Report on the evaluation of a supernumerary preceptorship period introduced to support students undertaking a pilot ‘direct-entry’ midwifery programme in the Republic of Ireland.
EBM: July 2005
Margaret Carroll1 MSc, BNS, RNT, RM, RGN. C Deirdre Daly2 MSc, Ad Dip Educ, BSc, Dip Mid, RM, RGN. Agnes Higgins3 MSc,
BNS, RGN, RPN. Cecily M Begley4 PhD, MSc, FFNRCSI, RNT, RM, RGN.
1 Director of Academic and Professional Affairs in Midwifery and Midwifery Programmes, School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier
Street, Dublin 2 Ireland. Email: firstname.lastname@example.org
2 Prinicipal Midwife Teacher, The Rotunda Hospital, Dublin 1 Ireland. Email: email@example.com
3 Health Research Board Fellow, School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin 2 Ireland. Email: firstname.lastname@example.org
4 Professor of Nursing and Midwifery/Director, School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin 2 Ireland. Email: email@example.com
The authors would like to thank the students who undertook this pilot direct-entry programme for the enthusiasm with which they entered into the evaluation phase,
and to the clinicians who participated so willingly. Thanks also to the direct-entry steering committee for their continuous support and to the Department of Health and Children for funding the project and the evaluation.
. The aim of this paper is to report on the evaluation of a supernumerary preceptorship period introduced to support students undertaking a pilot ‘direct-entry’ midwifery programme in the Republic of Ireland.
. To explore key stakeholders’ perceptions of the supernumerary perceptorship programme.
. Multiple methods of data collection were used including structured questionnaire, focus group interview, interview, programme evaluations, minutes of meetings and relevant correspondence. Questionnaires were completed by midwifery students and preceptors of the direct-entry pilot programme at the mid- and end-points of the preceptorship period. Focus groups were held with all key stakeholders.
. Students learned effectively by being present in practice and by being coached by experienced practitioners who had time to teach them. Both students and qualified staff stated that the preceptorship period was of inestimable value in terms of student learning. However, some students found being constantly with their preceptor intensive and felt that the 18-week period without annual leave was demanding.
. The process of the development of the supernumerary preceptorship period represented the beginning of a culture shift where preceptors and midwives began to value their role in educating, supporting and providing constructive feedback to students.
: Preceptorship, mentorship, midwifery student, direct-entry programme
Previously, all midwifery students in Ireland are required to be registered general nurses prior to undertaking a two-year programme leading to registration as a midwife and the award of either a higher or postgraduate diploma in midwifery. The introduction of a pilot programme of ‘direct entry’ to midwifery was recommended by the Commission on Nursing (Commission on Nursing, 1998) and as a result of the findings of a national study of midwifery students’ education (Begley, 1997). In June 2000, at the request of the Department of Health and Children, a three-year pilot direct-entry midwifery programme started in Ireland with 20 students. The course was offered by the School of Nursing and Midwifery in The University of Dublin, Trinity College in partnership with The Rotunda Hospital, Dublin and the Our Lady of Lourdes Hospital, Drogheda. On successful completion of the three-year programme, students were awarded a diploma in midwifery and were eligible to apply to An Bord Altranais to be registered as midwives.
It has long been an aspiration of all those involved in midwifery education in Ireland that midwifery students be supported in practice through a formal preceptorship/mentorship scheme. In the absence of requirements by An Bord Altranais and given the dual role of midwifery students as learner and employee, this aspiration was never fully realised.
Although students were supported by registered midwives, in practice the support was often on an ad hoc and informal basis. Maternity services in Ireland were, and are still, experiencing difficulty in recruiting and retaining midwives and midwifery students, especially within the Dublin area. This dearth of midwives, exacerbated by the national increase in the birth rate, led to a situation where midwives were fully engaged in giving clinical care with no time left to guide or supervise students closely (Begley, 1997). In recognition of the extra needs of direct-entry midwifery students and the lack of a formal support system, a commitment was made to ensure that these students would have the benefit of a formal preceptorship throughout their programme.
