The theme of the shortage of midwives in the UK continues across media and political outputs. A key concern is that many are leaving who have been less than 5 years in the profession. In this article Judi Smith, and Jan Bentley, Preceptorship Lead Liverpool Women’s Hospital, share how the Trust has recognised and is addressing the problem through effective preceptorship.
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Time to stop plugging holes in leaky- buckets?
A fresh perspective to recruitment and retention of Newly Qualified Midwives
The issue of workforce challenges and the threat of an impending staffing crisis continues to dominate headlines, identified in the final Ockenden report (2022) as an urgent priority and considered a real and significant threat to the continued safety of maternity services.
There has been an increasing call for government action to defuse the crisis, in front of us, following the publication of a study by the RCM (October 2021) warning of a possible “midwife exodus”. The report reveals issues around challenging working conditions exacerbated by the pandemic, burnout and plummeting morale, citing findings from a report by NHS digital (2021) 300 midwives, the highest number in 20 years have left the profession over a 2-month period. Of the 57% respondents who said they were considering leaving midwifery the highest proportion are midwives who have worked 5 years or less in the NHS.
Global reviews which support newly qualified midwives’ retention, show that if the recruitment and retention strategy is clear we will retain our staff. So – what does the evidence tell us, can we determine a baseline attrition rate, what is our retention plan and what contextual factors do we implement in our operational strategy?
The evidence clearly identifies that transition from student to accountable practitioner remains problematic, with a significant number leaving within the first two years of employment and the peak point for attrition, in the first year at 6 – 7 months (Newton and McKenna, 2007).
Research shows adapting to new roles and responsibilities often results in decreased self-confidence in the first months (Stulz et al., 2021, Kool et al., 2022).
Data analysis by the Australian arm of the “Work Health and Emotional Lives of Midwives (WHELM ) study cited dissatisfaction” an intention to leave in 50.8% of midwives with more than half dissatisfied with their managers. Those who selected this as their primary reason had been practising less than 5 years and were more likely to be aged between 18 and 29 years (Harvie, Sidebotham and Fenwick, 2019)
Following on from the introduction of the Capital Nurse Framework (HEE 2017) research, which considers retention beyond the first year, identifies nurses are leaving within the first two years of registration but crucially those who stay with the organisation are likely to stay five more years (HEE 2021)
Research exploring retention and why midwives stay is limited, and further studies are needed (Bloxsome, et al 2018). What is clear from the evidence is the need to scaffold and provide proactive support for younger newly qualified midwives who are identified as being particularly at risk of emotional compromise, to promote workforce sustainability and career longevity (Hunter, et al 2019)
NHSE (April 2021) announced an investment of £95.9m to help recruit 1,000 midwives. The findings of the Parliamentary cross-party Health and Social Care Committee on the report into the “Safety of Maternity Services” estimated that safe staffing of maternity services requires at least another 1,932 midwives.
It’s clear that when NQM’s feel unable to navigate the challenges of transition they are less likely to stay, so how do we plug the bucket? Or do we need to go back to the drawing board with a brand-new bucket? A new and innovative approach to recruitment and retention whilst crucially, reinforcing that bucket against future leaks with a robust and transformational retention strategy that anchors staff to stay.
The HEE RePAIR (Reducing Attrition and Improving Retention) project (2018) produced a toolkit of effective interventions to reduce attrition referring to the transition from final year student to New Qualified Midwife as a “shaky-bridge” with only 12% of students reporting a straightforward transition. The design of a Preceptorship programme and level of support is key in terms of retention and success and requires a collaborative approach with HEI’s and HCP’s working together to improve retention from pre-employment to two-years post-qualification.
While recognising one-size does not fit all when addressing issues around attrition. It is to be noted that this programme is for Newly Qualified Midwives. The multi-factorial causes affecting retention across the profession will need to be addressed separately.
If we consider learning/teaching methodologies which consider the most effective way to retain information is in active or participative learning methods as 75% of learning is in the practice of doing and 90% is therefore, creating momentum through active retention is key to its success.
As a trust, prior to the latest reports from the RCM and Ockenden we have been keen to implement a change in the provision and quality of support for newly qualified midwives. In summer 2021 following a focus-group, we employed two-dedicated preceptorship leads as part of an organisational commitment to address issues around recruitment and retention of newly qualified midwives, adopting a focussed future-driven solution, robust recruitment and retention strategy to bring together various elements of value improvement.
