Midwifery workforce part II: supporting midwives of the future

In the December 2022 edition of Midwife, we looked at current and upcoming initiatives to support the midwifery workforce, acknowledging what a tough few years we've had. This article reflects on supporting students as future midwives, specifically focusing on what makes a good clinical placement - how midwives who take on the crucial role of preceptors enable and enhance students’ learning experiences.

It's been said that we can’t make more midwives overnight to solve the workforce crisis. But we can support students over their Bachelor of Midwifery degree and welcome them to the profession as graduates. Successful completion of the degree relies on the student’s tenacity as well as support from their whānau, tutors, academic staff, midwifery preceptors, and of course the whānau at the centre of their care. It is a collective investment that surrounds the student to ensure the continuity and longevity of our profession – a team effort.

A snapshot of our student population in 2023 shows some exciting statistics for midwifery as we better represent the communities we serve, particularly for tāngata whenua and Pasifika. Across the five midwifery schools (AUT, Te Pūkenga Wintec, Victoria University of Wellington, Te Pūkenga Ara, Te Pūkenga Otago Polytechnic), students are heeding the call of Lisa Kelly, Chair of Ngā Māia Māori Midwives. “Midwifery is something to aspire to – go home and work for your iwi and look after your people.”

Māori students make up 20-25% of students at Otago Polytechnic, Ara and AUT, with much higher proportions in Te Tai Tokerau and Lakes satellite programmes. A further 3-15% of students identify as Pasifika across the schools.

Clinical practice is often the highlight of the degree; the opportunity for students to step into the reality of the profession they have been drawn to. However, stepping into the workplace can also be stressful if students experience the impacts of severe workforce shortages. They may also witness or be subject to unprofessional behaviour, powerlessness, culturally unsafe situations and for some, outright discrimination or racism. So what can we do to support them?

Ngatepaeru Marsters, National Pasifika Midwifery Co-ordinator of Tapu Ora points to our Standards of Practice. “I believe in Standard 10”, she says, which states the midwife: gives special recognition to student midwives and shares her expertise with them in a supportive manner as a preceptor, and considers their role as a mentor for colleagues. Ngatepaeru acknowledges the current situation but challenges us as well. “The stress and strain on our workforce – the trickle-down, our students are really feeling it. I accept that it’s hard out there, but we have to look after each other.”

Supporting students is about looking after our next generation and can be very satisfying, says Suzi Hume, LMC midwife and chair of the Wellington region. “I always look forward to the academic year rolling around, to be working together in collaboration with students and sharing that relationship again.”

So what makes a great placement? We looked at the literature and asked current students, preceptors and midwifery heads of school to collate some top tips for preceptor midwives.

Relationships Are Key

Relationship-building as a preceptor supports the student’s learning and grows the student’s ongoing midwifery network. Once you have been a preceptor, you remain a familiar face to the student. Corridor chats and check-ins about how things are going let the student know they are valued in the profession.

Talei Jackson, Midwifery Lecturer at AUT and Pasifika Liaison Lead, undertook her Masters study about what supports Pasifika students to succeed. She highlights the centrality of connectedness and reciprocity within a Pasifika worldview. “It always comes down to relationships,” she explains.

In community group practice, close working relationships can be developed with several midwives. Suzi Hume finds it works well to have a student working across the practice, “to give lots of clinical opportunities and share the responsibility of ensuring the student gets the best out of their placement by experiencing differing perspectives”. It also gives each midwife ‘down time’ to process or reset.

KAWA WHAKARURUHAU | CULTURAL SAFETY APPLIES TO WORKING WITH STUDENTS

Kawa whakaruruhau | cultural safety is the bedrock of midwifery relationships with whānau, and our organisational values and processes (Curtis et al. 2019). Cultural safety requires that health professionals “acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided” (p. 14). While kawa whakaruruhau is undeniably essential for midwifery care provision, it also applies to our professional and interprofessional relationships; how we interact with and provide professional care to one another as midwives and student midwives.

Joyce Croft, National Māori Midwifery Co-ordinator of Te Ara o Hine, likens the

Kawa whakaruruhau

Gifted by Irihapeti Ramsden in the 1990s and grounded in Te Tiriti o Waitangi, kawa whakaruruhau marked a profound paradigm shift from providing care regardless of who the person was (“I treat everyone the same”), to being regardful of that person’s wholeness (“tell me who you are”) - it celebrates our uniqueness and demands that we turn the mirror to ourselves as health care providers. Who am I? Where do I come from?