Throughout the literature, the concepts of mentorship and preceptorship are advocated as an important support mechanism for student learning during practice placements. Despite the fact that numerous debates have taken place over the meaning of the terms, they continue to be used interchangeably with little or no consensus on definitions (McCarthy and Higgins, 2003). Integral to both is the requirement for the student to work alongside an experienced practitioner who acts as a role model, resource and facilitator of learning (Quinn, 1995; Morton-Cooper and Palmer, 2000). Depending on the institution, the role may also encompass the completion of the student’s summative assessment (Andrusyszyn and Maltby, 1993; Ormerod and Murphy, 1994; Wilson Barnett et al, 1995; Phillips et al, 1996). Within the UK, the term ‘mentor’ appears to be favoured over ‘preceptorship’ for pre-registration programmes. In the Republic of Ireland, An Bord Altranais (1994) advocates the use of the term ‘preceptor’ for pre-registration midwives and nurses.
In midwifery, a constant difficulty reported by students is a lack of supervision, support and ongoing education in practice (McCrea et al, 1994; Bewley, 1995; Chamberlain, 1997; Fraser et al, 1997). One Irish study of midwifery students’ experiences has shown that they have little support in the practice environment (Begley, 2001a) and often complained of negative staff attitudes (Begley, 2001b; 2002) and lack of recognition of their student status (Begley, 1999). Kent et al (1994: 65) highlight the different learning and support needs of ‘raw recruits’ to midwifery. Having no nursing background, they lack the clinical and interpersonal skills that nurses bring to midwifery education programmes. Although a number of authors stress the importance of having structured preceptor programmes for midwives (Kent et al, 1994; Fraser et al, 1997; Stuart, 2002), the vast majority of empirical studies on preceptorship and mentorship have been mainly completed within nursing education.
The evidence on the benefits and outcomes of preceptor programmes with pre-registration nursing education remains contradictory and conflicting (Bain, 1996). Some students report increased confidence, increased technical and clinical
skills, more effective feedback, decreased stress and greater clarity in their role (Foy and Waltho, 1989; Wright, 1990; Littlejohn, 1992; Gray and Smith, 2000). However, students in other studies reported decreased access to their preceptor (Watson, 1999; Wilson-Barnett et al, 1995), interpersonal diffi- culties (Mamchur and Myrick, 2003), lack of support and lack of constructive feedback (Cahill, 1996). A small number of studies suggest that the key factor that influences the success of preceptorship schemes is the nature of the preceptor-preceptee relationship and the qualities of the individual preceptor (Myrick and Yonge, 2004). Adding weight to this theory, a study on pre-registration midwifery and nursing students (Jones et al, 2001) found a direct relationship between positive educational outcomes and the amount of preceptor-student contact.
A persistent theme throughout the literature is the difficulty experienced by preceptors/mentors in managing the competing demands of the clinical and teaching role. A number of studies report instances of absent preceptors and difficulties matching duty rosters due to annual leave, sick leave and night duty rota. Finding time to discuss issues with students and lack of support from university teaching staff are some other issues identified (Kent et al, 1994; Atkins and Williams, 1995; Usher et al, 1999; Ohrling and Hallberg, 2001; Stuart, 2002). Many of the difficulties reported are understandable given the fact that the preceptors were not supernumerary to the rostered midwifery and nursing team.
A model of preceptorship for direct-entry midwifery
In the planning period prior to the start of the pilot direct-entry midwifery programme in Ireland, the above constraints identified in the literature were acknowledged. A major consultative process took place, with the opinions of clinical midwives, midwife managers and educators sought. An innovative approach to supporting this group of midwifery students during the first year of the programme emerged. Preceptors were experienced midwives, appointed into the role of preceptor and were supernumerary to the rostered midwifery team i.e. they did not carry a caseload during the 18-week period except for the sole purpose of teaching/modelling midwifery practice for students. They were responsible for creating and facilitating a learning environment in practice for two direct-entry midwifery students each, for an 18-week period during the first year of the programme.
