Preceptorship in midwifery is a term used to describe a period of support given to newly qualified midwives to enable them to develop their knowledge and skills within their new working environment (Boon et al, 2005). Support from an experienced midwife (preceptor) enables them to consolidate experience gained as students, moving from being fit to practise at the point of registration to confident practitioners, as well as facilitating adaption to their new roles and responsibilities (Nursing and Midwifery Council (NMC), 2006). In support of this, the Departmentof Health (DH) (2008) states in its report, A High Quality Workforce, that a foundation year should be adopted following midwifery registration to build confidence, suggesting that financial commitment from NHS Trusts to implement this is essential. Midwifery 2020 (DH, 2010: 36) also supports the concept of preceptorship ‘as a means of providing structured, focused support and guidance’.
In view of the evidence supporting preceptorship in midwifery, a new preceptorship package within a local NHS Trust was commissioned using input from midwives in practice, educators and students. In order to inform development it was decided to explore students views of preceptorship and their learning needs at the point of registration to ensure a robust package could be produced that was fit for purpose.
Review of the literature
Broad et al (2011) suggests that preceptorship as a concept is not new, with reference being made to its importance in Florence Nightingale's era. In recent years, however, with changes in educational practices and the move from post-registration to undergraduate midwifery degree programmes, it appears that preceptorship has gained more prominence.
Dike (2005) states that since the introduction of direct entry midwifery programmes debate has escalated with regards to professional confidence and clinical competency at the point of registration and argues whether universities have the ability to adequately prepare students for clinical practice on qualifying. In the UK, direct entry midwifery programmes require students to be taught and assessed in ‘no less than 50%’ clinical practice and ‘no less than 40%’ theory (NMC, 2009). Clinical skills are acquired using experienced midwifery mentors and theory is taught by midwifery lecturers with close links between the two, suggesting an adequate balanced educational programme fit for purpose. It could be argued, therefore, that if the midwifery educational programme in the UK is robust, newly qualified midwives should not need preceptorship support. This is supported in part in a later study by Dike (2007) examining midwives perceptions of competence. She found no identifiable differences between direct entry and post-registration educated midwives perceptions of their training/educational programmes, both groups being extremely positive about their education stating that they felt well prepared for practice. However, post-registration midwives perceptions of direct entry midwives was negative with anecdotal suggestions that direct entry midwives lacked confidence, skills and knowledge. This would be worrying if there was evidence to support this and would challenge the effectiveness of direct entry educational programmes; however, the bias may be due to post-registration midwives lack of acceptance of changes in midwifery education and the perceived threat of newly qualified midwives being academically more qualified. Many post-registration educated midwives are experienced professionals who are also mentors to students, this raises issues surrounding how these midwives have allowed students who they feel are clinically lacking to successfully complete an educational programme. If this is the case then the need for preceptorship is paramount.
Davis and Mason (2009) suggest that due to the increasing complexities of midwifery practice, further skills need to be acquired and consolidated post-qualification. They suggest that newly qualified midwives should be given support following registration in line with the medical professionals ‘apprenticeship’ scheme, which is incorporated into post-graduate medical programmes and that a minimum of 1-year should be adopted in-line with recommendations from the NMC (2006). From a nursing perspective, The Royal College of Nursing (RCN) (2008) supports this, suggesting that a mandatory preceptorship year be implemented for all newly qualified nurses in the UK.
Hobbs and Green (2003) highlight the positive effects preceptorship has on newly qualified midwives. They acknowledge that when students are educated in Higher Education establishments with clinical placements spread out throughout the 3-year programme, they often find moving permanently into the work place environment a daunting experience and feel ill-equipped to deal with the realities of their new role. In response to this Hobbs and Green (2003) developed a 12 month preceptorship package using a model that promotes ‘motivation’, ‘facilitation’ and ‘support’ using ‘conscious reflection upon experience’ with the aid of learning outcomes specific to the individuals and that of the organisation. It is evident from this work that preceptorship is a valuable tool in consolidating practice on qualifying as well as bridging the link between workplace and education, working collaboratively in order to improve midwifery education and continuing professional development.
