Maternity care occupies different spaces in the public consciousness. For many, it is an essential and valued component of the NHS. However, in recent news and public media coverage, maternity has been criticised, with suggestions it is a broken public service (Lally, 2022; Lavallee, 2022; Vize, 2022). In particular, the consequences of serious failures in maternity care in the University Hospitals of Morecambe Bay NHS Foundation Trust and the Shrewsbury and Telford Hospital NHS Trust have dominated the news, captured in the Kirkup (2015) and Ockenden (2022) reports. The Morecambe Bay investigation uncovered failures and dysfunction at almost all levels in the organisation. A subsequent lessons learned review by the Professional Standards Authority (2018), independently commissioned by the Nursing and Midwifery Council (NMC), concluded that some of the investigative failures at Morecambe Bay reflected a culture at the NMC that focused on process over people (Seale and Killwick, 2019). All these concerns impact on the perception of professionalism in maternity care, a key characteristic that midwifery students are expected to develop in this challenging, contemporary context.
Professionalism in healthcare is multidimensional and socially constructed (Van De Camp et al, 2004; Martimianakis et al, 2009). Midwifery students learn about and adopt complex behaviours in a variety of organisational contexts. The present study took place between publication of the Kirkup and Ockenden reports, and before publication of the NMC (2019) standards of proficiency for midwives. The aim of the study was to explore how midwifery students define professionalism and how their professional identity develops during midwifery education. This was achieved through a conversation with final year midwifery students, captured in a performance of their words as poetry, as a novel approach.
Methods
Professional conversations
Qualitative research consists of a complex set of interpretative practices. A ‘performance turn’ has emerged in qualitative enquiry that is contributing to the reshaping of research methodology (Haseman, 2006; Denzin and Lincoln, 2018). In the present study, recognising the poetic quality of language, a conversation among a group of midwifery students was transcribed to capture the rhythm of the spoken word as a novel approach.
Midwifery students in the last year of their training were invited to participate in a group conversation about professionalism. Information about the study was made available to the 90 students in this group via an email from the leaders of the undergraduate and postgraduate midwifery programmes. Students were invited to contact the researchers to complete the consent process. Although one of the researchers was known to the students as a member of the wider midwifery teaching team, they were not currently teaching this group or a participant in any of their assessments. Nevertheless, the conversation was scheduled at a point when the students had completed all academic and practical components of their programmes to remove any notion of coercion.
Four students were successfully recruited, two from the undergraduate (BSc) and two from the postgraduate (MSc) programme. The conversation among the students and one of the researchers (a lecturer) was facilitated with a series of questions, in a semi-structured approach:
- How do you define the term professionalism?
- How has your view of what is professional changed?
- Do we need to define professionalism?
- How is professionalism explored in the curriculum?
- Does it transfer to practice?
Images were used to initiate and support the conversation. Apart from prompting with questions and images, the lecturer contributed little to the conversation. One researcher, who was not directly involved in the midwifery programmes, sat outside of the discussion group and transcribed the conversation ‘in the moment’ (Figure 1a). At the end of the conversation, the researcher performed the words back to the group as poetry (Figure 1b). After the performance, there was opportunity for further discussion among students and researchers (Figure 1c). The conversation before, and after, the performance was audio-recorded and transcribed. As all participants viewed that the performed words comprised a collective voice, they are reported in this paper without being attributed to individuals.
Data analysis
The entire conversation was transcribed in short phrases, with line breaks at natural speech pauses. The transcript was read and reread independently by the researchers and themes were identified, shared and discussed. Discussions between the researchers were recorded, transcribed, performed and further discussed. The summary themes were identified from these recorded discussions between researchers. A concept map was constructed from the full transcript, taken from the audio-recording, to confirm and refine these themes. The findings are presented as poetry, taken from the performance and the transcript, that reflects the dominant themes. Thus, while the words are from the performance, the themes they represent are those identified after the subsequent analysis, to reduce potential bias of the researcher who had captured the words and performed the poetry.
Ethical considerations
The research was carried out in compliance with relevant laws and institutional guidelines. Ethical approval was obtained from the School of Health and Life Sciences Ethics Committee, University of the West of Scotland (approval number: 8242).
Results
A group of final year midwifery students participated in the conversation about professionalism. When some of the conversation was performed by one of the researchers, there was consensus that the performance had impact and reflected the views of the group. This was captured in the ‘found’ poetry.