What is my culture and world view? How does this shape what I bring to my role as a health worker? And how might that differ from who is in front of me? This process of introspection reveals how aspects of culture (in its broad sense)socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/ refugee status, religious belief or disability (Ramsden 1997) - are important facets of identity but also loci of power.

needs of tauira to wāhine and their whānau during hapūtanga. "You want them in an environment where they feel respected and good about themselves. Like with wāhinerespected for the knowledge they come with. We have tauira who've come through kura kaupapa, so their worldview is different to someone who has gone through kura aoraki (mainstream), or who don't have a lot of connections to te ao Māori. Tāngata whenua are on their journey about being Māori themselves, as well as being tauira."

AT THE BEGINNING OF A PLACEMENT, TAKE TIME TO WELCOME AND GET TO KNOW THE STUDENT MIDWIFE

Anahera Ngatai (Ngāti Porou, Tainui) is a final year midwifery student at Victoria University of Wellington and a student representative on the College’s national board. Anahera remembers her earliest experiences of the degree. “It’s super intimidating to come into hospital. Stepping into handover on that first shift, I was shaking in my boots.” A friendly welcome from the co-ordinating midwife made all the difference – this included being expected and greeted, introduced to the midwifery team on shift, and being assigned to work with a specific midwife.

In her qualitative Masters study on student experiences of hospital clinical placements in Aotearoa, Rountree (2016) noted the negative impact on students’ learning when they were given the impression they were a burden to the midwife. Like most things, preparation is key - managerial communication with midwives in advance that students will be present (Rountree, 2016) and having a midwife pre-assigned for the student to work with supports them to feel valued and part of the team.

In hospitals and birthing units, midwives are highly skilled at building rapport quickly. Applying this to relationships with students means that even if it has to be brief, greeting and connecting goes a long way in building their confidence to get involved.

In community practice, it is valuable to meet with the student before commencing clinical work together. This provides time for the student to share goals and learning outcomes, setting up a professional relationship where information can be shared. For many students, long after their clinical placement is completed, these relationships continue as support structures and friendships.

Family and culture are central to many students’ identities and personal lives, and are often part of why they want to be midwives, so checking in about important events (e.g. religious observance, children’s activities, exercise classes) can help students balance commitments, where possible.

PRE-BRIEFING

Starting each hospital shift or community day by pre-briefing the student on the caseload or appointments gives the student an opportunity to mentally prepare. At the beginning of a community placement, go through the caseload, who is due each week, some details about them, and where they plan to give birth.

At the beginning of the day or shift:

• In community practice: discuss the day, who is scheduled to be seen and how you are prioritising care to allow for acute calls. Understanding your thought process is invaluable for students.

• In hospital: involve the student in handover discussions and talk through how the midwife plans the shift.

FAMILIARISE YOURSELF WITH THE STUDENT’S LEVEL AND THE CLINICAL SKILLS THEY ARE READY TO PRACTISE

Preceptor midwives are encouraged to familiarise themselves with the different expectations of first, second, third and fourth year students by checking in regularly with the student and liaising with their tutor.

Initially, reflects Anahera, “it can seem a little bit fragmented – you’re learning all of these individual skills [first years] and you’re strengthening and developing those and becoming really confident [throughout the degree] but it’s not until you’re putting it all together and doing an entire care plan that it really consolidates itself [towards final year]. And when you start to do that it’s just the best feeling”.

Support Students To Consult With Other Health Professionals

Patterson et al. (2021) identify “hierarchical and cultural practices in institutions” which can “inhibit engagement in interprofessional conversations” (p. 105), so it is essential that students have the opportunity to practise consulting as undergraduates. Schools prepare students with the theory and knowledge about the midwifery scope; having opportunities to lead a consultation in practice supports the consolidation of those skills.

Back the student – consultations can be nerve-wracking! Preparation is key – agree before the interaction that the student will lead the consultation, offer to practise or roleplay together and use the tools the student has learned, such as ISBAR. When a student has been with someone who has experienced a long labour, for example, who has been taken for a caesarean section, they are wellplaced to speak in theatre as they know the whole story.

Anahera is clear about being kept safe. “When the midwife asks you to do the consultation, it’s important for the midwife to be right there with you to tautoko you.”

FEEDBACK AND OPEN DIALOGUE –KŌRERO WITH YOUR STUDENT

Feedback, debriefing and reflection are crucial elements of students’ learning journeys and future practice. Te Pūkenga Otago Polytechnic’s online preceptorship course (2022) points to the three main types of feedback identified in the literature: affirming/positive, corrective, and reviewing/ reflecting. All three are important and require skilled communication and consideration of the appropriate timing. While some things need correcting at the time they occur (e.g. a medication dose calculation), it is vital to make opportunities for reflection outside the situation.

