The increased recognition of midwives as lead professionals in low-risk pregnancy and birth, and the proliferation of midwifery-led units within the NHS, have raised the profile of midwifery in the health-care setting in recent years (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010; Sandall et al, 2016). However, Wilkins (2010) has argued that while midwives have rejected the medicalisation of childbirth, they have not truly recognised their unique professional role and moulded new ways of inter-professional working. If midwives do not nurture and embrace inter-professionalism, there is a risk of increased tension, conflict and potential indecision between colleagues arising from changes to the traditional medical dominance that has previously existed in maternity care (Reiger and Lane, 2009). Recent findings from the Kirkup report unearthed the dangers of poor relationships between midwives and doctors where a ‘them and us’ culture of behaviour existed, leading to catastrophic breakdowns in communication in the maternity care setting (Kirkup, 2015: 13). Responsibilities for partnership working are reiterated in the Nursing and Midwifery Council (NMC, 2015) Code, to ensure effective care-giving and emphasising the need to respect colleagues' roles and expertise.
Evidence supports the assertion that health professionals who are able to communicate and work effectively together, and who have a mutual respect for and understanding of one another's roles, will ultimately provide a higher standard of care (McPherson et al, 2001; Royal College of Obstetricians and Gynaecologists and Royal College of Midwives, 2008; Begley, 2009; World Health Organization, 2010). The integration of inter-professional learning into an undergraduate curriculum can improve students' abilities to interact professionally and provides greater insight for students into relationship roles in the workplace than uni-professional education (Meterko et al, 2004; Pollard and Miers, 2008; Siassakos et al, 2009; Wilhelmsson et al, 2011; Murray-Davis et al, 2012). Students who have not been exposed to inter-professional learning have a greater inclination to ‘tribalism or professional protectionism’ which disregards other professional opinions (Barnsteiner et al, 2007: 144). This could further contribute to a divisive ethos of patriarchal practice and, ultimately, to the detriment of the service user experience.
Introducing inter-professional simulation education has been suggested to reduce stereotypical views and promote better understanding of the respective roles of professionals, in addition to enhancing future collaborative practice (Ateah et al, 2011; Liaw et al, 2014). Incorporating inter-professional education (IPE) into the university setting is logistically challenging, owing primarily to the competing demands of separate educational curricula and the differing sizes of student cohorts. A further challenge is striving to ensure equity of experience for all students. A small team of midwifery lecturers and medical colleagues met to explore ways of promoting inter-professional learning and overcoming some of these barriers in the university setting. During the course of these discussions, it became clear that fourth-year medical students, during their obstetric placements, found the experience of caring for women in normal labour both daunting and stressful. Feedback indicated a degree of disturbed relationships between medical students and midwifery staff, suggesting that the medical students were unclear about their role within the childbirth setting. Medical students were unsure how to engage with women, their partners and midwives in this intense, busy clinical setting.
It was felt that providing an opportunity for medical students and midwifery students to interact and commu nicate prior to the undertaking of an obstetric placement in a labour ward environment would help to improve the overall student experience and potentially enhance inter-professional relationships. Midwifery students would benefit from the opportunity to teach and facilitate learning in relation to normal labour and birth, while medical students would benefit by learning about the process of childbirth and familiarisation with the birth environment. This opportunity could provide midwifery students with a positive, confidence-building forum where the utilised teaching and learning strategies would be transferable both to their professional role as registered midwives and in their health-promoting role through providing parent education to women and their partners. Equally, medical students would be supported to understand their role and feel comfortable with assessing and supporting women in normal physiological labour (Table 1).
| Medical students | Midwifery students |
|---|---|
| Improve interaction and communication | Improve interaction and communication |
| Improve understanding of other professional roles | Improve understanding of other professional roles |
| Improve placement experience | Provision of an opportunity to teach and facilitate learning |
| Learn process of normal birth and familiarisation with labour ward environment | Provide a positive confidence-building forum |
| Improve confidence level to perform | Develop transferable skills |
Methods
An innovative inter-professional teaching strategy was developed by the midwifery teaching team in consultation with medical colleagues. Final-year midwifery students have, by this stage of their education programme, had exposure to facilitating normal birth in the labour ward environment and are working towards autonomous midwifery practice. The midwifery students were provided with the opportunity to introduce concepts of normal labour and birth via an interactive simulated workshop to fourth-year medical students who were about to embark on their first clinical placement in a maternity unit. The midwifery students had an outline agenda of key issues, such as promotion of woman-centred care and relationship building in labour; however, they were encouraged to use their own creativity in how this was translated to the medical students. The key focus of the workshops was that they would be participatory and interactive. During the planned workshops, the final-year midwifery students provided an interactive labour and birth scenario whereby various roles—including the woman, her partner, the midwife and a narrator—were adopted. A member of the midwifery teaching team facilitated the sessions and ensured that the information provided by the student midwives was of a consistently high standard, providing educational support if necessary. The midwifery students undertook a ‘practice run’ with their facilitator prior to the first workshop with medical students. They used a variety of birth manikins and support aids to promote learning, and the sessions encouraged hands-on participation and interaction by medical students to enhance the learning experience. Artistic licence in interpretation of information transmission was encouraged with the midwifery students, to allow them to deliver a unique workshop that demonstrated their own personalities and identities. Some students opted for straightforward lecture-style approaches, while others opted for small group workshops. The agenda was open-ended as long as the key elements were included.
