Midwives online: Oct/Nov 2008
Student midwives commonly indicate that they have difficulties coping with both the academic and clinical demands of the midwifery programme. Research into the stressors experienced by students undertaking these programmes is minimal, either looking into issues as perceived by higher education, or identifying the stressors and designing the research methodology around these. This paper will consider one area of concern for student midwives as identified in a larger study looking at the factors that cause stress to student midwives. This discussion surrounds the issue of clinical placements.
The larger study has been undertaken in two stages. Stage one utilised focus groups of second- and third-year student midwives, from both the three-year (direct-entry) and shortened (18-month) midwifery programmes, to explore the factors that cause stress within midwifery education. The student midwives were volunteers from two institutions, one in England, one in Scotland, and it is the findings from one aspect of these focus group interviews that is being discussed here. The findings presented only relate to stage one of the study.
Background and literature review
Prior to 1989, almost all midwifery education in the UK took place in hospitals. Since the introduction of direct-entry midwifery programmes and Project 2000, midwifery education has been offered in higher education institutes. Direct-entry students are considered supernumerary, to enable them to achieve the required standards of proficiency (NMC, 2004b). They are given placements designed to encourage appropriate learning, having previously been used as an extra pair of hands to fulfil a roster for staffing wards and communities. To enable them to pursue these studies anon-means-tested bursary is paid along with dependents allowance, where applicable.
A review of the literature identifies that much of the research that has been carried out has been with student nurses. Begley and White (2003) undertook a study that explored nursing student’s self-esteem and their fear of negative evaluation. This study identified that stress and bullying is commonplace within the nursing profession in Ireland leading to depression and low self-esteem. Evans and Kelly (2004) examined the stress experiences and coping abilities of student nurses in a large Dublin teaching hospital. In this study, students reported a widening gap between theory and practice as the most stressful element of clinical practice; other issues included student nurses experiencing stress as a result of relationship difficulties with clinical staff.
Cavanagh and Snape (1997) carried out a study in 1995 that investigated clinical and educational sources of stress among student midwives. Students from both direct-entry and 18-month programmes of midwifery education were interviewed, and a questionnaire was devised from the key themes or concerns identified by the students. Stressors were categorised into stress associated with the organisation of the learning experience and sources of home and family stress. While the researchers identify that clinical sources of stress may be expected to exist, much of this particular study focuses upon the educational sources.
Chamberlain (1997), in an ethnographic, grounded-theory study explored the factors that affect the learning of clinical skills by student midwives. The main findings of the study were that the student midwives’ previous socialisation in nursing had a major impact on their learning. The anxieties of being pushed into learning new skills without prior preparation and training, alongside exposure to midwives with communication difficulties were found to impact negatively upon learning, preventing student midwives from taking advantage of learning opportunities. This research was conducted a decade ago.
Yearsley (1999) explored the clinical experiences of eight direct entrant student midwives. This study used an ethnographic approach of inquiry, one of the findings indicating that student midwives resorted to making tea as a coping strategy; thus paving the way to being accepted within the workforce. Yearsley (1999) proposed that this subservient behaviour was necessary and facilitated a form of acceptance. This study suggests that students have to invest a wealth of emotional labour into the process of learning, and the students in this particular study admitted to adopting a number of strategies, in order to successfully manage their relationships with midwives.
Reasons for leaving midwifery were presented in a study conducted by Ball, Curtis and Kirkham (2002). Among the findings of this study were that midwives experience contradictions between what their education prepares them to expect, and what they find in practice. Furthermore, lack of support, intimidation and horizontal violence were prevalent among vulnerable groups of midwives. Significantly, there were criticisms made of newly-qualified midwives, their inability to practice autonomously on qualification, and their ‘over cosseted’ education. Midwives apologetically admitted that there was a bias against midwives who had accessed the profession via the direct-entry route (Ball et al, 2002).
