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The evolution of midwifery education at the master's level: A study of Swedish midwifery education programmes after the implementation of the Bologna process
Nurse Education Today 33 (2013) 866–872
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Nurse Education Today journal homepage: www.elsevier.com/nedt
The evolution of midwifery education at the master's level: A study of Swedish midwifery education programmes after the implementation of the Bologna process Evelyn Hermansson a,⁎, Lena B. Mårtensson b, 1 a b
Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Box 457, SE-405 30 Gothenburg, Sweden School of Life Sciences, University of Skövde, Box 408, SE-54128 Skövde, Sweden
a r t i c l e
i n f o
Article history: Accepted 26 September 2012 Keywords: Postgraduate level Midwifery education programme Bologna process Higher education Survey Midwifery curriculum
s u m m a r y In Europe, midwifery education has undergone a number of reforms in the past few decades. In several countries, it has shifted from vocational training to academic education. The higher education reform, known as the “Bologna process” aimed to create convergence in higher education among a number of European countries and enhance opportunities for mobility, employment and collaborative research. It also indicated a transparent and easily compared system of academic degrees, generating a new educational system in three cycles. This study explores the implementation of the process in Sweden when the midwifery education was transferred from diploma to postgraduate or master's level. The aim of this study was to analyse how the implementation of the Bologna process in the Swedish higher education system has impacted midwifery education programmes in the country. Descriptive statistics and content analysis were employed to analyse 32 questionnaire responses from teachers and the 2009–2010 curricula and syllabi of 11 postgraduate midwifery education programmes at Swedish universities and university colleges. The results revealed variations among the universities at the major subject into the three disciplines; midwifery, nursing and caring with different conceptualisations, even when the content was identical in the curricula to that of the midwifery professional knowledge base. Implementation of the new reform not only has accelerated the academisation process, but also puts higher demand on the students and requires higher competencies among teachers to involve more evidence-based knowledge, seminars, independent studies and a postgraduate degree project in the major subject. Thus the students earn not only a diploma in midwifery, but also a master's degree in the major subject, which affords the opportunity for an academic career. But still there is a tension between professional and academic education. © 2012 Elsevier Ltd. All rights reserved.
Introduction The education of midwives varies greatly worldwide in terms of its content, scope and subject, from short programmes with minimal educational content and clinical practice to university programmes preparing students to provide quality care to childbearing women and newborns (Thompson et al., 2011). To be fully qualified, however, midwives must be educated and trained according to the Global Standards for Midwifery Education 2010, International Confederation of Midwives (ICM, 2011). In Europe, midwifery education has recently undergone a number of reforms, and the educational programmes differ greatly throughout Europe whether or not countries are members of the European Union (EU). In several countries, midwifery education has shifted from vocational training to higher education (Fleming et al., 2011; Hermansson, 2003). The latest European reform in higher ⁎ Corresponding author. Tel.: +46 703 3223774. E-mail addresses: [email protected] (E. Hermansson), [email protected] (L.B. Mårtensson). 1 Tel.: +46 500 44 80 00. 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.09.015
education, known as the Bologna process, aimed to create convergence in higher education among a number of European countries and enhance opportunities for mobility, employment and collaborative research. Further, the Bologna Declaration indicated a transparent and easily compared system of academic degrees, generating a new educational structure at the bachelor's, master's (postgraduate) and doctoral level, each with generic descriptors based on learning outcomes and competencies as formulated in the Dublin descriptors (Karseth, 2008). A common system for credits with 60 European Credit Transfer System (ECTS) for one year of full-time study has also been introduced (Davies, 2008; Oliver and Sanz, 2007; Zabalegui and Cabrera, 2009). According to Davies (2008), this reform is of great importance to educational programmes for nurses and midwives, raising their educational status from the diploma to the graduate level throughout Europe and beyond. This development of nursing and midwifery in higher education is moving forward, and steps towards national implementation have been reported, particularly in nursing programmes (Hegarty et al., 2008; Ohlen et al., 2011; Roxburgh et al., 2008; Spitzer and Perrenoud, 2006; Zabalegui and Cabrera, 2009). However, as Raholm et al. (2010) stated, nursing specialization and midwifery education are not always
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a part of the Bologna system. This means that most registered midwives in Europe are still educated at the diploma level. In addition to the Bologna process, midwifery programmes have long been subjected to other European directives regarding midwife qualifications. These directives requires at least three years of fulltime training specifically as a midwife, or at least 18 months (3000 h) of full-time training as a midwife beyond receiving formal qualification as a general care nurse (Directive 2005/36/EC). In contrast to the Bologna process, they do not indicate academic status requirements for registration, creating a great opportunity for the recognition of nursing and midwifery education at academic levels throughout the EU (Davies, 2008). The development of a Master of Science degree in midwifery must be justified as an independent discipline in the field (Farley and Carr, 2003). Historically, midwifery education was first closely related to the discipline of medicine and later to nursing, meaning that midwives have completed their education and received academic degrees in other disciplines (Hermansson, 2003). Although there are no universally accepted criteria for identifying a discipline, common aspects include a knowledge domain involving distinct intellectual tasks developed through research, a network of communication with a common language and specific concepts, a department of learning with an educational subject in progression and a particular set of values and beliefs (Becher, 1987, 1989; Clark, 1983; Donaldson and Crowley, 1978). Farley and Carr (2003) suggest that the discipline of midwifery has moved from the vocational level towards the establishment of a cognitive base for professional practice that is separate from medicine and nursing. The Master of Science in midwifery, which allows students to learn both the art and the science of practice in this field, is therefore ‘the result of an evolutionary process’ (p. 134). Midwifery Education in the Swedish Context From the 1700s until the mid-1950s, Swedish midwifery education was a direct entry programme. The development of prenatal care and hospitalized childbirth and maternity care resulted in new and different demands on the midwife; as a result, it was determined that midwives needed to be registered nurses as a basis for their profession. Midwifery education came thus to became a specialist programme within the rubric of nursing education (Hermansson, 2003). Over centuries, the scope of Swedish midwifery broadened gradually, affecting the course content and structure of midwifery education programmes. Since the beginning of the 1970s, such education has been mandated to prepare students for professional work with and for women's sexual and reproductive health according to a life cycle perspective. According to the competence description for midwives (The Swedish National Board of Health and Welfare, 2006), the following are incorporated into midwifery education: prenatal care, delivery and postnatal care, including antenatal education and gynaecological care comprising gynaecological health tests, family planning and contraception (including prescriptions). The shift of midwifery education to a degree programme started with higher education reform in 1977 and was implemented in 1984 (SoU, 1978:50); however, two decades passed before it became a bona fide national academic programme. The Swedish government's decision to reform the higher education (SFS, 1992:1434, updated 2006:173) and follow Sectorial Directives of EU/EES (DS, 1992:14) resulted in both academisation and an extension of Swedish midwifery education from 50 to 60 credits (1 credit/week), after a three-year nursing education programme (120 credits). The decentralisation and deregulation of higher education to promote autonomy, pluralism and flexibility, which occurred after 1993, gave institutions the freedom to determine the content, scope and major subject in their own midwifery curriculum based on a nationally regulated qualification descriptor for a Graduate Diploma of Midwifery (SFS, 1993:100, updated 2006). This led to differentiation in the Swedish midwifery
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education programmes in terms of content and scope, not least in the concepts and definition of the major subject, representing a crucial part of the academisation process. Recently, evaluations of those programmes revealed tension between vocational training and academic education, and the programmes have shifted their reference point to varying extents (Swedish National Agency for Higher Education, 1996, 2000). The 2007 higher education reform (SFS, 1992:1434, updated 2006:173), one of the measures of adaptation to the Bologna process requires additional academisation (Government Offices of Sweden, 2005). The reform places the midwifery education programme at the postgraduate/master's level, which signifies a ‘deepening of knowledge, skills and abilities…to further develop the student's ability to independently integrate and use knowledge…and deal with complex phenomena, issues and situations…as well as their potential for professional activities that demand considerable independence or for research and development’ (SFS, 1992:1434, updated 2006:173) 1 chap §9. This educational transition has given students the opportunity to complete a postgraduate degree project/master's thesis of 15 ECTS as an in-depth study on students' major subject, without extending its duration of 90 ECTS. Thus, they simultaneously obtain professional qualifications as midwives and an academic master's degree (one year) in their major subject. In Sweden, there is an on-going disciplinary debate on what constitutes the knowledge domain of midwifery. This has resulted in differences in the major subject's disciplinary affiliation, and raises questions related to diversity in the curricula and syllabi for midwifery education programmes, as framed by the nationally regulated qualification descriptions (SFS, 1993:100, updated 2006). The present inquiry into the transition of midwifery education, and particularly the impact of the Bologna process, has been motivated by the programme's transition to the postgraduate level, the disciplinary debate over the major subject and the tension between professional and academic education. As of yet, few scientific studies have investigated the development of midwifery education in relation to reforms and changes in the educational system.