Low-fidelity simulation was the chosen approach for the simulated workshops. The level of fidelity required is dependent on the type of task, required outcome and the stage of learning within the education programme (Munshi et al, 2015). While low-fidelity simulation does not imitate the realism of the woman in labour, it does provide the medical students with an appropriate learning opportunity prior to undertaking their first maternity placement. A low-fidelity simulated approach is considered more beneficial for novice learners (Munshi et al, 2015), and midwifery students may also feel more comfortable and confident with their own teaching abilities using this approach.
Following the interactive workshops, the midwifery students (n = 30) completed an evaluation questionnaire which asked them to rate their response to 11 questions. Ten of the questions used a Likert scale of 1–7, where 1 = none and 7 = very much, and one question required a yes or no response. The questionnaire also allowed for a comment response to each question. The medical students (n = 44) completed a separate but similar evaluation questionnaire for which the descriptive statistics are presented in Table 2.
| Medical students (n = 44) | Midwifery students (n = 30) | ||||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Improved understanding of birth process | 44 | 100.0 | Enjoyable and rewarding experience | 27 | 90.0 |
| Less anxious about placement | 43 | 97.7 | Postitive interaction | 25 | 83.3 |
| Improved understanding of the birth environment | 41 | 93.2 | Positive benefit of team working | 28 | 93.3 |
| Improved confidence about caring for a woman in labour | 38 | 86.4 | Improved confidence working with other professionals | 28 | 93.3 |
| Better understanding of the role of the midwife | 43 | 97.7 | Beneficial for future midwifery practice | 28 | 93.3 |
The requirement for formal ethical approval was carefully deliberated within the team in addition to approaching the School Research Ethics Committee (SREC). However, as this was considered an element of curriculum evaluation, formal ethical approval was not considered a requirement by the SREC. Nonetheless, voluntary written informed consent was requested from all potential participants, who were assured that non-participation would have no deleterious consequences. While formal ethical approval was not required, the evaluation study adhered to ethical principles throughout the process and was conducted under the necessary ethical procedures of the School of Nursing and Midwifery. The students were considered valuable to achieving the aim of the evaluation; however, it was also recognised that their status as students could make them more vulnerable and, therefore, careful consideration was given to ensure that these students would not perceive themselves as coerced, disadvantaged or harmed in any way (Anderson, 2011). The students were informed that participation should be voluntary and they could withdraw from the evaluation at any time without fear of discrimination. Confidentiality was guaranteed and assurance provided that no names or personal details would be used in the dissemination of the evaluation.
Findings
A total of 30 midwifery students participated in the interactive workshops, all of whom completed the evaluation questionnaire (100% response rate). The results of the questionnaires strongly suggested a distinct benefit of this education strategy for both sets of students; the descriptive statistical findings for both midwifery and medical students are presented for the purpose of comparison (Table 2). The findings support much of the current evidence regarding the benefits of inter-professional learning, particularly in relation to promoting increased levels of confidence and the understanding of professional roles within the multidisciplinary team. Of the midwifery students, 93.3% (n = 28) perceived a positive benefit of teamwork in preparing for the interactive workshop, with the same number (93.3%) indicating that they felt an increased level of confidence with regard to working with other professionals in the future. The inter-professional learning workshop served to highlight the importance of all health professionals aiming to promote normal birth for low-risk women, with all 44 (100%) of the medical students indicating that they had an improved understanding of the process of normal birth and a better understanding of the role of the midwife (n = 43, 97.7%).