Preceptorship period – structures
In both the linked maternity hospitals, the position of supernumerary preceptor was advertised. Some 13 midwives volunteered and were selected, nine in The Rotunda Hospital (seven full time and two relief) and four in Our Lady of Lourdes Hospital (three full time and one relief). All were registered general nurses and registered midwives, one was male and the remainder were female. The majority of these midwives stated that they volunteered because of the desire to take part in some- thing new and challenging and to be more involved in teaching midwifery students. Their midwifery practice experience ranged from three years to 14 years and four months. A 40-hour programme of ‘teaching, learning and assessing in midwifery practice’ was developed, implemented and evaluated (Daly and Carroll, 2001). Funding for replacement costs was provided by the Department of Health and Children.
Preceptorship period – process
The preceptorship period began in the students’ first practice placement and after they received nine weeks of theoretical input. The focus of the theoretical component was to provide the students with the skills and attitudes necessary to be ‘with women’ in practice in a inquisitive but safe manner. Each supernumerary preceptor was responsible for two midwifery students and this triad was randomly formed. The students and preceptors rotated into all areas of midwifery practice within the maternity hospitals. Rather than students adopting a pure observational role, emphasis was placed on the preceptor coaching the student to engage in midwifery practice. To maintain the link between theory and practice, the students spent one half-day each week in the classroom in their respective maternity hospital. When the students were in class, this provided the preceptors with time for reflection and preparation.
Case study research was selected as the research approach to the overall evaluation as it allows for the description, exploration and explanation of single or multiple cases, in this instance a single case (Yin, 1994).
All key stakeholders were included in the study: direct-entry midwifery students, postgraduate diploma in midwifery students, midwives, midwife managers, midwife teachers, obstetricians and paediatricians. Of the 20 direct-entry midwifery students that started the programme, one withdrew from the programme prior to the supernumerary preceptorship period and a further four withdrawals occurred during the remainder of the programme. Only 15 students took part in the final group interview and questionnaire, at the end of year three. Some 12 out of 13 preceptors responded to the questionnaire at the mid-point of the preceptorship period, but only seven responses (54%) were received from that group at the end-point and, as there was no identification number on the evaluation forms, it was not possible to follow up non-responders. At the end of the programme, the response rate to the questionnaire was as follows: midwifery students (n=15, 100%), midwife teachers (n=15, 100%), midwife managers (n=7, 100%) and midwives (n=119, 40%). Findings from the preceptors and midwives need to be read in the context of a lower response rate.
Before the start of the programme, permission was sought from the direct entry to midwifery committee, composed of representatives of the three linked institutions, to approach key stakeholders in relation to the evaluation of the programme. This was granted. Ethical approval for the study was also granted by the ethics committee, School of Nursing and Midwifery, Trinity College, Dublin. Consent was viewed as an ongoing process, which required negotiation throughout all aspects of the evaluation. All participants were given both written and, in the case of the focus group interviews, verbal information about the evaluation. Written consent was given by all participants who volunteered to take part and they were informed that they had the right to withdraw at any stage.
Data regarding the supernumerary preceptorship period were collected at three points: at mid-point (after nine weeks), at the end of the supernumerary preceptorship period, and at the end of the programme. The aim of the mid-point evaluation was to address issues that required immediate attention and to consider how best to proceed. Data from the preceptors’ evaluations at the mid-point in the preceptorship period have been presented previously (Daly and Carroll, 2002) and will therefore be omitted. The preceptors and midwifery students were requested to complete questionnaires at both the mid-point and end-points of the supernumerary preceptorship period. These questionnaires were derived from the literature and contained mainly open questions. At the end of the programme, in seeking the views of key stakeholders regarding the development and delivery of the programme, two main methods of data collection were employed: structured questionnaire and focus group interviews.
Structured questionnaires, containing mainly closed questions and adapted from instruments used to evaluate the introduction of Project 2000 nursing programmes in Northern Ireland (McEvoy, 1995) were developed and administered to each group of key stakeholders. Following analysis of these data, the findings were used to develop structured interview guides for focus group interviews. In total, five focus group interviews were held with key stakeholders and were audio-taped.