Theoretical Frame of Reference According to Karseth (2008), curriculum as a field of study has not played an essential role in higher education in Europe. With the expansion and increased complexity of academic education, however, it has become more important to analyse this problem. In this study, a theoretical curricular perspective (Lundgren, 1983) was used as a framework to uncover the relationship between society's demands, governments steering documents and ideological starting points that guide and control midwifery education, expressed in the curricula of midwifery educational programmes. Bernstein's (1977) code concept, with its categories collected and integrated codes, is another way to conceptualise curriculum in terms of how it is formed. Collected code refers to a clear demarcation between subjects (disciplines) and various courses. In contrast, integrated code is characterised the subordination of previously disparate subjects or courses to an integral or rational idea; as a result, the boundaries between subjects and courses are blurred. Thus, the curriculum is formed by themes instead of subjects. The manner in which the Bologna process has been implemented in the structure and content of the midwifery education curriculum documents at the national level and realised in different forms at universities can raises questions about what forms such changes in the process may take. The aim of this study was to analyse how the implementation of the Bologna process in the Swedish higher education system has impacted midwifery education programmes in the country. Specific research questions were raised and operationalized using the indicators presented in Table 1.
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Table 1 Operationalized indicators related to the research questions. Research question
Indicators
Type of resources
How is the major subject described in midwifery programme curricula? What is the scientific foundation for midwifery education curricula, how is the subject demarked from others and how is the progression clarified? How are the progression and implication for the outcome described and clarified between undergraduate and advanced levels and within the advanced level?
▪ Terms and concept for the major subject ▪ Description of the major subject ▪ Scope, content and structure of the major subject and others in the curricula ▪ Pedagogical profile and structure ▪ Entry requirements ▪ Learning outcomes ▪ Courses in research methods ▪ Master's thesis (one year) ▪ Professional and/or academic degree ▪ Teacher competency ▪ Major subject's relation to midwifery practice and its scope and content in the curricula
Programme curricula Survey Programme curricula Syllabi
What kind of relationship exists between the major subject and the midwifery profession?
Methods Design This descriptive study was designed as a national survey disseminated by post to collect self-reported information from midwifery teachers in combination with a review of curricula and syllabus documents from all 11 Swedish universities/university colleges offering midwifery education programmes. Sample and Data Collection Fifty-two questionnaires, which specially developed for this study, were sent out to all teachers in Swedish midwifery education programmes, followed by two reminders. The questionnaires comprised 50 questions related to the research questions and the specific indicators presented in Table 1, of which 36 had predetermined response alternatives, most with the opportunity to add comments. Fourteen questions were open ended. Further, documents such as curricula and syllabi from all midwifery education programmes (11 curricula and 89 syllabi) for 2009/2010 were simultaneously collected from the programme websites. In some cases, it was difficult to find this information, so that personal contact was made with the programmes' directors. For comparison, the pre-reform curricula and syllabi from 2005/2006 (10 curricula and 80 syllabi) were also obtained, as well as the results from the latest quality evaluation (Swedish National Agency for Higher Education, 2007). Data Analysis Descriptive statistics, including frequencies, means ± standard deviation, median and percent were used for the quantitative data in the survey. Using a constructivist approach, we regarded curriculum documents as text constructed through interpretations, compromise solutions and negotiation between different persons with influence over local curriculum development. Text analysis (Hermansson, 2003; Ohlen et al., 2011) was used in order to investigate the different parts, content and meaning of this material and generate interpretations. Content analysis (Krippendorff, 2004) was then used to analyse the curricular documents and open-ended questions and comments of the survey in relation to the study's aim and research questions. The data were reduced in a stepwise manner with the specific indicators in focus, and different qualitative and quantitative aspects of the texts were compared and organised into categories and themes. To obtain inter-reader reliability, the data were examined and re-examined several times by the two authors. Ethical Considerations As this study did not fall under the Swedish Act concerning Ethical Review of Research Involving Humans (SFS, 2003:460), no ethical permission was sought. However, all participants gave informed consent
Programme curricula Syllabi Survey
Programme curricula Syllabi Survey
in accordance with the Declaration of Helsinki (2008), assuring confidentiality, voluntariness and the freedom to withdraw from the study at any time. The curricula and syllabi are all publicly available documents.
Results Of 52 questionnaires, 32 (62%) were completed and returned. The teachers were all female and aged between 41 and 66 years (mean 54.9 ± 6.9, median 56.0), with teaching experience of 1 to 31 years (mean 11.3 ± 10.8, median 7.5). All teachers were involved to some extent in teaching, supervision and examination of theses. All curricula and syllabi were related to national, local and professional steering documents (national and international laws and regulations). Learning outcomes were described at a postgraduate level, with progression in all documents based on nationally regulated qualification descriptors (SFS, 1993:100, updated 2006). These specifications have led to a more demanding educational programme with greater integration of research and evidence-based content in both theory and practice. In the midwifery educational programme curricula, five major subjects were described using a variety of terms and definitions (Table 2). These subjects represented three different paradigmatic orientations in which the students could obtain their academic degree, specifically midwifery-, nursing- or caring science. When analysing the descriptions and/or definitions of the major subjects in the programmes, we found that the significant concepts were also oriented to the three main paradigms (Table 3). Only in the programmes with midwifery science as the major subject was there a connection between the concepts and the content. In the other programmes, there was a discrepancy between the concepts and the content; independently of the major subject or discipline, the content in all syllabi was related to reproductive, perinatal and sexual health (Fig. 1). The midwifery programmes included one to three different subject areas in addition to the major subject. The ECTS for the major subject varied between 52.5 and 90. Of these ECTS, within the major subject, as many as 15 ECTS could be allocated to a postgraduate degree project Table 2 Overview of the major subjects in midwifery programmes (n = 11). Major subjects
Number of universities
Midwifery science
3
Nursing science Nursing science with a focus on reproductive Perinatal and/or sexual health (nursing)
1 3
Caring science Caring science with a focus on reproductive Perinatal and/or sexual health (nursing)
3 1
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Table 3 Significant concepts in major subjects as described in midwifery programme curricula. Midwifery science
Nursing science
Caring science
Human reproduction/reproductive Health/women's health Life cycle perspective Beginning of life transitions Childbearing/childbearing period/parenthood Normal/normality/risk factors Midwifery care/health promotion/prevention/treatment with and for women, child–family family-centred Family planning sexuality Autonomy/integrity empowerment
Health/wellbeing/human being/life context/environment/culture
Human being/health/caring
Reaction to health and disease/needs/recourses Nursing care/primary/secondary prevention Patient-centred Nurse–patient–relatives Relationship/interaction/communication Quality of life/lifestyle Respect/dignity
Suffering/wellbeing/learning Patient-/family-centred Caring relationship/dialogue Life-world/patients, relatives, caregiver subjective lived experience/subjective body Existence/context/competence/interaction Respect/integrity/dignity
(master's thesis). Eight programmes included medical science (7.5 to 30 ECTS); in one programme, social and behaviour sciences represented 15 ECTS, and in one other, public health sciences represented 7.5 ECTS (Fig. 2). Independent of the structure of the curricula and syllabi, in 2009/ 2010 it was most common to integrate the content of research methods into the major subject. Only one university had a separate course consisting of 7.5 ECTS. This contrasts dramatically with 2005/2006, when 7 of 10 universities offered separate courses within this area. The present situation was described by teachers as follows: the ‘research method course has been removed in order to make room for degree project’ and ‘re-instatement of research method course would be desirable’. The content structure of the major and other subjects in the programme curricula varied; of the 11 programmes, 3 used collected code and 7 used integrated code whilst 1 used a combination of these (Table 4). As the integrated code was the most common structure, medical, social and behaviour and public health sciences were more or less apparent in the contents. In the review of the syllabi, it was quite easy to identify these subjects when reading the content and learning outcomes. The teachers reported that the choice of pedagogic profile changed after the reform. At present, there are more seminars, case studies, independent study and clinical examinations. In most curricula, the amount of clinical practice was clearly stated. Some referred specifically to the EU directive regarding the proportion of studies, i.e. 50% should represent clinical practice. This requirement has not always been fulfilled. After the reform in 2007, there seems to have been a greater ambition for a more even distribution between theoretical and clinical studies (Table 5).
