At the point of registration, the newly qualified midwife (NQM) is a competent novice practitioner in low-risk midwifery care, and is expected to refine and develop skills and confidence in caring for women with more complex clinical needs (Nursing and Midwifery Council, 2009; Department of Health [DH], 2010). Seminal work by Kramer (1974) suggested that newly qualified healthcare practitioners at the start of their first clinical role post-qualification experienced ‘reality shock’, which was supported by subsequent research (Maben and Clark, 1996; Godinez et al, 1999; Gerrish, 2000; Montgomery et al, 2004; van der Putten, 2008).
The DH advises that all NQMs undertake a preceptorship period to smooth the transition from student to qualified midwife and to enhance clinical skills and confidence, (DH, 2010). Preceptorship remains unstandardised and is determined at a local level, thus length and content of programmes is at the discretion of individual NHS Trusts (Bannister, 2012; Mason and Davies, 2013). The local Trust adopts a 12-month programme to support NQMs, incorporating rotations to each area of practice that include obstetric and midwifery-led care pathways. Time spent on each rotation varies each year as the service requires.
As a foundation to preceptorship, transition programmes have been propounded to involve senior student midwives in practice-based activities, such as suturing workshops and obstetric emergencies training, in order to bridge the gap between student and qualified midwife (Kitson-Reynolds et al, 2015). A pivotal component of this transition programme is the autonomous practice module, in which student midwives provide continuity of carer for a small caseload of women throughout the childbirth continuum and complete an academic module focused on decision-making (Kitson-Reynolds et al, 2014; 2015). Despite preceptorship and transition programmes, incongruity remains between expectations of competence and autonomy, and the lived experiences of NQMs (Kitson-Reynolds et al, 2014). In view of attrition rates of 5-10% in the first 12 months post-qualification (Royal College of Midwives [RCM], 2010), exploring the experiences of NQMs may provide an insight into how the transition to autonomous practice can be facilitated to improve job satisfaction and reduce attrition rates.
Fairy tale midwifery: the original research
A decade after data were collected to explore the lived experiences of NQMs graduating from one university in the south of England, the subject has been revisited to assess whether there has been a shift in the experiences of NQMs (Kitson-Reynolds, 2010; Kitson-Reynolds et al, 2014).
In the original study, 12 of the 15 NQMs in one cohort decided to participate. This consisted of three semi-structured interviews: at the point of qualification, and at four and 12 months post-qualification. The research, which had an interpretative phenomenological methodology, reported two final interpretive themes: ‘fairy tale midwifery’ and ‘between a rock and a hard place’. NQMs felt that their idealised (fairy tale) expectations of midwifery were shattered by the realities of life as a qualified midwife, and that their training had not fully prepared them for this real world experience. Furthermore, participants felt tired and frustrated by their workload and disillusioned by the ad hoc provision of supernumerary shifts and preceptor support. Being an NQM was characterised by self-doubt and an inability to cope with increased workload and responsibilities (Kitson-Reynolds et al, 2014).
Literature review
Literature searches were conducted to identify primary research focusing on the experiences of NQMs (Table 1).
| Avis M, Mallik M, Fraser DM. ‘Practising under your own Pin’-a description of the transition experiences of newly qualified midwives. J Nurs Manag. 2013;21(8):1061–71 |
| Barry MJ, Hauck YL, O'Donoghue T, Clarke S. Newly-graduated midwives transcending barriers: mechanisms for putting plans into actions. Midwifery. 2014;30(8):962–7 |
| Clements V, Fenwick J, Davis D. Core elements of transition support programs: the experiences of newly qualified Australian midwives. Sex Reprod Healthc. 2012;3(4):155–62 |
| Davis D, Foureur M, Clements V, et al. The self reported confidence of newly graduated midwives before and after their first year of practice in Sydney, Australia. Women Birth. 2012 Sep;25(3):e1–10 |
| Fenwick J, Hammond A, Raymond J, et al. Surviving, not thriving: a qualitative study of newly qualified midwives' experience of their transition to practice. J Clin Nurs. 2012;21(13-14):2054–63 |
| Foster J, Ashwin C. Newly qualified midwives' experiences of preceptorship: a qualitative study. MIDIRS Midwifery Digest. 2014;24(2):151–7 |
| Hobbs JA. Newly qualified midwives' transition to qualified status and role: assimilating the ‘habitus’ or reshaping it? Midwifery. 2012;28(3):391–9 |
| Hughes AJ, Fraser DM. ‘SINK or SWIM’: the experience of newly qualified midwives in England. Midwifery. 2011;27(3):382–6 |
| Kensington M, Campbell N, Gray E, et al. (2016) New Zealand's midwifery profession: Embracing graduate midwives' transition to practice. New Zealand College of Midwives Journal 2016;(52):20–5 |
| Mason J, Davies S. A qualitative evaluation of a preceptorship programme to support newly-qualified midwives. Evid Based Midwifery. 2013;11(3):94–8 |
| Wain A. Examining the lived experiences of newly qualified midwives during their preceptorship. Br J Midwifery. 2017;25(7):451–7 |
Organisation
Supernumerary time for NQMs varied, even within the same study, from none at all to four weeks' supernumerary status (Clements et al, 2012; Avis et al, 2013; Foster and Ashwin, 2014; Wain, 2017). Provision of supernumerary shifts was associated with acclimatisation and socialisation to the ward, while being deprived of supernumerary status increased stress and feelings of abandonment (Clements et al, 2012; Foster and Ashwin, 2014).
