Midwifery shortages are a global issue (World Health Organization, 2018). Maintaining an adequate and competent workforce is a major challenge for health service providers. An increasingly important component of workforce strategy, introduced by employers, is directed at encouraging midwives to return to the workforce.
Economically, recruiting midwives back to practice is deemed to be more cost- and time-effective than training at undergraduate level (Alden and Carozza, 1997; Payne, 2010). The midwifery profession also benefits as the returning midwives bring with them life experience, skills and maturity which are seen as assets in promoting autonomy and leadership in clinical practice (Payne, 2010; NHS, 2014). Yet, there are mixed reports as to how successful this recruitment strategy is at returning midwives back to practice.
Programmes to assist midwives to return to practice, are available internationally. In some jurisdictions, for example the UK, these programmes are mandatory in order to regain midwifery registration (Nursing and Midwifery Council [NMC], 2019). Interestingly, in Ireland, irrespective of duration away from practice, midwives retain their registration. However, while not mandatory, the Nursing and Midwifery Board of Ireland ([NMBI], 2015) strongly recommends that registered midwives who have been out of practice for a period of five years or more should complete an approved return to midwifery practice programme.
Currently in Ireland, an approved return to midwifery practice programme stipulates a minimum six-week duration which covers theory and clinical practice (NMBI, 2015). While adhering to these minimal requirements, there is anecdotal evidence suggesting that return to midwifery practice programmes delivered historically in Ireland have varied significantly in duration and content.
In 2016, a national return to midwifery practice programme was developed in Ireland to support the recruitment of midwives and provide standardisation to programme delivery. Based on contemporary midwifery practice, the content of such programmes encompass the continuum of antenatal, intrapartum and postnatal care. Returning midwives are required to complete three weeks of theory and nine weeks in clinical practice placement. During clinical placement, midwives are supernumerary to normal midwifery staffing levels. Financial support of €1 500 was made available by means of a bursary payment from the Health Service Executive ([HSE], 2015). On programme completion, midwives must go through normal recruitment procedures to seek employment.
The literature describes the varied experiences of those undertaking programmes of education and re-entering the workforce. These experiences include feelings of anxiety (Barriball et al, 2007; Amin et al, 2010) a requirement for support throughout the programme (Hammer and Craig, 2008; Payne, 2010) and a preference for flexible working hours on programme completion (Langan et al, 2007; Kent, 2015). However, there is little evidence on these programmes' effectiveness from a learner's perspective. The aim of this research was to explore the experiences of registered midwives undertaking a return to midwifery practice programme in Ireland, with the objective of identifying how effective and successful the programme is at preparing and returning midwives to practice.
Methods
A mixed-methods approach was used with the objective of ensuring richness in data through triangulation of methods (Cowman, 1993; Bressan et al, 2017). The study investigated the research question: ‘What are the reported experiences of registered midwives undertaking a return to midwifery practice programme?’ A purposeful sample of nine registered midwives undertaking the first national return to midwifery practice programme were invited to participate in the study. Questionnaires were completed by participants at the start, midpoint and the end of the programme. The questionnaires included demographic details, open- and closed-ended questions and Likert scales.
A focus group was conducted at the end of the theoretical component of the programme and in advance of the clinical component. It was conducted by a gatekeeper, lasted 35 minutes and was digitally recorded. Semi-structured interviews took place with each participant six months post-completion of the return to midwifery practice programme. Participants were given the opportunity to either do a face-to-face or telephone interview at their convenience. Interviews lasted 20–35 minutes and were digitally recorded. The interviews were conducted by midwifery tutors who were known to the participants. An interview guide was used to ensure consistency and participants were sent their analysed transcripts for review. Quantitative data was tabulated and entered onto an excel spreadsheet. Thematic and frequency analysis was used to analyse the qualitative data.
Findings
All participants were female with 56% (n=5) in the 41–50 age group. The mean length of time out of midwifery practice was 12.1 years (SD=6.0). Of the midwives, 78% (n=7) of midwives had completed their midwifery training outside of Ireland. The mean length of post-registration midwifery experience was 8.2 years (SD= 6.6). One midwife had no post-qualification midwifery experience Table 1.
| Age (years) | Number of midwives |
|---|---|
| 29−40 | 1 (11%) |
| 41−50 | 5 (56%) |
| >51 | 3 (33%) |
| Years out of midwifery practice | |
| 5−10 years | 5 (56%) |
| 11−15 years | 2 (22%) |
| > 20 years | 2 (22%) |
| Post-registration midwifery experience (years) | |
| None | 1 (11%) |
| 1−3 years | 1 (11%) |
| 4−9 years | 3 (33%) |
| 10−15 years | 2 (22%) |
| > 16 years | 2 (22%) |
| Practised as a midwife in Ireland | |
| Yes | 3 (33%) |
| No | 6 (67%) |
Passion for midwifery
It was apparent that returning to midwifery practice had been a long-held ambition for the majority of respondents. From the outset, all nine reported a desire to return to practice in their profession with a passion for midwifery being reported as a key driver for returning to practice.
