The student population in higher education is becoming more ethnically diverse. Since 2003/2004, the proportion of White students has been steadily decreasing alongside a year-on-year increase of those identifying as Black, Asian and minority ethnic (Advance Higher Education (AHE), 2022). However, it is widely documented across all sectors that Black, Asian and minority ethnic students are less likely to achieve final first class/2:1 degrees at UK universities than their White counterparts (Gov.uk, 2022, AHE, 2022).
Over recent years, the UK government has demanded improvements to do more to close the gap in final grades. Reasons for the gap are multifactorial and are likely to include structural, organisational, financial and cultural attitudes (Singh, 2011; AHE, 2022). The ‘closing the gap’ report (Universities UK and National Union of Students, 2019) highlighted that there is an urgency to improve the curriculum of all university courses to address issues of diversity, equality and discrimination. Midwifery educators and stakeholders are being urged to decolonise midwifery education by removing the Eurocentric lens that currently dominates most curriculums (Royal College of Midwives (RCM), 2023).
Although some headway may have been made in addressing these issues, there are concerns that interventions to address the current disparity are predominantly university campus based (Nightingale et al, 2022). However, over their degree programme, midwifery students spend learning time in both the placement area and the university setting (Nursing and Midwifery Council (NMC), 2019). Grades awarded in both areas can contribute to a student's final degree classification at the end of the programme, and both are therefore essential to understanding attainment gaps. The practice-based assessment requires students to integrate their skills and knowledge into clinical practice. As the student gathers experience, they are evaluated by midwives with assessor status (NMC, 2018; 2019).
Historically, it has been reported that assessment grades awarded by healthcare professionals in the placement area can be variable (Alpine et al, 2021). Between 2018 and 2019, the NMC (2019) reported that 90% of midwives working the UK identified as White, 4% as Black and 6% of another ethnicity. The lack of diversity in the workforce is known to contribute to disparities in maternal health (Knight et al, 2021). Recommendations are in place from professional bodies involved in maternity care to raise awareness of the explicit and implicit racial bias that exists; the NMC (2021), RCM (2023) and the Royal College of Obstetricians and Gynaecologists (2023) address negative stereotypes and beliefs about race, and how these impact the care provided to women. Despite this, nurses and midwives continue to experience racism in practice (Ford, 2021) and students are thus likely to have similar experiences. What remains unknown is ‘how’ or indeed ‘if’ ethnicity impacts assessment outcomes for midwifery students when in placement, who are being assessed by a predominantly White workforce.
The preliminary findings of the author's wider doctorate work (in press at the time of writing) identified that ethnicity has a significant impact on final degree attainment, with Black, Asian and minority ethnic students being much less likely to achieve the highest grades compared to White students. However, it is unknown if this is true throughout the degree programme and which part of the midwifery student assessment contributes to this phenomenon. Better understanding of student performance as they progress through the course, and specifically how they are marked and assessed in their practice placements (which is largely outside university oversight), may identify where key interventions are needed to ensure equitable and fair assessment for all.
This study explored whether the attainment gap in final grades was the result of Black, Asian and minority ethnic students not performing as well as White counterparts in practice placement settings.
Terminology
The term Black, Asian and minority ethnic has been used in this research. However, it is acknowledged that there are challenges in using homogenous language. Black, Asian and minority ethnic is a term that can be seen as too general and groups together all those who are Black, Asian and minority ethnic British. No disrespect or offence is intended, and it is acknowledged that language and terminology will evolve beyond publication of this work.
Methods
A retrospective cohort observation study was carried out at a UK university in the south of England. The sample included all students who entered the BSc (Hons) 3-year midwifery programme between 2014 and 2018.
Data collection
Anonymised data were retrieved from the university student record system, which tracks each individual student journey from the point of admission to the course through to graduation. Over the 5-year period, 332 students were enrolled, with those who completed the degree included in the analysis (n=248). Two further students were removed from the dataset, as one had missing assessment outcome data and another had not disclosed ethnicity.
The main outcome measures used for this study were yearly university assessment grades and practice-based assessment grades. The university grade was derived from a 30-credit written assessment anonymously marked and moderated by university lecturers. The practice-based assessment grade was derived from a practice assessment document graded in practice by registered midwives.
Data analysis
The practice assessment document was graded by midwives in practice with a holistic assessment descriptor. The descriptors for overall student performance ranged from ‘excellent’ to ‘unsatisfactory’. Each descriptor had a percentage mark attached to it, which was the mark awarded for the assessment. The following system was used: ≥70% was categorised as first class, 60–69% was a 2:1, 50–59% was a 2:2, 40–49% was a third class. Statistical comparisons were done using the Statistical Package for Social Sciences programme (version 29) through Chi-squared analysis, with P<0.05 used to indicate significance.