Clinical rotations were not without problems. Planned rotations enabled NQMs to prepare and were viewed positively, but they were subject to change if ward acuity and skill mix demanded, which left participants feeling as though they were used to fill gaps within the service (Clements et al, 2012; Mason and Davies, 2013). Confidence gained in one area was quickly lost upon rotation (Avis et al, 2013) and inadequate time in each rotation made some feel as though they were students once more and did not belong (Foster and Ashwin, 2014). Conversely, Clements et al (2012) found that rotations were an opportunity to create networks within various clinical settings and enhance skills.
Some confusion was expressed about the need to sign off similar competencies pre- and post-registration, which was seen as a tick box exercise necessary for career progression, but that remained unchecked (Hughes and Fraser, 2011; Foster and Ashwin, 2014). Additionally, NQMs reportedly lacked time in their schedule to complete paperwork (Foster and Ashwin, 2014).
While some studies made recommendations for practice that involved an individualised preceptorship programme for each NQM (Hughes and Fraser, 2011; Avis et al, 2013; Wain, 2017), Kensington et al (2016) reported a programme based on NQM choice: of preceptor, learning goals, and model of care (obstetric-led or continuity of carer).
Learning environment
Preceptorship was not always viewed as a time to learn and enhance skills in a supportive environment where NQMs felt valued (Avis et al, 2013; Barry et al, 2014). Workload, skill mix and staffing levels sometimes meant that the labour ward was not conducive to learning and was viewed as a hostile environment that undermined, rather than fostered, confidence (Fenwick et al, 2012).
Support
When NQMs lost sight of their own personal philosophy of midwifery, they rediscovered it when they debriefed with peers on study days (Clements et al, 2013; Mason and Davies, 2013; Barry et al, 2014). A shared philosophy of midwifery was also important between NQMs and their preceptors (Barry et al, 2014; Kensington et al, 2016).
The relationship with the preceptor was considered significant in developing confidence, making progress, and feeling supported (Avis et al, 2013; Foster and Ashwin, 2014). Preceptors were viewed positively when they provided support and were approachable, but enabled NQMs to practise autonomously (Hughes and Fraser, 2011; Kensington et al, 2016). Key roles of preceptors included goal setting, debriefing and reflecting (Kensington et al, 2016).
While some NQMs were able to work their supernumerary shifts with their preceptor (Mason and Davies 2013), others were not and would have preferred their preceptor to be more present to supervise clinical skills such as suturing (Wain, 2017). Midwives on the wards were integral to NQMs' experiences and determined whether they felt as though they were sinking or swimming (Fenwick et al, 2012; Clements et al, 2013).
NQMs felt more confident in gaining competence when their colleagues were supportive, friendly and encouraging (Fenwick et al, 2012; Clements et al, 2013; Wain, 2017). Although support for NQMs was often subject to service demands, such as staffing levels or midwives being assigned to work alongside NQMs and students simultaneously (Avis et al, 2013), Kensington et al (2016) described a collective sense of responsibility felt by midwives towards NQMs.
Competence and confidence
NQMs felt competent to care for women at low risk of complications, but lacked confidence in providing more complex care (Davis et al, 2012; Avis et al, 2013). NQM confidence increased over their first year in practice, evidenced by participants' increased willingness to challenge ingrained practices (Davis et al, 2012; Hobbs, 2012).
