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National Review of Nursing Education

Midwifery Education

Literature Review and Additional Material (Revised Edition)

Appendix E

This document, ‘A vision for midwifery education’, was produced as a brochure by the Association of Radical Midwives (ARM) in the United Kingdom.

The document originated from the Consensus Conference on Midwifery Supervision in April 1995. ARM members formed a Working Party with the view to discussing strategies to improve midwifery education. Contributions were received from a range of midwifery fields of practice, including hospitals, the community, teaching, research, management, supervision and independent sources. Student midwives also provided their unique insights into both the positive and negative aspects of the current midwifery education system. This final document is the result of substantial discussion and revision in conjunction with members of ARM and the United Kingdom Central Council for Nursing, Midwifery and health Visiting (UKCC) Education Commission, The UKCC is the registering authority, sets standards and regulations, ensures recency of practice, handles professional misconduct enquires and disciplinary procedures and publishes statutory documents such as The Midwife’s Rules and Code of Practice (Authors of the Review).

A VISION FOR MIDWIFERY EDUCATION

Association of Radical Midwives

1. Introduction

1.1. Background to the project

1.1.1. Midwifery education has undergone unprecedented change over the last two decades in terms of content, style and place of delivery.

1.1.2. Since the late 1980s, an increasing number of midwifery students have taken the direct entry route into midwifery, that is, they have no prior nursing qualification. This has been an important factor in re-confirming the midwifery profession as distinct and separate from nursing and has, in the main, been deemed successful. Some problems have been encountered such as the teaching of midwifery students alongside nursing students on a core foundation program in some institutions, despite midwifery's opting out of Project 2000.¹ This is antithetical to the aims of midwifery education and the needs of midwifery students.

1.1.3. Also from this time, schools of midwifery moved out of hospitals and into institutions of higher education with programs being offered at diploma and degree level. This raised issues regarding the splitting of theoretical and practical learning and how and where assessment should take place.

1.1.4. A more positive legacy of this development is the supernumerary status of students. In theory this affords the student the freedom to direct her own learning without being counted as part of a particular workforce. However, in practice students are frequently expected to form part of the primary workforce, and while this may help them gain acceptance and feel that they belong, it needs to be carefully balanced.

1.1.5. These two changes, whilst having positive dimensions, have placed a large burden of responsibility on clinical midwives to support the clinical learning of students. This is often done with inadequate preparation and support and can result in stress for both students and midwives, as well as inconsistency of standards.

1.1.6. Meanwhile, midwifery educationalists have found their role in clinical education and assessment greatly diminished, not least because of their geographical isolation from the settings of midwifery care. The movement into higher education has created difficulties for midwives wishing to pursue a career in education while retaining their participation in midwifery practice. Many of these difficulties stem from issues surrounding University and Trust perceptions of risk and vicarious liability.

1.1.7.Whilst this is by no means a comprehensive recent history of midwifery education, it serves to highlight some of the current issues and areas of debate. With concerns around 5 - 15% attrition rate, paucity of places available for applicants and a general air of confusion and dissatisfaction, it can only be concluded that all is not well within midwifery education, and this will ultimately impact upon future practice.

1.1.8. Evidence abounds as to the ways in which childbearing women prefer to be cared for and it is our hope that midwives will be better prepared educationally to provide that care. Whilst recognising and applauding the great strides made by the midwifery profession to date, the Association of Radical Midwives [ARM] believes that there is room to improve and develop education to uphold and drive forward changes to benefit the women and babies we care for. To this end, ARM convened a working group in early 1998 to consider the current trends within midwifery education and to propose a Vision for Midwifery Education.

1.1.9 While recognising that there are midwives of both genders, the female gender has been used throughout.

1.2. The Aim of Midwifery Education

1.2.1. Midwifery education seeks to facilitate the development of skilled, caring, knowledgeable and effective midwives who communicate openly and engender trust from a wide range of people.

1.3. The ARM Philosophy for Midwifery Education

1.3.1. Midwifery education aspires to develop midwives who are able to be with women in any society acknowledging that people continue to experience inequalities, deprivations and injustices as well as a growing number of professional, family and environmental stresses. It is ARM's vision that midwifery education, through its content and processes, will be individually and collectively liberating in terms of gender, class, race, sexuality and creed.

