Are educators and practising midwives working together to support the future workforce?

The changing role of practice in midwifery higher education

Prior to 2019, practice staff were largely involved in midwifery education through a ‘mentorship’ arrangement, which saw each student midwife assigned to a specific ‘sign-off’ mentor who they were required to work with for at least 40% of their practice placements (Nursing and Midwifery Council (NMC), 2008). The sign-off mentor was responsible for any assessment, grading or other evaluation of a student's proficiency in practice. While there were issues with this model, not least that it introduced an element of partiality when assessing and grading students (Chenery-Morris, 2021), there was evidence to suggest that it could also be positive for both students and staff in relation to continuity, feedback and planning (Chenery-Morris, 2015; Moran and Banks, 2016).

The Nursing and Midwifery Council (2023a) standards for student supervision and assessment were introduced in 2019, and changed this model so that students would be supervised by multiple practice supervisors and evaluated more objectively by a single practice assessor who would generally not be involved in the day-to-day supervision of the students they assessed. The standards model has undoubtedly ensured some improvements to both the student and midwife experience, particularly in relation to removing potential assessment bias as assessors are now further removed from the day-to-day supervision of students and this enables a more objective and holistic approach.

A 2023 efficacy assessment of the new standards used an evaluative survey of 48 practice supervisors and practice assessors to ascertain experiences of supporting pre-registration learners under the new part 2 standards across a range of health settings (Whaley et al, 2023). Three quarters (75%) of respondents reported perceived benefits and these related largely to practice supervisors and assessors reporting that the new model allowed more freedom to be involved in ensuring student growth and development, and that this could be a source of pride and professional fulfilment (Whaley et al, 2023).

However, the review pointed to more challenges than benefits, highlighting concerns around preparation of practice supervisors and assessors, prohibitive workloads and role conflict (Whaley et al, 2023). Crucially, bearing in mind the interplay between higher education and practice, not a single respondent in the survey mentioned academic assessor roles (Whaley et al, 2023), despite the significant part they play in collating and confirming student proficiencies, and despite the standards stating that practice and academic assessors must work closely together in evaluation of students (NMC, 2023a).

Research does not appear to have explored the effect of changing standards on academic assessor roles but there has undoubtedly been an impact. First, with an increased remit for most academics to take on an academic assessor role in triangulation of placement assessment, this has undoubtedly added to workload. Whereas lecturers may have already been responsible for signing off practice assessment documentation at the end of each academic year for their students, there is an increased workload associated with meeting the standards for student supervision and assessment standards. An academic assessor cannot confirm student progression for consecutive parts of the midwifery programme (NMC, 2023a). This means changing the students who are assessed and by whom each year; this is more than an administrative burden, it creates confusion among students between personal tutor, academic assessor, link lecturer, practice supervisor and practice assessor roles, particularly when these are changing frequently (McKelvin et al, 2023).

Additionally, with students reporting less relationship continuity in practice (McKelvin et al, 2023), it can appear that academics are also taking the bulk of the responsibility for the crucial job of supporting, nurturing and guiding students in practice as well as at university. With the removal of mandated ‘mentorship’ training, variability in knowledge, confidence and quality of those in practice assessor roles can leave academics called on to fill the gap by supporting practice supervisors and assessors who may not be clear on aspects of their role or responsibility. The comments in the Whaley et al (2023) study pointed to a feeling from participants that universities had the answers, and it was their responsibility to ensure all were confident and competent in their roles. Standardisation of practice supervisor and assessor training and preparation may go some way to improving this.

The regulatory requirement for midwives supervising and assessing students ‘that are at least equal to, or at a higher level than, the students’ (NMC, 2008) has been removed in the newer standards (NMC, 2023a). This may have compounded the variability in knowledge and confidence reported, as it eliminates the need for staff to continue their own credited learning and development. This may be reflected in the way that trusts and health boards are opting for non-credit bearing and cheaper courses for staff that do not exceed the £333 per person continuous professional development budget (NHS England, 2023). However, the reverse may also be true, and there is evidence to suggest that novice, rather than expert, midwives are better able to teach students and build relatability and belonging more effectively (Thomas et al, 2023).

Anecdotally, midwifery lecturer colleagues report that they are far more often called into practice or contacted to oversee problems in practice than they once were, and there is a feeling that colleagues in practice supervisor and assessor roles are less confident and, as a result, less autonomous, referring issues more consistently to higher education institutions to resolve rather than attempting to address them directly themselves. An NMC (2023b) insight report reinforces that this lack of confidence exists, finding that a minority of newly registered midwives may be ‘unhappy and underconfident’, and noted that this is more prevalent in midwives than nurses. While this lack of confidence for newly qualified staff may be part of transition and development into their new roles, it would be interesting to explore if it may also be symptomatic of the lack of continuity in supervision they experienced throughout their training that then negatively impacted their learning.

