Professional priorities for the next generation of midwives are wedded to the notion of combined excellence as a colleague, scholar and leader. The aspirations for ‘future midwife’ described in the Nursing and Midwifery Council (2019) standards of proficiency for midwives suggest that midwives across the board are critical thinkers, able to problem solve, act as a role model and lead, and that such a skillset is key to building effective and safe midwifery services. In pursuit of excellence, midwives will be encouraged in scholarly activity and be able to critically appraise and engage with the evidence to drive improvement. The standards recognise that midwives will be able to develop careers encompassing practice, education, research, leadership, management and policy. Rospopa and Pezaro (2020) cite the commitment to academic achievement for midwives that is needed to realise this vision. However, a lack of clarity about how midwives can build academic skills and experience may threaten its success. Reflecting on personal experience, this article will discuss some of the pertinent issues and steps that can be taken by midwives to progress in a clinical academic midwifery career.
A question of identity?
The intention to increase the capacity of nursing, midwifery and allied health professions-led research is clear. Routes to clinical academic careers for non-medical healthcare professionals are championed through the National Institute of Health Research (NIHR) integrated clinical academic pathways (Health Education England (HEE), 2017a), the 70@70 NIHR nurse and midwifery research leadership programme, the recent launch of the chief nursing officer for England's strategic plan for research, and the chief midwifery officer research strategy to come. These initiatives indicate the value of non-medical healthcare professionals leading research is well recognised. When HEE, in partnership with NHS England and NHS Improvement, outlined a national framework for developing and aligning multiprofessional advanced clinical practice careers (HEE, 2017b) the Academy of Medical Royal Colleges (2017) issued a joint professions' statement, saying ‘new ways of working and delivering healthcare requires employers to ensure clinicians have the professional development they need to adapt to changing circumstances’. This confirmed that the desire to extend nursing, midwifery and allied health professionals' career options beyond traditional clinically focused professional boundaries was shared by medical colleagues.
Although it is clear an academic skillset is valued on one level, defining the identity or characteristics of midwives involved in a combination of clinical, research and education work can be challenging. This is because there is no standard model for this way of working, a point demonstrated in the Royal College of Midwives (2022) midwifery careers framework. This framework presents case studies of midwives having pursued various ways of integrating academic work into their practice and the variation across the case studies indicates there is no set route to follow. While this shows midwives can achieve clinical academic career goals, anecdotally, many midwives undertake postgraduate level study without any defined job plan or career progression available to them. While higher level study is a personally valuable and rewarding pursuit, the lack of defined roles or expectations for midwives with these academic skills is potentially a wasted opportunity for further personal and service transformation (Cowley et al, 2020).
Furthermore, this lack of definition can be problematic for job and workforce planning, an issue raised by directors and heads of midwifery interviewed about advanced clinical practice in Midwifery (Crozier et al, 2021). Advanced clinical practice is a distinct career pathway characterised by healthcare professionals possessing knowledge and skills across clinical practice, research, education and leadership and management (HEE, 2017b). The clearest framework for a clinical academic career, where non-medical clinicians undertake academic work, has been provided via the NIHR integrated clinical academic pathway, where nurses, midwives and allied health professionals compete for entry-level research internships through to postdoctoral awards (HEE, 2017a). There is no definition of the professional nature of a generalist midwife undertaking higher level study or research, or a primarily academic midwife maintaining a degree of clinical practice, outside of the advanced clinical practice and NIHR frameworks. In the author's view, both should still be considered ‘clinical academics’.
Clinical academic: the author's account
With academic aspirations from early in my midwifery career, being unsure of where I fit has been a defining characteristic of my professional journey. ‘Fingers in pies’ and ‘a foot in both camps’ are the expressions colleagues have used to show their understanding of how I work, with unhelpful connotations of greed or conflict. I have sought out role models, definitions and pathways to provide a compass or roadmap that could help me locate myself and the way ahead, with mixed success at finding those tools. I have made it my mission to be the person who is available for other midwives feeling that same sense of disorientation, and have tried to make sense of the challenges to help myself and others overcome them.