NQMs' confidence was affected by other members of the team (Fenwick et al, 2012; Avis et al, 2013; Mason and Davies, 2013; Kensington et al, 2016), and also by gaining competence throughout their preceptorship year (Wain, 2017). A preoccupation with achieving clinical skills was observed. NQMs initially felt their skills were inadequate, but viewed competencies as achievable with time and support (Mason and Davies, 2013).
Reality shock
The transition from student to NQM was considered a step into the unknown (Avis et al, 2013). NQMs found an incongruence between the ideal espoused during their midwifery education and the reality of care in busy clinical environments (Clements et al, 2012; Fenwick et al, 2012; Hobbs, 2012; Avis et al, 2013; Barry et al, 2014; Wain, 2017). Barry et al (2014) described transition as an adjustment period in which NQMs moved from a woman-centred philosophy of care to a medical model and, through the acquisition and refinement of clinical skills, NQMs were able to recentre their care to a woman-centred model. As they progressed through their preceptorship, NQMs were able to reassess their core values and advocate for women and for themselves (Mason and Davies, 2013; Barry et al, 2014).
It has been suggested that NQMs, rather than allying with the women in their care, must pledge allegiance to the institution in which they are working in order to assimilate (Fenwick et al, 2012; Hobbs, 2012). Sacrifice and service compel NQMs to work beyond their contractual hours, stay past the end of their shift, or forego lunch breaks, which NQMs begin to negotiate during their first year post-qualification (Hobbs, 2012; Barry et al, 2014).
In order to minimise the reality shock experienced by some NQMs at their increased workload and autonomy, it was suggested that third-year student midwives should be given a greater level of responsibility in care planning and provision, and decision-making (Avis et al, 2013).
Beyond preceptorship
During their preceptorship, NQMs began to consider their own progress and achievements and became ‘architects of their own and women's experiences' (Barry et al, 2014), although some felt they had not progressed adequately and risked losing sight of what motivated them to become midwives (Foster and Ashwin, 2014). Some NQMs felt that by the time they were finishing their preceptorship, they were no longer ‘babies’ and were able to advocate for themselves and for the women in their care (Mason and Davies, 2013).
Discussion
The transition from student midwife to NQM has been described as a time of both immense vulnerability (Mason and Davies, 2013) and excitement at the successful completion of midwifery training (Clements et al, 2012).
The challenges of preceptorship, which is intended to bridge the gap between student and qualified midwife, have been well-documented (Kitson-Reynolds, 2010; Fenwick et al, 2012; Hobbs, 2012; Clements et al, 2013; Mason and Davies, 2013; Avis et al, 2013; Barry et al, 2014; Barry et al, 2014; Wain, 2017). Findings in this literature review have supported those of the original research (Kitson-Reynolds, 2010; Kitson-Reynolds et al, 2014).
Fairy tale midwifery – false promises and reality shock
Preceptorship enables NQMs to develop competence and confidence, and begin to progress from novice to more advanced practitioner (Benner, 1984; Kitson-Reynolds et al, 2014). It can be postulated that part of the reality shock experienced by NQMs is the transition from expert student midwife to novice midwife, with a concomitant decline in perceived status and confidence. A final year student may feel confident to perform the required skills at the expected level, and is situated at the top of a chronological hierarchy of cohorts. Conversely, a NQM is once again the least experienced, notably in areas of clinical decision-making and caring for women with complex needs (Kitson-Reynolds, 2010; Davis et al, 2012; Avis et al, 2013; Kitson-Reynolds et al, 2014).
The autonomous practice module for third-year student midwives endeavours to bridge the gap between theory and practice by introducing decision-making in a way that encourages critical reflection and enables students to carry a small caseload of women throughout the childbirth continuum (Ashforth and Kitson-Reynolds, 2018, 2019; Kitson-Reynolds et al, 2015). The academic module is further supported by a transition passport that aims to align clinical skills and training with those required in future practice (Kitson-Reynolds et al, 2015). The recent introduction of pre-registration cannulation training should further diminish the chasm that exists between student and qualified midwife, and enhance existing pre-registration training that includes suturing and medicines management (Kitson-Reynolds et al, 2015; Kitson-Reynolds and Trenerry, 2019). If NQMs' skills are more closely aligned with those of experienced midwives, reality shock may be diminished.
It has been suggested that university education provides students with an idealised notion of practice (Armstrong, 2010), their fairy tale midwifery (Kitson-Reynolds, 2014), and it is prudent to consider the sources of disillusionment. Woman-centred care is the cornerstone of contemporary midwifery education and practice, although it is anecdotally not rewarded in practice, which may be a source of frustration, disillusionment and reality shock for NQMs.