I was shocked by how powerful it was I wasn't expecting To be moved by it It is our words Not all of them are my words It's not clear who's saying what Other students Would they find it as powerful? Would they find themselves hearing their own voices? They probably would
In the discussion of the themes emerging from the conversation, the quotes presented are extracts from the participant words that were ‘performed’ to the students.
Midwifery spaces
Midwifery practice was seen as a room, a space into which students were entering. It was suggested that while desirable attributes might reflect individual personal beliefs, personal matters might need to be left outside that room, with the student needing, metaphorically, to clothe themselves differently in the organisation's space:
You have to step into a different pair of shoes You have to have your different hat on You're acting for an organisation And they're working to a set of rules and standards Part of you has to be outside the room
Having entered the midwifery space, students recognised that professionalism extended beyond that workplace and included social media spaces. This widening of the space where they were required to represent the workforce was somewhat unexpected, with one student remarking that ‘prior to that, I wouldn't have thought that your professionalism extended that far’. The students spoke of the university space as one in which they were treated as of central importance. In contrast, the practice space was seen as hierarchical, even determining their physical position, with students at the door and even ‘way, way out in the corridor, trying to listen in’.
In university You're told you're important In practice You're not Senior midwives sit Junior midwives stand Students stand at the door
This sense of being peripheral in the midwifery space was sometimes viewed as extreme.
And we sit just there as students And they just blank us We don't really exist when they're in their little chat It's horrible Not a nice place to be
Although there was agreement that students were often not deemed important, it was acknowledged that in some contexts, the environment was more nurturing. This was reflected in poetry about the midwives.
Support each other They cuddle the students in Know your name
It was regarded as particularly important that midwives should be able to create spaces with students, which they referred to as a ‘bubble’, for explicit reflection on practice.
And this midwife says “Don't do that” “Come with me” “Sit on a chair” And we sit And we have a full discussion about exactly what's happening
Thus, midwifery students who move between spaces in the university, practice and the wider community value personal spaces being created for tailored learning.
Bad professionalism
Students spoke of understanding professionalism by observing what it is not. There was agreement that in practice, it was often difficult to speak out against ‘bad professionalism’ and all that could be done is say ‘that's never going to be me’. Observation of inappropriate language in midwifery spaces was a particular example of what professionalism is not.
Words are power and affect people They can be flippant They can swear Everybody has their moments But it's unprofessional That kind of language In reference to colleagues Or the people that they're caring for
A description of a ‘fast midwife’, was offered as another example of ‘bad professionalism’. The found poetry was structured to reflect the staccato delivery.
Ticking those boxes All sorted Ticking those boxes And afterwards Get her up to the ward Quick as possible And get The bed Back
Students explained that an important driver for this behaviour was feeling that midwifery spaces are often closely watched. In response, the practitioner was seeking to do their work in an observably correct and efficient way.
Feeling A sister over your shoulder Keeping you in check You shouldn't have done this You should have done that Good thing or not They're really scared the sister's going to shut the door And tell them that they've done something wrong
The sense that the midwifery space was one that was constantly watched was a source of fear that recurred throughout the conversation.
In control but not controlling
While the importance of close supervision was acknowledged, it was felt that that it could be controlling.
Sisters Keep everybody safe That's their role The safety of Every Single Woman And the midwives as well But The safest thing to do Can also be Holding Power Over
As well as being a source of anxiety for midwives, the controlling environment was perceived as having the potential to take away from a woman's experience.
Being in control And being controlling Some people don't feel in control unless they are controlling To make their life easier Instead of the woman's
Later in the conversation, in expressing concern that students might need more support than some mentors were providing, it was suggested that lecturers might look over mentors' shoulders by dropping in unannounced, so that mentors would do everything ‘by the book’ in terms of their supervisory practice and role.
While images were placed on the table to facilitate discussion, they were rarely picked up and used to illustrate points in an explicit way. One image that was selected was that of an angry face, which was used to underpin a discussion of the importance of calm and control and how to achieve it. While the image was negative, most of the conversation was framed in positive language.
If you can't handle a situation When you see something wrong Instead of instantly reacting Keep everything factual Take the emotion out of it Just Take a breath Find a way to stay calm
We should make it more personal
The need to define professionalism was considered essential: ‘if you're ever going to hold someone to a standard then we need to know what that standard is’. Students referred to this as the code.