The student practice experience

The student experience of practice is also of concern. There is burgeoning evidence that students in higher education face a range of challenges, with students reporting experiences of racism, commented on in a previous article (Chenery-Morris and Divers, 2024a), poor mental wellbeing (Oates et al, 2019), lack of support and bullying (Simpson et al, 2023). A study of midwifery student experiences described the student experience as a ‘rollercoaster’, detailing the repeated ‘culture shocks’ that students experienced as they transitioned between different (and new) clinical placements, staff and situations (Oates et al, 2020).

There is also undoubtedly a very real and detrimental impact on students (as there is on clinical staff) of ongoing reports into the safety and efficacy of midwifery care, such as the recent Care Quality Commission (2024) national maternity review. Maintaining enthusiasm in a profession that is under constant public scrutiny and critique may be a challenge, particularly when a student's ability to influence this is limited. This contributes to the emotional toll on student midwives throughout their training, from various sources, resulting in a need for robust support that they may not be receiving in practice (Oates et al, 2019; 2020).

Research into the student experience of the standards for student supervision and assessment standards is fairly limited, although an exploratory study of 22 students and 13 midwives in practice supervisor/assessor roles highlighted some interesting findings (McKelvin et al, 2023). Both students and midwives reported a sense of being ‘thrown in at the deep end’ and wanting and needing more preparation and training for the practice and practice supervision experience. There was also a lack of continuity, with the majority of student respondents reporting that they had at least three supervisors each week, and a lack of time for education or feedback between students and practice supervisor staff. Those in practice supervisor roles reported not as actively participating in student education and, as they were supervising several students regularly, not being able to meaningfully contribute to their ongoing development in any continuing sense. One student reported that she does not ‘even bother asking [for feedback] as my supervisor is snowed’ and several student participants noted that they felt they were a burden to already overloaded staff (McKelvin et al, 2023).

This begs the question of where students are receiving support, ongoing development and a sense of belonging built from meaningful relationships where there are such reported challenges in practice. In addition to the regulatory requirements of midwives acting in practice supervisor and assessor roles, NHS trusts are also funded to provide pastoral and supervisory support to students via the education and training tariff (Department of Health and Social Care, 2023). In 2023/24, this constitutes an annual payment of £5343 for each full-time equivalent healthcare student from a list of professions that includes nursing and midwifery. The authors' local experience is that as tariff payments are combined and paid to ‘support all professions for which it has been allocated’ (Department of Health and Social Care, 2023), this can lead to greater investment in support services and more allocated practice education staff for larger programmes, such as nursing, and less allocated staff for student midwives.

Supporting students and performing essential tasks, such as off duty, is crucial but time-consuming work. Anecdotally, the authors have found that if there is no dedicated person with ringfenced time to perform these tasks in practice, they can fall either to already overloaded clinical staff who are unable to prioritise the work, or else to administrative staff who may not have the oversight of student learning needs or skills mix to appropriately plan student placements and allocate practice supervisors. The authors have also experienced frustration in being unable to ensure that tariff monies are being used to support midwifery students in practice when there is no dedicated resource, and have seen that higher education institutions have needed to step in to cover administrative tasks that they are not directly responsible for nor funded to complete (Department of Health and Social Care, 2023).

Higher education staff and practice

There is little evidence that captures the experiences of higher education staff in supporting midwifery students in academic assessor roles. What is known of the role and experience of academics supporting students arises from understanding the challenges that students are facing (including those in relation to practice), as these challenges dictate what is required and expected from staff.

Student mental health concerns are a growing concern, with the numbers of students declaring a mental health problem on entry to higher education more than doubling since 2014/15 to over 5% in 2020/21 (Lewis and Bolton, 2023). These statistics only reflect those who ‘officially’ declare a condition and a 2023 student survey reported much higher numbers; 57% of respondents self-reported a mental health issue and 27% of these reported that they had received a medical diagnosis (Student Minds, 2023). A nationwide survey of midwifery students in France (1920 participants) found that 10% of student midwife respondents were suffering from major depressive disorders and/or suicidal ideation and nearly half suffering from burnout (Frajerman et al, 2024). While this is clearly not wholly transferable to the UK context, it suggests that mental health is and should remain a key area of focus.