The opportunity for additional comments in the ques tionnaires provided further valuable insight into the thoughts and feelings of the midwifery students, in addition to enhancing the validity of the results of the evaluation. The overarching theme that emerged from the findings was that the midwifery students felt an improved level of confidence, which was enriched by the teamwork preparation involved in organising the workshops. Comments in relation to an improved level of confidence and teamwork included:
‘A very beneficial exercise although nerve wracking at the start… it was good for confidence building… working as a group we were able to utilise each other's knowledge and to build on skills and relationships…’
‘Really enjoyed it and it allowed us to show our knowledge of labour and birth… working as a group we were able to utilise each other's skills.’
‘Made me more confident in what I know and aided my ability to teach others…’
‘Realised my own level of knowledge and understanding.’
The realisation that the medical students were equally keen to learn and participate in the interactive workshops helped to dissolve some of the ‘them and us’ assumptions which may have existed (Barnsteiner et al, 2007). Comments from the midwifery students in relation to this included:
‘The medical students were very receptive… engaged well and were keen to learn from our experience.’
‘Medical students were enthusiastic…’
‘Really enjoyed their participation…’
‘Good to learn from the perspective of other professionals…’
‘…broke barriers between medical and midwifery students.’
Discussion
The findings of this evaluation support much of the current evidence regarding the benefits of inter-professional learning, particularly in relation to promoting increased levels of confidence and the understanding of professional roles within the multidisciplinary team. Furthermore, the inter-professional learning workshop served to highlight the importance of all health professionals aiming to promote normal birth for low-risk women.
Midwives often work under the constraint of obstetric practice, where their autonomy has been eroded and they can be torn between promoting normality and working within the overarching biomedical framework
These findings suggest that the interactive workshops notably increased the midwifery students' confidence to interact with medical students. Midwifery students commented that they enjoyed being able to demonstrate their knowledge of labour and birth to the medical students, and felt positive about their ability to teach their skills.
While there appears to be a paucity of studies that refer solely to inter-professional education and confidence-building, there are a small number of studies that report on the concept of confidence building as a relevant finding (Mellor et al, 2013; Alinier et al, 2014; Kumar et al, 2014). The midwifery students stated that they felt they had gained confidence by interacting with each other and actively listening to one another. Alinier et al (2014) reported that, even with limited exposure, students' positivity was significantly reinforced in simulation training within an inter-professional arena.
The biomedical influences in modern birth culture are highly prevalent, with technology being valued by obstetricians and also by women and midwives, who can feel reassured and safe through its use (Stewart, 2010). Arguably, however, this patriarchal influence over birth can sometimes disregard some of the more subjective knowledge held by women; often, despite purporting to work in partnership with women, health professionals may actually assert power (Hollins Martin, 2012; Clewes, 2013; Anderson, 2015). Evidence has demonstrated that, historically, midwives often work under the constraint of obstetric practice, where their autonomy has been eroded and they can be torn between promoting normality and working within the overarching biomedical framework (Ruiz and Limonero, 2013). It is now widely accepted that midwifery-led care for low-risk pregnant women is a positive and effective tool for healthy outcomes (Sandall et al, 2016).
Opportunities for inter-professional working where the midwife is viewed comfortably within his/her sphere of practice and actively enables medical colleagues to participate in that shared vision must be viewed as a positive step towards dissolving the ‘them and us’ culture of behaviour. Sharing and embracing the benefits of normal birth is a positive concept and should be viewed as a participative model with a clear vision for improving the maternal experience. The evaluation of the inter-professional workshop highlighted the positive elements of translating the personal knowledge of supporting women in normal labour and birth across to the medical students and gave the midwifery students an additional insight to their own professional role. The workshops identified that the medical students had their own anxieties and needs requiring support, which were not dissimilar to how midwifery students had felt at an earlier stage of their training. Exploring common anxieties between the two sets of students, such as supporting and communicating with women in labour, helped to break down social barriers.
‘Effective team working is at the core of the foundations of safety in maternity care. Enablement or hindrance of effective inter-professional working is often dependent on external factors, such as the supportiveness of the organisation and the culture within it’
It was evident from the current evaluation that midwifery students demonstrated mutual recognition of one another's level of knowledge and skill, which has been referred to as ‘reciprocal expertise affirmation’ (Kozlowski and Ilgen, 2006: 362). Participants with higher reciprocal expertise affirmation are suggested to be more motivated towards effective team working (Grutterink et al, 2013). This theory suggests that as participants communicate, voice their opinions and work together on specific tasks over a period of time, their reciprocal expertise affirmation becomes stronger, which develops their overall confidence thus enabling them to attempt more complex tasks. Reciprocal expertise affirmation is suggested to motivate participants' contribution to the overall effectiveness of the sessions and facilitates sharing of information and seeking of appropriate advice (Grutterink et al, 2013). Before the interactive workshops, many of the midwifery students vocalised a degree of apprehension; this finding is supported by McLelland et al (2013). However, following the workshop there was often an element of euphoria and motivation expressed by the students.