The code Seems like this big, long list of things Then out on placement It brings it all together It all Just Falls into place That's exactly right
The importance of creating closer connections between the university and practice spaces was highlighted. However, for students, being a midwife was much more personal, involving placing a woman at the centre and recognising her rights and the midwife's responsibilities.
I thought professionalism was Being strong Someone in power Everyone has their version of professionalism A list of things they would never do and things that they always do But It's caring for women Doing something good for your woman I'm allowed to be here I'm allowed to protect this woman Allowed to have the birth that she wants We should make it more personal We're all human
Students spoke about being on a journey towards greater autonomy in which they could work with women in a way that gave women more control. There was an emphasis on the individual experiences of students as playing a key role.
We all have different experiences It's your luck or not luck What message you're being fed Depending on your mentor Which classes you've been in Who you're working with And you're interacting with It depends on the student as well What they take on And what they don't take on Whether they take on good habits or bad habits
The group acknowledged the importance of understanding one's limitations as essential to being in control. Being able to ask for help was seen as vital.
I need some help from someone I'm at the end of what I can do This is my capacity
Walking in the door
A second image was used by one of participants, a photo of handprints clustered together.
Being professional is Being able to work in a team With respect Treating everybody that you work with Including every woman that you care for With respect
Respect and being respected, together, was one of three concepts they regarded important to professionalism. The other concepts offered as being of central importance were honesty and confidence. There was recognition that students, as future colleagues, should be treated and should see themselves in relation to these concepts.
The further you're walking in the door You don't have the dread and fear You're going to be confident and competent You're going to be treated as a professional Because that's how you have been treated When you step into being a fully-qualified midwife You're going to be a mentor yourself You're going to be educating people You're going to be nurturing people You need to do that with your colleagues as well Can professionalism be taught? Yes To a certain extent There's a professional language There are professional behaviours Competencies No To some extent You can't teach compassion You can't teach empathy Professional attributes Qualities that some people possess
Discussion
According to the literature, professionalism in midwifery is a multidimensional concept (Khakbazan et al, 2019). A range of themes identify the requirements for the professional. These include possession of discreet theoretical knowledge and professional skills (Butler et al, 2008; Halldorsdottir and Karlsdottir, 2011), an ability to communicate that instils confidence and mutual trust (Rogers and Ballantyne, 2010’ Renfrew et al, 2014) and delivering person-centred care in a compassionate and relationship-based way (Kennedy, 2000; Renfrew et al, 2014). The role of the team around the individual, responsiveness to public expectations, compliance with standards and commitment to their profession are additional themes that have emerged (Sanagoo et al, 2006; Wilkinson et al, 2009). Khakbazan et al (2019) suggested that these themes coalesce around three key domains: personal requirements, professional requirements and intraprofessional morality. Most recently, the notion of e-professionalism for nurses and midwives in the social media age has emerged (Griffin et al, 2021).
To add to this discourse, the present study explored the concept of professionalism through a conversation with final year midwifery students. The ideas generated were immediately performed to the group, using their own words, as poetry. While arts-based approaches, including poetry, are often used in research (Flores, 1982; Butler-Kisber, 2018), the present study's approach was unique in that it involved immediate transcription and presentation to participants. Poetic transcription was also used later in the research process to facilitate discussion of themes by the researchers. The performance was seen as valuable by the students, as they explained that it made their conversation a single voice that they thought was likely to be generalisable to others in their wider peer group. Furthermore, the use of a performance of poetry portrayed the ‘feeling’ of the words in a way that would not have been captured in a standard transcription. For this reason, the authors chose to present the findings in this article as poetry as well. Richardson (2001) argued for alternatives to writing as prose, which were ‘not the sole legitimate carrier of knowledge’. An additional strength of this approach is the possibility of evoking emotional responses that promote dialogue.
Students spoke of the different spaces they inhabit, and move between, in their journey to becoming midwives (Figure 2). They moved between university and practice, but also saw themselves as ‘always a midwife’ in their social lives and saw these spaces as interconnected. In stepping into the space of an organisation, students brought personal attributes but needed to leave some of the personal outside that room. However, in stepping into the private sphere, standards of professional conduct accompanied them.