Reliability and validity
Content validity of the questionnaires was assured by basing them on the relevant literature (Gibbon, 1995) and by submitting them to the scrutiny of outside experts (Burns and Grove, 1993). Face validity was confirmed following review of the questionnaires by the members of each group. The stability of the instruments could not be tested in the usual test-retest format, as the population was too small to risk losing any participants through exclusion as a result of pre-testing. Similarly, a pilot study could not be carried out.
Quantitative data from the questionnaires were analysed using simple descriptive statistics and SPSS. Qualitative data were analysed using content analysis (Polit and Hungler, 1999). Similar themes were grouped together to produce the qualitative findings. Data from the focus group interviews were transcribed into Microsoft word documents. The responses to each question were summarised and were presented to explain or illuminate the findings from the questionnaires.
Experience of the preceptorship period at mid- and end-point – students
Nine weeks into this period, students reported a sense of achievement and enjoyment from learning new skills and knowledge. They identified supernumerary preceptorship as ‘invaluable’. A number of students stated that ‘without the preceptor, we would be lost’. The value of being able to learn ‘through a hands-on approach’ was appreciated. Receiving encouragement and support was also valued. By the end-point, the commonest strength described by students was the amount of experience gained and the learning achieved. Students also commented on the value of always having ‘somebody there to seek advice from’, and that they ‘never felt alone’. At the end-point, 14 (78%) students described themselves as feeling well supported, three (17%) moderately supported and one (5%) poorly.
Students described the strategies used by their preceptors to ensure that they got the best educational experience in the practice environment. Several students referred to the preceptor seeking out/looking for opportunities to facilitate the student’s learning. A recurring theme was the ability of the preceptor to allow the student to set their own pace by recognising when they were ready ‘to move on’, ‘comfortable with it’.
By the end-point evaluation, three students (17%) commented on the intensity of and difficulties in their relationship with the preceptor alone and/or with the other midwifery student in the triad. However, equal numbers said they would and would
not have liked to change preceptor midway through the preceptorship period. This is aptly illustrated by one student:
‘The intensity of the three is very hard. Spending every minute of every day together is very demanding, especially if there are personality clashes. This has been a down side for me.’
The intensity of the period itself was also identified as a weakness:
‘I’ve struggled with the intensity of the 18 weeks, lack of space and time for learning and overload of information during the eight hours.’
Two students were concerned about becoming dependent on the preceptor:
‘I don’t know what I am going to do when I am on my own without her in February.’
Due to annual and sick leave, the majority of the students practised with more than one preceptor. Comments suggest that they valued seeing ‘a different way of doing things’ as illustrated by the following comments:
‘It was good to see and hear how another midwife approached midwifery practice and theory.’
‘It was wonderful getting another’s viewpoint. Some preceptors had been trained here in Ireland and others in England and it was amazing to see the difference in practice.’
Experience of the preceptorship period at end-point – preceptors
Preceptors perceived the main strength of the programme lay in their supernumerary status. The absence of responsibility for carrying a caseload facilitated the preceptor to devote themselves full time to teaching two students. Students were described as being able to work independently in some areas after nine weeks of practice (Daly and Carroll, 2002) and by the end-point were described as having learned ‘a huge amount’. The preceptorship period was described as giving students great support to develop their skills without undue stress. Unlike previous midwifery students who were expected to be responsible for a caseload from day one, these students were permitted to develop their skills in a more supported manner. The 12 midwives (100%) made numerous references to staff shortages, the activity levels within the hospitals and how this sometimes led to their supernumerary status being overlooked. They stated that they had feelings of guilt at having to say ‘no’ to taking on a larger caseload and they referred to the ‘them and us’ situation that this created. Some midwives cited a lack of support from colleagues and management. Coping with differing personalities and what the preceptor perceived as ‘envy’ by colleagues were initially chal- lenging. By the end of the preceptorship period, these issues seemed to have resolved themselves.
