My clinical placement: Maddie Saunders
Student midwife Maddie Saunders talks to us about her experiences in clinical placements.
What and where have your clinical placements been? Could you explain a bit about them and your experiences?
I have worked in a standalone birth centre, with a team of community midwives and at two district general hospitals. This has given me labour ward experience, home birth experience and experience of the low-risk birth centre setting, as well as ward-based ante- and postnatal care. I have also worked within the antenatal clinic setting, on a gynaecology ward and on a special care baby unit. The experience has therefore been varied from high-risk maternity care through to women birthing in their own homes with no intervention. This diversity is an aspect of midwifery that I find really enjoyable.
What were/are your key concerns about your clinical placements?
My main concern was that women would find it hard to tolerate a learner. In practice, I have found it much harder to tolerate myself as a learner than the women have, and this has been a humbling experience. All women that have consented to having a student present (and that must be about 95%) have been incredibly patient and supportive of the learning experience. This has awed me many a time. I was concerned about seeing the more ‘raw’ sides of midwifery, such as suturing, episiotomies, and instrumental deliveries. Most midwives have empathised with the anxiety these events can generate when being witnessed for the first few times and this has helped me grow in confidence when participating in the care of women in these situations.
What difficulties/issues have you had? What things would you change?
The main issue has been the number of students, limiting experiences for us all. Another problem is the opportunity to work with the same mentor, because of the proportion of midwives working part time. This can fragment the learning experience and does not help build confidence because of the time spent learning how different midwives like things done. It is also difficult to have time to debrief with mentors, both from positive and negative experiences. I often find discussions after events that have taken place are invaluable in terms of learning what to do differently next time, and for receiving much needed encouragement. The busyness of the midwives often makes these discussion-based learning opportunities too infrequent. So if I could change anything, it would be fewer students on each placement, and less pressured midwives to learn from.
Do you think your expectations of clinical placement are realistic? Do you think they differ from your mentor or are they the same?
I definitely expected to share experiences with other students (this is different to there being what I’d perceive as too many students within the practice setting) and to be ‘thrown in at the deep end’. I also worked hard to prepare myself for the impact the medicalisation of maternity services has on practice, and women. In this respect, my expectations were fairly well aligned with reality. Each mentor perhaps has a different notion of what a placement should be like for their student, but some settings are so busy it is difficult to have the time to ask them what they expect before being expected to do it.
I expected mentors to be more committed to initial conversations regarding stage of training, skill level expected, and assessment issues than many of them seem to be. That said, I only know how helpful those discussions are because some midwives have been excellent in their willingness to engage in a conversation along those lines. I find this improves my enjoyment of the time spent with the midwife in the clinical setting, because it increases my confidence that they know I intend to do my best, within the limits of my skill and experience. This makes it easier to cope with the inevitable mistakes and steep learning curves that that placement provides.
Do you think there is a big gap between theory and practice?
In some respects, yes. The Valsalva manouvre seems to be very commonly employed within the labour ward setting although unsupported in midwifery literature. On the other hand, I have been privileged to witness some excellent practice, particularly midwives prepared to go the extra mile for their commitment to breastfeeding support in the community.
Are your clinical placements really learning environments or do you feel that you are simply just 'another pair of hands'?
I have felt like ‘another pair of hands’, particularly on understaffed busy antenatal and postnatal wards. During these busy shifts, it is good to learn the skills of prioritisation and management of a workload, especially when learning to work more independently. However, a conflict arises when something interesting to learn from is happening and other tasks that don’t provide the same quality of learning opportunity need completing (perhaps blood pressures, urinalysis). I think there is a balance to be found here. Is the midwife too busy to notice a good learning opportunity and would be quite happy to suggest involvement? Or did I participate in that yesterday and it would be more helpful to continue responding to requests for all the other things that need doing? I feel fortunate in that most midwives I have worked with have really encouraged me to take part in new opportunities.
What tips do you have for improving the learning environment within your clinical placement?
The learning environment is the practice environment as far as I have experienced, with little distinction between the two. Therefore the way to improve the learning environment is to increase the potential of the mentor-student relationship and free up the time of mentors to be able to provide more teaching to students, or just complete the student’s paperwork without being rushed. The time spent with midwives in practice is invaluable and forms the foundation for the development of skills and confidence. However, not all midwives want to have students and not all midwives feel comfortable with teaching.
As students, we are rightfully subject to continuous assessment in order to gain a professional qualification and highly responsible position. However, I think the quality of the learning experience we have in practice partly depends on the enthusiasm of the mentor to teach students. Mentors are expected to teach and train the next generation of midwives through their mentorship but are these skills updated and assessed? Learning at an undergraduate level the value of the teaching role would perhaps stimulate student midwives to think about their development as a mentor right from the start of training, rather than it being an obligatory undertaking when you achieve Band 6.
How effective are the simulation rooms in preparing student midwives for practice? Can you explain your experience of a simulation room?
The simulation suite within the university setting is of a very high standard, with modern equipment to aid our learning. The simulation suite helps consolidate theory-based learning and provides opportunities to practise ‘hands on’ skills in a non-pressured manner, particularly obstetric emergencies. Simulation sessions give the opportunity for confidence and knowledge building without the pressure of the genuine situation. However, their use could possibly be built upon by creating opportunities to practise team-working and quick thinking required in emergency situations. This sounds dangerously close to role-play, which is disliked by many! However, experiencing skills drills as a student would, I feel, be beneficial for practice once qualified. Also, more access to simulation opportunities would be useful. I have not experienced a simulation suite in the practice setting, although practice development midwives have been happy to provide learning opportunities in the staff room by bringing out the model pelvis and birthing model on quiet shifts.
What makes a good mentor?
A good mentor is passionate about her job. Midwives who display the privilege it is to work with women and provide the best care they can are inspiring and their enthusiasm infectious, even if they are quieter individuals. These mentors, in my experience, enjoy being asked questions and are prepared to give thoughtfully constructed answers. They are also able to think back to their experience as a student, remembering how challenging the journey towards qualification can be, and they provide support and encouragement. When a mistake is made or something said incorrectly, they gently help you see the error and move on, viewing it as a learning experience without causing humiliation. They also make time for conversations about events in practice and help you feel like you have something to contribute, perhaps something as simple as suggestions for practice from the latest evidence.
Have you had any issues with your training and your mentorship? Perhaps your mentor only works part time? Have you had an issue with your paperwork being completed if you've not been on all your shifts with her?
In a workforce where a considerable proportion of staff work part time, continuity with a consistent mentor is challenging, and other members within my cohort have experienced this to an even worse degree. This does make paperwork difficult to complete, and the 50% rule (time spent with mentor on placement) is not always straightforward to adhere to. When it comes to a summative assessment, it can be hard to gauge whether midwives recognise the significance of the mark they award especially as the portfolio contributes to the degree classification. When assessments are squeezed in at the end of a shift, as often happens, my gratefulness felt for their extra time makes it difficult to ask more in-depth questions about progress and suggestions for improvement.
If you were honest, do you think that some students swap shifts and hence potentially mentors because of personal issues and hence aren't helping themselves in their training?
The vast majority of students will have to swap shifts at some point during their training. This is necessary to maintain a healthy work/life balance, and ensure that personal and family commitments can be fulfilled. For example, as someone without children, I have immense respect for students able to successfully juggle their training alongside their children’s needs. However I think all students should balance their needs for continuity and flexibility, and use the ability to request shift swaps wisely.