Qualified midwives were viewed as models of good, but also bad, practice. Some of the bad behaviour was interpreted as a reaction to external forces, including the pressure of time and resources that influence institutional functioning. In a metasynthesis of midwifery students' practice experiences, Arundell et al (2018) identified experiences that were predominantly negative and profoundly influenced by workplace culture. In the present study, students spoke of watching role models but also of being watched, and the fear of inevitable childbirth complications and being judged by others as breaching ‘the code’. This reference is to the professional standards of practice and behaviour for nurses, midwives and nursing associates (NMC, 2018). Midwives' autonomy and ability to properly support the needs of ‘their woman’ were seen as constrained by these forces. The participants spoke of this being a source of fear and stress. There seemed to be a tension between the practice space being controlled by the midwives and being controlled by the woman, a dichotomy already identified from a sociological perspective for the ‘woman-centred’ practice paradigm (Sandall, 1995). This was not the student expectation for woman-centred care.
The participants spoke of the need to create closer connections between the spaces in which they were learning. In the conversation, it appeared that the connection between university and practice was through the students themselves. However, the participants did not make this explicit, but emphasised their more central and important role in supporting a woman's birth journey. Therefore, they felt these spaces needed to be imagined differently. Instead of focusing on them as physical spaces, they should be considered conceptually with the woman central to each of these. In the university space, for example, the idea of the woman's space and the relationship of the midwife to that space was discussed critically. University support was felt to help students to imagine aspects of their professional role that were then realised in practice. The practice setting drew on theories explored at university. This would suggest that bringing these learning spaces closer together requires a closer collaboration. The authors recommend that environments be co-created in an integrated fashion with a focus on the experience of the woman. There should also be consideration of the wider culture in healthcare and education spaces, which have an impact on the role models for future midwives. It is important that midwives and educators are aware of the influence workplace culture can have on the development of professional behaviours in student midwives. This research joins calls (Catling and Rossiter, 2020) for further research to be conducted in this area.
Limitations
While the message delivered by student voices is powerful, they reflect only a selection of voices occupying a limited space in midwifery. However, this is counter-balanced by the confirmation of those participating that the poetry captured their collective experiences and the similarities noted with the findings on culture and behaviour by both the Kirkup (2015) and Ockenden (2022) reports. The use of this methodology requires a researcher with the necessary skill to create poetry in the moment. Key characteristics of, and alternatives to, this approach will be the subject of future research writing.
Implications for practice and policy
In the context of the Ockenden (2022) report, the present study adds to this discourse in midwifery as it faces challenges that are damaging to the profession. Behaviours that have always been considered unacceptable continue to permeate these spaces. The findings of this study are of particular importance to any organisation delivering or supporting pre- and post-registration midwifery programmes. It highlights a ‘disconnect’ between the educational and practice spaces and reinforces the importance of their alignment to support midwifery students to develop as respectful professionals.
Conclusions
Despite its complexity, educational programmes often frame, and students see, professionalism as a list of individual attributes and behaviours. Midwifery students, however, see themselves as ‘always a midwife’ as they move between different spaces, from university to practice, and in their social lives. There are tensions between these spaces. There is a sense, from their experiences and observing the behaviour of role models, that midwives are constrained and made fearful by external forces, that limit their ability to properly support the needs of women in childbirth.
The use of poetry to uncover, capture, elucidate and communicate views is useful ‘in the moment’ for participants and in discussions between researchers. The use of poetry creates a ‘shared voice’ and allows emotions to be more authentically conveyed, adding to its power. The approach will also be of interest and value to educational developers, midwives in practice, and the wider community.
Key points
- The notion of ‘spaces’ in maternity care, both physical and conceptual, is important for policy developers, educationalists and researchers.
- Capturing the experiences of midwifery students as they approach the threshold of professional registration is helpful for educational programme design and delivery.
- Poetry facilitates research conversations and provides a powerful medium for thematic analysis and the dissemination of findings.
CPD reflective questions
- For midwifery students, consider the main findings of this study. How are these similar to your own experiences and how do they differ?
- For academic staff delivering programmes of midwifery education, do you effectively prepare students for the ‘real world’ of midwifery practice? What do you do well? What could be improved?
- For midwives supporting students in clinical practice, are these findings recognisable? If so, how can you address the points identified?
- For policy makers and midwifery leaders, how will you use this evidence, and that provided in recent service reviews, to positively influence and improve midwifery practice for all involved?