (0) | 0 (0) |
| PhD | 0 (0) | 0 (0) |
| Country | ||
| Brunei | 29 (100) | 10 (100) |
| Knowledge of ICM Global Standards for Midwifery Education | ||
| Yes | 27 (93.1) | 9 (90.0) |
| No | 2 (6.90) | 1 (10.0) |
Ethical considerations
The data collection was carried out in February 2017. The research was given ethical clearance by the University Research and Ethics Committee before the study was conducted. Although funding was received from the host university, the funding agency had no role or influence on the study or results. Participation in this study was entirely voluntary and consent was obtained from participants at the beginning of the study. A participant information sheet provided participants with the study's overview and assured confidentiality.
Results
The midwifery student and faculty member response rate to this study was 92.9%. A total of 39 participants were recruited out of 42. Of these, 29 were students, 20 (69.0%) of whom were diploma level and 9 (31.0%) were Bachelor's degree level). All the participants were female. Among the students, 10.3% were less than 20 years old; 69.0% were 20-30 years old; 13.8% were 31-40 years old and 6.9% were 41-50 years old. The highest educational attainment for the students varied, from higher secondary (55.2%), college (37.9%) to Bachelor's degree (6.90%). With regards to their knowledge in ICM Global Standards, 93.1% declared that they were aware of it and 6.90% had no knowledge. This demographic information is presented in Table 1.
Demographic characteristics of faculty members are also presented in Table 1. There were 10 participants from this group, 100% of whom were female. Of these, nine were midwife lecturers or teachers and one identified as part of the administration. In terms of the programme level that they were associated with, 30% were diploma level, 40% were Bachelor's level and 30% were Masters level. The participants' ages ranged from 41-50 years (60.0%) to over 51 years old (40.0%). Their highest educational attainment ranged from Bachelor's degree (30.0%) to Masters degree (70.0%). When asked on their knowledge of the ICM Global Standards for Midwifery Education, 90.0% were aware of it, whereas 10.0% were not.
The overall evaluation of ICM Global Standards for Midwifery Education can be broken down further according to the different domains of the questionnaire. These were: institution's organisation and administration; institution's midwifery faculty (including midwife teacher's competency and midwife clinical preceptor/teacher/mentor qualification); student body (including admission policies, student policies, student support and student candidate admission); institution's curriculum (including programme purposes and curriculum elements); resources, facilities and services; and assessment strategies. The results for both students and faculty members are shown in Table 2.
| Variable | Students (n=29) | Faculty Members (n=10) | ||
|---|---|---|---|---|
| Mean (SD) | Median (IQR) | Mean (SD) | Median (IQR) | |
| Institution's organisation and administration | 2.00 (0.50) | 2.00 (0.13) | ||
| Institution's midwifery faculty | ||||
| Midwife teacher's competency | 0.46 (0.33) | 2.50 (1.00) | 0.72 (0.37) | 2.00 (0.63) |
| Midwifery clinical preceptor/teacher/mentor qualification | 0.45 (0.30) | 0.68 (0.35) | ||
| Student body (admission policies) | ||||
| Student policies | 2.00 (0.25) | 2.00 (0.25) | ||
| Student support | 2.00 (1.00) | 2.00 (1.00) | ||
| Student candidate admission | 0.57 (0.18) | 2.00 (1.00) | 0.65 (0.24) | 2.00 (0.25) |
| Institution's curriculum | ||||
| Programme purposes | 0.48 (0.31) | 2.00 (0.25) | 0.73 (0.36) | 2.00 (1.00) |
| Curriculum elements | 0.52 (0.25) | 0.70 (0.33) | ||
| Resources, facilities and services | 2.00 (1.00) | 2.00 (0.00) | ||
| Assessment strategies | ||||
| Assessment strategies | 0.58 (0.37) | 2.00 (1.00) | 0.76 (0.35) | 2.00 (1.00) |
SD=Standard deviation; IQR= Interquartile Range
For students, their overall evaluation for the institution's organisation and administration median was 2.00 (interquartile range (IQR)=0.50) and similarly, for faculty members, the median was also 2.00 (IQR=0.13). Results for this category indicated that both the students and faculty members agreed that the midwifery programme's organisation and administration adhered to the ICM Global Standards.