The teachers surveyed stated that the distribution between theoretical and clinical studies was 50/50. However, in the analyses of the curricula and syllabi, some variations were found, at 42–45.5 ECTS and 44.5–48 ECTS, respectively. Further, in two programmes, work in a clinical training centre was included in the total ECTS regarding clinical studies. Eight curricula stated that students had to care for 100 women during labour; whilst nine mandated that the students had to handle 50 births of the 100 women cared for (Table 5). Clinical education usually comprised the following areas: prenatal care/family planning, delivery ward, maternity/neonatal care and gynaecology care (Figs. 3 and 4). In midwifery education, the entry requirements have changed, but they are not the same at all universities (Fig. 5). Seven required a bachelor's degree; the teachers commented that with an undergraduate degree, ‘the students are better qualified to make both verbal and written presentations, writing essays, seeking literature, citing sources and thinking critically’ and ‘they are more competent at seeking all kind of information’. On the other hand, some teachers did not think that students with bachelor's degrees differed significantly from those without. Of the teachers, 53% were not satisfied with the dimensions of the programme. They thought that the stipulated time was insufficient for both professional and academic degrees. One teacher commented that the programme should be at least two years, stating that ‘the student can barely make it work since the master's course was included; more time for in-depth study is needed’. However, the higher entry requirements have affected professional education in a positive way, as the students show better competence regarding generic skills. This was expressed as follows: a ‘higher degree of independence [is] required, including critical approach and thinking’ and there is ‘more awareness of problematisation, reflection, analysis and synthesis’.
Discipline
Midwifery
Nursing
Caring
Major Subjects
Midwifery Science
Nursing Science (with or without focus on RPSH)
Caring Science (with or without focus on RPSH)
Concepts from definitions of major subject
Significant concepts
Significant concepts
Significant concepts
Content of the program
Reproductive, Perinatal and Sexual Health (RPSH)
Fig. 1. The relationship between disciplines, major subjects, concepts and syllabus content. Independently of the major subject, all syllabi in Swedish midwifery programmes have the same or similar content. The programme content fully corresponds to significant midwifery science concepts.
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90
The most interesting finding in this study was that the universities described the major subject and its specific concepts in relation to three different disciplines: midwifery, nursing and caring. For the first time, some universities chose curricula oriented towards midwifery science as the major subject and scientific foundation. Other curricula were oriented either to nursing or caring science, similar to nursing educational programmes. The latter is probably because midwifery education is based on the nursing education degree. In nursing educational programmes in Sweden, the curricula are oriented to either
nursing- or caring science, which is a Scandinavian phenomenon (Ohlen et al., 2011). As Donaldson and Crowley (1978) described, nursing and midwifery are both professional disciplines directed towards knowledge development of significance to a specific field of practice. Influenced by societal factors outside the scientific community as well as professional groups, practice disciplines like these develop mainly through academisation and professionalisation. The discipline of caring, on the other hand, can be characterised as academic or theoretical, developed mainly through internal processes in the scientific community through specialisation or differentiation from already established disciplines, with no relation to a specific professional field (Elzinga, 1987; Hermansson, 2003; Ohlen et al., 2011). In these cases, the discipline and the profession are totally separate. The relationships between the major subjects, disciplines and professions are illustrated in Fig. 6. Even if the major subject is found within the three different disciplines with different conceptualisations and knowledge bases, the analysis reveals that the content in the syllabi is almost identical to the midwifery professional knowledge base as given in the description of competencies for midwives (The Swedish National Board of Health and Welfare, 2006). How this will influence the development of the discipline, the profession and the students' understanding of this relationship is difficult to answer. Like all formal education programmes, Master of Science in midwifery programmes transmit knowledge and values to their students, but will also contribute value to the profession. As stated by Farley and Carr (2003), those who teach and learn in these programmes will undoubtedly augment the theoretical basis of the discipline. Moreover, postgraduates will have had discipline-specific learning experiences that will help them to advance the profession and practice of midwifery. There is a call for a national consensus regarding the major subject of all midwifery programmes in Sweden, but there are still different opinions among the professionals in academic institutions, as well as in clinical practice. Another issue is the major subject's relation to other subjects. Most universities use the integrated code to structure their curricula, meaning that there is no clear boundary between subjects. The choice of employing integrated code can be problematic because it then becomes unclear where and to what extent other important subjects can be found in the curricula or syllabi. For students, this means that they are not always aware that they are studying various subjects. In the long term, this could have consequences for students when they become midwives. For example, students' desire to deepen their knowledge in medical science could be hampered by their inability to identify the subjects that have formed their midwifery education. It could also be problematic for midwives who want to register in another country. Teachers' competence has increased dramatically since 2005/2006, and has continued to do so since this study was carried out. Besides midwifery education, a PhD is now required for employment at a university; this is important in the integration of scientific knowledge and clinical practice. This study showed that teachers strive to make even the clinical elements of education more academic, for example,
Table 4 Major subjects and the relation to curriculum structure, 2009/2010 (n = 11). Figures indicate number of universities.
Table 5 Comparison of theoretical and clinical studies before and after the Bologna reform. n indicates number of universities.
Social and Behavioral Science
ECTS
80
Public Health Science
70
Medical Science
60
Caring Science Nursing Science
50
Midwifery Science
40 30 20 10 0
University Fig. 2. Major subject in relation to other subjects.
Although the midwifery programme is now at postgraduate level, a postgraduate degree project/master's thesis is only compulsory at five universities (Table 6). The teachers stated that it had not been easy to insert a 15 ECTS thesis in the programme, saying that ‘combining academic and professional demands can be problematic’, ‘for some students it is difficult to finish the thesis in allotted time, in combination with other demands’, ‘most students manage, with some degree of stress, but students feel that the programme is demanding’ and ‘we try to work it into non-existent time’. At present, teachers' competence is higher than before the reform; 60% of all teachers had at least a PhD, but not always in the major subject. Of these, 22 were assistant professors, 8 associate professors and 4 professors. The proportion of teachers with a PhD differed widely among the universities, from 25% to 100%. The remaining 40% of the teachers had a master's degree at the least. The opinion among the teachers is that more associate professors and professors are required in the major subject. About 90% of the teachers had at least 15 ECTS in pedagogical courses. However, fewer teachers had a university diploma in nursing/midwifery education compared to before the Bologna reform. In their clinical education, students are supervised by one or several midwives, who often lack undergraduate or graduate degrees, and the university teachers saw this as a weakness. They stated that a higher academic level among midwives in clinical practice is desirable. Discussion
Major subjects 2009/2010
Integrated code
Midwifery science Nursing science Nursing science with a focus on reproductive, perinatal and/or sexual health (nursing) Caring science Caring science with a focus on reproductive, perinatal and/or sexual health (nursing)
3
Collected code
Integrated and collected codes
2005/2006 (n = 10)
2009/2010 (n = 11)
1
Theoretical studies 45–52.5 ECTS
42–45.5 ECTS
Clinical studies 37.5–45 ECTS
44.5–48 ECTS
Number of women cared for 100 (n = 7) 50% must be births (n = 8)
100 (n = 8) 50% must be births (n = 9)
3
1
2 1
E. Hermansson, L.B. Mårtensson / Nurse Education Today 33 (2013) 866–872
50
Maternity/Neonatal Care
40 35
ECTS
Entry Requirements
Gynaecology Care
45
30
Prenatal Care/Family Planning
25
Delivery Ward
871
Bachelor´s Degree
2009/2010
One year work as a Nurse
20
2005/2006
15 10
Registered Nurse
5 0
0
Fig. 3. Distribution of clinical studies, 2005/2006.
