Midwifery globally is currently facing immense pressures. In this environment midwifery educators still must work with practice environments to develop and support students to become the midwives of the future. In this article Sheila Brown, midwifery lecturer, Julie Roberts, Midwifery Course Director, and Emily Ford, newly qualified midwife, all from Bangor University, reflect on their journey improving student experience, from an extraordinary review, to being top scoring in the National Student Survey.
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Extraordinary review to extraordinary: improving student experience at Bangor University
Midwifery and maternity services are facing unprecedented scrutiny and pressures in the midst of several exposed failings in maternity services in the UK (Kirkup, 2022; Independent Maternity Review, 2022; Royal College of Obstetricians and Gynaecologists, 2019; Kirkup, 2015). Despite these challenges, midwifery educators continue to be tasked with working in partnership with practice learning partners (PLPs) to ensure safe and effective learning environments for student midwives and to optimise student experience (Nursing and Midwifery Council (NMC) 2018 & 2019). Back in 2015 the midwifery course at Bangor University has an extraordinary review when the National Student Survey (NSS) for the programme was 39% (NMC, 2015). We, Sheila Brown (SB) and Julie Roberts (JR), midwifery educators, along with newly qualified midwife Emily Ford (EF), share our reflections on how we have worked to improve student experience in recent years to be the top scoring midwifery programme in the UK for the NSS in 2020 (100%) and again in 2022 (96%) https://www.thebangoraye.com/bangor-universitys-midwifery-course-ranking-best-in-the-uk/.
Bangor University was established in 1884, https://www.bangor.ac.uk/ , and whilst the main arts building is affectionately referred to as “Hogwarts” by students, recent programme improvements are not due to waving a magic wand. We have outlined key strategies and approaches that we have taken to work to improve the quality of the midwifery programme and student satisfaction in the hope that this information may be useful for midwifery educators and students in the UK and beyond.
Simple and effective strategies
Sheila (SB) took over as lead midwife for education (LME) in 2016 in the wake of the extraordinary review and after only 2 years in a substantive post as a midwifery educator. Learning from the previous LME, advice from the extraordinary review team, the LME Welsh and UK wide groups, and from her LME mentor, Dr. Christine Furber (LME at The University of Manchester), Sheila primarily used the joint school and local health board (PLP) escalation of concerns policy https://www.bangor.ac.uk/health-sciences/professional-conduct-guidance.php.en to guide decisions and revision of strategies to work to improve the overall quality of the learning environment and to optimise student experience. She encouraged the ethos of the midwifery education team to view students as future colleagues. There was a clear expectation that if any issues were identified by students in theory or practical aspects of the programme that students should approach and speak to the person the issue(s) related to in the first instance https://www.councilofdeans.org.uk/bangor-university-improving-the-practice-learning-environment/; support from the midwifery education team was provided for students to enable them to do this. The aim of this advice and strategy was to foster a professional ( https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/enabling-professionalism.pdf ), and humanistic approach of openness and transparency, candour (https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/), reciprocity and respect, ( https://www.nmc.org.uk/standards/code/ ) ensuring that the student voice was heard.
Listening to students and encouraging them to speak up communicated that they were valued as stakeholders in the ongoing evaluation and development of the programme. Students were advised that decisions made by the education team and PLPs would always prioritise quality and safety for women and families; students were also encouraged to consider this as their primary focus. Prioritising public safety as a foundation for our approaches going forward was underpinned by our collective adherence to the NMC code and by lessons learned from national failings in maternity services.
Student feedback was encouraged both informally (e.g. during taught sessions) and formally from theory and placement evaluations scheduled three times during the academic year. Cohort representatives were invited to a quarterly course board meeting with representation from the midwifery education team, PLPs and service users. The focus for this meeting was quality improvement for the programme ensuring the NMC standards as well as university regulations were met and key to this was review of student feedback. This forum fostered mutual understanding between all stakeholders, again with the ethos of focusing on women, people and families; i.e. public safety was paramount. This resonates with the ethos that midwives are ‘professional servants’ (Cronk, 2010). The midwifery education team and PLPs responded to student feedback to make improvements where possible, also explaining why in some instances student requests for changes could not be accommodated. The LME chaired this meeting initially and guided group decisions based around key principles outlined in the following acronym (KISSES) adapted from the North American “KISS” principle (Keep it Simple and Straightforward):
Keep
It
Simple – use simple guidance i.e. the escalation of concerns policy. Review, amend and streamline any ‘messy’ processes.
