Sink or swim
A study was undertaken to explore the experiences of NQMs and the support they received. Dr Sarah Norris explains what it found.
Clinical practice is under extreme pressure to operate in a lean, efficient manner and this has been found to have an impact on NQMs’ experiences. This prompts the question about how an NHS employer can take steps to help NQMs. There is evidence to suggest that resilience is an important characteristic for midwives to develop (Hunter and Warren, 2014) and clearly it is sensible for the NHS to support NQMs in this endeavour. One way that the health service can promote resilience is to offer preceptorship programmes. Although these programmes are common, they vary in effectiveness. In Wales, to gain an insight into NQMs’ experiences during the first six months of their practice and to evaluate a preceptorship programme, a qualitative study was undertaken.
The study’s methodology was based on the principles of action research. A purposive sample of five midwives agreed to take part in the study and three volunteered to keep a reflective diary. In view of the small number of participants in the first stage of data collection, the design of the study was adapted to include a further focus group of four participants to evaluate the findings of the previous group and comment on the recommendations made. A quantitative survey was also undertaken.
What did the research find?
In the early days of their practice, five NQMs in one focus group reported feelings that were very emotional and angry when describing their experiences, while all participants agreed that it was a challenging and difficult time.
However, as NQMs became more socialised to the workplace, their emotions became less intense but, initially, there was a real strength to their feelings.
One NQM described feeling ‘completely vulnerable and on my own and really unsupported on the ward’. This NQM described how she felt that there had been no recognition of how difficult it was as an NQM and other participants shared her sense of being unsupported. All the participants found that their new role impacted on their whole life and their experiences included sleeplessness, counting down the days until the next shift and anxiety about what might happen.
The participants were highly influenced by their perceptions of their relationships with their colleagues – ‘fitting in’ and being recognised as a valued team member was an aspirational goal. The quality of support was found to be related to the workload and staffing levels, particularly in the ward situation. One participant stated: ‘Most of the time the midwives were as supportive as they could be... most of them were really nice... again, they were under the same pressure so they did as much as they could.’
Other participants felt like being newly qualified was a baptism of fire to be endured. This sense of it being a rite of passage was inferred from the utterings of the NQMs’ more experienced colleagues who would say things like: ‘We did it, so you’re going to have to go through it’, ‘Oh, you new girls, you’re going to have to suck it up – it’s sink or swim’, and ‘She just can’t hack it here, she needs to go to a quieter unit’.
Initially, NQMs were concerned about the tasks that needed to be completed in an environment with multiple competing workload demands. This concerned participants much more than a woman-centred approach, however, they did talk about their relationships with women, mostly when things were not going very well, and especially when they felt inadequate and unsupported. The NQMs worried that women would think less of them because they were newly qualified. One participant reported that she would say she was new to the NHS trust rather than admitting she was newly qualified.
The focus group agreed that the medical staff were helpful, even though they felt in awe of them in the early days, they grew in confidence as time progressed. This confidence was essential, as one NQM describes in an incident when she had to be assertive with a doctor who was reluctant to review one of the women on the ward. She describes saying: ‘If you don’t do this now I’m going to escalate to your senior because I need this woman seen now and, as a midwife, I can’t sit on her.’
In the focus group, the midwives participating appeared to express much more confidence in their practice and their relationship with the workplace. Initially, it seemed there was a gap between how these NQMs felt and the confidence they believed was required in the workplace. An excerpt from a diary refers to the need to show confidence and assertiveness: ‘I find you have to be quite bold. I’m naturally quite a quiet person, not shy, but just quiet. I have to learn to portray a boldness of character and also that it is a process of learning to have confidence in my own practice. Confidence in what I know and confidence in what I don’t know.’
This qualitative study highlights how the NQMs participating underwent an effective transition from student to confident practitioner. From this data recommendations were developed, these include: recognition that NQMs are Band 5s and need support; induction and orientation around every new area; preceptorship documentation was judged to be repetitive of pre-registration competency documentation and its value was questioned; and the possibility of a transition document without the pre-qualifying skills.
