Poor outcomes in maternity services have been well documented in the media, including examples such as the Morecambe Bay (Kirkup, 2015) and Shrewsbury and Telford (Ockenden, 2022) hospital trust investigations. More recently, the media has followed midwives speaking out about poor quality care and unsafe working conditions caused by the staffing crisis (Royal College of Midwives (RCM), 2023). The ‘March for Midwives’ movement highlighted how workload and poor working conditions impact quality of patient care (King, 2021), while the United Nations Population Fund (2021) estimated that there was a global shortage of 900 000 midwives. England alone has a shortage of 2500 full-time midwives (Bona, 2023). A UK survey of almost 2000 midwives reported that they experienced emotional distress, burnout, stress, anxiety and depression (Hunter et al, 2019). Two thirds (66.6%) of midwives had considered leaving the profession (Hunter et al, 2019).
The ‘Reducing Pre-registration Attrition and Improving Retention’ project reported that 11.5% of pre-registration midwives withdrew from their programmes between 2012 and 2015 (Health Education England (HEE), 2018). As part of this project, the National Education and Training Survey was launched to understand the factors that caused students to withdraw from their programmes (HEE, 2019). Twice a year, healthcare students are encouraged to complete these surveys and rate their training and education, with the aim of calling attention to areas that require improvement. In 2022, 58.3% of student midwives considered leaving their courses (HEE, 2022), although it is important to note that this was during the pandemic, when organisations and clinical supervisors were coping with additional demands.
The ‘impact of COVID-19 on student's survey’ was developed to explore how students experienced the pandemic. The 2022 report highlighted that 60% of student midwives considered withdrawing from their course, an increase from 41% who reportedly considered leaving in 2021 (HEE, 2022). A possible reason for the increased number of students considering leaving their course were that placements had been postponed in some cases, causing stress and worry about not being able to meet clinical requirements (Kuliukas, 2021). In addition, the NHS Resolutions (2023) ‘Being Fair 2’ campaign identified that bullying and incivility was prevalent among all NHS staff. Student midwives have echoed this, with 31.8% reporting negative experiences such as bullying and harassment (HEE, 2021).
Staff shortages in maternity services can have far-reaching consequences. Turner et al's (2022) scoping review examined the link between understaffed units and patient outcomes. The review concluded that neonates had an increased risk of neonatal resuscitation and admission to the neonatal unit. In addition, maternal outcomes such as postpartum haemorrhage and postnatal readmission were also increased. The Baby Loss and Maternity Report urged the government to take drastic action on the maternity staffing crisis because of its effect on the quality and safety of maternity and neonatal services (Sands, 2022). Patients reported feelings of abandonment and minimal support (Sands, 2022).
This study was carried out to explore student midwives' experiences of clinical placement, in order to elicit if, and how, students' experiences affected their decision to leave the profession during pre-registration programmes or at the point of registration.
Methods
Phenomenology is the study of lived experiences of human beings (Smith et al, 2009) and an interpretative phenomenological approach was chosen for this study to understand how student midwives experience clinical placement, how these experiences were interpreted by the students and how they influenced the decision to join the professional register. Interpretative phenomenological approach requires the researcher to interpret the participants' perceptions of their lived experiences and investigate further by reading between the lines of what participants say and how it is said, in a process known as double hermeneutics.
The study took place online using Microsoft Teams to interview participants from across England. The study was conducted online as a result of the imposed limited mobility during the pandemic and to ease participant recruitment.
Participants
The inclusion criteria for the study selected for students who were in years 1–4 of a pre-registration midwifery course and had been on clinical placement in England within the past 12 months. Participants were recruited via an online screening questionnaire link in an advertisement on the ‘Secret Community for Midwives in the Making’ social media platform. The group comprises 32 000 members who were either student, aspiring or newly qualified midwives. The page administrator (gatekeeper) posted the advertisement to all members for a 3-week duration. A total of 74 people completed the screening questionnaire, 68 wished to participate in the study and 67 included their email addresses. Each of the 67 participants were provided with a participant information sheet and consent form. Seven participants replied and returned their consent forms within the 3-week deadline.