This transformational approach ensures an innovative and robust framework which supports and safeguards our preceptees for clinical practice and promotes patient safety. In the long term this requires funding, protected time, resources, and organisational commitment.
A review of the evidence and examples of best practice told us we need to think creatively to create the right environment to ensure preceptees feel valued and their needs are met.
It is clear our workforce is more diverse then, ever before (Arsenault 2004,Hu, Herrick and Hodgin, 2004). Generational cohort typologies are essential in ensuring the effectiveness and stability of any retention strategy. Maslow’s human motivation theory provides a framework to consider specific developmental needs (Benson and Dundis 2003). An understanding of the specific characteristics and values of our group helped us to structure an effective model of support and adjust our organisational structure.
The health and wellbeing of staff is integral to the provision of quality of care (West 2001). Feeling valued; making a difference; feeling supported professionally and emotionally, inclusion belonging, and team-spirit were identified as key values for this cohort recognising, ultimately, if staff feel valued and have job satisfaction, they have increased commitment to their employer and profession.
Data collected by HEE and NHS England (HEE 2021) to assess the implication of the pandemic on attrition identified this cohort of midwives may not have put down roots and don’t have the same support structure which means they may be as likely to stay at a Trust a long way from home
It was clear we needed to foster an accessible community of practice to support communication, with initiatives to encourage inclusion and friendship with team building exercises including a “scavenger-hunt, for preceptees to help establish friendships and get to know the city”:
- Investment in responsible social media platforms to boost communication; ease social discomfort; increase engagement and build peer-to-peer supportive relationships.
- A dedicated team’s channel with resources for staff to access with operational information and guidance to assist them in their clinical areas and improve productivity.
- A social media group created prior to employment, allowing the opportunity to ask questions informally to managers and exchange information about issues such as relocation with others who will be part of their support network.
Students use social media forums
- to debate their employment preferences, accessing these platforms has proved key to our recruitment strategy with a recent event attracting attendees from across the UK.
- We celebrate success with recognition and reward and provide on-going opportunities to boost staff morale, harnessing social media to welcome new starters and celebrate achievements, creating a fly-wheel effect and considerably increasing our reach.
- We work collaboratively with HEI’s presenting our programme and career opportunities to students in their 2nd year as the research tells us it is these students that are most likely to consider leaving and require additional support to continue to feel valued (HEE 2018). Attending HEI’s to support with interview preparation and statement writing.
- We created and facilitated a dedicated 2-week induction off-site to continue a group dynamic, using a multi-professional approach to training to promote collaboration and socialisation into the work environment.
- Dedicated teaching from specialist midwives and multi-disciplinary teams across the disciplines, designed to incorporate Trust policies and procedures, to avoid unwarranted variation in practice to acclimatise preceptees and promote their understanding of accountability and responsibility associated with safe clinical practice
- Informal “drop-ins” from clinical, organisational and Trust leads to open dialogue and allow for leaders to be seen as accessible and approachable promoting an inclusive culture that encourages preceptees to raise concerns or make suggestions for improvement.
- Preceptees meet the team’s including theatre staff, neonatal staff and pharmacy staff, to break down hierarchies, improve collaborative practice and encourage recognition and respect for the contribution of each team member.
The fundamentals of our strategy include effective governance, a strong safety culture using a collaborative approach to reduce clinical errors and strengthen care co-ordination. Providing 1:1 expert support across the clinical areas to safeguard patient safety, addition emphasis and support is given to fetal surveillance; medicines management and the care of complex antenatal and postnatal women.
In the first two-weeks of orientation Preceptorship Leads provide 7-day support with skills essential to effective patient care including delegation, focus and time management to improve professional judgement and decision making.
It is recognised and reinforced that preceptees bring their own skills, knowledge and have met the necessary competencies required for practice, but that this period is often not without some anxiety; preceptees wear a discreet yellow badge to identify they may need additional support.
The preceptees take on the role of the primary-care giver but with supernumerary status and a dedicated buddy for guidance, with clinical acuity and complexity increased as they build on their skills and develop their role as a practitioner and lead carer.