This paper reports on one aspect of the findings of stage one of a research project in which focus-group interviews were undertaken using volunteers from a convenience sample of all second- and third-year student midwives from two universities. Focus-group interviews were considered an appropriate method to explore the student’s experiences of situations that cause stress, the expectation being that group interaction generates a wealth of interesting material. Morgan (1998) highlights that focus groups are particularly good at measuring the degree of consensus on a topic, group members stimulating each other to think and express opinions. Kitzinger (2004) identifies that focus-group interviews often reveal dimensions of understanding that may remain untapped by more conventional data collection techniques; they are particularly suitable for use as a tool for empowering participants.
An independent informed facilitator, who initiated discussion in the form of previously agreed open-ended questions, carried out a total of five focus-group interviews. From knowledge of midwifery education and the literature to date, students were asked simply what factors caused them stress in the three main areas involved in their everyday lives: academic issues, clinical issues and work/life balance. Each focus group consisted of six to ten student midwives and the sessions were tape-recorded and later transcribed with the consent of participants. Ethical approval was granted in both universities, and informed consent was gained through information sheets and a signed consent form. Participants were assured of confidentiality.
The two researchers undertook analysis independently. The transcriptions were read repeatedly. Content analysis was undertaken in order to identify relevant ‘common themes’ (Burnard, 1991). This approach was taken in order to identify themes from a bottom-up approach – themes were not predetermined. These were further refined by discussion and emerged as the themes discussed in this paper.
On initial immersion with the data, it was clear that issues could easily be grouped into three categories: academic issues, clinical/practice issues and work/life balance. Clinical issues only will be discussed in this paper. The data revealed that among the main sources of stress for student midwives in clinical placements were lack of supernumerary status, and mentorship dynamics.
Supernumerary status was identified by all direct entrants as impossible to achieve, and was clearly not the reality of clinical placements:
‘The reality is that you are part of the numbers. On most days… you are definitely one of the numbers… there was a breastfeeding workshop and on two different occasions, I wasn’t able to go because the unit I was at was too busy’ (DE 2).
‘OK the NHS is funding that bursary, but you’re working for half a year for them and quite honestly on placement, you’re meant to be supernumerary but in all honesty you’re counted’(DE 1).
Among the common themes found in the literature on supernumerary status is confusion over its definition, the effect of supernumerarystatus on becoming part of the team, the importance of the mentor, and power relationships (Elcock, 2007). Given the organisational culture of the clinical learning environment, one has to question if and why students struggle to exercise their own rights to supernumerary status, and this may present a classic example of the subservient behaviour theory proposed by Yearsley (1999) as students look for ways of being accepted within the workforce. Further research is required to clarify why supernumerary status is difficult to achieve for individual student midwives.
Mentorship created much discussion. Some comments were positive in relation to mentorship; others questioned and commented on the calibre of mentors. Students suggested that some mentors were not using evidence to underpin and guide their practice:
‘We’re in this unique position where we know so much and it’s evidence based and it’s driven into us that it’s evidence based, and theirs isn’t’ (DE 2).
Students felt that this resulted in conflict between themselves, and their mentors in the care offered to women.
Some student midwives feel isolated at times, referring to incidents when they have been:
‘…made to feel like a leper’ (DE 3).
Being ignored by midwives:
‘But they would sit and they never said a word to me and they didn’t want to sit with me for lunch’ (DE 3).
One student midwife alluded to the fact that she was continually referred to as ‘the student’ despite displaying a name badge.
Much discussion focused on the students’ interpretations of some inappropriate behaviours of clinical staff, some behaviours being perceived by students as intimidating and bullying. This was largely specific to direct-entry students:
‘So she’s getting away with it; and there is bullying enough among the staff without bullying students as well’(DE 3).
‘I think it’s terrible that your day, your shift on labour ward can depend on what staff you’re on with... it’s not about the patient, it’s about what staff you’re on with’ (DE 2).