Data collection
Semi-structured interviews were used to elicit participant experiences. The interviews lasted 30–45 minutes and were undertaken from October to November 2022. Participants were encouraged to engage in a flexible conversation with the use of open-ended questions, guided by an interview prompt schedule. The prompts included considering:
- Professional relationships
- Experience and support
- What potentially needs to be changed, if anything?
- How did that make you feel?
All interviews were digitally recorded and transcribed via Microsoft Teams. This platform was chosen as it met the university's ethical requirements. The rationale for its selection was that it:
- Was well-known to the researcher
- Enabled transcription and recording of interviews
- Had a chat function that enabled participants to send scans or photographs of documents, such as consent forms
- Was accessible to the participants and researcher with permissions later removed so only the researcher had access to the recordings and chat function.
Data analysis
The data were transcribed immediately during interviews, and were checked for accuracy and anonymised within 48 hours of the recording. Transcriptions were subject to an ‘exploratory commenting phase’ whereby what the participant said and the subject were designated as descriptive comments (Smith et al, 2009). Linguistic comments were made that focused on the words and language used to describe the subject, and conceptual comments focused on an interrogative and questioning approach of the subject (Smith et al, 2009). Identifying emergent themes from the transcriptions using descriptive, linguistic and conceptual comments was key to identifying whether the participants' experiences could be described as positive or negative.
Trustworthiness
Lincoln and Guba (1985) stated that trustworthiness in research evaluates its credibility and its aid to future research. They expressed that a research study's trustworthiness relied on four factors: credibility, transferability, dependability, and confirmability. The research supervisor had access to the anonymised data to independently check for interpretation to minimise bias. Acknowledging one's own bias before attempting to understand the experiences of others is recommended in Heidegger's theory of phenomenological analysis (Smith et al, 2009). Possible biases were articulated in a reflexivity diary and discussions with the research supervisor were documented to minimise bias while conducting this research. No participants were known to the researcher.
Ethical considerations
Ethical approval for this study was granted by the Ethics and Research Governance Online committee at University of Southampton (record: 75773) on 27 July 2022. All anonymised data were stored in a university shared file that was password protected and only accessible by the researcher and research supervisor. Data were stored in accordance with general data protection regulations (European Parliament and Council of the European Union, 2016) and the university data storage policy (University of Southampton, 2019). The interviews were only accessible to the researcher until all identifiable information had been removed to ensure participant confidentiality. Participants were given the opportunity to choose their own pseudonym and recordings were deleted when analysis was complete.
Because of the sensitivity of some experiences, participants were given the option to pause or discontinue throughout the interview. None of the participants chose to withdraw. The researcher recommended participants speak with professional midwifery advocates via their university or practice areas if they required psychological support.
Results
A total of 79 emergent themes were identified from the seven participant transcripts; these were categorised into five sub-ordinate themes (Table 1). From the emergent themes, two super-ordinate themes ‘kindness and compassion grows future midwives’ and ‘strength and resolve from COVID-19 and beyond’ combined into one overarching theme: ‘I can be a good midwife, when I qualify’.
Table 1. Super-ordinate and sub-ordinate themes
| Super-ordinate themes | Sub-ordinate themes |
|---|---|
| Kindness and compassion grows future midwives | Support from others |
| Self-reliance supports development | |
| Guardians for the future of the profession | |
| Strength and resolve through COVID-19 and beyond | Realities on the shop floor during a pandemic |
| Avoiding unprofessional behaviours |
Note: the complete list of 79 emergent themes within the sub-ordinate themes is available from the authors on reasonable request.
Kindness and compassion grows future midwives
This super-ordinate theme comprised three sub-ordinate themes and described experiences in clinical practice that made the participants feel appreciated, valued and respected, as well as successful in their role.
Support from others
Support from midwives, students and other healthcare professionals empowered students in practice, as well as providing them with the ability to support other students.
‘I always tend to have a good relationship with [midwifery support workers] because they appreciate were doing a lot of the same things, in terms of doing the little extra jobs, so I feel appreciated and I enjoy helping them’.
Mary
All participant felt that positive feedback from women, their families, supervisors and other healthcare professionals was a crucial factor to feeling like a ‘good midwife’.