1.3.2. ARM believes that all midwifery education should be formulated in content, design and delivery to assist those who wish to pursue the ancient and noble art of midwifery. We wish to see midwifery education attracting applicants with a vocational commitment to mothers, babies, families and midwifery and meeting their diverse social, personal and educational needs. Visionary midwifery is enabled by non-hierarchical relationships and this needs to be reflected in the way we educate future midwives.

2. THE POTENTIAL MIDWIFE AND THE ROLE OF THE MIDWIFE

2.1. Identifying potential midwives

2.1.1 There is apparently no well documented evidence to indicate what are the essential core qualities necessary to make the transformation into the type of committed, competent, compassionate midwife whom a childbearing woman would desire as her attendant

2.1.2. A midwife has an essential role in promoting and maintaining health. She facilitates normal childbirth, and seeks to enable women to make informed choices about their care. She recognises when childbearing falls outside the parameters of normality, and secures and participates in appropriate therapies. Part of the midwife's role is to support the woman and her family through social, relational and personal problems during the time of childbearing. It is important that pregnant women are able to value themselves as birthing women and mothers, and that all babies are welcomed into their family and society in the optimal emotional circumstances.

2.1.3. Midwifery activities contribute to the well-being of women and babies. It is essential that the student midwife has the potential to develop a range of personal, interpersonal, psychomotor, critical and analytical skills as well as a broad centred on health care but focused on maternity care.

2.2. Selection of midwifery students

2.2.1. A potential student of midwifery will be able to demonstrate characteristics that are pre-requisites to the building blocks of holistic midwifery education.

2.2.2. Applicants will present a short portfolio of evidence of a vocational calling to midwifery, howsoever they wish to interpret that.

3. THE OUTCOME OF MIDWIFERY EDUCATION

3.1. The holistic outcomes of midwifery education is a midwife who:

Personally

• has a positive self-concept and values women and the role of the midwife

• can facilitate and maintain her own well-being

• can face and experience grief and heal herself or know when and how to seek help for her own recovery

• knows how to learn and facilitate others' learning

• recognises that childbearing is a woman's lived experience.

Interpersonally

• communicates openly and freely

• observes and participates sensitively

• supports clients, families, peers and colleagues

• will provide continuity of care-giving

• knows how to build supportive networks

• builds honest relationships with women, their families and friends

• affirms women as individuals and their individual needs as central to care

• can convey ethically the information women want

• enables women to develop confidence in their own childbearing, breastfeeding and parenting abilities

• communicates and defends women's rights to self-determination

• knows how to be with women during birth, in joy, in loss and in grief

• acknowledges the grief of others

• understands that women need to tell their stories to an active listener and can be a listener

• listens to other midwives tell their stories and can learn from this

• knows how to close relationships sensitively, and at the right time And with knowledge and skill

• understands and facilitates normal physiological childbearing

• promotes health and well-being to women and their families

• supports, facilitates and implements the woman's choice

• understands, recognises and safeguards the range of normal maternal, foetal and neonatal well-being

• refrains from undertaking interventions not based on sound evidence

• can critically evaluate the evidence-base for midwifery knowledge and practice is able to diagnose pathological states which may affect maternal, foetal or neonatal well-being and is able to secure appropriate assistance and intervention while continuing to give support to her clients

• can undertake skilled emergency interventions

• understands how to be and will be a change agent in many forums

• gives practical help during bereavement

• acts as a resource to women and their communities

• understands how local, national and global maternity and health care services are organised

• collaborates in and works towards the further development of midwifery knowledge

4. EDUCATIONAL PROCESSES

4.1. Rationale for teaching methods

4.1.1. To achieve these outcomes, midwifery education must not only ensure that it teaches a broad but focused curriculum, but also that its methods for teaching and learning assist in the development of the personal and interpersonal qualities and skills identified above.