Anahera recalls “those golden moments in the car”, when the midwife and student have a chance to kōrero while travelling between appointments. The value of students travelling in the midwife’s car can’t be overstated; it supports the student’s financial situation and is a great opportunity for discussion and learning.

During a hospital shift, shared lunch and tea breaks offer similar opportunities for reflective conversations.

It’s important that these conversations involve open dialogue, for example “can you tell me why you did it that way?” Conversely, closed (yes/no) questions make it harder for the student to reflect. Corrections can be made with empathy, understanding the well-meaning intention behind a student midwife’s action that may not have come across well to the woman and whānau (for example, apologising a lot). Offering opportunities for students to consider the midwife’s actions is also valuable – “when I did [action], what did you think?”

Reassurance

Students need three times more positive feedback than corrective feedback to flourish (Otago Polytechnic, 2022).

The sensitive nature of midwifery and the inherent power dynamic of the preceptorstudent relationship mean that students can often worry they are not doing things right. Letting students know how they are valued by the midwife can go a long way in supporting their confidence.

Suzi Hume notes, “it’s just so helpful having students at the birth. It adds another level of knowledge and insight, not to mention the physical support. You end up with women having optimal birth care – the real essence of whānau having support for a normal physiological birth, and also for complex decision-making and births”.

ROLE MODEL SELF-CARE

Anahera points out that students observe everything, including how midwives care for themselves to ensure longevity in the profession. “We often only see their mahi but we don’t see their lives and the things they do to keep themselves safe. This is so important.” On one of Anahera’s placements, the midwives shared how they shape their practice arrangements to achieve work-life balance, giving her a sense of how she could make community midwifery work in her own life.

Anahera felt valued as a person and not just a student when precepting midwives checked in with her about her wellbeing – simple things like a reminder to drink enough water during a long labour. Seeing midwives take breaks, and being able to take a break herself, was extremely important.

INCLUDE THE STUDENT IN ‘BEHINDTHE-SCENES’ ASPECTS OF MIDWIFERY

A lot of midwifery happens away from direct contact with whānau, and students need to be exposed to the administrative aspects of the job to be ready for practice. Employed midwives explaining how they approach a shift before commencing inperson care supports students to organise and prioritise. Small things are useful early on in the programme, like asking students to send lab tests and look up results, while later, it is about putting the whole picture together.

Inviting students to group practice meetings builds relationships, includes them in the team and supports their understanding of how community midwives engage in professional peer-to-peer conversations.

Involving students in the office work of LMC practice highlights the realities of managing a caseload, including following up results, claiming for payments, keeping accounts and paying taxes.

Take The Opportunity To Do A Preceptorship Course

The Midwifery Council strongly encourages preceptor midwives to undertake a course in preceptorship at least once. There are several options for midwives, including the College’s mentoring workshop The Practicalities of being a Mentor Midwife. Otago Polytechnic offers an online preceptorship course on Moodle, which midwives can access with the same login they used for online abortion education. An in-person study day is also available at Ara in Ōtautahi.

REMEMBER WHAT IT’S LIKE TO BE A STUDENT!

Every midwife has been a student midwife, and knows the journey is a major commitment and a life-changing experience, not only for themselves but also their whānau. Being a midwifery student is challenging, rewarding, eye-opening, humbling, exciting and sometimes overwhelming. And while students’ knowledge expands rapidly, it can be easy for experienced midwives to forget that study still continues after students have left workplaces. Empathy goes a long way in making students feel validated, welcomed and confident to practise what they have learned.

Finally, as our students graduate and move into the profession, AUT head of school and College board education representative Tania Fleming’s key message is simple. “These are beginning practitioners; hold on to that thought. They have an amazing, broad range of foundational, contemporary knowledge. So wrap your arms around them.”

Talei Jackson acknowledges the significant challenges students have overcome. “The students have been super-resilient through the last three years with what they have had to sustain themselves through – I think wow, this group of soon-to-be graduates … they’re amazing.”

And as Anahera enters her final year she reflects, “being a student midwife is probably the proudest thing I’ve ever done. I love midwifery, I love the midwives that I’ve worked with, I love the whānau that I’m involved with and I love my peers”. square

NAMULAU’ULU LETITIA TAIHIA CLINICAL MIDWIFE MANAGER, NGĀ HAU MANGERE BIRTHING CENTRE