incorporating scientific knowledge through case studies, clinical examinations and the development of generic skills. In terms of the balance between theoretical and more academic content in relation to clinical aspects, it is always risky when very practical education becomes more academic (Farley and Carr, 2003; Thompson et al., 2011). However, at present, this balance has nearly been achieved in Swedish midwifery education. This represents a great achievement for the teachers, because there is a lack of undergraduate or postgraduate degrees among midwives in clinical practice. The need for midwives with a master's degree who can supervise midwifery students in clinical practice suggests that a master's thesis should be included in the midwifery programme. Midwifery is still a very practical profession, and approximately half of the programme involves clinical practice. In the delivery ward, the student has to care for 100 women; 50 of these cases must be births. This has been agreed upon by all Swedish universities. Since the Bologna process was implemented and midwifery education came to be offered at the postgraduate level, the degree project/master's thesis became compulsory at five universities. This means that the thesis corresponds to 17% of the whole programme. Many teachers expressed that it is difficult for the students to handle the required number cases along with this thesis in the stipulated time. However, this is valuable for the student, even if there is ambivalence related to expected learning outcomes (German Millberg et al., 2011). One desirable feature is that this could stimulate the students to be better research consumers and participate in research projects. Midwifery education at the postgraduate level will guarantee that midwives have good and relevant tools to give evidence-based care for women and their families, and allow the possibility of evaluating and developing treatment and methods within midwifery. Because of midwives' broad field of knowledge and more advanced tasks, the content in the midwifery education has increased dramatically
50
Clinical Training Center Gynaecology Care Maternity/Neonatal Care Prenatal Care/Family Planning Delivery Ward
45 40
ECTS
35 30 25
4
6
8
10
12
Fig. 5. Entry requirements before and after the Bologna reform (n=11). Figures indicate number of universities.
over the past decades (Hermansson, 2003). Together with the demands on an additional academisation this study highlights that the midwifery education today did not give students time enough for critical thinking, reflection and problem solving in their new role as becoming midwives. Altogether, the results of this study indicate that midwifery education is too short, an idea supported by the teachers who participated in the present study. Midwifery education should be extended to at least two years after a three-year nursing programme. However, the question of why we do not have direct entry to the midwifery programme is also relevant, and an increase in this programme to five years in total with a master's degree in the science of midwifery should be considered.
Conclusions The implementation of the Bologna reform in the Swedish higher educational system has contributed to a postgraduate/master level of education for midwives. The students did not earn only a professional diploma in midwifery, but also an academic degree at the post-graduate level with opportunities for a continued academic career. This will strengthen the professional and disciplinary development in this field. However, it is clear that the academisation process places higher demands on students' performance, as well as teachers' competencies, in midwifery education programmes. For the students, it requires a greater focus on generic skills in theory and practice with evidence-based knowledge, seminars and independent studies and a postgraduate degree project. Some teachers stated that the students have difficulties to integrate these professional and academic demands in such a short time, meaning that there is still tension between professional and academic education. The midwifery education needs therefore to be longer than 90 ECTS after the completion of nursing education to solve these problems. Thus, it is imperative to establish a national consensus regarding the major subject of all midwifery education in Sweden. The results of this study could be of international significance, since the integration of midwifery education into higher education systems in different countries is as yet uncommon; thus, there will be interest in the academisation process of Swedish midwifery education.
Table 6 Comparison of thesis requirements before and after the Bologna reform.
20 15 10 5 0
2
University
University
Fig. 4. Distribution of clinical studies after the Bologna reform, 2009/2010.
Master's degree (one year) Elective Compulsory Bachelor's degree
2005/2006 (n = 10)
2009/2010 (n = 11)
6 0 7
6 5 0
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Major Subject Profession of Midwifery
Discipline of Midwifery
Major Subject
Profession of Midwifery
Major Subject
Profession of Midwifery
Discipline of Nursing
Discipline of Caring
Major subject similar to the professional knowledge base
Major subject dissimilar to the professional knowledge base
Fig. 6. Relation between disciplines, profession of midwifery and major subject.
References Becher, T., 1987. Disciplinary Discource. In Disciplinary Perspective on Higher Education and Research. Group for the Study of Higher Education and Research Policy (Report no 37). Stockholm: Department of Political Science, University of Stockholm. Becher, T., 1989. Academic tribes and territories. Intellectual Enquiry and the Cultures of Disciplines. Buckingham Open University Press/SRHE. Bernstein, B., 1977. Class, codes and control. Toward a Theory of Education Transmission, vol. 3. Routledge & Kegan Paul, London. Clark, B.R., 1983. The Higher Education System: Organization in Cross-national Perspective. University of California Press, Los Angeles. Davies, R., 2008. The Bologna process: the quiet revolution in nursing higher education. Nurse Education Today 28 (8), 935–942. Donaldson, S.K., Crowley, D.M., 1978. The discipline of nursing. Nursing Outlook 26 (2), 113–120. DS, 1992:14. Introducing the EES regulation: a mutual acknowledgement of a certificate of competence for practitioners in health care (Införande av EES rätt: ömsesidigt erkännande av kompetensbevis för verksamhet inom hälso-och sjukvården). In: Socialdepartementet (Ed.), Allmänna Förlaget, Stockholm. Elzinga, A., 1987. Internal and external regulative in research and higher education systems. Disciplinary perspectives on higher education and research. Group for the Study of Higher Education and Research Policy. Farley, C., Carr, K.C., 2003. New directions in midwifery education: the master's of science in midwifery degree. Journal of Midwifery & Women's Health 48 (2), 133–137. Fleming, V., Pehlke-Milde Hebamme, J., Davies, S., Zaksek, T., 2011. Developing and validating scenarios to compare midwives' knowledge and skills with the International Confederation of Midwives' essential competencies in four European countries. Midwifery 27 (6), 854–860. German Millberg, L., Berg, L., Lindstrom, I., Petzall, K., Ohlen, J., 2011. Tensions related to implementation of postgraduate degree projects in specialist nursing education. Nurse Education Today 31 (3), 283–288. Goverment Offices of Sweden, 2005. New world — new higher education (Ny värld — Ny högskola). (No. 2004/05:162) Ministry of Education and Research. Hegarty, J., McCarthy, G., O' Sullivan, D., Lehane, B., 2008. A review of nursing and midwifery education research in the Republic of Ireland. Nurse Education Today 28 (6), 720–736. Hermansson, E., 2003. Academisation and professionalization - midwifery education in transition. (In Swedish: Akademisering och professionalisering - barnmorskans utbildning i förändring). Dissertation. Göteborg University, Göteborg. ICM, 2011. Global Standards for Midwifery Education 2010: International Confederation of Midwives. Karseth, B., 2008. Qualification Frameworks for the European Higher Education Area. Örebro University, Sweden. Krippendorff, K., 2004. Content Analysis: an Introduction to its Methodology, 2 ed. Sage cop, Thousand Oaks Calif.