Hurdles
Since qualifying in 2008, I have maintained an element of academic work within my midwifery practice, including part-time work as a research midwife, as well as completing several research projects alongside clinical work. Combining these dual aspects of midwifery has been highly rewarding, while challenging, and has relied on a willingness to undertake unpaid work, which may not be desirable or practical for many midwives. Miller at el (2020) note that, currently, nurses and midwives rarely engage simultaneously in clinical and research practice, despite how integral the professions are to the generation of new knowledge. The reasons for this are manifold, and may include the difficulties associated with balancing clinical academic work with caring responsibilities (Trusson and Rowley, 2021). The potential implication of this is that nursing and midwifery perspectives and expertise may be lost in emergent evidence-based practice.
Box 1.Gathering your tribe: the Midwifery Research GroupThe author set up the Midwifery Research Group in spring 2021. The group is open to all midwives, maternity support workers and other clinical maternity staff and students across the local maternity and neonatal system. The aim of the group is to provide a forum for like-minded colleagues to come together and discuss areas of professional and academic interest, research skills, career development and project ideas. Over the past year, meetings have included:
- Strengthening the midwifery voice through research
- Aiming for postgraduate study
- Presentation of midwifery PhD findings
- Structured discussion on increasing physiological birth
- Literature searching skills session
- Informal socials about project ideas.
The Midwifery Research Group has given midwives with a clinical academic interest the chance to be part of a supportive community while building confidence and experience in academic pursuits.
Even if social and personal hurdles can be overcome, how well are NHS Trusts geared up for supporting midwives to develop this type of career? Whitehouse and Smith (2018) cited numerous cultural and organisational challenges preventing nurse and midwife engagement in research, including a lack of dedicated time for publishing and disseminating work. Richardson et al (2019) echoed that lack of organisational support is a key barrier to nurse, midwife and allied health professional research engagement, alongside enablers such as successful funding applications, gaining experience in research activity and support and guidance. My experience has been a sense of otherness and going against the grain, having to justify the value of a midwifery career that combines ‘shop floor’ clinical midwifery with the pursuit of new knowledge and a different way of understanding. Trusson et al (2021) cite the case of a clinical academic midwife defending the value of their research involvement to managers and note that among clinical academic nurses, midwives and allied health professionals, this is a common frustration. I have been buoyed by winning funding for projects, having work published and the unwavering support of a few key colleagues. I have gained valuable exposure as a research midwife. I have also had numerous uneasy conversations making the case for supporting my academic aspirations within the clinical environment. However, alongside the sense of discomfort, progressing through my current doctoral studies has simultaneously been transformative, teaching me a new level of criticality regarding the generation and application of evidence-based practice. This sense of transformation matches the experiences of clinical academic nurses, midwives and allied health professionals described by Cowley et al (2020). I have had successes and knockbacks and I have carried on.
Box 2.Top tips for incorporating research/scholarship into a midwifery career
- Work as a research midwife Taking the opportunity to gain experience as a research midwife gives hugely beneficial insight into the world of practical research. Research midwives tend to work on large NIHR portfolio studies, or studies linked to the work of a particular research group or institution. The NIHR link can provide another route into clinical academic work and being involved in local research network groups can present opportunities for professional development. Skills learnt relating to research governance, trial set-up, recruitment, data collection, reporting and management will inform future work leading research projects. These opportunities are often available on a bank or part time basis, enabling a midwife to continue with other clinical work at the same time. Look at NHS jobs or contact the regional clinical research network to find out if there is work to get involved in.
- Figure out the funders Approach the practice development and education team to find out what funding is available within a trust. The Royal College of Midwives' website provides links to organisations that fund midwives' academic study, including the Iolanthe Trust, Florence Nightingale Foundation and the Royal College of Nursing Professional Bursary Scheme: https://www.rcm.org.uk/promoting/learning-careers/research-and-funding/
- Gather a tribe Seek out people who will bring something positive to clinical academic pursuits. Build clinical allies: medics who are linked to local and national studies, those with similar research interests, midwives engaged in research, a senior nursing, midwifery and allied health professional clinician, a manager with a doctorate or a professor of midwifery at a local higher education institution. Set up a midwifery research group.
- Identify an area of interest, network, build expertise Sometimes trying to narrow down a clinical area or interest to focus on can be difficult when you have many different ideas. Gradually, try to find a specific focus by reading and attending relevant conferences. Become an expert on an aspect of care. Get involved with small projects to build a portfolio of research publishing that will enable competing for funds. Link up with people beyond the immediate working environment by looking for professional networks within an area of interest. Twitter can be a great place for finding connections with people further afield.
