Leadership and management are crucial, mandatory elements of midwives' daily work. The International Confederation of Midwives (ICM, 2023) highlights the importance of leadership roles in the development of midwifery education and clinical scope of practices. This is also emphasised by the Nursing Board of Brunei, in their core competency standards for registered nurses and midwives; these require all midwives to act with professionalism and competence and demonstrate leadership and management skills (Ministry of Health Brunei, 2013).
Midwifery leadership is midwives' ability to guide, inspire and influence their colleagues, including both other midwives and the wider multidisciplinary team (Bannon et al, 2017; Adcock et al, 2022). Midwifery management is the process of planning care, including organising, directing and controlling resources for care delivery (Hewitt et al, 2021). Collectively, leadership and management are aimed at achieving common goals related to midwifery care delivery, to improve the quality of care and outcomes for women and their families. Leadership and management are complementary elements, with leadership being important for promoting innovation, teamwork and quality improvement in midwifery practice, while management is vital for ensuring that resources are used effectively and efficiently (Hewitt et al, 2021). Midwives are expected to both take a role in leading care and to have strong management skills, to ensure high-quality care delivery.
Midwifery training should prepare students for midwifery leadership and management expectations that will form part of their role after they qualify. Equipping midwifery students with comprehensive leadership and management competencies during training prepares them to become registered midwives, enabling them to function effectively in their new role. Investing in training early reduces the need for postgraduate training and facilitates a shorter transition process to becoming registered midwives (Eslamian et al, 2015). Early preparation can also reduce newly qualified midwives' stress and uncertainty, allowing them to embrace midwifery leadership and management roles (van Diggele et al, 2020). This article explores the leadership and management competencies required by and expected of midwifery students, through the experiences of 15 students in Brunei Darussalam, who gave their feedback as part of a larger research study on leadership and management transitional preparation for nursing and midwifery students. These experiences are compared and analysed against existing international literature on the importance of and challenges to developing leadership and management competencies for student midwives.
The importance of leadership and management competencies
There are a limited number of studies concerning midwifery leadership and management, even more so in terms of studies that relate to students. In addition, midwifery leadership and management are often indirectly implied in the literature, rather than being the explicit focus (Hewitt et al, 2021). A scoping review by Hewitt et al (2021) identified 25 papers published between 2005 and 2019 that explored leadership and management in midwifery. These articles predominantly comprised opinion pieces, discussion and narrative papers, rather than research studies.
A pivotal aspect of midwifery leadership and management is their role in improving maternity care and promoting maternal and child health (Byrom and Kay, 2011). Effective leadership and management in midwifery transcend seniority and rank (Hewitt et al, 2019). In essence, management in midwifery revolves around prioritising and implementing the right actions, instead of mere task execution. This places strong emphasis on the role of midwives as ‘change agents’ (Russell et al, 2018).
There is growing interest in published literature in the significance of midwifery leaders applying different leadership styles that are suitable in different situations (Fenta Kebede et al, 2023). For example, democratic and laissez-faire leadership styles have been found to be positively correlated with midwives' performance and productivity, contributing to achieving organisational goals (Fenta Kebede et al, 2023). By way of contrast, an autocratic leadership style has been negatively associated with these outcomes (Fenta Kebede et al, 2023).
A historical review of midwifery leadership indicated that acquiring leadership and management competencies improves midwives' overall work performance (Bannon et al, 2017). Competencies comprise a combination of observable and measurable knowledge, skills, abilities and personal attributes that constitute individual performance (Achempim-Ansong et al, 2021). In leadership and management, competencies are imperative in shaping students into effective leaders who can manage, comprehend and respond to complex situations (O'Connor and Kearney, 2023). A scoping review of 23 studies across Canada, the UK, the USA, Ireland, Australia and New Zealand reported that midwives need to manage the expectations of senior midwives, other collaborative healthcare professionals, women and families, and understand how to lead and manage in their roles while handling these expectations (Corbin et al, 2021). Leadership and management are fundamental for midwives' critical thinking, decision making, delegation and problem-solving skills, and are an essential element of teamwork and group dynamics (Bannon et al, 2017; Hewitt et al, 2021). Critical skills such as communication, interpersonal, interprofessional and multidisciplinary skills are needed to enhance collaborative care, and handling change and challenging situations (Sheikhi et al, 2016). This is vital for midwives as the primary caregivers for women throughout pregnancy and birth.