Participants discussed the need to have an experienced mentor when in their third year of midwifery education and training and also whether there might be an opportunity for independence and caseloading when undertaking clinical duties as final-year students. Participants felt these attributes would help to build skills such as time management, confidence, independence and prioritising workload – all of which would assist in the transition from student to qualified practitioner. In addition, it would be helpful if the pre-qualifying placement could be in the same clinical area as the first qualified placement. In this case, the mentor becomes the preceptor.
These findings resonate with evidence from published literature (Boakes and Shah, 2017; Pezaro et al, 2017; Whitehead et al, 2016; Kitson-Reynolds et al, 2015), in that all newly qualified healthcare professionals are emotionally challenged in the first few months of their employment. NQMs’ emotional responses to their experiences was found to be comparable in different health boards across Wales and dependent, to a great extent, on the empathy and support they received from colleagues.
The NQMs’ emotional responses resonate with theories about transition where it is recognised that, in the process of any change from one status to another, individuals will experience feeling of loss and bereavement, fear, uncertainty, bewilderment and loss of performance (Hobbs, 2012; van Gennep, 1960). It emerged from the data that participants needed to let go of their former identity as students, accept that they will feel ‘in the wilderness’ for a while before they can move forward as qualified midwives.
HoMs and LMEs in Wales were keen to respond to the issues raised and the recommendations made by the study. In response to the recommendation to provide a seamless transition from student to NQM, an agreement is in place between the higher education institutions (HEIs) and health boards in Wales, to provide a transition placement, or pre-qualifying placement, which will be implemented by bringing forward the commissioning and recruitment process.
The curriculum planner in the HEIs will be changed so that the final year summer break is brought forward and the final four to six weeks of the pre-registration midwifery programme will comprise of a pre-qualifying placement in the area where the student will be employed. During this placement, independent practice will be facilitated to promote skills in independent thinking and clinical decision-making. The mentor allocated for the pre-qualifying placement will become the preceptor as the student makes the transition into the new role as qualified midwife and, while awaiting confirmation of NMC registration, NQMs will be completing their induction programme.
This initiative is to be implemented across Wales in the summer of 2018 and to be evaluated three months after the NQMs’ registration with the NMC. The rationale is that establishing familiarity in the workplace and the provision of pastoral support could ease the process of transition prior to and across the time of qualification. It is envisaged that NQMs will feel more supported and better equipped to cope with the demands of practice as they start out on their career.
Read the RCM’s position statement on preceptorship for NQMs at bit.ly/PS_preceptorship_NQMs
Dr Sarah Norris is lead midwife for education at Swansea University. Illustration: Tim Bradford.
Boakes E, Shah N. (2017) Improving the transition from medical student to junior doctor: a one-month course in the final year of medical school. See: https://www.mededpublish.org/manuscripts/658/v1 (accessed 27 March 2018).
Hobbs J. (2012) Newly qualified midwives’ transition to qualified status and role: assimilating the ‘habitus’ or reshaping it? Midwifery 28(3): 391-9.
Hunter B, Warren L. (2014) Midwives experience of workplace resilience. Midwifery 30(8): 926-34.
Kitson-Reynolds E, Ferns P, Trenerry A. (2015) Transition to midwifery: collaborative working between university and maternity services. British Journal of Midwifery 23(7): 330-5.
Pezaro S, Clyne W, Fulton EA. (2017) A systematic mixed-methods review of interventions, outcomes and experiences for midwives and student midwives in work-related psychological distress. Midwifery 50: 163-73.
Van Gennep A. (1960) The rites of passage. Chicago Press: Chicago.
Whitehead B, Owen P, Henshaw L, Beddingham E, Simmons M. (2016) Supporting newly qualified nurse transition: a case study in a UK hospital. Nurse Education Today 36: 58-63.