Preceptors expressed some reservations around the possible impact of two students constantly working together and intimated that in some instances, students had some difficulties relating to each other and that this may have interfered with their learning. Several references were made to the ‘big shock’ these students would experience at the end of the preceptorship period when they would be ‘alone in practice’ i.e. without a supernumerary preceptor. Reference was also made to thefact that they were not part of the team and that the students sometimes felt different to other midwifery students.
Five (71%) of the preceptors agreed that their approach to teaching had ‘greatly altered’ and three (43%) described gaining confidence in their ability to teach. They also stated that their teaching was now in response to the student’s identified needs and also encouraged student involvement using questioning and self-assessment, and allowing time for reflection instead of ‘spoon feeding’. The majority stated that their ability to assess and give feedback had improved and that their confidence to give both positive and negative feedback had grown. Preceptors, however, did request further education in the area of constructive feedback. The preceptors attributed the supernumerary preceptorship period as a key to the development of the student as a ‘confident knowledgeable member of the midwifery team’.
Students’ views of their preceptor(s) at mid- and end-point
At the mid-point, students identified qualities of the preceptor that they found enhanced their learning and overall experience. Qualities such as being knowledgeable, experienced and having the ability to teach were repeatedly identified:
‘She’s a natural teacher, competent and confident... and if I can keep her teachings in mind, I don’t think I’ll go far wrong.’
The majority of students also identified affective qualities that focused on creating an environment that enabled them to learn:
‘She is an excellent listener, patient, flexible, empowering, responsive to my needs, focused on my learning.’
‘She is open, non-threatening... humorous, singularly lacking in egotism, happy to facilitate her students learning in a relaxed manner.’
‘She does not undermine and gives positive encouragement’.
A further quality identified by five students was the preceptor’s interaction with women:
‘Her attitude to women is so sincere and genuine.’
By the end-point evaluation, students began to identify the ability of the preceptor to allow them to practise independently:
‘I felt she enabled us to work independently when possible, which gives us confidence.’
These comments on the helpful qualities their preceptor possessed are mirrored in some of the words selected by the majority to describe their relationship: positive, supportive, facilitative, open, respectful.
When asked about qualities that they found unhelpful, eight students (44%) at the mid-point and five (28%) at the end-point indicated that their preceptor did not possess unhelpful qualities.
Unhelpful qualities identified were: lacked confidence/skills in certain areas of practice, lack of feedback on performance, adherence to policy at the woman’s expense and in fear of litigation, lack of structure and time management, attitude to both woman and student (aggressive, overbearing, mocking, undermining,defensive), and overloading with theory.
Students were asked to indicate their level of agreement/disagreement with a number of statements regarding their preceptor. The majority of students agreed/strongly agreed that their preceptor wanted the best out of this period for them and possessed the characteristics identified with successful acquisition of knowledge and practice.
In the final evaluation, 156 key stakeholders were asked their level of agreement /disagreement with a number of statements regarding supernumerary preceptorship period in year one. There was majority agreement that this model of preceptorship was an indispensable part of the programme and that without it midwifery students would have been ‘lost’ in practice placements.
In the focus group interviews, students were absolutely adamant that they could not have done without super-numerary preceptors in year one:
‘It’s got so busy in both hospitals that that 18-week preceptorship course is invaluable and I don’t think anything can replace that for a direct-entry student going out onto the wards.’
‘People who don’t have that intimate experience of working with you, don’t know what you’re capable of. It would be highly dangerous, I think, to have people supervising us who didn’t really know us.’
These views were echoed by the midwifery managers and midwives. One midwife said:
‘I don’t think it could be done without it. I don’t think they would have done quite so well. And I think the staff would have turned against the programme a bit, if they were left to it.’
Almost all students agreed with the statement that they had learned fundamental midwifery skills during the supernumerary preceptorship period. Students were in unanimous agreement that exposing them to practice after nine weeks theoretical input facilitated them to make sense and see the relevance of subsequent theoretical input. One student said:
‘That was fantastic because then you came back into the classroom, like, it was like all the pieces of a jigsaw fitting together…
“Oh, yeah, that’s why she did it that way!”’