Ethical considerations
Ethical approval was granted from the University School Research Ethics Panel (approval number: ESC-SREP-21-094) to explore entry route, student demographics and final degree outcomes in the cohort of students. To explore specific assessment outcomes, the university Research Ethics Panel was approached following initial findings (in press) for a significant amendment to the initial application. Approval was granted (approval number: ETH2223-10509). The ethics panel did not require individual consent to be obtained from the students, because of the size and nature of the study.
Results
Cohort demographics
A total of 246 students were included in the analysis, with 192 identifying as White, 29 identifying as Black and 25 identifying as another ethnicity, including Asian, mixed ethnicity and Arab.
Initial analysis used descriptive statistics to analyse the whole cohort, with final grades year on year in the university and practice module recorded for each student. The findings are shown in Table 1. In the practice module assessments, students performed consistently well, with most students receiving a grade of 2:1 throughout the 3 years (year 1: 91.5%, year 2: 98%, year 3: 100% respectively). However, many students were awarded a first-class grade in the cohort. Therefore, further analysis was performed to identify if there was a difference in the number of first-class grades for the practice module, compared to a grade of 69% or below. It was identified that 47.6% of students in year 1 achieved a first-class mark, 68.7% in year 2 and 92.3% in year 3. Chi squared analysis identified that this finding was statistically significant (P<0.0001).
Table 1. Yearly grade awarded in practice assessment document and university theory module
| Assessment mark awarded | Frequency, n=246 (%) | |||||
|---|---|---|---|---|---|---|
| Practice assessment document | University theory module | |||||
| Year 1 | Year 2 | Year 3 | Year 1 | Year 2 | Year 3 | |
| First or 2:1 | 225 (91.5) | 241 (98.0) | 246 (100.0) | 141 (57.3) | 134 (54.5) | 132 (53.7) |
| First | 117 (47.6) | 169 (68.7) | 227 (92.3) | 85 (34.6) | 73 (29.7) | 68 (27.6) |
| 2:1 | 108 (43.9) | 72 (29.3) | 19 (7.7) | 56 (22.8) | 61 (24.8) | 64 (26.1) |
| 2:2 or third | 21 (8.5) | 5 (2.0) | 0 (0.0) | 105 (42.7) | 112 (45.5) | 114 (46.3) |
| 2:2 | 19 (7.7) | 2 (0.8) | 0 (0.0) | 53 (21.5) | 50 (20.3) | 64 (26.1) |
| Third | 2 (0.8) | 3 (1.2) | 0 (0.0) | 52 (21.1) | 62 (25.2) | 50 (20.3) |
University assessment
Year on year, there was a significant difference in the academic performance of White students compared to Black, Asian and minority ethnic students (Figure 1). In year 1, more than half of White students scored a 2:1 and above, whereas only one in three Black, Asian and minority ethnic students received the same grade (P=0.0002). In years 2 and 3, the patterns were identical, with a definite difference in grades (P=0.0004 and P=0.005 respectively).
Practice placement assessment
In the clinical assessment modules, there was very little difference in students' scores, regardless of ethnicity, based on achieving a 2:1 grade or higher (Figure 2). Although it was slightly more likely for White students to be awarded a 2:1 grade in years 1 and 2, by year 3 both White and Black, Asian and minority ethnic students received a 2:1 or above in their clinical assessments.
Re-analysis using attainment of first class grades as an outcome measure
It was noted that most students achieved a 2:1 grade or higher overall in both university and practice assessments. To better delineate achievement, the analysis was repeated using attainment of first class grades as the outcome.
White students were statistically more likely to receive the highest scores compared to Black, Asian and minority ethnic students in university assessments (Table 2). This pattern continued across the 3 years of the midwifery programme. When measuring practice assessment performance, a difference emerged in students' scores by ethnicity, but only in year 1 (Table 2). Black, Asian and minority ethnic students were less likely to receive the top grade, with 53.1% of White students achieving 70% and above compared to 27.8% of Black, Asian and minority ethnic students (P=0.0009). In years 2 and 3, there were no observable differences. By year 3, all Black, Asian and minority ethnic students had achieved a first in practice assessments (Table 2).
Table 2. Final grades achieved in practice assessment document and university theory module
| Year and ethnicity | Frequency, n=246 (%) | |||||
|---|---|---|---|---|---|---|
| Practice assessment document | University theory module | |||||
| First class | Other degree | P value | First class | Other degree | P value | |
| Year 1 White students | 102 (53.1) | 90 (46.9) | 0.001 | 73 (38.0) | 119 (62.0) | 0.030 |
| Year 1 BAME students | 15 (27.8) | 39 (72.2) | 12 (22.2) | 42 (77.8) | ||
| Year 2 White students | 134 (69.8) | 58 (30.2) | 0.490 | 69 (36.0) | 123 (64.0) | <0.001 |
| Year 2 BAME students | 35 (64.8) | 19 (35.2) | 4 (7.4) | 50 (92.6) | ||
| Year 3 White students | 173 (90.1) | 19 (9.9) | N/A | 60 (31.3) | 132 (68.7) | 0.017 |
| Year 3 BAME students | 54 (100.0) | 0 (0.0) | 8 (4.8) | 46 (85.2) | ||
Discussion
The hypothesis for this study was that Black, Asian and minority ethnic students may not receive the same grades as White students in placement. However, the results do not support this, instead showing that Black, Asian and minority ethnic students perform comparably to their White colleagues in placement, with differences in grades instead seen in university work.