Ball et al (2002) identified bullying as one of the reasons why midwives experience stress and subsequent dissatisfaction within the working environment. Additionally, Hutchinson et al (2005) highlight the inner workings of organisations as contributing to or perpetuating a culture of bullying, suggesting that both downward and upward bullying are likely to occur in environments where unhealthy conflict flourishes. Research by Gray et al (2000) on student nurses’ perceptions of the qualities of good mentorship highlight a link between poor mentorship and mentors openly admitting to disliking their jobs. Studies of institutional bullying, intimidation and discrimination suggest a myriad of theories explaining the complexities of social dominance and subordinate behaviour (Sidanius and Pratto, 1999). It is acknowledged that these theories have significance to the situation under discussion, and it is more important at this stage to recognise that clinical staff and mentors have a vital role in facilitating not only the development of a range of practical skills, but professional skills and behaviours too.
Having different mentors was identified as being both problematic and beneficial. Some student midwives highlighted the benefits of working with a range of different mentors; however, problems arose for others in terms of being apprehensive about how some midwives preferred things done. Being unfamiliar with the differing practices and preferences of midwives was particularly stressful for some student midwives; specifically for direct-entry student midwives:
‘Like you’re supposed to put this galley pot on the left of the delivery pack and you’ve put it on the right, some of them are really quite persistent about where you have to put it; freaking out about what side to put each thing on’ (DE 3).
The overall theme that emerged in terms of mentorship continuity was that students in the early stages of the midwifery programme felt more confident if they worked with one mentor, whose ways of working become familiar to them, allowing them to concentrate on and develop their basic midwifery skills. However they did recognise the advantages of acknowledging how different midwives worked over time, as this enabled them to critically analyse the many different approaches.
Stage one of this study involves student midwives within two institutions of higher education and it is unclear whether or not these findings are generalisable across all settings. Stage two of the project should however identify those areas of concern within the student body as a whole as student midwives in five universities are completing the questionnaires across the UK.
The NMC (2004a) identify the crucial determinants of a positive and beneficial learning experience to be climate (a welcoming, enquiring and reflective culture), structure (clarity about the learning opportunities available) and focused attention (the facilitation of an interested and skilled mentor). The reality is that clinical placements are not always welcome and attractive to new students (Castledine, 2002) and the data seems to reflect this. This stage of the study supports previous research, which identifies ongoing problems with student support, the theory-practice interface and mentor attitudes (Cavanagh and Snape, 1997; Yearsley, 1999; Evans and Kelly, 2004; Last and Fullbrook, 2003; Begley and White, 2003).
Other areas of concern specific to these findings relate to role-modelling and the impact that inappropriate behaviours may have on the future mentoring role of current students. Clinical midwives must be aware of the effect their attitudes have on the learning environment. There appears to be an inherent bullying culture within the NHS and this is a matter of considerable interest and concern (Gould, 2004). All those involved in health care should recognise their own moral obligations for the safety, care and wellbeing of students. According to research by Kirkham and Stapleton (2000), being listened to, feeling protected, and having an advocate have been highlighted by midwives as valuable aspects of feeling supported. These rudimentary aspects of care and support, which should exist as a theme throughout the midwife-student midwife dyad are at times absent, perhaps due to midwives themselves experiencing a dearth in appropriate support.
When exploring the culture of the NHS, Kirkham and Stapleton (2000) highlight that midwives often manifest classic behaviours of an oppressed group (Freire, 1972) such as lack of self-esteem and hostility, and these composite behaviours tend to be as a consequence of profound organisational change. As maternity provision in the UK continues to undergo changes, there is clearly a need to strengthen the relationship between the university and the clinical setting, in order to ensure that student midwives and midwives feel supported. Furthermore, this case could highlight the potential for education to become a lever for service improvement (Department of Health, 2007) in terms of developing intelligent helping behaviours, with regular annual updating being a platform for discussions around appropriate support strategies.
This paper has discussed one aspect of the findings of stage one of a larger research project looking at factors that cause stress for student midwives. Midwifery education recognises that clinical placements are an essential part of the learning environment for student midwives. The integration of midwifery into higher education would appear not to have improved conditions for student midwives. Support from lecturers and the university is at times inadequate, some mentors are failing to offer a positive environment for learning clinical skills, and commonly supernumerary status does not exist. Attrition rates continue to be high throughout the UK; this part of the study may provide some possible reasons for this ongoing problem.
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