‘I would like to go back to my main occupation. Midwifery is my life's passion and I chose to do it a long time ago, and I don't regret it’
Support
All of the midwives experienced varying degrees of anxiety in advance of the clinical practice component of the programme. These apprehensions appeared to be related to appearing incompetent as a result of being out of practice for so long. For example, one midwife said:
‘I'm hoping to be an asset rather than a hindrance.’
The midwives anxiety levels appeared to reduce with exposure and support in the clinical area. Continuous professional support during practice placements was considered to be very important for this cohort. As one midwife commented:
‘…I'm starting out again and they need to be supportive, understanding and engaging in my effort to strive towards confidence and competence.’
All midwives reported receiving good support during their clinical placement. However, there was a perception that there was a lack of understanding amongst supporting staff of the level and type of support they required. As one midwife commented:
‘I had to put myself forward, I had to use all my maturity to say, “Listen, you have to take me seriously here. I am a trained midwife, please let me do things.”’
Another was of the opinion that staff were not adequately prepared.
‘…they just didn't know what to do with me…’
Preparation for practice
The return to midwifery practice programme was likened to a ‘crash course’ in midwifery and all respondents agreed that their confidence, knowledge and skill acquisition had grown throughout the course of the programme.
‘…the course has helped greatly in re-orientating me in this area of practice…’
On programme completion, all but one of the midwives was of the opinion that the 12-week return to midwifery practice programme was of adequate duration to prepare them to return to practice. This particular midwife had not completed her midwifery training in Ireland and had no post-registration midwifery experience. A significant number of the respondents suggested restructuring of the clinical component to allow more time to meet their own individual learning needs ie extra weeks on labour ward, less weeks in postnatal.
Returning to the midwifery workforce
At the end of the programme, midwives were asked about their plans to take up employment in midwifery. All nine (100%) midwives indicated that they planned to return to work as a midwife with over half, five (55%), indicating that they would seek full-time employment in a maternity hospital.
Work-life balance was one factor influencing their decision making, as this midwife said:
‘I love the work but the hours are long and hard. I will only take a job where the hours and conditions are suitable.’
Six months post-programme completion, of the eight midwives contacted, three (38%) were employed in full-time posts as midwives in maternity hospitals. Another had taken up a full-time post but she had resigned within one month due to a change in family circumstances. Two dual-qualified midwives had continued to work part-time as nurses while undertaking the programme and were still working in their nursing roles.
They had requested a transfer to their co-located maternity units; however, they had been informed by their manager that there was no guarantee their request could be granted due to nursing shortages. This lack of opportunity to consolidate knowledge and skills gained on the return to midwifery practice programme was of concern to them.
‘I need to get back into midwifery. I suppose what is happening is … just you lose, you start to lose your confidence, because I was starting to build on the 12 weeks that we did and, you know, I had got a little bit of momentum going, but now … I start to feel that I have lost my confidence.’
Of the remaining two midwives, one had taken up a post as a practice nurse in primary care. This had not been her original intention and she also expressed her disappointment at not been given the opportunity to utilise her refreshed midwifery knowledge and skills.
‘I thought I was going to be offered a job on the postnatal ward as I kind of had been led to believe that but it didn't happen. I was offered gynae … I didn't step one foot on the gynae ward when I was doing my return to midwifery practice programme, and I thought, you know what, this isn't what I signed up for … I haven't done all of this for a job on a gynae ward.’
Finally, one midwife failed to gain employment in the hospital where she had completed her clinical placement and returned to her native country.
Discussion
The findings of this study adds to the dearth of current literature on returning to practice from a midwifery perspective and to the authors' knowledge, for the first time, describes the experiences of midwives returning to practice in Ireland. Four main themes emerged from the analysis; passion for midwifery, support, preparation for practice and returning to the midwifery workforce. The demographic profile of midwives in this study was representative of returning midwives in other countries; predominantly female age 35–50 years (NHS, 2014). All midwives in this study reported passion for the midwifery profession as the primary reason for returning to practice. Similarly, a study carried out on returning midwives in the UK, identified that a deep love of the profession was the main motivator for them to return (Payne, 2010).
This passion and love that midwives hold for their profession is well documented in the literature (Catling et al, 2017; Bloxome et al, 2019; Harvie et al, 2019). It is thought to manifest itself in the joy of childbirth and being able to make a difference in women's lives (Crother et al, 2016). Passion is also deemed to contribute to retention within the profession (Matlala and Lumaidi, 2019). Returning to practice has been described in the literature, and also recounted by these midwives, as being associated with feelings of anxiety, lack of confidence and fear of appearing incompetent (Kirkham and Morgan, 2006; Elwin, 2007; Sheppard et al, 2010).