Leadership and management competencies include the ability to use available resources and to assess and decide on the best action to be taken in different clinical situations (Corbin et al, 2021). The ICM (2023) global standards for midwifery education require a midwife to possess a holistic body of knowledge, skills and professional attitudes. This includes leadership and management skills, which can enhance their progression in the framework of autonomy, partnership, ethics and accountability (ICM, 2023).
Preparing students for the role of a midwife includes not only providing education but also evaluating students' leadership and management competencies (Corbin et al, 2021). This can significantly enhance students' confidence in their ability to manage and lead in clinical settings (van Diggele et al, 2020). Midwifery education institutions should ensure that student midwives are appropriately and adequately prepared with the required leadership and management competencies, both in the classroom and in practice, before they enter the workforce (Adcock et al, 2022).
Preparing students for leadership and management: the Brunei context
In Brunei, two public education institutions offer pathways to becoming a registered midwife. One option is to complete a 3-year Higher National Diploma in Midwifery at the School of Health Sciences, Politeknik Brunei, following completion of secondary education. The other is to graduate with a Bachelor of Health Sciences Honours Degree in Midwifery at the Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam. This path can be completed either through a traditional 4-year or accelerated 3-year programme for post-diploma graduates. There are two modules on leadership and management in the midwifery degree programmes that encompass classroom teaching components and their application to clinical settings. These modules are taken in the final year of the diploma and degree programmes.
Classroom teaching components provide a theoretical foundation for midwifery students to develop an understanding of leadership and management. In Brunei's midwifery programmes, the classroom teaching components include knowledge of the healthcare system and its organisational structure, as well as policies, theories, self-management, leadership and management in the ward setting (Universiti Brunei Darussalam, 2022).
Clinical components provide students with hands-on experience through practical opportunities and allow them to apply the knowledge from the classroom to real-world situations. The clinical teaching components in Brunei include leading, managing, coordinating and collaborating with patients, families, midwifery teams and other healthcare professionals, emergency procedures, clinical governance and clinical teaching (Universiti Brunei Darussalam, 2022). Students are also able to observe and participate in different leadership and management roles through exposure to clinical areas during their course. This allows them to observe different leadership and management styles, providing the students with opportunities to apply their theoretical knowledge and skills in clinical practice.
Students' feedback
The Universiti Brunei Darussalam's (2022) modules comprehensively cover topics on leadership and management for midwifery students. An evaluation of final year midwifery students' (n=15) experiences of the leadership and management modules was undertaken as part of a larger research study. The wider study is ongoing and explores leadership and management transitional preparation for nursing and midwifery students. It was approved by the Institutional Ethics Committee (approval number: UBD/PAPRSBIHSREC/2022/143).
Midwifery students were invited to provide their feedback via email with the university's assistant registrar. A link to a survey containing open-ended questions was provided, focusing on the students' general experience of the modules. All ethical principles were adhered to, and feedback was kept anonymous. Full details of data collection and analysis were reported as part of the wider study, and are available from the authors on reasonable request.
All 15 students acknowledged the importance of leadership and management competencies. They highlighted that the acquisition of basic leadership and management competencies were a priority, as they provided a foundation for the start of their career as a midwife. The students stressed that these competencies were the foundation of leadership and management preparation, which was crucial for the gradual development of more advanced competencies that would inform the progression of their career. However, the students reported that the comprehensive content of the modules was overwhelming, and it was not apparent which elements of the course were most important.
The students felt that all midwives should possess foundational leadership and management competencies, regardless of their career progression. However, as evidenced by the evaluation, the exact nature of the essential leadership and management competencies was ambiguous. The students shared their experiences of what they considered to be the foundational leadership and management competencies. However, not all of the competencies they considered significant were covered, and the existing modules also contained advanced competencies (Universiti Brunei Darussalam, 2022).