Lundgren, U.P., 1983. To Organize the World. An Introduction to Curriculum Theory (Att organisera omvärlden. En introduktion till läroplansteori). Liber Förlag, Stockholm. Ohlen, J., Furaker, C., Jakobsson, E., Bergh, I., Hermansson, E., 2011. Impact of the Bologna process in Bachelor Nursing Programmes: the Swedish Case. Nurse Education Today 31 (2), 122–128. Oliver, R., Sanz, M., 2007. The Bologna process and health science education: times are changing. Medical Education 41 (3), 309–317. Raholm, M.B., Hedegaard, B.L., Lofmark, A., Slettebo, A., 2010. Nursing education in Denmark, Finland, Norway and Sweden—from Bachelor's degree to PhD. Journal of Advanced Nursing 66 (9), 2126–2137. Roxburgh, M., Watson, R., Holland, K., Johnson, M., Lauder, W., Topping, K., 2008. A review of curriculum evaluation in United Kingdom nursing education. Nurse Education Today 28 (7), 881–889. SFS, 1992:1434, updated 2006:173. Higher education act. Swedish Statues in Translation. SFS, 1993:100, updated 2006. Higher education ordinance Swedish statues in translation. SFS, 2003:460. The Swedish Act concerning ethical review of research involving humans (Lag (2003:460) om etikprövning av forskning som avser människor). http://www.notisum.se/rnp/sls/lag/20030460.htm. SoU, 1978:50. New Health Care Education: report from the committee of certain health care programmes in higher education; Vård 77 (Ny vårdutbildning: betänkande av Utredningen om vissa vårdutbildningar inom högskolan; Vård 77). Ministry of Education and Research, Stockholm. Spitzer, A., Perrenoud, B., 2006. Reforms in nursing education across Western Europe: implementation processes and current status. Journal of Professional Nursing 22 (3), 162–171. Swedish National Agency for Higher Education, 1996. Vårdutbildningar i Högskolan. En utvärdering. Swedish National Agency for Higher Education, Stockholm. Swedish National Agency for Higher Education, 2000. Utbildningar inom vård-och omsorg. En uppföljande utvärdering. Swedish National Agency for Higher Education, Stockholm. Swedish National Agency for Higher Education, 2007. Evaluation of Undergraduate Programmes in Medicine and Health Care at Swedish Universities and University Colleges . (No. 2007:23R) Ministry of Education and Research. The Swedish National Board of Health and Welfare, 2006. Description of competences for registered midwife (Kompetensbeskrivning för legitimerad barnmorska). The National Board of Health and Welfare, Stockholm. Thompson, J.B., Fullerton, J.T., Sawyer, A.J., 2011. The international confederation of midwives: global standards for midwifery education (2010) with companion guidelines. Midwifery 27 (4), 409–416. World Medical Association Declaration of Helsinki, 2008. Ethical principles for medical research involving human subjects. Zabalegui, A., Cabrera, E., 2009. New nursing education structure in Spain. Nurse Education Today 29 (5), 500–504.
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The evolution of midwifery education at the master's level: A study of Swedish midwifery education programmes after the implementation of the Bologna process Evelyn Hermansson a,⁎, Lena B. Mårtensson b, 1 a b
Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Box 457, SE-405 30 Gothenburg, Sweden School of Life Sciences, University of Skövde, Box 408, SE-54128 Skövde, Sweden
a r t i c l e
i n f o
Article history: Accepted 26 September 2012 Keywords: Postgraduate level Midwifery education programme Bologna process Higher education Survey Midwifery curriculum
s u m m a r y In Europe, midwifery education has undergone a number of reforms in the past few decades. In several countries, it has shifted from vocational training to academic education. The higher education reform, known as the “Bologna process” aimed to create convergence in higher education among a number of European countries and enhance opportunities for mobility, employment and collaborative research. It also indicated a transparent and easily compared system of academic degrees, generating a new educational system in three cycles. This study explores the implementation of the process in Sweden when the midwifery education was transferred from diploma to postgraduate or master's level. The aim of this study was to analyse how the implementation of the Bologna process in the Swedish higher education system has impacted midwifery education programmes in the country. Descriptive statistics and content analysis were employed to analyse 32 questionnaire responses from teachers and the 2009–2010 curricula and syllabi of 11 postgraduate midwifery education programmes at Swedish universities and university colleges. The results revealed variations among the universities at the major subject into the three disciplines; midwifery, nursing and caring with different conceptualisations, even when the content was identical in the curricula to that of the midwifery professional knowledge base. Implementation of the new reform not only has accelerated the academisation process, but also puts higher demand on the students and requires higher competencies among teachers to involve more evidence-based knowledge, seminars, independent studies and a postgraduate degree project in the major subject. Thus the students earn not only a diploma in midwifery, but also a master's degree in the major subject, which affords the opportunity for an academic career. But still there is a tension between professional and academic education. © 2012 Elsevier Ltd. All rights reserved.
Introduction The education of midwives varies greatly worldwide in terms of its content, scope and subject, from short programmes with minimal educational content and clinical practice to university programmes preparing students to provide quality care to childbearing women and newborns (Thompson et al., 2011). To be fully qualified, however, midwives must be educated and trained according to the Global Standards for Midwifery Education 2010, International Confederation of Midwives (ICM, 2011). In Europe, midwifery education has recently undergone a number of reforms, and the educational programmes differ greatly throughout Europe whether or not countries are members of the European Union (EU). In several countries, midwifery education has shifted from vocational training to higher education (Fleming et al., 2011; Hermansson, 2003). The latest European reform in higher ⁎ Corresponding author. Tel.: +46 703 3223774. E-mail addresses: [email protected] (E. Hermansson), [email protected] (L.B. Mårtensson). 1 Tel.: +46 500 44 80 00. 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.09.015
education, known as the Bologna process, aimed to create convergence in higher education among a number of European countries and enhance opportunities for mobility, employment and collaborative research. Further, the Bologna Declaration indicated a transparent and easily compared system of academic degrees, generating a new educational structure at the bachelor's, master's (postgraduate) and doctoral level, each with generic descriptors based on learning outcomes and competencies as formulated in the Dublin descriptors (Karseth, 2008). A common system for credits with 60 European Credit Transfer System (ECTS) for one year of full-time study has also been introduced (Davies, 2008; Oliver and Sanz, 2007; Zabalegui and Cabrera, 2009). According to Davies (2008), this reform is of great importance to educational programmes for nurses and midwives, raising their educational status from the diploma to the graduate level throughout Europe and beyond. This development of nursing and midwifery in higher education is moving forward, and steps towards national implementation have been reported, particularly in nursing programmes (Hegarty et al., 2008; Ohlen et al., 2011; Roxburgh et al., 2008; Spitzer and Perrenoud, 2006; Zabalegui and Cabrera, 2009). However, as Raholm et al. (2010) stated, nursing specialization and midwifery education are not always
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a part of the Bologna system. This means that most registered midwives in Europe are still educated at the diploma level. In addition to the Bologna process, midwifery programmes have long been subjected to other European directives regarding midwife qualifications. These directives requires at least three years of fulltime training specifically as a midwife, or at least 18 months (3000 h) of full-time training as a midwife beyond receiving formal qualification as a general care nurse (Directive 2005/36/EC). In contrast to the Bologna process, they do not indicate academic status requirements for registration, creating a great opportunity for the recognition of nursing and midwifery education at academic levels throughout the EU (Davies, 2008). The development of a Master of Science degree in midwifery must be justified as an independent discipline in the field (Farley and Carr, 2003). Historically, midwifery education was first closely related to the discipline of medicine and later to nursing, meaning that midwives have completed their education and received academic degrees in other disciplines (Hermansson, 2003). Although there are no universally accepted criteria for identifying a discipline, common aspects include a knowledge domain involving distinct intellectual tasks developed through research, a network of communication with a common language and specific concepts, a department of learning with an educational subject in progression and a particular set of values and beliefs (Becher, 1987, 1989; Clark, 1983; Donaldson and Crowley, 1978). Farley and Carr (2003) suggest that the discipline of midwifery has moved from the vocational level towards the establishment of a cognitive base for professional practice that is separate from medicine and nursing. The Master of Science in midwifery, which allows students to learn both the art and the science of practice in this field, is therefore ‘the result of an evolutionary process’ (p. 134). Midwifery Education in the Swedish Context From the 1700s until the mid-1950s, Swedish midwifery education was a direct entry programme. The development of prenatal care and hospitalized childbirth and maternity care resulted in new and different demands on the midwife; as a result, it was determined that midwives needed to be registered nurses as a basis for their profession. Midwifery education came thus to became a specialist programme within the rubric of nursing education (Hermansson, 2003). Over centuries, the scope of Swedish midwifery broadened gradually, affecting the course content and structure of midwifery education programmes. Since the beginning of the 1970s, such education has been mandated to prepare students for professional work with and for women's sexual and reproductive health according to a life cycle perspective. According to the competence description for midwives (The Swedish National Board of Health and Welfare, 2006), the following are incorporated into midwifery education: prenatal care, delivery and postnatal care, including antenatal education and gynaecological care comprising gynaecological health tests, family planning and contraception (including prescriptions). The shift of midwifery education to a degree programme started with higher education reform in 1977 and was implemented in 1984 (SoU, 1978:50); however, two decades passed before it became a bona fide national academic programme. The Swedish government's decision to reform the higher education (SFS, 1992:1434, updated 2006:173) and follow Sectorial Directives of EU/EES (DS, 1992:14) resulted in both academisation and an extension of Swedish midwifery education from 50 to 60 credits (1 credit/week), after a three-year nursing education programme (120 credits). The decentralisation and deregulation of higher education to promote autonomy, pluralism and flexibility, which occurred after 1993, gave institutions the freedom to determine the content, scope and major subject in their own midwifery curriculum based on a nationally regulated qualification descriptor for a Graduate Diploma of Midwifery (SFS, 1993:100, updated 2006). This led to differentiation in the Swedish midwifery
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education programmes in terms of content and scope, not least in the concepts and definition of the major subject, representing a crucial part of the academisation process. Recently, evaluations of those programmes revealed tension between vocational training and academic education, and the programmes have shifted their reference point to varying extents (Swedish National Agency for Higher Education, 1996, 2000). The 2007 higher education reform (SFS, 1992:1434, updated 2006:173), one of the measures of adaptation to the Bologna process requires additional academisation (Government Offices of Sweden, 2005). The reform places the midwifery education programme at the postgraduate/master's level, which signifies a ‘deepening of knowledge, skills and abilities…to further develop the student's ability to independently integrate and use knowledge…and deal with complex phenomena, issues and situations…as well as their potential for professional activities that demand considerable independence or for research and development’ (SFS, 1992:1434, updated 2006:173) 1 chap §9. This educational transition has given students the opportunity to complete a postgraduate degree project/master's thesis of 15 ECTS as an in-depth study on students' major subject, without extending its duration of 90 ECTS. Thus, they simultaneously obtain professional qualifications as midwives and an academic master's degree (one year) in their major subject. In Sweden, there is an on-going disciplinary debate on what constitutes the knowledge domain of midwifery. This has resulted in differences in the major subject's disciplinary affiliation, and raises questions related to diversity in the curricula and syllabi for midwifery education programmes, as framed by the nationally regulated qualification descriptions (SFS, 1993:100, updated 2006). The present inquiry into the transition of midwifery education, and particularly the impact of the Bologna process, has been motivated by the programme's transition to the postgraduate level, the disciplinary debate over the major subject and the tension between professional and academic education. As of yet, few scientific studies have investigated the development of midwifery education in relation to reforms and changes in the educational system.