The supernumerary preceptorship period of practice provided a safe environment, conducive to learning, with preceptors acting as a buffer for the students to an extent. Students considered that they learned effectively by being present in practice and by being coached through experiences by experienced practitioners. This is often stated as missing in university-based programmes (Benoit, 1989) and is unfortunate, as such close contact with practitioners may assist students to develop the skills of effective clinical decision-making (Cioffi, 1998). Other studies have described midwifery students as learning by ‘trial and error’ and ‘on women’ (Chamberlain, 1997; Begley, 1999) and that learning in practice has been focused on getting the ‘work done’ (Begley, 1999). This is in contrast to how this group of students described how they learned. For most students, learning was challenging yet enjoyable. They were able to question practices in contrast to feeling the need to ‘fit in’ and conform to the norm (Begley, 2001b). The generally good relationships between preceptor and students may also have decreased the stress that is often felt by students when their teachers are not interested in them or their problems (Cavanagh and Snape, 1997).
As this was a new programme to Ireland, it was not without its advocates and dissenters. The long-held cherished belief that one needs ‘to be a nurse first’ has led to the demise of direct-entry midwifery in many countries during the 20th century. Introducing a method of education and training that differed from what the majority had experienced can be seen as threatening. The preceptors, however, protected the students from this to an extent, and over the period of the supernumerary preceptorship enabled the acceptance of the direct-entry midwifery student as a legitimate alternative to the postgraduate diploma students, who are all qualified general nurses first. There was a considerable and welcome increase in the confidence and ability of the preceptors to teach and assess students in practice, which should have beneficial effects on the education of all students in the clinical area. A number of preceptors would have liked further input on how to give constructive feedback, both positive and negative, results similar to a recent audit of mentoring in midwifery (Jones, 2004). They also described themselves as personally and professionally benefiting from the period. It gave them time to teach and think and may have a positive influence on their practice into the future, findings similar to studies of preceptors in nursing education also (Bizek and Oermann, 1990; Atkins and Williams, 1995; Dibert and Goldenberg, 1995; Usher et al, 1999). The preceptors did, however, report ‘feeling guilty’, when they observed their colleagues under pressure due to staff shortages (Daly and Carroll, 2002).
There was total agreement with the necessity for supernumerary preceptorship for direct-entry midwifery students and with some preceptors and midwives commenting on the need for all students to be assigned a named preceptor. The intensity of the 18-week period without a period of annual leave was an issue for many students, but was unavoidable within the pilot programme due to funding difficulties. As suggested by students and preceptors, consideration needs to be given to a change of preceptor and student partners at the mid-point. Personality differences have been shown in other studies to be a potential difficulty in all preceptor/preceptee relationships (Cahill, 1996; Mamchur and Myrick, 2003; Myrick and Yonge, 2004). Placing a greater emphasis within the programme for students and preceptors on managing difficult relationships, assertiveness skills and working in a team may overcome this problem.
An unanticipated outcome of the 18-week preceptorship period in year one of the programme was the degree to which midwives and preceptors became conscious of their role as educators. The process of the development of the supernumerary preceptorship period represented the beginning of a culture shift where preceptors and midwives began to value their role in educating, supporting and providing constructive feedback to students. While supernumerary preceptorship may be considered a luxury that very few services can afford in today’s economic climate, the evaluation suggests that as an endeavour it was valued by all the key stakeholders including students, midwives, managers and teachers.
Subsequent to the publication of the final report of the evaluation of the pilot direct-entry programme (Carroll and Begley, 2003), the Department of Health and Children announced in 2005 (Department of Health and Children, 2005) that direct- entry midwifery education will become a route to the midwifery profession in Republic of Ireland in 2006. In the light of the positive evaluation of the supernumerary preceptorship period, the authors suggest that the 18-week supernumerary preceptorship should be maintained as an essential and integral part of direct-entry midwifery education in Ireland. Consideration needs to be given to preparing all midwives to take on the role of preceptor, including the role of supernumerary preceptor.
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