4.2. Caseload holding and apprenticeship style learning

4.2.1. We believe that caseload holding and apprenticeship style learning provide a strong model on which to base the future teaching of midwifery students, and should be underpinned by education which values midwifery practice, and recognises and respects the skills of midwives. The contribution women make to our educational processes needs to be valued as essential to this important way forward.

4.2.2. In this model, the ability of students to meet their own learning needs is recognised. Students will be enabled to identify their learning needs, nurture their individual and collective power in teaching and learning and use it to develop their personal and professional perspective’s of practice. This may seem a far cry from current understandings of teaching methods, but it is within such a framework that the bulk of most learning occurs. Caseload holding and apprenticeship style learning must therefore form the bedrock of the midwifery curriculum and preparation for practice.

4.3. One to one and group learning

4.3.1. Sharing of personal experience, birth stories, peer review and reflection on practice are all valuable learning tools. The dynamics arising from this kind of learning experience offers additional opportunity for teaching. Group dynamic exercises and the workings of any group are of value because they help educate about social behaviour and both verbal and non-verbal interaction and exchange. Group interaction allows discussion of topics which are personal or threatening in an environment which is challenging yet safe and supportive.

4.4. Inquiry-based learning

4.4.1. Although the concept of problem-based learning is deemed educationally valuable, the name itself suggests pathology. We therefore propose inquiry-based learning as alternative nomenclature. Triggers for such learning can include written scenarios, simulated situations, case presentations and videos. Inquiry-based learning would incorporate the benefits of 4.3

4.5. Role play

4.5.1. We believe that simulated experiences offer a very useful method for learning and teaching. These would include simulated birth situations and emergency procedures which require team work. Post role-play discussion will lead to the understanding of the role played, facilitate emotional identification, and integration of invasion of personal space and other emotional challenges. The development of peer review skills is an integral part of this kind of learning.

4.6. Shared learning

4.6.1. Shared learning will be multi-professional, interdisciplinary and equitable in focus and is a useful means to understanding problems from a variety of viewpoints. Its value is enhanced when participants are grounded in their respective disciplines. The use of shared learning should derive from clear educational objectives and not considerations of cost.

4.7. Information Technology

4.7.1. Information technology will continue to make a major contribution to future teaching and learning and assist in the development of evidence-based practitioners. Educational software will be useful provided its intended learning outcomes are in keeping with those outlined in section 3 above.

4.8. Assessment of Practice and Theory

4.8.1. Assessment is a multifaceted ongoing developmental process and ideally includes:

• Case-studies

• Examinations:

• Testimonies from women

• Self-assessment

• Essays

• Visual material

• Oral presentations

• Three-way (midwife/student/teacher) practical assessment

This list is not definitive.

4.8.2. In any assessment process, whether practical or theoretical, assessment criteria will be clearly articulated and linked to the desired outcome. Practice assessments should form a substantial part of overall course assessment and involve the full range of midwifery skills. While the theory/practice split is not currently defined in the Midwives Rules, we believe that the practice element should comprise no less than 50%, with both elements being integrated as fully as possible throughout the program.

5. THE STRUCTURE OF MIDWIFERY EDUCATION

5.1. Recognising that students have a variety of needs and circumstances, midwifery

education will be diverse, and consist of both part-time and full-time routes to registration of varying duration.

5.2. Courses can be located in a number of settings ranging from apprenticeship with

independent midwifery schools, to NHS community-based or hospital-based midwifery schools and Institutions of Higher Education. Open and distance learning are possible for parts of the midwifery curriculum.

5.3. Validation and monitoring of standards should be consistent and rigorous and controlled by the midwifery profession in partnership with relevant institutions and lay organisations.

5.4. The profession will publish a guide to all routes to registration annually, to enable potential midwifery students to select the route most appropriate to them. This guide will include recent student evaluations of each route.

5.5 ARM affirms the value and importance of a direct entry program. We believe this should be available throughout the UK and should be the principle route of entry into midwifery, and that recruitment and funding streams should recognise this.

5.6 Whilst the current 18 month course enables qualified nurses to enter midwifery it is not without its difficulties for both the student and the profession. ARM supports an appropriate recognition and assessment of prior experience and learning, as they apply to midwifery, for all prospective entrants.