Methodology
Purposive sampling was used. The sample was fully inclusive of the year group. Questionnaires (Appendix) were given to all third year student midwives (n = 10), 2 months before qualifying, following a face-to-face discussion explaining the research. Due to the small scale size of the study and time constraints a pilot study was not undertaken. The students had followed a 3-year undergraduate midwifery programme leading to BSc Midwifery at the University of Cumbria. Many of these students had had clinical placements in the Trust developing the preceptorship programme in question. This was followed up 2 months later at the students' final day in university with a focus group session, which was audio taped and subsequently transcribed. Open ended prompts were used to allow the students to discuss their own experiences around their learning needs at the point of registration and their feelings on qualifying with reference to their learning to date and the value of preceptorship. By using both a questionnaire and focus group, a wide variety of data were gained, from the individual opinions voiced in questionnaires to the rich data gained through the spoken word of a focus group. The focus group allowed observation of the interaction between peers, capturing the synergy within the forum (Morgan, 1996; Green and Thorogood, 2004), with the questionnaire enabling participants to comment confidentially without having to disclose their thoughts to others within the group.
A qualitative phenomenological approach was adopted using Husserlain phenomenology as this method not only provides an understanding of life through the participants lived experience but requires the researcher to suspend their beliefs and prejudices surrounding the research subject ensuring that those taking part are not influenced by the beliefs of the researcher (Robinson, 2006; Mapp, 2008). It was important to follow this approach as the researcher was an experienced midwife closely involved with the development of the preceptorship programme with pre-conceived ideas regarding its content. It was imperative that the students were not influenced by this but were able to discuss their own experiences, understanding and expectations.
Consent was gained as per University guidelines and ethical approval granted. All data collected were kept confidential and anonymity imposed on collation of information.
Data analysis
The results were analysed by carefully reading the questionnaires and transcribing the focus group recording. Developing themes became apparent during analysis. Identifying themes enabled the data collected to be sorted into manageable categories for discussion and a cross-sectional code and retrieve method was adopted to ensure a systematic review of the data as identified by Spencer et al (2003).
Three main themes were identified for discussion in relation to students learning needs: clinical practice, education, and organisation. Information was also gained around student's feelings on qualifying and the value of preceptorship. An inductive approach to identifying themes was used which was coded and analysed manually using mind maps.
Results
From the ten questionnaires distributed, eight were returned giving a response rate of 80%. Nine students participated in the focus group.
The students questioned from both the questionnaire (Q) and the focus group session (FG) were all extremely positive about qualifying as midwives and talked of being excited about embarking on their chosen career. Comments included:
‘I am proud of my achievements.’ (Q)
‘I look forward to the challenges of working independently.’ (Q)
The students however expressed concerns with ‘nervous’ being cited in all but one case. Four students felt they did not know enough to be working as qualified midwives and lacked confidence in their abilities. All the students spoke of being worried about not getting employment and were concerned about losing their clinical skills if out of the profession for any length of time:
‘Preceptorship would make you feel eased into being registered instead of dropped into the deep end.’ (FG)
‘It is a scary time moving from student to midwife and to have support from a Trust and the midwives that you already know would feel like a huge benefit to me whilst finding my feet and continuing to develop as a newly qualified midwife working with autonomy.’ (FG)
‘I would like to gain confidence in learning to practise autonomously in an environment I am already familiar with.’ (Q)
All but one student hoped to work in the maternity unit where they were students.
All of the students were able to articulate their understanding of preceptorship. They felt preceptorship was a period of work experience where they would be able to ‘consolidate’ their practice and
‘…gain additional skills not provided by pre-registration courses.’ (Q)
‘Support, guidance, supervision and confidence building’ were words frequently used to highlight how they envisage preceptorship.
They all had ideas on what a preceptorship programme should include. Clinical skills enhancement and further skills acquisition was seen as a priority. Instruction in episiotomy, suturing, catheterisation, cannulation and medicine management appear to be important to them. They talked of having ‘tick lists’ to access competencies with a pass or fail as opposed to the ‘woolly’ domains and Essential Skill Clusters (NMC, 2009) used in Higher Education which they stated as being ambiguous and open to interpretation. Participants stated that a preceptorship package should focus on NHS Trust/organisational issues and practical clinical competencies.