Students rated the institution's midwifery faculty slightly lower, with a median of 2.50 (IQR=1.00), while faculty members rated it at median 2.00 (IQR=0.63). This indicated that students rated adherence to the ICM Global Standards in this particular category to be between ‘agree’ and ‘neutral’, instead of fully ‘agree’, as the faculty members did. The midwife teacher's competency and midwife clinical preceptor/teacher/mentor qualification were also analysed under this category. For the midwife teacher's competency, students evaluated it be slightly below the midpoint with a mean of 0.46 (standard deviation (SD)=0.33). Faculty members, on the other hand, rated it a lot higher at a mean of 0.72 (SD=0.37). The same trend was observed for the midwife clinical preceptor/teacher/mentor qualification, which students rated lower, at mean of 0.45 (SD=0.30), while faculty members rated it higher (mean=0.68; SD=0.35). Both results signified that faculty members firmly agreed that the programme adhered to the ICM Global Standards in these two components, whereas students did not. In general, this specific domain does not score well among the students in this study.
For the category of student body, the components of admission policies and student policies were rated to be similar by both students and faculty members, with medians of 2.00 (IQR=0.25) and 2.00 (IQR=1.00), respectively. The same is found with the student support component, which students evaluated with a median of 2.00 (IQR=1.00) and staff at 2.00 (IQR=0.25). These results imply that for these components, both groups agreed unequivocally that the programme adhered to the ICM Global Standards. Students and faculty members rated the student candidate admission component about the same, with means of 0.57 (SD=0.18) and 0.65 (SD=0.24), respectively. This result suggested for this particular component, both groups agreed (although not as firmly as the other three in this domain) that the programme complied with the ICM Global Standards.
The institution's curriculum was another domain that was thought to fulfil the ICM Global Standards by both students and faculty members, who rated the mean to be 2.00 (SD=0.25) and 2.00 (SD=1.00) respectively. There were discrepancies, however, within the components of this category. The programme purpose was rated higher by faculty members (mean=0.73; SD=0.36), compared to students (mean=0.48; SD=0.31). The same was also observed with the curriculum elements, which faculty members scored higher (mean=0.70; SD=0.33) compared to students (mean=0.52; SD=0.25). From these findings, it is implied that the institution curriculum generally adhered to the ICM Global Standards; however, students believed that the specific programme purposes component did not.
Students rated the programme's resources, facilities and services with a median of 2.00 (IQR=1.00) and faculty members rated it similarly, with a median of 2.00 (IQR=0.00). This indicates that both groups perceived the programme's resources, facilities and services to comply with the ICM Global Standards.
For the assessment strategies category, both students and faculty members evaluated the domain to have a median of 2.00 (IQR=1.00), whereas for the assessment strategies component, students rated it to be a mean of 0.58 (SD=0.37) and faculty members rated this much higher (mean=0.76; SD=0.35). Although both groups agreed that the domain mostly adhered to the ICM Global Standards, students did not rate the assessment strategies component as highly as faculty members.
Overall rating of the midwifery programme
The overall student rating for the programme was a median of 6.00 (IQR=3.00). This result signified that students generally rated the programme to be ‘above average’. For faculty members, the median overall rating was 7.50 (IQR=1.25), which indicated that they rated it to be between ‘significantly above average’ and ‘good’. These figures are presented in Table 3. The results indicated that both students and faculty members perceived the whole programme to be satisfactory, however this finding resonates with the key findings trend stated above, that students tend to rate most domains lower than faculty members in this study.
| Group | Median | IQR |
|---|---|---|
| Student | 6.00 | 3.00 |
| Lecturers/administration staff | 7.50 | 1.25 |
IQR= Interquartile Range
ICM Global Standards mean score differences between students and faculty members
For the total mean scores between both groups, Table 4 shows that their difference was not statistically significant (P=0.562). Therefore, it can be concluded that there was no significant association between the total mean score of the ICM Global Standards and participant groups.
Discussion
To the best of the authors' knowledge, this is the first study that has assessed the level of adherence with ICM Global Standards of Midwifery Education in any country from the perspectives of student midwives and midwifery faculty members. According to the student group's demographic characteristics, more (69.0%) students were enrolled at diploma level compared to the Bachelor's degree (31.0%). There are a few possible reasons for this, one of which is that most (55.2%) students' highest educational attainment was higher secondary, hence they were unable to be enrolled directly on to the Bachelor's degree. Moreover, the higher entry requirement for the Bachelor's degree compared with the diploma programme may have caused these results (Department of Nursing Services, 2014).
Although the faculty members were highly qualified, most (40%) were teaching on the Bachelor's degree programme rather than on the diploma (30%), on which most of the students were enrolled. This may unbalance the ratio of student to academic staff, which could be unfavourable in maintaining an engaging and interactive teaching environment (Minsky, 2016). The student-to-faculty-member ratio has been used widely as a key measure for higher education provision (Court, 2012). This metric is therefore important for universities to increase their position in the university rankings at a global level. In terms of gender, the sample used in this study used only female students and faculty members. This may be due to patients preferring to have female staff around them due to cultural norms and religious beliefs, which may be the case in Brunei, where 83% of the population is Muslim (United States Department of State, 2012). Other studies have also found that patients prefer to have female staff attending them during childbirth in both Muslim and non-Muslim countries (Bashour and Abdulsalam, 2005; Reitmanova and Gustafson, 2008).