Based on the findings of this study, and on the evidence, support in the clinical area helps to reduce anxiety levels (Elwin, 2007). Several studies have confirmed the critical importance of support for professionals returning to practice (Payne, 2010; Stevens, 2014; Kent, 2015). However, it is important that the appropriate support is provided. In a review of return to practice programmes in the UK, mentors acknowledged that returning midwives had specific needs but there was a tendency to treat them like student midwives (NHS, 2014). As evidenced, in the literature, support mechanisms for returning practitioners must value pre-existing knowledge and skills (Bariball et al, 2007). Furthermore, it is vital that those who provide the support are adequately prepared (Bariball et al, 2007).
There is significant variation in the duration of programmes to assist midwives to return to practice (Kirkham and Morgan, 2006; McMurtie et al, 2014). As a result, it is difficult to determine what the optimum length a return to midwifery practice programme should be. Unpublished evaluations of return to midwifery practice programmes delivered in Ireland, which were of 6–8 week's duration, indicated that these programmes were too short. Payne (2010) suggests that longer and more detailed programmes may be required for midwives longer out of practice. In contrast, our findings suggest that it was those who have little or no post-registration experience or those who have never practiced midwifery in Ireland required extended programmes. Nevertheless, concurring with the literature (Payne, 2010), return to midwifery practice programmes do need to meet the individual needs of returning midwives. This challenges the ‘one size fits all’ standardised approach to return to midwifery practice programme education currently available in Ireland.
There is a lack of robust data indicating the success or failure rates of return to midwifery practice programmes for returning midwives back to practice. Attrition rates following programme completion have been reported to be as high as 75% (Kirkham and Morgan, 2006; Payne, 2010). An informal audit in the UK identified that only one-third of midwives who had undertaken a return to midwifery practice programme had registered their intentions to practice (Payne, 2010). Similarly, only 38% of midwives in this study returned to practice and, overall, figures in Ireland suggest that just 36% of those who completed return to midwifery practice programmes since 2016 returned to midwifery practice (n=22).
It is apparent that flexible working conditions are a factor in attracting healthcare professionals back to the workforce (Durand and Randhawa, 2002; Barriball et al, 2007; Yu et al, 2016). However, as reported in this study, some midwives were not offered employment opportunities to consolidate their knowledge and skills gained on the return to midwifery practice programme. The current emphasis on the return to midwifery practice programmes appears to be based solely on programme delivery and fails to support midwives to gain employment post-completion. This is negatively impacting on the effectiveness of the initiative in returning midwives back to practice. Considering the financial implications and demand on resources associated with delivering return to midwifery practice programmes, one can only question the cost effectiveness of return to midwifery practice programmes as a recruitment initiative.
Strengths and limitations
The strengths of this study lie in the use of a mixed-methods approach. This capturing of different but complementary data corroborates findings and provides a greater perspective of the phenomenon under study and a solid foundation for drawing conclusions (Simonovich, 2017). Limitations of this study include its small scale, based on one study cohort and exploratory, therefore the findings may not be generalisable.
Conclusion and recommendations
This study has demonstrated that midwives who commit to undertaking a return to midwifery practice programme are passionate about their profession. Returning midwives have unique learning and support needs that are influenced by their pre-existing knowledge and skills. However, clinical staff are not always adequately prepared to provide the appropriate level and type of support they require. Only one-third of midwives who completed this return to midwifery practice programme returned to midwifery practice. Others did not return because of challenges they encountered when seeking employment in midwifery.
Despite the Department of Health's drive and investment to attract midwives back to practice, the success of return to midwifery practice programme in its current format as a national recruitment initiative is questionable. This study highlights that there needs to be a two-pronged approach that does not focus solely on the educational component, but through engagement with employers and other relevant stakeholders offers a structured pathway into midwifery employment. In recognition of returning midwives' prior knowledge and skills, a move away from the standardised approach to return to midwifery practice programme is required and a bespoke approach adopted to meet their individual learning needs. This should include specific education for clinical staff to enable them to provide the required support for this unique cohort.
The NMBI are currently developing a scheme for monitoring the maintenance of professional competence that will provide guidance on restoration to the register. It is likely that there will be revisions required to the existing NMBI's (2015) standards and requirements for return to midwifery practice courses. With this in mind and based on our findings highlighting issues with return to midwifery practice programme, this is now an opportune time to undertake a comprehensive national review of return to midwifery practice programmes with all relevant stakeholders. This should include a cost benefit analysis if return to midwifery practice programmes are to be a successful strategy in returning midwives back to the workforce.