Theoretical Frame of Reference According to Karseth (2008), curriculum as a field of study has not played an essential role in higher education in Europe. With the expansion and increased complexity of academic education, however, it has become more important to analyse this problem. In this study, a theoretical curricular perspective (Lundgren, 1983) was used as a framework to uncover the relationship between society's demands, governments steering documents and ideological starting points that guide and control midwifery education, expressed in the curricula of midwifery educational programmes. Bernstein's (1977) code concept, with its categories collected and integrated codes, is another way to conceptualise curriculum in terms of how it is formed. Collected code refers to a clear demarcation between subjects (disciplines) and various courses. In contrast, integrated code is characterised the subordination of previously disparate subjects or courses to an integral or rational idea; as a result, the boundaries between subjects and courses are blurred. Thus, the curriculum is formed by themes instead of subjects. The manner in which the Bologna process has been implemented in the structure and content of the midwifery education curriculum documents at the national level and realised in different forms at universities can raises questions about what forms such changes in the process may take. The aim of this study was to analyse how the implementation of the Bologna process in the Swedish higher education system has impacted midwifery education programmes in the country. Specific research questions were raised and operationalized using the indicators presented in Table 1.
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Table 1 Operationalized indicators related to the research questions. Research question
Indicators
Type of resources
How is the major subject described in midwifery programme curricula? What is the scientific foundation for midwifery education curricula, how is the subject demarked from others and how is the progression clarified? How are the progression and implication for the outcome described and clarified between undergraduate and advanced levels and within the advanced level?
▪ Terms and concept for the major subject ▪ Description of the major subject ▪ Scope, content and structure of the major subject and others in the curricula ▪ Pedagogical profile and structure ▪ Entry requirements ▪ Learning outcomes ▪ Courses in research methods ▪ Master's thesis (one year) ▪ Professional and/or academic degree ▪ Teacher competency ▪ Major subject's relation to midwifery practice and its scope and content in the curricula
Programme curricula Survey Programme curricula Syllabi
What kind of relationship exists between the major subject and the midwifery profession?
Methods Design This descriptive study was designed as a national survey disseminated by post to collect self-reported information from midwifery teachers in combination with a review of curricula and syllabus documents from all 11 Swedish universities/university colleges offering midwifery education programmes. Sample and Data Collection Fifty-two questionnaires, which specially developed for this study, were sent out to all teachers in Swedish midwifery education programmes, followed by two reminders. The questionnaires comprised 50 questions related to the research questions and the specific indicators presented in Table 1, of which 36 had predetermined response alternatives, most with the opportunity to add comments. Fourteen questions were open ended. Further, documents such as curricula and syllabi from all midwifery education programmes (11 curricula and 89 syllabi) for 2009/2010 were simultaneously collected from the programme websites. In some cases, it was difficult to find this information, so that personal contact was made with the programmes' directors. For comparison, the pre-reform curricula and syllabi from 2005/2006 (10 curricula and 80 syllabi) were also obtained, as well as the results from the latest quality evaluation (Swedish National Agency for Higher Education, 2007). Data Analysis Descriptive statistics, including frequencies, means ± standard deviation, median and percent were used for the quantitative data in the survey. Using a constructivist approach, we regarded curriculum documents as text constructed through interpretations, compromise solutions and negotiation between different persons with influence over local curriculum development. Text analysis (Hermansson, 2003; Ohlen et al., 2011) was used in order to investigate the different parts, content and meaning of this material and generate interpretations. Content analysis (Krippendorff, 2004) was then used to analyse the curricular documents and open-ended questions and comments of the survey in relation to the study's aim and research questions. The data were reduced in a stepwise manner with the specific indicators in focus, and different qualitative and quantitative aspects of the texts were compared and organised into categories and themes. To obtain inter-reader reliability, the data were examined and re-examined several times by the two authors. Ethical Considerations As this study did not fall under the Swedish Act concerning Ethical Review of Research Involving Humans (SFS, 2003:460), no ethical permission was sought. However, all participants gave informed consent
Programme curricula Syllabi Survey
Programme curricula Syllabi Survey
in accordance with the Declaration of Helsinki (2008), assuring confidentiality, voluntariness and the freedom to withdraw from the study at any time. The curricula and syllabi are all publicly available documents.
Results Of 52 questionnaires, 32 (62%) were completed and returned. The teachers were all female and aged between 41 and 66 years (mean 54.9 ± 6.9, median 56.0), with teaching experience of 1 to 31 years (mean 11.3 ± 10.8, median 7.5). All teachers were involved to some extent in teaching, supervision and examination of theses. All curricula and syllabi were related to national, local and professional steering documents (national and international laws and regulations). Learning outcomes were described at a postgraduate level, with progression in all documents based on nationally regulated qualification descriptors (SFS, 1993:100, updated 2006). These specifications have led to a more demanding educational programme with greater integration of research and evidence-based content in both theory and practice. In the midwifery educational programme curricula, five major subjects were described using a variety of terms and definitions (Table 2). These subjects represented three different paradigmatic orientations in which the students could obtain their academic degree, specifically midwifery-, nursing- or caring science. When analysing the descriptions and/or definitions of the major subjects in the programmes, we found that the significant concepts were also oriented to the three main paradigms (Table 3). Only in the programmes with midwifery science as the major subject was there a connection between the concepts and the content. In the other programmes, there was a discrepancy between the concepts and the content; independently of the major subject or discipline, the content in all syllabi was related to reproductive, perinatal and sexual health (Fig. 1). The midwifery programmes included one to three different subject areas in addition to the major subject. The ECTS for the major subject varied between 52.5 and 90. Of these ECTS, within the major subject, as many as 15 ECTS could be allocated to a postgraduate degree project Table 2 Overview of the major subjects in midwifery programmes (n = 11). Major subjects
Number of universities
Midwifery science
3
Nursing science Nursing science with a focus on reproductive Perinatal and/or sexual health (nursing)
1 3
Caring science Caring science with a focus on reproductive Perinatal and/or sexual health (nursing)
3 1
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Table 3 Significant concepts in major subjects as described in midwifery programme curricula. Midwifery science
Nursing science
Caring science
Human reproduction/reproductive Health/women's health Life cycle perspective Beginning of life transitions Childbearing/childbearing period/parenthood Normal/normality/risk factors Midwifery care/health promotion/prevention/treatment with and for women, child–family family-centred Family planning sexuality Autonomy/integrity empowerment
Health/wellbeing/human being/life context/environment/culture
Human being/health/caring
Reaction to health and disease/needs/recourses Nursing care/primary/secondary prevention Patient-centred Nurse–patient–relatives Relationship/interaction/communication Quality of life/lifestyle Respect/dignity
Suffering/wellbeing/learning Patient-/family-centred Caring relationship/dialogue Life-world/patients, relatives, caregiver subjective lived experience/subjective body Existence/context/competence/interaction Respect/integrity/dignity
(master's thesis). Eight programmes included medical science (7.5 to 30 ECTS); in one programme, social and behaviour sciences represented 15 ECTS, and in one other, public health sciences represented 7.5 ECTS (Fig. 2). Independent of the structure of the curricula and syllabi, in 2009/ 2010 it was most common to integrate the content of research methods into the major subject. Only one university had a separate course consisting of 7.5 ECTS. This contrasts dramatically with 2005/2006, when 7 of 10 universities offered separate courses within this area. The present situation was described by teachers as follows: the ‘research method course has been removed in order to make room for degree project’ and ‘re-instatement of research method course would be desirable’. The content structure of the major and other subjects in the programme curricula varied; of the 11 programmes, 3 used collected code and 7 used integrated code whilst 1 used a combination of these (Table 4). As the integrated code was the most common structure, medical, social and behaviour and public health sciences were more or less apparent in the contents. In the review of the syllabi, it was quite easy to identify these subjects when reading the content and learning outcomes. The teachers reported that the choice of pedagogic profile changed after the reform. At present, there are more seminars, case studies, independent study and clinical examinations. In most curricula, the amount of clinical practice was clearly stated. Some referred specifically to the EU directive regarding the proportion of studies, i.e. 50% should represent clinical practice. This requirement has not always been fulfilled. After the reform in 2007, there seems to have been a greater ambition for a more even distribution between theoretical and clinical studies (Table 5).