Regarding the knowledge of ICM Global Standards for Midwifery Education, both groups stated that most (93.1% of students and 90.0% of faculty members) were well-informed, suggesting a high level of knowledge of this framework. Although students knowing the standards of the education they should be receiving is an advantage, this knowledge is crucial for faculty members, as it will act as a benchmark for them to deliver high quality midwifery teaching based on standardised global expectations (ICM, 2010b).
These findings suggest that both students and faculty members scored the ICM Global Standards equally, finding only slight differences. The highest difference between students and faculty midwives was found in the scores for the category of midwifery faculty, which included midwife teacher competency and midwife clinical preceptor/teacher/mentor qualification. Faculty members rated this considerably higher in terms of adherence to the ICM Global Standards compared to the students. Reasons for this possibly lie in the presence of response bias, where participants might score such components more highly for reasons of social desirability (Winter, 2010), or that perceived competency and reported educational attainment are subjective matters, which may have resulted in the difference of opinions. This is reflected when analysing the highest educational attainment of the faculty members, who are considered to be highly qualified (70% with Master's and 30% with Bachelor's degree).
Conversely, categories such as institutional curriculum and assessment strategies were considered to fulfil the ICM Global Standards. This is because although these domains were evaluated through their median values, the scores were uniform across both groups (i.e. both agreed that these categories adhered to the standards), whereas when assessing the mean values there were discrepancies between both groups. Faculty members were more inclined to score the components of the two categories much higher than students, which could be explained by the fact that the faculty members were better-versed on the programme compared to the students. This is especially true as the components involve curriculum and assessment, on which faculty members are expected to be experts (Wingate, 2012).
In other domains, including institution's organisation and administration; student body (admission policies); and resources, and facilities & services; both students and faculty members were in agreement. All three categories suggested that on organisational level, this programme's standards were on par with the ICM Global Standards to produce competent midwives with a solid foundation in midwifery practice (Adegoke et al, 2013). This indicated that half of the main categories strongly adhered to the ICM Global Standards according to both groups, which was further supported by the independent t test, which showed no significant difference between groups for the ICM Global Standards total mean score.
Overall programme rating
The programme's overall rating is the benchmark for this survey's result and provides an indicator of participant satisfaction with the programme (Williams and Mindano, 2015). Similar to previous results, faculty members rated it to be slightly higher, median=7.50; IQR=1.25), compared to students (median=6.00; IQR=3.00). Considering the overall programme rating score from both groups, it can be said that the whole programme was perceived to be satisfactory; however, neither group rated this programme to be near the maximum (i.e. excellent), which signifies that more could be done to improvise this. Initiatives could be taken to increase adherence to the ICM Global Standards, which would constitute an effort towards better provision of a quality midwifery programme.
Study limitations
This study has the following limitations. Firstly, convenience sampling methods were used. Although other sampling methods that provide better quality control were available, such as random sampling (Rossi, 2010), this was not possible, due to the small number of participants within one selected faculty. Nevertheless, more than 90% completed the questionnaire. Secondly, internal recruitment may have jeopardised the student's score due to bias. The programme leader sent an invitation letter to all students and staff to participate, and as an indication of respect for the leader and teacher in Asian culture, the study almost reached maximum sample size. Another limitation that might impact the scope of study findings was that students may have been less familiar with their curriculum and assessment methods according to the ICM standards in comparison to faculty members. Consequently, they may have struggled to complete the questionnaire. Finally, students have different expectations of their course, which in itself is also subjective, so this may have also affected the study findings.
Conclusion
This study showed that the level of adherence level to the ICM Global Standards of Midwifery Education in Brunei was satisfactory, according to faculty members and student midwives. The study also determined that there was no significant difference between these groups in terms of the ICM Global Standards score.
Recommendations
To maximise adherence to the ICM Global Standards, our study suggests several recommendations. In-house faculty-competency development programmes could be introduced to promote competency and credentials of the faculty members. Additionally, faculty members could also actively engage their students on the programme curriculum and assessment strategies to enable them to better understand the outcomes of the midwifery curriculum. Moreover, future comparative research is needed at a global level on ICM standards adherence in order to find out where midwifery education in Brunei Darussalam stands at a global level.