6 THE SELECTION AND ROLE OF THE MENTOR

6.1. Selecting a mentor

6.1.1. In view of ARM's long held belief that all midwives will be caseload holders, we would expect that student midwives would apprentice to several named midwives throughout the educational period (ARM, 1986).

6.1.2. Complementary to this, as a student identifies her learning needs she will develop and use her communications skills to create learning opportunities with a variety of midwives in a variety of settings.

6.2. The mentor

6.2.1. The midwife chosen by the student would fulfil the role of mentor, teacher and assessor of midwifery skills

6.2.2. The chosen midwife will:

• nurture

• cherish

• guide

• respect

• be a role model

• show a genuine concern for how the student will develop

• communicate

• acknowledge her own needs

• demonstrate evidence-based practice

• demonstrate a desire to teach

• document her personal midwifery philosophy

6.2.3. A midwife taking on this role requires workshop preparation and on-going professional support. This preparation, as well as appropriate remuneration and time concessions, will motivate midwives to embrace this role.

6.2.4. The relationship between the student and her chosen midwife for apprenticeship could occur by introduction facilitated by the lecturer/practitioner (see section 7 below). However there would be provision for a probationary period during which the student and the chosen midwife could change the learning arrangement if necessary.

7. THE MIDWIFE LECTURER-PRACTITIONER

7.1. The role of the midwife teacher will evolve into a role of lecturer-practitioner. The midwife lecturer-practitioner will act as a bridge between the intellectual, academic and theoretical basis and the complex daily realities of midwifery practice.

7.2. The Lecturer/Practitioner will hold a small caseload within a group practice. She will facilitate the academic and theoretical development of a designated group of students, and will act as an assessor.

For students:

• Actively promote recruitment of and select candidates for midwifery courses

• Plan and facilitate anatomy and physiology courses as a pre-requisite for all entrants to midwifery (acknowledging that knowledge of anatomy and  physiology underpins effective and autonomous practice)

• Facilitate inquiry-based learning as a method of linking theory to practice

• Facilitate students carrying a personal caseload as a means of linking theory to practice

• Support students in achieving the holistic outcomes listed above

• Encourage self-awareness and critical thinking through reflection.

For midwives:

• Promote educational resources for midwives and facilitate lifelong learning

• Act as a resource for midwives to appraise evidence for practice, undertake research and write for publication

• Encourage self-awareness and critical thinking through reflection.

• Act as an educational resource

a) for midwives in their role as chosen mentor
b) in clinical assessment

7.4. The Lecturer/Practitioner will have a broad understanding of the dynamic preparations required for the facilitating of the educational processes referred to in this document. She will need to have a broad experiential grounding in midwifery theory and skills.

7.5. The route to becoming a lecturer/practitioner would be multi-faceted. A teaching

qualification or degree will be likely but not mandatory. More emphasis will be placed on attracting passionate, inspirational midwives to this role.

8. CONCLUSION

8.1. Recent developments in midwifery education have rarely been instigated by the

profession nor formulated in terms of the needs of women and babies. Whilst some gains have been made, there are many weaknesses in the current framework, particularly in the relationship of theory to practice.

8.2 The current structure of midwifery education is leading to a disintegration of midwifery theory and practice, in terms of its geographical configuration and the role of midwifery educationalists. This has many negative effects; on midwife teachers, midwifery students and on those midwives in practice who are being asked to undertake roles for which they are inadequately prepared, supported and remunerated. At the same time, few if any courses are geared in content and methods primarily towards developing midwives who can be "with women".

8.3 ARM believes that midwifery education can be much more creative and ambitious in what, how, whom and where it teaches and how it facilitates learning. Midwifery education should consistently and holistically work towards recruiting and nurturing the sort of midwives women need and want. This Vision has laid out some of the ways we think this can be done.

Produced with permission from the Association of Radical Midwives (Ormskirk, United Kingdom),1999.

Foot NOte:

1.Project 2000 was an initiative in the United Kingdom, which introduced a new mode of course delivery that attempted to combine all nursing specialties into commencing ‘core’ studies. Midwifery has remained, essentially, separate from this (Authors of the Review).

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