Foundational leadership and management competencies
The authors' evaluation showed that the students felt that they were expected to immediately function as a fully-realised midwife after completing their course and becoming registered midwives. They felt that this role was mandatory for all registered midwives, and that foundational leadership and management competencies would enable them to perform their role effectively. Foundational leadership and management skills encompass decision making, handling resources, working as a team, collaborating effectively with other healthcare professionals, managing conflicts, solving problems, delegating tasks appropriately, and managing time efficiently (Corbin et al, 2021).
The ICM (2023) highlights the attributes of a midwife in terms of leadership and management. It is expected that registered midwives can communicate well, contribute to the team and show respect and confidence. The importance of critical thinking, decision making and using research to inform practice is also emphasised. Student midwives must understand the scope of practice for registered midwives' leadership and management, so that they know what is expected of them, and their boundaries and limitations. Midwives at the workplace are expected to facilitate students' understanding of the required leadership and management competencies (Papadopoulos et al, 2022). Table 1 illustrates some foundational leadership and management competencies based on the literature. Further research is required to practically confirm that these competencies are required and relevant to practice.
Table 1. Suggested foundational leadership and management competencies
| Competency | Rationale |
|---|---|
| Knowledge | |
| Leadership and management styles and theories underpinning practice | Knowledge of styles and theories are important for application and as a basis for underlying actions in the real world (Hewitt et al, 2021) |
| Attitude | |
| Commitment and dedication | A core attitude for registered midwifery, which requires a high level of responsibility and focus in daily work (Ministry of Health Brunei, 2013; International Confederation of Midwives, 2023) |
| Trust and integrity | Crucial for midwives to be honest, so that they can perform their ethical responsibility accordingly (International Confederation of Midwives, 2023) |
| Respecting others | Vital for gaining others' cooperation and leading (Fenta Kebede et al, 2023) |
| Influential | Crucial to ensure effective leadership of others (Goodman et al, 2020) |
| Skills/practice | |
| Communication | Leadership and management requires establishing relationships with the midwifery team and other healthcare professionals (Cleary et al, 2018) |
| Advocate | Being an advocate for the team and patients is essential (Papadopoulos et al, 2022) |
| Delegation | Leading and managing roles require understanding of how to effectively allocate tasks to others (Palimbo et al, 2023) |
| Decision making | Leaders and managers must make decisions to ensure team management and maintain positive team dynamics (Ngabonzima et al, 2020) |
| Managing resources | A leader needs to plan, organise, direct and allocate human resources, equipment and facilities accordingly (Polvinen et al, 2020) |
| Conflict management and problem resolution | Fundamental for promoting a positive work environment and improving team dynamics (Fleshman, 2020) |
| Teamwork and collaboration | Midwifery leaders and managers need to ensure positive team dynamics, and cooperate and work harmoniously with other healthcare professionals to ensure quality patient care (Cleary et al, 2018) |
| Time management | The ability to prioritise care and complete tasks in a set timeframe is imperative, enabling effective management of daily duties (Hewitt et al, 2021) |
Challenges to learning foundational competencies
For midwifery students to adequately prepare themselves for leadership and management roles, it is essential that they understand what is expected of them in the clinical setting. This enables students to be proactive and strive to acquire the required competencies, and for midwives to facilitate their learning effectively (Sheikhi et al, 2016). There is substantial research on a global scale of leadership and management, but this largely originates from the fields of business and psychology, with limited specific focus on midwives (Sangy et al, 2023). Foundational leadership and management competencies explicitly for different levels of midwives are also limited and not well-defined.
Applying theory to practice
Midwifery students may not feel confident in leading and managing in clinical settings, despite being prepared through theoretical teaching. If lessons focus on theoretical aspects and lack application to clinical settings, students may be unable to relate their classroom learning to practice (Williamson et al, 2021).
Using a variety of teaching methods, such as case studies, simulations and seminars, is imperative, as practicing skills in the classroom may not be reflective of real-world settings. Simulation-based training provides artificial scenarios for students to immerse themselves in before clinical exposure. One of the benefits of this approach is that simulation is conducted in a controlled environment. Repeated exposure to simulation-based scenarios has the potential to significantly improve student's midwifery competencies, including leadership and management skills, self-efficacy and learning satisfaction, which overall improves learning outcomes (Polvinen et al, 2020). Nonetheless, no matter how well a simulation is designed, it may not entirely replicate the real world. A scoping literature review of 10 studies from the UK and USA concluded that it is important to simulate real-life clinical-based scenarios that ensure students' learning objectives and skill competencies are achieved (Labrague, 2021).