Creating a positive work-based culture means dedicated time is given to multi-disciplinary and human factors training to encourage and ensure preceptees feel valued, respected, and able to challenge without fear, working together towards the same goal, to provide safe effective patient care. An environment of learning has been developed with the rest of the midwives keen to support and coach this new cohort.
A clearly defined and structured pathway which promotes resilience; self-management; preceptee empowerment, accountability and encourages innovation and problem solving. Informed by regional/national policy relating to preceptorship and good practice examples we monitor and track newly qualified practitioners with a 1:1 meeting at crucial points during their orientation
We created a clearly defined purpose of preceptorship with our “Preceptorship Promise”, to ensure good role-modelling and leadership, that is mutually understood by preceptors and preceptees.
This streamlined approach identifies outcomes and completion of skills and key competencies that are easily transferable across different Trusts, with an ambition to create a digital document that preceptees can access from their mobile phones.
Authentic leadership involves support from a managerial, pastoral and clinical perspective. It is essential that we demonstrate clinical expertise and understand current service pressures if we are to provide direction. We carry a bleep to provide direct and proactive support with enhanced clinical skills and care provision.
Ensuring effective infrastructures are in place are important to protect professional and emotional development by creating a psychologically safe environment with an open-door policy and communicating in a personal and relatable way, recognising when NQM’s feel pressured performance decreases and the threat of burnout increases. We work in partnership and access numerous resources to help keep our midwives happy and healthy in work.
Recognising individual professional and personal needs requires active encouragement – promoting leadership and next-step career development. If preceptees have submitted a dissertation or developed a specific interest, encourage them to get involved with improvement projects; local audits; research projects and service development.
The collection and analysis of both qualitative and quantitative data and its integration, using anonymous questionnaires accessed by a QR codes, observation and one-to-one interviews
ensure our programme is flexible and meets the needs of preceptee’s and stakeholders
The data to date shows we are on a good trajectory. Our current cohort of 36 midwives have no attrition, reduced sickness, reduced work-based stress, and improved morale. Which has resulted in more confident staff, improved performance, improved productivity, and a reduction in incidents.
REFERENCES
Arsenault, P., 2004. Validating generational differences. Leadership & Organization Development Journal, 25(2), pp.124-141.
Benson, S. and Dundis, S. (2003) Understanding and motivating health care employees: integrating Maslow’s hierarchy of needs, training and technology. Journal of Nursing Management, 11(5), pp.315-320.
Bloxsome, D., Ireson, D., Doleman, G. and Bayes, S., 2018. Factors associated with midwives’ job satisfaction and intention to stay in the profession: An integrative review. Journal of Clinical Nursing, 28(3-4), pp.386-399.
Harvey, S. and Uren, C., 2019. Collaborative learning: Application of the mentorship model for adult nursing students in the acute placement setting. Nurse Education Today, 74, pp.38-40.
Harvie, K., Sidebotham, M. and Fenwick, J., 2019. Australian midwives’ intentions to leave the profession and the reasons why. Women and Birth, 32(6), pp.e584-e593.
Hu, J, Herrick, C. and Hodgin, K., 2004. Managing the Multigenerational Nursing Team. The Health Care Manager, 23(4), pp.334-340.
Hunter, B., Fenwick, J., Sidebotham, M. and Henley, J., 2019. Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors. Midwifery, 79, p.102526
Jackson, J., 2016. Myths of Active Learning: Edgar Dale and the Cone of Experience. HAPS Educator, 20(2), pp.51-53.
Kool, L., Schellevis, F., Bax, I., Jaarsma, D. and Feijen-de Jong, E., 2022. Midwives’ perceptions of the performance- and transition into practice of newly qualified midwives, a focus group study. Women and Birth,
Newton, J. and McKenna, L., 2007. The transitional journey through the graduate year: A focus group study. International Journal of Nursing Studies, 44(7), pp.1231-1237.
Stulz, V., Francis, L., Pathrose, S., Sheehan, A. and Drayton, N., 2021. Appreciative inquiry as an intervention to improve nursing and midwifery students transitioning into becoming new graduates: An integrative review. Nurse Education Today, 98, p.104727
West, E 2001. Management matters: The link between hospital organisation and quality of patient care. Quality in Health Care, 10(1), pp.40-48.
Judi Smith and Jan Bentley
Preceptorship Leads, Liverpool Women’s Hospital
June 2022