Discussion
Clinical practice
It was generally felt that the main learning needs of the students at the point of registration were associated with clinical skills in practice. All the students identified areas were they felt their clinical skills were lacking. They stated that this was partly due to lack of opportunity because of the unpredictable nature of midwifery and they acknowledged that it was impossible to cover/experience all clinical scenarios as midwifery students in practice. They felt preceptorship was important in aiding clinical skills enhancement as they would be able to develop their skills with support and guidance from an experienced midwife rather than being ‘dropped into the deep end’. This is supported by Hobbs and Green (2003) who found that newly qualified midwives expressed concerns at lack of practice skills which affected their confidence. It could be argued that lack of confidence may contribute to feelings of ‘not knowing enough’ as expressed by several of the students questioned therefore generating a perceived as opposed to actual lack of competence. It could also be argued that students may be actually lacking essential skills yet have been deemed competent by mentors in practice when gaps in their knowledge exist. This highlights the need for a robust preceptorship programme to be available for all newly qualified midwives as well as the need for further work to be undertaken to ensure that perceived gaps in knowledge have been addressed prior to registration.
Education
All the students expressed a desire to undertake more structured clinical skills and drills in university, in a controlled environment where they felt safe. They felt unprepared for dealing with emergency situations when qualified with the potential to be expected to know what to do. With the introduction of the new midwifery curriculum in September 2013, these issues have been taken forward by the University and will be addressed for future cohorts.
The students overwhelmingly supported a preceptorship programme with no input from higher education. They felt that they wanted a ‘rest’ from the demands of academia in order to concentrate on consolidating clinical skills. It could be argued that theory and practice go hand in hand and that current research informs practice therefore you cannot separate the two. Midwifery 2020 (DH, 2010: 36) highlight preceptorship has being the beginning of ‘the journey of lifelong learning’ suggesting that education is a continuum. Myrick (1998) suggests that implementing and sustaining preceptorship programmes is improved if a partnership approach between education and health is fostered. This is supported by Broad et al (2011) who advocate a ‘transition module’ towards the end of a student's 3-year midwifery programme which includes an overview of preceptorship, helping to identify additional training needs, as well as developing close links between the faculty and the local NHS Trust. They suggest that not only does this alleviate some of the concerns students have around being newly qualified but it also acts as a ‘safety net’ for the Trust involved to ensure quality and safety.
Organisation
There was a general feeling that knowledge was lacking in areas surrounding the working environment. Students felt they lacked skills in ward management, clinical audit and risk. Hobbs and Green (2003) reflect these findings. All the students expressed concerns and anxiety around finding employment following qualification. This is supported by Huges and Fraser (2011) who suggest that the transition period from student to midwife causes increased stress and anxiety, more so if there is a delay in taking up employment. The students also suggested that the maternity unit they ‘trained’ in should acknowledge their hard work and commitment by giving them the opportunity to consolidate their practice. One student stated:
‘There are no jobs locally. I feel I have wasted 3 years of my life.’ (FG)
Davies and Mason (2009) suggest that preceptorship is important in retaining midwives who may be lost from the profession before their career has begun and that NHS Trusts should support and recruit newly qualified midwives as trends suggest a National shortage (RCM, 2013). This is supported by an earlier survey (RCM, 2011) examining the availability of employment for newly qualified midwives who state that although the Government have increased the number of student places to address midwifery shortages more midwives are out of work and advocates extra funding so that NHS Trusts can recruit. It could be argued that it is counterproductive to provide extra funding for education then be unable to employ students on qualifying.
Since undertaking this work local Trusts have expressed commitment in recruiting and retaining midwives which is good news for newly qualified midwives graduating at the University of Cumbria who wish to consolidate their learning in a maternity unit they are familiar with and with staff they know and trust. In addition the new preceptorship programme commenced in the autumn of 2013 and will be evaluated late 2014.
Limitations
This study had a small sample size of 10 students. The University only recruits small numbers of midwifery students each year (cohorts of 15); therefore, the study is not representative of all student midwives nearing registration. It does however represent the views of students who have had clinical placements locally and that are more likely to apply for midwifery posts within the maternity units they have worked.
Conclusions
Student midwives value preceptorship and its use in supporting the transition from student to autonomous, accountable practitioner. Opportunities should exist for students to begin their midwifery careers in a maternity unit they are familiar with in order to build confidence in a supportive, secure environment with experienced professionals they know and trust. Preceptorship programmes should focus on clinical skills enhancement as well as provide development in prioritising care, ward management and socialisation into the workplace. Higher Education should consider increasing the delivery of clinical skills drills as part of the pre-registration midwifery programme to allow students to learn in a safe and secure environment enabling them to feel more confident in dealing with clinical situations in the workplace. More studies are needed in examining students perceived lack of confidence and competence on registration with particular regards to clinical skills and the role of the mentor in clinical practice in assessing competency.