The divergence between the midwifery transmitted through pre-registration education and the midwifery that NQMs feel able to deliver in the face of staff shortages, time constraints, long working hours, and adapting to practice as novice practitioners is described below.
‘I don't imagine anyone sets out to become a midwife with intentions other than beneficence, non-maleficence, justice, equity. Whatever our motivations to be midwives, these values were surely fundamental when we began and must certainly be key to every shift we work, mustn't they? It's interesting to consider whether (and how quickly) these values are jeopardised when we're faced with someone bigger, bolder, seemingly more important than ourselves shouting the odds or calling the shots.
‘I finished a shift last week wondering where consideration for the women was when us midwives were being scolded for not moving women slickly to the ward. “Time efficiency” sacrificed individual care, threatened women's experience and perception of labour and birth, and put breastfeeding at risk. In addition, it put midwives under immense pressure to perform superhuman feats in order to achieve a quick turnaround of beds and rooms. Were we tempted to compromise our own standards of care and compassion because there was someone breathing down our neck to quite simply get a move on? I felt stressed and had a huge sense of failure and underachievement.’
The pressures that threaten woman-centred care are detrimental to women's experiences of care and to midwives' sense of job satisfaction. The literature proposes that study days afford NQMs the opportunity to debrief with their peers and re-engage with their values (Clements et al, 2013; Mason and Davies, 2013; Barry et al, 2014). However, if similar experiences are shared by their colleagues, this may create a heightened sense of despair and disillusionment. Gaining confidence, competence and experience was associated with the ability to provide woman-centred care in line with academic teaching, which was enhanced when NQMs shared a philosophy of care with the preceptors supporting them (Barry et al, 2014; Kensington et al, 2016). The impact of the NQM-preceptor relationship will be explored in the second article in this series.
Submissive empowerment – between a rock and a hard place
The local Trust signposts NQMs' newness or otherness by providing new staff with a different coloured badge holder. It is both a warning shot and a beacon of safety, explaining a lack of confidence and experience in more advanced clinical skills or knowledge. Trading in the badge at the end of the preceptorship is akin to shedding the ‘P’ plates on your first car (Ashforth, 2019a). This preceptorship period is characterised by a sense of vulnerability and lack of confidence (Banister, 2012; Mason and Davies, 2013; Kensington et al, 2016), and rotations through clinical areas are intended to develop confidence and competence.
The literature and anecdotal evidence suggest that rotations and supernumerary status are compromised by service demands, which increases NQM anxiety and threatens their learning experience if rotations are missed (Clements et al, 2012; Mason and Davies, 2012). Arriving on shift and being redirected to another ward due to ‘skill mix’ may cause feelings of inadequacy and a loss of confidence. Confidence may be further impacted by the attitudes of midwives on shift and their willingness to welcome NQMs and to teach them new skills.
NQMs need access to learning opportunities in a non-threatening environment (Fenwick et al, 2012; Avis et al, 2013; Barry et al, 2014). The busyness of the ward and availability of staff to supervise also influence the chance to refine skills. The impact of an appropriate learning environment cannot be underestimated, as evidenced below.
‘Finally I had an experienced set of eyes encouraging and praising me rather than desperately wanting to cut in and take over. She provided guiding hands from a distance (that she sat on), and because she didn't want to intervene I didn't want her to. I didn't need to apologise or ask for help because she trusted me and I trusted her. I knew she'd step in or question me if I needed, which gave me the confidence to carry on. I didn't feel judged or stupid or rushed. She had other things to do but she made me feel as though watching me suture was the most important thing in the world.’
Conclusion
At the point of qualification, NQMs are expected to be competent novice practitioners in low-risk midwifery care and preceptorship is intended to facilitate the development and refinement of advanced clinical skills. The original research upon which this piece is based described a preceptorship characterised by self-doubt, frustration, disillusionment, and incongruence between the expectations and realities of being a midwife, the so-called fairy tale midwifery. This review has found similar themes and experiences, which could suggest data saturation. NQMs experienced varying degrees of supernumerary status and rotations, they initially lacked competence and confidence, but gained both as their first year in practice progressed, and they used peers and preceptors to re-engage with their philosophy of midwifery care that allowed them to advocate for women and themselves.
A continuing divergence between expectations and reality may signify that further work needs to be conducted to better align student expectations of midwifery so that they do not experience Kramer's reality shock. The second piece in this series will focus on the role of the mentor and preceptor in facilitating the transition from student to NQM, and the third article will synthesise the evidence and makes recommendations for practice.