‘A good experience of working with really amazing mentors…I'm making a difference to a lot of women and that's why I'm carrying on’.
Bella
Self-reliance supports development
Experiences of clinical practice, academic workload and personal life stressors led some participants to feel undecided as to whether to continue their programmes. However, all participants had distinct reasons for wanting to join the professional register.
‘I want to prove these people wrong. And it makes me want to carry on as a midwife, work my way up…be the next co-ordinator or manager’.
Bella
‘I'm really interested in student experiences. I want to be a student link or go into teaching in the future. So that's why I would need to keep going’.
Zara
Guardians for the future of the profession
Each new cohort of student midwives is named as the next generation of midwives; for the participants, this made them want to make a difference, not only in clinical practice but in midwifery.
‘I found with continuity, it's really nice to see those women and feel like you're making a difference and you're impacting their care positively’.
Rosie
One participant described their experience as mostly negative, but wanted to make a difference for future student midwives.
‘It makes you feel down, but I won't be like that. So, I change the experience of other students and you know, I know I can be a good midwife’.
Mary
‘If we leave, then nothing is going to bring the change’.
Zara
As part of one participant's programme, she had the opportunity to work in secondary and tertiary centres. These experiences affected her decision regarding her first post.
‘I changed to a bigger hospital, and I didn't find it as positive an experience. I like smaller trusts, it's personal. Midwives focus on you as a student… and [are] more willing to support you. Whereas the bigger trust…you felt like a little bit more like a number’.
Jade
Strength and resolve during COVID-19 and beyond
Two sub-ordinate themes made up this super-ordinate theme, which describes how each participant felt about staffing, workload and the pandemic.
Avoiding unprofessional behaviour
Encouragement to develop autonomous practice was a topic that most participants discussed, although some registered midwives did not encourage autonomy and this caused stress and frustration for the participants.
‘I'm having a delivery with one midwife. It's like “oh, why are you doing it like that? Don't do it like that! Oh just let me do it!”’
Mary
‘Nobody seemed happy to have a student. When one midwife said, “oh I will have her then”, you could tell that she wasn't as happy as some other midwives would be, to have a student's help’.
Zara
‘She completely looked past me and walked on, which I thought was really rude and it just made me think I don't want to work with this person’.
Bella
Realities on the shop floor during a pandemic
The pandemic put the healthcare professional community under strain. One participant discussed working conditions during the pandemic and how this caused doubt on whether she wanted to work in the NHS.
‘What kind of NHS are we going into? What kind of pressures are we going to have?…It's the workload and the conditions we will be working in, that's what put me off’.
Beth
Unfortunately, as a result of low staffing levels, one participant reported that they had an adverse incident, which made her question leaving the profession.
‘We were extremely low staffed…I really, really beat myself up about it, to the point that I thought to myself, I'm not coming back’.
Chelian
One participant observed that their supervisor could be emotionally overwhelmed by a mixture of workload and home life. As a result, the participant frequently revisited her decision to continue her course because she believed she would not be able to cope with the work demand.
‘One of my midwives who I was working with a lot…I would have seen her cry on shift about three times…it's the workload and the conditions I will be working in is what puts me off’.
Beth
Discussion
This study explored seven student midwives' experiences of clinical placement and their decision to join the professional register. The findings highlight how good working conditions and positive feedback encouraged student midwives to feel valued and appreciated as a team member. Similarly, Dewar et al's (2020) Australian study reported that student midwives emphasised wanting to feel included as part of a team with a recognised and valued contribution.
The COVID-19 pandemic had a profound impact on working conditions in maternity (RCM, 2020), that neither qualified nor student midwives had ever experienced (Hartz et al, 2022). The present study's participants stated that what they experienced was not what they had expected because of the pandemic's effect on healthcare systems. Some participants witnessed midwives crying daily because they were feeling overwhelmed. One participant believed that seeing her supervisors in such an emotional state made her concerned for her own mental health, and led her to consider leaving the profession.