- Start postgraduate study Options for postgraduate study in midwifery and 3-year undergraduate degrees with an option for gaining a masters in the fourth year are increasing. PhD opportunities can be found at www.jobs.ac.uk. Or consider a professional doctorate, which is a structured programme of doctoral study closely linked to professional practice. An increase in blended learning has made access to academic programmes far easier, and opportunities to study remotely from a registered academic institution are only likely to grow.
Trusson et al (2019) describe the experiences of nurses, midwives and allied health professionals that closely mirror my own, including motivation stemming from an interest in evidencing and understanding the care midwives give, and seeing potential for improvement in patient care. I have experienced similar barriers to the nurses, midwives and allied health professionals in this study, including challenges with funding and striking a healthy balance between clinical and academic work, home life and motherhood. My current position, half time as a midwifery lecturer, half time in clinical work and midway through a professional doctorate, has led me to reflect on how things are for midwives new to the profession and what has changed over the time I have been walking this path. The question remains: can opportunities for career progression that enable midwives to develop holistically across clinical care and academic and research interests be provided? I believe the answer to this lies in the organisations and processes in which midwives work, not the ability, talent, creativity or energy of the midwives themselves.
A seat at the table: creating space for the clinical academic midwife
Crucial support for me has come from a handful of individuals at my Trust and local higher education institution. Midwives need support from management and leadership that understands and values this combined role, and if this is missing, then the introduction of clinical academic pathways will be hindered (Van Oostveen et al, 2017). Nurse, midwife and allied health professional clinical academics surveyed by Deane and Clunie (2021) stated the need for a clear career pathway, citing the model of medical education where hybrid roles are the norm. Creating a framework for nurses, midwives and allied health professionals based on the well-established medical education model is an apparently logical suggestion. However, when the experiences of a group of medical and nurse, midwife and allied health professional clinical academics were compared, it was revealed that although the career trajectories of the groups varied, there were common challenges and obstacles to negotiate (Trusson et al, 2021). This would suggest that simply aligning the means for nurses, midwives and allied health professionals to develop a clinical academic career with medics may not be a golden bullet.
O'Keeffe et al (2015) describe the frustration felt by advanced clinical practitioners when the role and ability to demonstrate a full skillset are not fully supported, meaning the potential to drive change is compromised. Challenges to fully establishing advanced clinical practice midwives described by the directors and heads of midwifery interviewed by Crozier et al (2021) included difficulty protecting time for study and envisaging where a midwife with these advanced skills can be situated. Consultant midwives face barriers to robustly embedding their academic practice as links with higher education institutions are rarely formalised (Wilson and Brigante, 2020). In my opinion, it is essential that midwives with academic skills are valued, and that this skillset is normalised for its potential to be maximised. If there is a true commitment to midwives as scholars, then those that have this interest and aptitude need to be supported, not side-lined. I believe a crucial element of this is support for masters and doctoral study, alongside career planning that is aligned to the strategic direction of the service. Cooper et al (2019) describe the potential for improvement arising from commitment to building nurse, midwife and allied health professional research capacity and career progression, aligned with the trust's strategic aims. Of equal importance is an integrated approach with higher education institutions to ensure long term capacity building and ultimately guarantee the success of these combined clinical academic roles (Westwood et al, 2018).
I would argue that midwives with academic aspirations need role models and to be valued for what they can offer the service to improve patient care. Avery et al (2022) found that clinical academic survey respondents asked about their initial interest in research stated it had arisen from interacting with a colleague involved in research. In my view, these interactions could impact retention, inspiring both experienced and novice midwives to remain in a job that allows them to stretch their academic wings. Facilitating this means trusts responding with a commitment to flexible working and protected time for scholarship (Whitehouse and Smith, 2018), so that this career choice is not only made by those in a privileged enough position to be able to take on unpaid work. Midwives should have the opportunity to showcase their academic work and for this to be celebrated. As a clinical academic midwife who has forged a ‘do it yourself’ path, I believe these are the things that will make the difference to culture, practice and patients and ultimately help make future midwife's scholarly credentials a reality.