The teachers surveyed stated that the distribution between theoretical and clinical studies was 50/50. However, in the analyses of the curricula and syllabi, some variations were found, at 42–45.5 ECTS and 44.5–48 ECTS, respectively. Further, in two programmes, work in a clinical training centre was included in the total ECTS regarding clinical studies. Eight curricula stated that students had to care for 100 women during labour; whilst nine mandated that the students had to handle 50 births of the 100 women cared for (Table 5). Clinical education usually comprised the following areas: prenatal care/family planning, delivery ward, maternity/neonatal care and gynaecology care (Figs. 3 and 4). In midwifery education, the entry requirements have changed, but they are not the same at all universities (Fig. 5). Seven required a bachelor's degree; the teachers commented that with an undergraduate degree, ‘the students are better qualified to make both verbal and written presentations, writing essays, seeking literature, citing sources and thinking critically’ and ‘they are more competent at seeking all kind of information’. On the other hand, some teachers did not think that students with bachelor's degrees differed significantly from those without. Of the teachers, 53% were not satisfied with the dimensions of the programme. They thought that the stipulated time was insufficient for both professional and academic degrees. One teacher commented that the programme should be at least two years, stating that ‘the student can barely make it work since the master's course was included; more time for in-depth study is needed’. However, the higher entry requirements have affected professional education in a positive way, as the students show better competence regarding generic skills. This was expressed as follows: a ‘higher degree of independence [is] required, including critical approach and thinking’ and there is ‘more awareness of problematisation, reflection, analysis and synthesis’.
Discipline
Midwifery
Nursing
Caring
Major Subjects
Midwifery Science
Nursing Science (with or without focus on RPSH)
Caring Science (with or without focus on RPSH)
Concepts from definitions of major subject
Significant concepts
Significant concepts
Significant concepts
Content of the program
Reproductive, Perinatal and Sexual Health (RPSH)
Fig. 1. The relationship between disciplines, major subjects, concepts and syllabus content. Independently of the major subject, all syllabi in Swedish midwifery programmes have the same or similar content. The programme content fully corresponds to significant midwifery science concepts.
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90
The most interesting finding in this study was that the universities described the major subject and its specific concepts in relation to three different disciplines: midwifery, nursing and caring. For the first time, some universities chose curricula oriented towards midwifery science as the major subject and scientific foundation. Other curricula were oriented either to nursing or caring science, similar to nursing educational programmes. The latter is probably because midwifery education is based on the nursing education degree. In nursing educational programmes in Sweden, the curricula are oriented to either
nursing- or caring science, which is a Scandinavian phenomenon (Ohlen et al., 2011). As Donaldson and Crowley (1978) described, nursing and midwifery are both professional disciplines directed towards knowledge development of significance to a specific field of practice. Influenced by societal factors outside the scientific community as well as professional groups, practice disciplines like these develop mainly through academisation and professionalisation. The discipline of caring, on the other hand, can be characterised as academic or theoretical, developed mainly through internal processes in the scientific community through specialisation or differentiation from already established disciplines, with no relation to a specific professional field (Elzinga, 1987; Hermansson, 2003; Ohlen et al., 2011). In these cases, the discipline and the profession are totally separate. The relationships between the major subjects, disciplines and professions are illustrated in Fig. 6. Even if the major subject is found within the three different disciplines with different conceptualisations and knowledge bases, the analysis reveals that the content in the syllabi is almost identical to the midwifery professional knowledge base as given in the description of competencies for midwives (The Swedish National Board of Health and Welfare, 2006). How this will influence the development of the discipline, the profession and the students' understanding of this relationship is difficult to answer. Like all formal education programmes, Master of Science in midwifery programmes transmit knowledge and values to their students, but will also contribute value to the profession. As stated by Farley and Carr (2003), those who teach and learn in these programmes will undoubtedly augment the theoretical basis of the discipline. Moreover, postgraduates will have had discipline-specific learning experiences that will help them to advance the profession and practice of midwifery. There is a call for a national consensus regarding the major subject of all midwifery programmes in Sweden, but there are still different opinions among the professionals in academic institutions, as well as in clinical practice. Another issue is the major subject's relation to other subjects. Most universities use the integrated code to structure their curricula, meaning that there is no clear boundary between subjects. The choice of employing integrated code can be problematic because it then becomes unclear where and to what extent other important subjects can be found in the curricula or syllabi. For students, this means that they are not always aware that they are studying various subjects. In the long term, this could have consequences for students when they become midwives. For example, students' desire to deepen their knowledge in medical science could be hampered by their inability to identify the subjects that have formed their midwifery education. It could also be problematic for midwives who want to register in another country. Teachers' competence has increased dramatically since 2005/2006, and has continued to do so since this study was carried out. Besides midwifery education, a PhD is now required for employment at a university; this is important in the integration of scientific knowledge and clinical practice. This study showed that teachers strive to make even the clinical elements of education more academic, for example,
Table 4 Major subjects and the relation to curriculum structure, 2009/2010 (n = 11). Figures indicate number of universities.
Table 5 Comparison of theoretical and clinical studies before and after the Bologna reform. n indicates number of universities.
Social and Behavioral Science
ECTS
80
Public Health Science
70
Medical Science
60
Caring Science Nursing Science
50
Midwifery Science
40 30 20 10 0
University Fig. 2. Major subject in relation to other subjects.