Learning while on placement
Applying foundational leadership and management competencies across different clinical settings can be challenging for midwifery students (Abraha et al, 2023). In practice, clinical areas have varying degrees of complexity and a range of responsibilities related to patients' needs, routine tasks, mandatory observations and documentation, which can make it difficult for student midwives to practice and develop leadership and management skills effectively (Sheehan et al, 2023).
In some cases, clinical settings may be overstimulating, limiting opportunities for students to practice competencies. Some clinical settings, such as intensive care units, clinics and operating theatres, may not provide opportunities for students to explore leadership and management roles, leading to a lack of confidence and proficiency. Time constraints can also affect the ability to practice leadership and management skills; at least initially, students need time while on clinical placement to adjust to the ward setting (Mbakaya et al, 2020).
Some wards and hospitals may not be well equipped to train students in leadership and management roles. Understaffing can deprive students of the necessary guidance and supervision to embrace leadership and management roles. Additionally, students may have to assume unexpected workloads to compensate for a lack of staff, leaving students to perform routine tasks that lack leadership and management physiognomies (Berryman, 2021).
Managing expectations
A mismatch of expectations and understanding between midwifery students and their mentors can also present challenges to developing leadership and management skills (Abraha et al, 2023). Students in their final year may feel that they are expected to be capable of leading, managing and practicing without supervision. A South Korean study of 171 students reported that they faced burnout related to clinical practice experiences, as a result of role confusion and the inability to adapt to the environment and workflow of the ward, leading to stress, anxiety and depression (Hwang and Kim, 2022). Universities and clinical institutions should establish a conducive and holistic learning environment to reduce these concerns and improve students' learning satisfaction.
Addressing challenges
The limitations to teaching students leadership and management mean that students graduate with different experiences, learning opportunities and preparedness for leadership and management roles. To address these challenges, midwifery education institutions and clinical settings should collaborate to provide timely, relevant and comprehensive training that meets the demands of the workplace and allows students to practice and develop their competencies adequately and safely.
Midwifery students can learn from their educational institution, clinical settings and mentors, but should also be proactive in seeking learning opportunities and designing initiatives to ensure continuous personal and professional development (Ngabonzima et al, 2020). As the job market becomes increasingly competitive, so do the high expectations placed on the midwifery workforce. Through independent learning, student midwives can develop the abilities necessary to thrive in their roles, creating a growth mindset that is essential for lifelong learning. Ultimately, student midwives who take ownership of their learning and professional development are better equipped to succeed in their careers and achieve long-term success (Folkvord and Risa, 2023).
Conclusions
Preparing midwifery students to become registered midwives with foundational leadership and management competencies is essential but also highly complex. A lack of appropriate input on advanced competencies may leave students unprepared to effectively perform foundational leadership and management responsibilities upon joining the workforce. Student midwives should be made given clear education on their role, scope of practice and the expectations of leadership and management competencies. Midwifery education institutions and stakeholders must provide an appropriate environment for learning to take place. Midwifery students must be proactive, invest in continuous personal and professional development and equip themselves with the required competencies. Development of specific instruments that appropriately and specifically evaluate midwifery students' foundational leadership and management preparation is warranted.
Key points
- The fundamental competencies for midwifery leadership and management must be made explicit for students on midwifery courses.
- Newly graduated midwives must be prepared for their roles, scope of practice and expectations for leadership and management skills.
- There is a need to develop standards to guide and evaluate midwifery students' core leadership and management skills in Brunei Darussalam.
- Midwifery education institutions should consider gradual development of leadership and management skills beginning from the first year of study.
CPD reflective questions
- What are the basic core fundamental and foundational leadership and management skills for newly graduate midwives?
- How can a midwifery educational institution better prepare learning needs of the student for their leadership and management skills?
- How are midwives in your settings being assessed and evaluated for their leadership and management competencies?
- What are the standardised tools currently available internationally for evaluating newly graduate midwives' leadership and management skills?