The midwifery students appeared more confident with IPE when discussing familiar topics such as the management of normal labour and birth. Kumar et al (2014) offer a rationale for this, suggesting that there is a cultural acceptance of the role in which midwives perceive themselves and how they then view their role in comparison with other professionals. Bainbridge and Wood (2012) suggest that confidence within IPE groups increases when learners feel comfortable in their level of knowledge in order to transfer it to others in the group, and this emphasises the important concept of learning from others. It was noted that as each interactive workshop progressed, the medical students became more confident in asking questions. Bainbridge and Wood (2012) view this as a necessary component to effective IPE, where participants should feel confident to ask questions within a safe environment.
As the workshop progressed, the midwifery students appeared more confident in their delivery of the session and they became more relaxed and interactive with the medical students, often adding some humour. Carpenter and Dickinson (2011) defined this progressive development as social contact theory, and support its application to inter-professional education. Social contact theory originates in social psychology and explains how working effectively with other professionals can change attitudes within the group. However, Carpenter and Dickinson (2011) also argue that merely bringing groups of health professionals together with an aim of changing attitudes and behaviours is not enough; emphasis and attention must be placed on the actual content of the interactions between the groups and the structure of the work shop sessions.
To facilitate confidence in learners in IPE groups, there must be a willingness to learn and interactions between the groups must be nonjudgemental (Bainbridge and Wood, 2012). For the groups in this case, the learning was particularly salient owing to the expectation that the medical students would be in a labour ward placement the following day. The majority of midwifery students expressed that they felt they had been able to enhance the medical students' experience and alleviate some of their anxiety prior to placement by providing them with realistic expectations, thanks to their own personal experiences. This finding was also supported by the medical students.
Effective team working is at the core of the foundations of safety in maternity care (The King's Fund, 2008). Enablement or hindrance of effective inter-professional working is often dependent on external factors, such as the supportiveness of the organisation and the culture within it (Hastie and Fahy, 2011). However, it is countered that individuals are ultimately responsible for helping to make relationships work (West and Borrill, 2005). Downe et al (2010) suggest that an effective mix of both a supportive organisation and the individual will ultimately lead to successful collaboration, which will influence safe care. Mutual appreciation and role recognition will lead to enhanced trusting relationships.
Reiger and Lane's (2009) qualitative study reiterated the value of midwives being treated as equals in the maternity setting, and the importance of doctors respecting midwives' opinions. A significant number of NHS hospitals now adopt the Practical Obstetric Multi-Professional Training (PROMPT) approach to preparing for obstetric emergencies, which has demonstrated successful outcomes in helping to bridge relationships within maternity services and improve communication skills and respect for professional roles (Cornthwaite et al, 2013). PROMPT involves multi-professional workshops where emergency scenarios are enacted utilising low-fidelity simulation. At the university in this study, this further development of interactive workshops using similar approaches with low-fidelity simulation demonstrates the benefits and potential success for improving and enhancing inter-professional relationships.
Conclusion
This paper has reported on the evaluation of an inter-professional interactive workshop which utilised low-fidelity simulation as a means by which final-year midwifery students teach fourth-year medical students about normal labour and birth. While this evaluation has predominantly focused on the perceptions of the midwifery students, it also demonstrates that fourth-year medical students benefit from this innovative education strategy. This education initiative provides an opportunity for medical students to recognise how to care for healthy low-risk women in labour, while also gaining an insight into their own role within this setting and the role of the midwife as the expert in normal birth. This, in turn, eases the felt anxiety which had been reported by medical students prior to commencing their obstetric and gynaecological clinical placement.
The midwifery students perceived themselves to have achieved a greater level of confidence, which will be of benefit to them in their future educative role as health-promoting midwives in teaching women and their families as well as other health professionals. This perceived increase in confidence will also enhance their ability for future inter-professional collaboration.
Low-fidelity simulation offers ideal opportunities for improved interaction and provides a safe, non-threatening learning environment. The benefits of this innovative education strategy have been recognised by both the School of Nursing and Midwifery and the School of Medicine at the university. Such was the considered success of this education initiative that a commitment has been made by both schools to embed this education strategy into their respective curricula, with a vision for further growth and development of undergraduate inter-professional education involving student midwives and medical students.
This education strategy holds promise for the future of inter-professional collaboration and goes some way to eradicating a ‘them and us’ culture in clinical practice. However, the concept requires further research to identify the long-term benefit of undergraduate inter-professional education within the university.