So while the national and professional commitment to clinical academic midwifery careers gathers pace and trusts and higher education institutions embrace the responsibility for nurturing these pathways, how can midwives with an academic interest develop the research and scholarship skills that underpin the ethos of future midwife? What does the aspiring clinical academic midwife look like and where do they start?
The aspiring clinical academic midwife
My midwifery colleagues have taught me so much, largely by way of their natural curiosity, questioning care delivery and the impact of practice on families and themselves. They are frustrated when they feel unable to provide the care women and birthing people deserve, with an inherent drive to challenge. I have observed that some midwives fulfil the desire to question by seeking a more formal way to find answers, sometimes through research or scholarship. There are moments in practice that fuel a question; these ‘disorienting dilemmas’ are the catalysts to view a situation with a fresh perspective (Fletcher and Meyer, 2016). I experienced a formative disorienting dilemma during my preceptorship year working on the antenatal ward, with a patient being monitored for suboptimal fetal growth. An ultrasound scan unexpectedly reported accelerated fetal growth, and an induction of labour was commenced on this basis. At birth, it was revealed this newborn was an average weight. I devised, completed and published a retrospective cohort study to explore the accuracy with which fetal weight is estimated and the implications of this for management of pregnancy. The resulting paper added to the local conversation about an important change in practice, which shortly after was adopted, thereby allowing me a firsthand taste of research translating to practice (Hargreaves et al, 2011).
This example highlights an important point about midwife-led research, being with the woman or birthing person, feeling the dilemma and hearing the question that needs to be explored. This experiential learning is at the heart of transformation (Mezirow and Taylor, 2009). Richardson et al (2019) note that among nurses, midwives and allied health professionals pursuing clinical academic careers, experiencing a practice or service delivery issue was a primary motivator in triggering an interest in research. Thinking beyond the personally formative example given, there is the potential for deep professional fulfilment among nurses, midwives and allied health professionals engaged in clinical academic activity, alongside a significant positive impact on research culture, trust reputation, leadership for strategic change and approaches and improvements to patient care (Begley et al, 2013; Atsalos et al, 2014; Newington et al, 2021). Drawing on contemporary experiences, nurses, midwives and allied health professionals are perfectly positioned to identify and address gaps in evidence (Gallagher et al, 2021). Feeley et al (2021) highlight the value of the midwife's unique lens, which provides the potential for women-centred practice transformation through midwifery-led research.
Sawatsky et al (2018) describe how the experience of transformational learning is linked to the development of professional identity, and it was this early antenatal ward experience that was the foundation of my emerging professional identity as a clinical academic midwife. The midwife that moves their curiosity beyond one of personal reflection or inward thinking, takes a holistic view of the questions arising within their practice and strives to find answers in the name of improvement: in my view that is the essence of the clinical academic midwife.
Conclusions
The landscape for non-medical clinical academic careers has changed significantly over the past 15 years, with both formal and informal opportunities for midwives to take a clinical academic career route. However, there are still many cultural and organisational challenges to overcome, and these barriers may mean that capable and talented midwives never develop their academic interests. Nevertheless, many midwives are forging their own path, and in doing so are role models helping drive the cultural, organisational and professional change that is needed to robustly embed this valuable midwifery role.
Key points
- There is growing national impetus for the development of Nurse, Midwife and Allied Health Professional clinical academic careers and midwifery scholarship is a ‘Future Midwife’ priority.
- Academic work fosters personal and professional transformation for clinical midwives and this combined skillset can help midwives drive improvements in patient care.
- Clinical academic midwifery careers are often not well defined, or their value appreciated, which hinders their development.
- Midwives aspiring to forge clinical academic midwifery careers face organisational and cultural challenges which may have an impact on midwifery retention.
- Clear career pathways, role models and Trust support at strategic level are needed to help nurture clinical midwives with academic aptitude.
- There are avenues midwives can explore to gain skills and experience to develop their clinical academic skillset.
CPD reflective questions
- Think about an experience in practice that led you to question whether care delivery could be improved.
- Consider the kinds of questions that arose from what you experienced – which question feels most significant or urgent?
- How might you approach a research project that would provide an answer to your question?
- How might your findings help make a change in practice?
- What obstacles might stand in your way when planning your project?
- Who or what do you have around you that might be able to help you take your idea forward?