Standardised – optimise consistency of advice and feedback to students. Work to ensure that all members of the midwifery education team, and PLPs have a similar approach to supporting and advising students. Communication between staff and students was (and continues to be) through mechanisms provided by the university i.e. by university email and phone numbers only. We do not provide students with personal mobile numbers or use any other communication platform (e.g. WhatsApp). This fosters the expectations for professional communication with students as future colleagues.
Equitable – ensure processes are equitable for students, across cohorts, with the allowance of individualising support for students with mitigating circumstances. Ensure that midwifery educators and PLPs are ‘singing from the same hymn sheet’ to reduce miscommunication with students. In response to student feedback, we worked to ensure equity with assessment marking by introducing a pre-verification marking process to enhance standardisation (the idea for this was from midwifery education colleagues at Cardiff University). This involved all members of the marking team agreeing assessment expectations and through blind marking one piece of work. Students were made aware of the introduction of this strategy in response to their feedback (to ‘close the loop’).
Strategic view – the lens for our discussion with students and other stakeholders was and is to prioritise the safety of women and families. We upheld and fostered professional expectations and requirements that enhance public safety prioritising them over university guidance. Students are made aware that not speaking up can compromise public safety (as clear in reviews of failings in maternity services). We ensured that resources are sufficient to meet programme requirements, which has improved the overall quality of the programme. This has required strong leadership from the LME within the university and with externally facing bodies.
Positive approaches
Following the extraordinary review we needed an injection of positivity into the programme for students, the team and PLPs. We moved forward with plans for UNICEF UK Baby Friendly Initiative (BFI) accreditation, (https://www.unicef.org.uk/babyfriendly/accreditation/universities/ ), for the midwifery programme which we achieved in August 2017. This provided an accolade for the programme and sense of pride for the cohort qualifying in September 2017 whose experiences during the programme where most impacted due to the extraordinary review. We received a UK BFI Gold award this year (2022) following reaccreditation as Baby Friendly with sustainability.
We encouraged students to focus on success, and to support each other and celebrate achievements. Students began putting each other forward for awards which led to a few nominations for student midwife of the year. This resulted in one of the third-year student midwives winning the Nursing Times Student Midwife of the Year award 2018. This accomplishment not only provided a boost of confidence for the individual student but engendered a sense of pride within the cohort.
Midwives and student midwives were provided with the RCM undermining behaviour training, ( https://www.ilearn.rcm.org.uk/enrol/index.php?id=227 ). This is now shared with students as part of managing wellbeing sessions. We also share key strategies from positive psychology with students (Seligman, 2011) which are now summarised in the Once for Wales Midwifery Practice Assessment Document (MPAD) under the managing challenges section (see RCM elevator pitch presentation by Dr. Lucie Warren from Cardiff University and SB https://www.rcm.org.uk/promoting/education-hub/research-and-funding/research-news-views/ ). In addition, we provided links to self-care resources on the virtual learning site. These approaches align with the NMC Standards of proficiency for midwives (NMC, 2019) that call for future midwives to:
“..demonstrate awareness of the need to manage the personal and emotional challenges of work and workload, uncertainty, and change; and incorporate compassionate self care into their personal and professional life” (p.28).
There is a body of literature outlining that student and NQMs experience challenges in learning environments, citing undermining or bullying behaviour in practice environments as the reason for some midwives choosing to leave the profession (Hunter, Fenwick, Sidebotham & Henley, 2019; Weir & Lake, 2022). The learning environment is the practice environment and therefore it follows that supporting a new generation of midwives by sharing tools to enable them to manage the challenges in a positive way, may work to improve environments and their experience.
Strengthening of Welsh Language provision
We were successful in obtaining a grant to support Welsh language provision within the midwifery programme enabling us to offer a temporary post for a bespoke Welsh medium midwifery lecturer. This enabled us to meet Welsh Government guidance of an active offer of language choice for students for skills sessions and tutorials. Whilst we appreciate that this may not be readily replicated in other programmes, essentially, this is an example where we listened to the needs of our student body and sought to fund required resources.
Peer support
The midwifery student society introduced a buddy scheme for students. Third and second year students were linked with first years to provide support and guidance, via email or messages, on anything from how to organise their portfolios to where the best parking spots are at the hospital. During the pandemic, this was made more difficult as the students would only ever meet face-to-face in the practice learning environment. However, remembering how daunting it can be to begin their first placements, the more experienced students were able to provide some reassurance to first years during their initial weeks on placement, and beyond.