Ethnicity did not have an impact on overall practice assessment scores with a boundary grade of 2:1 and above. However, there was a significant difference in the distribution of first-class awards, but only in the first year of placement. Grades achieved in year 1 do not contribute to final degree classification at the end of the programme, and therefore do not contribute to the final degree awarding gap. However, there could be a possible impact on self-esteem and placement experience for Black, Asian and minority ethnic students. Previous qualitative research has shown that placement can be challenging for midwifery students from Black, Asian and minority ethnic backgrounds (Pendleton et al, 2022). Students may be concerned that they will not be welcomed or supported by midwives in practice because of the colour of their skin. There have been reports from healthcare students in placement of racism, discrimination, trauma, cultural and religious microaggressions and a sense of not belonging, which have been found to impact mental health and experiences in placement settings (Pryce-Miller et al, 2023; Walker et al, 2023; Ramamurthy et al, 2023). It has been identified that for students to feel accepted in NHS culture, they must adapt quickly to meet cultural norms (Rojo et al, 2020). If this is the case, then students are adopting the ‘expected’ behaviour in the early part of the course and are increasingly able to perform well in the current system. Further qualitative research is needed to identify these results on a larger scale, to see if similar findings are apparent in similar populations. However, it is encouraging to see, from the data in this study, that Black, Asian and minority ethnic students are overcoming the challenges that are in place during the first year of placement and are demonstrating an ability to perform equally well, if not better than, White counterparts by the end of the course. This should provide a level of confidence for midwifery students from Black, Asian and minority ethnic backgrounds in a climate where placement has been a concern.
However, urgent attention is required, as the findings from the present study expose stark differences in attainment for university-based assessments between Black, Asian and minority ethnic and White students. This is reflective of wider national university data (Universities UK and National Union of Students, 2019). The quantitative nature of this study does not explain why Black, Asian and minority ethnic students receive lower grades, and the cause of the gap is likely to be multifactorial. Developing and embedding an inclusive curriculum in midwifery education needs to be a priority. Diversity in midwifery cohorts is a key strength and addressing curriculum content and inclusive assessment design needs to be top of the agenda for midwifery course providers (RCM, 2023). There is a clear need to acknowledge the different learning styles, educational experiences, cultural capital and levels of confidence and self-esteem for those entering midwifery education (Office for Students, 2023). Universities and staff need to take a considered look at their curriculum and be encouraged to question current practice in relation to the diverse population that is needed in the midwifery profession.
Limitations
The nature of a retrospective observational method does not identify causality. Additionally, the sample involved students from one university in the UK, and therefore the data pool is small. The findings may not be generalisable and need to be replicated and validated in a larger scale study, involving cohorts from different universities and geographic locations.
Conclusions
Although universities in the UK are becoming increasingly vigilant, the rate of improving the attainment gap for Black, Asian and minority ethnic students is slow. In the cohort analysed at a single university in the present study, the current awarding gap for Black, Asian and minority ethnic students was the result of academic assessments, which take place in university, rather than those in placement. Targeted interventions from universities, course providers and midwifery lecturers are therefore urgently needed to address this.
It is reassuring that the present study's findings showed that Black, Asian and minority ethnic students were resilient in the practice area and performed equally as well as White students. Although the first year of the course may be challenging in the placement setting, any difficulties are quickly overcome. Black, Asian and minority ethnic students are equally likely to perform well in placement assessments as their White counterparts by the point of graduation. More research is needed to identify findings are similar in a larger cohort of students in different geographical regions.
Key points
- Black, Asian and minority ethnic students received similar grades as White students in practice-based assessments; although they received lower grades in the first year of the degree programme, their final practice-based grades were the same as White students.
- These findings suggest that Black, Asian and minority ethnic students are quicky able to adapt and improve in practice-based assessments.
- However, Black, Asian and minority ethnic students consistently received lower grades in university-based assessments compared to White peers, regardless of year of the degree programme.
- Closing the final degree attainment gap is likely to need a different approach to university-based teaching and learning.
CPD reflective questions
- How can midwives and assessors in the placement setting improve teaching, support and guidance for Black, Asian and minority ethnic students to ensure that the attainment gap is improved in the first year of degree programmes?
- How can education programmes be revised to help close the attainment gap in grades between Black, Asian and minority ethnic students and their White peers?
- What does an inclusive curriculum mean in the context of the findings from the present study?