Training during the pandemic may have given students a distorted view of what midwifery would look like once they qualified, which could have affected their decision to join the professional register. Unsafe staffing levels cannot be resolved without recruiting newly qualified midwives and other maternity staff, as voiced in the ‘three year delivery plan for maternity and neonatal services’ (NHS England, 2023). The plan promised service users and staff that appropriate staffing levels would be achieved by 2027/28, so that personalised safe, equitable care can be delivered (NHS England, 2023).
The report was ambitious and detailed numerous actions to be taken to improve services, although it did not specify how expectations will be met and what support will be needed to make these improvements sustainable (Sullivan, 2023). One of the plan's objectives was for NHS England to boost the midwifery workforce supply across undergraduate training, but it did not explain how. England's midwifery numbers rose by only 67 midwives in 2018, although 2000 student midwives qualified from English universities; this equates to one out of every 30 newly qualified midwives choosing to work for the NHS (RCM, 2018).
In the present study, participants reported that they felt fortunate that they were able to support women and families throughout pregnancy and the puerperium, irrespective of their negative experiences. This passion for midwifery should be celebrated, as students had to overcome virtual learning, lack of peer support, isolation and quarantine during the pandemic (Renfrew et al, 2020).
It is evident that student midwives can become confident, motivated and autonomous practitioners when maternity teams provide an inclusive, safe and supportive learning environment. If this is not provided, this creates a negative environment for midwives and student midwives, confirming the findings of the Kirkup (2022) report. This report found that unprofessional behaviour and cultures negatively impacted the midwifery workforce. Most of the experiences described by participants left them feeling appreciated, valued and respected (Kirkup, 2022).
Relationships among student cohorts in the present study demonstrated value when they could support each other. This reciprocal approach has been well documented as beneficial for students to develop independence and prepare them to take on more responsibility (Markowski et al, 2022). Ensuring that students feel counted as a valued member of the maternity team and are asked about their opinions regarding plans of care positively fosters safe working and quality care (Kitson-Reynolds et al, 2014; Ashforth and Kitson-Reynolds, 2019).
Strengths and limitations
This was a small undergraduate research project, which was therefore time limited. Having more time to dedicate to recruitment might have allowed more participants to take part in interviews. However, the interviews were in depth and offered participants the ability to discuss their experiences fully.
Interviews were conducted online, which was necessary because of the pandemic, and enabled a safe space where participants could discuss their experiences in absolute confidence. Future studies may benefit from conducting face-to-face interviews, which could provide a deeper perspective of lived experiences as the researcher will be able to visualise how questions and responses affect body language. Focus groups could also provide further security for participants to feel more able to discuss sensitive topics while being surrounded by people with similar experiences.
Conclusions
Student midwives need to feel like ‘a good midwife’ to motivate them to complete their training; this can be achieved through positive feedback from clients, families and supervisors. Peer support from other students is valued, especially when they can encourage and empower one another, but also when they need someone to talk to. Supervisors should encourage students to have autonomy and feel included as members of the team, in order to develop students' confidence. Although this research represents a small sample of participants, it provides insight into the student midwife experience. This research will be of value in growing the future workforce of students and midwives, but further research is needed for global dissemination.
Key points
- In 2022, 58% of student midwives reportedly considered leaving their pre-registration programmes, compared with 41% in 2021.
- COVID-19 potentially distorted perceptions of the future of midwifery for students, considering the working conditions and the impact it had on physical and mental wellbeing.
- Most of the seven participants interviewed in this study had positive experiences of clinical placement.
- All participants considered leaving their course, but had decided to continue with their training at the time of the interviews.
- Student midwives wanted to feel like ‘a good midwife’, to feel confident and competent at the point of registration.
- Positive feedback and a supportive learning environment motivated students to commence with and continue their training.
CPD reflective questions
- As a student midwife, what experiences have you had, and did you ever consider leaving midwifery?
- As a midwife, what could you do to enrich the learning experiences of student midwives you supervise while in clinical practice?
- What does it mean to you to feel valued, appreciated and included as a member of your team?
- What would you recommend to further enrich the clinical practice experience for student midwives?
- How did/would you feel if you experienced negative behaviour during clinical placement? Would you know who to talk to, should this occur?