Resources
Ensuring adequate resources to meet the requirements of the programme is key and links to all aspects of educational provision. The LME was invited to strategic meetings in the school as well as meetings with external funding bodies. The LME ensured that midwifery featured on the agenda in strategic meetings and was persistent in working to maintain a staff student ration of 1:17 (a recommendation from the extraordinary review). When students commented on ‘tired’ skills equipment during session, we asked them to use formal mechanisms to communicate this feedback which we then quoted to put forward requests for new equipment. Involving students and working in partnership with them in this way provided transparency and clarity on how their feedback worked to improve the quality of the programme.
Staff were encouraged to try to ring fence some time for continuing professional development (CPD) and to apply for study time for scholarly activities. This remains challenging to achieve, however, as a team, we have encouraged each other with respect to our individual development and achievements. This links strongly to the growth and development of the midwifery education team and directly impacts on programme quality. The first agenda item at team meetings is to ask how the midwifery education team are (in terms of wellbeing) and to share and celebrate any achievements and recent CPD activities. This appears to have fostered a cohesive team who work effectively and support each other. If a staff member had/has any issues within the team, or in the wider school, they are encouraged and expected to use the same approach that we advise students to use: i.e. speak to the person first.
Summary
In summary, our strategies and approaches for improvement align with the NMC code. Prioritising people, women and families is our main focus in everything we do. This requires us to ensure sufficient resources to support the development of graduates who will practise effectively. We are passionate about supporting students to raise, and also to enable them to deal with, concerns and challenges (with our support) in order to foster their ability to advocate for people, women and families in the future. This is key to preserve safety within maternity services. It is our belief and hope that to ensure psychological safety in maternity care environments (Edmondson, 2019) we need to educate and support the future workforce to exercise their duty of candour and ensure that they feel valued from day one of their journey to becoming a registered midwife. We also need to explore and highlight what works to support student midwives to be responsible and accountable professionals – this is the focus of Sheila Brown’s PhD study. Finally, student midwives are on a professional programme. Expectations to promote professionalism and trust must be clear from the outset and prioritised above university guidance and processes.
We hope that sharing our strategies, views and experience may be useful for midwifery educators and students who are seeking to improve programme quality and student experience.
References
Cronk, M. (2010) The midwife: a professional servant? In M. Kirkham (Ed.), The midwife-mother relationship (2nd ed.,pp. 55-65). Hampshire: Palgrave MacMillan.
Edmondson, A.C. (2019) The fearless organization: Creating psychological safety in the workplace for learning, innovation and growth. New Jersey: John Wiley & Sons, Inc.
Hunter, B., Fenwick, J., Sidebotham, M., & Henley, J. (2019) Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors. Midwifery, 79, 1-12.https://doi.org/10.1016/j.midw.2019.08.008.
Independent Maternity Review. (2022). Ockenden report – Final: Findings, conclusions, and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. HC1219).Crown. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf
Kirkup, B. (2022) Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation. House of Commons. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1111992/reading-the-signals-maternity-and-neonatal-services-in-east-kent_the-report-of-the-independent-investigation_print-ready.pdf
Kirkup, B. (2015) The report of the Morecambe Bay investigation. London: The Stationery Office. http://data.parliament.uk/DepositedPapers/Files/DEP2015-0267/The_Report_of_the_Morecambe_Bay.pdf
Royal College of Obstetricians and Gynaecologists (2019) Report – Review of Maternity Services at Cwm Taf Health Board. London: RCOG https://gov.wales/sites/default/files/publications/2019-04/review-of-maternity-services-at-cwm-taf-health-board_0.pdf
NMC (2015) Extraordinary review Bangor university and Betsi Cadwaladr University Health Board, Wales. London: NMC.
NMC (2018) Part 1: Standards Framework for Nursing and Midwifery Education. Retrieved from https://www.nmc.org.uk/standards/standards-for-midwives/
NMC (2018) Part 2: Standards for student supervision and assessment. Retrieved from https://www.nmc.org.uk/standards/standards-for-midwives/
NMC (2019) Part 3: Standards for pre-registration midwifery programmes. Retrieved from https://www.nmc.org.uk/standards/standards-for-midwives/
NMC (2019) Standards of proficiency for midwives. Retrieved from https://www.nmc.org.uk/standards/standards-for-midwives/
Seligman, M. 2011. Flourish. London: Nicholas Brealey Publishing.
Weir, J., & Lake, K. (2022) Making the transition: A focus group study which explores third year student and newly qualified midwives’ perceptions and experiences of becoming a registrant midwife. Midwifery, 111(103377). https://doi.org/10.1016/j.midw.2022.103377
Sheila Brown (midwifery lecturer, Bangor University) [email protected] , Julie Roberts (Midwifery Course Director, Bangor University) [email protected] and Emily Ford (newly qualified midwife, Bangor University)
October 2022