Midwifery education staff are left to support and promote the mental wellbeing of their students with little input from practice, despite many of the stressors in the ‘rollercoaster’ explored in this article arising from the practice environment itself. This can lead to educators taking on quasi-counselling roles, often without the necessary training. A good example of this is in the need to support students with specific practice needs, such as neurodivergence (Edwards et al, 2022). The previous article in this series mentioned how this support can be challenging for newer lecturing staff, particularly as they navigate the transition from clinical practice into education roles where they are expected to support students in a much more comprehensive pastoral way than they may have been used to (Chenery-Morris and Divers, 2024b).

Education staff are often tasked with ‘building resilience’ in student cohorts to equip them to endure the challenging practice environment (Williams and Hadley, 2022). They may also be tasked with developing self-compassion among students to cope with practice and academic pressures (Kotera et al, 2021). These tasks come at a cost, are usually additional to the core content of already crowded midwifery curricula and are often organised around core content, sometimes using a great deal of staff extra time and good will. Expansion of the professional midwifery advocate role in higher education may go some way to providing an alternate outlet for students to use for debriefing and finding support and this is being effectively implemented by several higher education institutions as a way of providing restorative supervision to midwifery students (Power and Thomas, 2018).

It can be frustrating for staff working in higher education institutions both to see the difficulties that students are experiencing in practice and to be held responsible for such issues when these are beyond the institution's control. ‘Off duty’ is a common but understandable issue for students, impacting the mainly female student body who are often charged with organising childcare around unpredictable shifts (Brook and Kemp, 2021). The responsibility for this crucial work lies with practice and is directly funded via the education and training tariff (Department of Health and Social Care, 2023), but is not always appropriately actioned or owned. With students not having a dedicated practice supervisor and/or available or allocated practice education staff to support them, the authors have found that complaints about issues such as off duty are directed to lecturers who are largely powerless to influence change. Self-rostering may provide some solution here and was used fairly effectively during the COVID-19 pandemic with student midwives and student nurses, who appreciated the flexibility that this afforded (Brook and Kemp, 2021; Fleming et al, 2022). However, it would require practice buy-in to operationalise this.

With 50% of midwifery student time spent in practice, student practice experiences heavily influence (if not dominate) overall assessment of student experiences of higher education. Evaluations such as the National Student Survey are key tools in reflecting on and improving higher education provision (and are also used to rank higher education institutions in numerous league tables). Yet midwifery (along with many other programmes where there are mandatory placements that constitute significant proportions of programmes) continually score lower among respondents than other subject benchmarks, particularly against the themes that relate to ‘academic support’ and ‘organisation and management’ (Office for Students, 2024). The National Student Survey questions and themes changed in 2022, so patterns over time are difficult to see, but Table 1 illustrates some data from the last 2 years for midwifery in comparison to all subject scores.

Data such as this can be incredibly demoralising for education staff who attempt each year to listen to student feedback and continually improve programmes. This is even more frustrating when qualitative student feedback (either via the National Student Survey or captured locally at module level) delineates practice problems that higher education institution staff have little control over. Relationships with practice could be seen to be key here, but sometimes there is no one with accountability for students in practice to discuss student feedback with.

The authors' practice

At the authors' institution, visits of link lecturers in practice have increased since the pandemic, ensuring a more consistent presence. Students are engaged in specific ‘practice reflection’ days during each of their placement blocks, specifically to reflect (often to debrief) on their experiences in practice. The curriculum has also changed to incorporate training on personal resilience and a partnership has been established with a local mental health charity to provide students with training on developing a ‘mental health toolkit’. The institution is also embedding the role of the academic professional midwifery advocate. However, the authors acknowledge that the work of student support takes a toll on academic staff that is over and above that needed to support a student in a non-health specific discipline and recognise that staff must be equally supported and nurtured.

Conclusion

The authors' lived experience and consideration of recent literature suggests that education staff and practice could work more collaboratively to train and support the future midwifery workforce, particularly since changing standards for student supervision and assessment from 2019. New standards may have removed partiality from the process of student assessment and have only been in use for 5 years, but have also introduced complexities for students, practice staff and academics alike. Higher education institution staff are then more heavily involved in the work of supporting students in both contexts, despite not always being funded or able to necessitate change when difficulties relate specifically to practice.

The solution to these issues is by no means clear. Practice learning partners must properly ringfence tariffs to ensure the organisation and management of student midwives in practice is appropriately supported. Higher education institutions should also think creatively about how to better support students in practice.

Key points

CPD reflective questions