Although the midwifery programme is now at postgraduate level, a postgraduate degree project/master's thesis is only compulsory at five universities (Table 6). The teachers stated that it had not been easy to insert a 15 ECTS thesis in the programme, saying that ‘combining academic and professional demands can be problematic’, ‘for some students it is difficult to finish the thesis in allotted time, in combination with other demands’, ‘most students manage, with some degree of stress, but students feel that the programme is demanding’ and ‘we try to work it into non-existent time’. At present, teachers' competence is higher than before the reform; 60% of all teachers had at least a PhD, but not always in the major subject. Of these, 22 were assistant professors, 8 associate professors and 4 professors. The proportion of teachers with a PhD differed widely among the universities, from 25% to 100%. The remaining 40% of the teachers had a master's degree at the least. The opinion among the teachers is that more associate professors and professors are required in the major subject. About 90% of the teachers had at least 15 ECTS in pedagogical courses. However, fewer teachers had a university diploma in nursing/midwifery education compared to before the Bologna reform. In their clinical education, students are supervised by one or several midwives, who often lack undergraduate or graduate degrees, and the university teachers saw this as a weakness. They stated that a higher academic level among midwives in clinical practice is desirable. Discussion
Major subjects 2009/2010
Integrated code
Midwifery science Nursing science Nursing science with a focus on reproductive, perinatal and/or sexual health (nursing) Caring science Caring science with a focus on reproductive, perinatal and/or sexual health (nursing)
3
Collected code
Integrated and collected codes
2005/2006 (n = 10)
2009/2010 (n = 11)
1
Theoretical studies 45–52.5 ECTS
42–45.5 ECTS
Clinical studies 37.5–45 ECTS
44.5–48 ECTS
Number of women cared for 100 (n = 7) 50% must be births (n = 8)
100 (n = 8) 50% must be births (n = 9)
3
1
2 1
E. Hermansson, L.B. Mårtensson / Nurse Education Today 33 (2013) 866–872
50
Maternity/Neonatal Care
40 35
ECTS
Entry Requirements
Gynaecology Care
45
30
Prenatal Care/Family Planning
25
Delivery Ward
871
Bachelor´s Degree
2009/2010
One year work as a Nurse
20
2005/2006
15 10
Registered Nurse
5 0
0
Fig. 3. Distribution of clinical studies, 2005/2006.
incorporating scientific knowledge through case studies, clinical examinations and the development of generic skills. In terms of the balance between theoretical and more academic content in relation to clinical aspects, it is always risky when very practical education becomes more academic (Farley and Carr, 2003; Thompson et al., 2011). However, at present, this balance has nearly been achieved in Swedish midwifery education. This represents a great achievement for the teachers, because there is a lack of undergraduate or postgraduate degrees among midwives in clinical practice. The need for midwives with a master's degree who can supervise midwifery students in clinical practice suggests that a master's thesis should be included in the midwifery programme. Midwifery is still a very practical profession, and approximately half of the programme involves clinical practice. In the delivery ward, the student has to care for 100 women; 50 of these cases must be births. This has been agreed upon by all Swedish universities. Since the Bologna process was implemented and midwifery education came to be offered at the postgraduate level, the degree project/master's thesis became compulsory at five universities. This means that the thesis corresponds to 17% of the whole programme. Many teachers expressed that it is difficult for the students to handle the required number cases along with this thesis in the stipulated time. However, this is valuable for the student, even if there is ambivalence related to expected learning outcomes (German Millberg et al., 2011). One desirable feature is that this could stimulate the students to be better research consumers and participate in research projects. Midwifery education at the postgraduate level will guarantee that midwives have good and relevant tools to give evidence-based care for women and their families, and allow the possibility of evaluating and developing treatment and methods within midwifery. Because of midwives' broad field of knowledge and more advanced tasks, the content in the midwifery education has increased dramatically
50
Clinical Training Center Gynaecology Care Maternity/Neonatal Care Prenatal Care/Family Planning Delivery Ward
45 40
ECTS
35 30 25
4
6
8
10
12
Fig. 5. Entry requirements before and after the Bologna reform (n=11). Figures indicate number of universities.
over the past decades (Hermansson, 2003). Together with the demands on an additional academisation this study highlights that the midwifery education today did not give students time enough for critical thinking, reflection and problem solving in their new role as becoming midwives. Altogether, the results of this study indicate that midwifery education is too short, an idea supported by the teachers who participated in the present study. Midwifery education should be extended to at least two years after a three-year nursing programme. However, the question of why we do not have direct entry to the midwifery programme is also relevant, and an increase in this programme to five years in total with a master's degree in the science of midwifery should be considered.
Conclusions The implementation of the Bologna reform in the Swedish higher educational system has contributed to a postgraduate/master level of education for midwives. The students did not earn only a professional diploma in midwifery, but also an academic degree at the post-graduate level with opportunities for a continued academic career. This will strengthen the professional and disciplinary development in this field. However, it is clear that the academisation process places higher demands on students' performance, as well as teachers' competencies, in midwifery education programmes. For the students, it requires a greater focus on generic skills in theory and practice with evidence-based knowledge, seminars and independent studies and a postgraduate degree project. Some teachers stated that the students have difficulties to integrate these professional and academic demands in such a short time, meaning that there is still tension between professional and academic education. The midwifery education needs therefore to be longer than 90 ECTS after the completion of nursing education to solve these problems. Thus, it is imperative to establish a national consensus regarding the major subject of all midwifery education in Sweden. The results of this study could be of international significance, since the integration of midwifery education into higher education systems in different countries is as yet uncommon; thus, there will be interest in the academisation process of Swedish midwifery education.
Table 6 Comparison of thesis requirements before and after the Bologna reform.
20 15 10 5 0
2
University
University
Fig. 4. Distribution of clinical studies after the Bologna reform, 2009/2010.
Master's degree (one year) Elective Compulsory Bachelor's degree
2005/2006 (n = 10)
2009/2010 (n = 11)
6 0 7
6 5 0
872
E. Hermansson, L.B. Mårtensson / Nurse Education Today 33 (2013) 866–872
Major Subject Profession of Midwifery
Discipline of Midwifery
Major Subject
Profession of Midwifery
Major Subject
Profession of Midwifery
Discipline of Nursing
Discipline of Caring
Major subject similar to the professional knowledge base
Major subject dissimilar to the professional knowledge base
Fig. 6. Relation between disciplines, profession of midwifery and major subject.
References Becher, T., 1987. Disciplinary Discource. In Disciplinary Perspective on Higher Education and Research. Group for the Study of Higher Education and Research Policy (Report no 37). Stockholm: Department of Political Science, University of Stockholm. Becher, T., 1989. Academic tribes and territories. Intellectual Enquiry and the Cultures of Disciplines. Buckingham Open University Press/SRHE. Bernstein, B., 1977. Class, codes and control. Toward a Theory of Education Transmission, vol. 3. Routledge & Kegan Paul, London. Clark, B.R., 1983. The Higher Education System: Organization in Cross-national Perspective. University of California Press, Los Angeles. Davies, R., 2008. The Bologna process: the quiet revolution in nursing higher education. Nurse Education Today 28 (8), 935–942. Donaldson, S.K., Crowley, D.M., 1978. The discipline of nursing. Nursing Outlook 26 (2), 113–120. DS, 1992:14. Introducing the EES regulation: a mutual acknowledgement of a certificate of competence for practitioners in health care (Införande av EES rätt: ömsesidigt erkännande av kompetensbevis för verksamhet inom hälso-och sjukvården). In: Socialdepartementet (Ed.), Allmänna Förlaget, Stockholm. Elzinga, A., 1987. Internal and external regulative in research and higher education systems. Disciplinary perspectives on higher education and research. Group for the Study of Higher Education and Research Policy. Farley, C., Carr, K.C., 2003. New directions in midwifery education: the master's of science in midwifery degree. Journal of Midwifery & Women's Health 48 (2), 133–137. Fleming, V., Pehlke-Milde Hebamme, J., Davies, S., Zaksek, T., 2011. Developing and validating scenarios to compare midwives' knowledge and skills with the International Confederation of Midwives' essential competencies in four European countries. Midwifery 27 (6), 854–860. German Millberg, L., Berg, L., Lindstrom, I., Petzall, K., Ohlen, J., 2011. Tensions related to implementation of postgraduate degree projects in specialist nursing education. Nurse Education Today 31 (3), 283–288. Goverment Offices of Sweden, 2005. New world — new higher education (Ny värld — Ny högskola). (No. 2004/05:162) Ministry of Education and Research. Hegarty, J., McCarthy, G., O' Sullivan, D., Lehane, B., 2008. A review of nursing and midwifery education research in the Republic of Ireland. Nurse Education Today 28 (6), 720–736. Hermansson, E., 2003. Academisation and professionalization - midwifery education in transition. (In Swedish: Akademisering och professionalisering - barnmorskans utbildning i förändring). Dissertation. Göteborg University, Göteborg. ICM, 2011. Global Standards for Midwifery Education 2010: International Confederation of Midwives. Karseth, B., 2008. Qualification Frameworks for the European Higher Education Area. Örebro University, Sweden. Krippendorff, K., 2004. Content Analysis: an Introduction to its Methodology, 2 ed. Sage cop, Thousand Oaks Calif.
Lundgren, U.P., 1983. To Organize the World. An Introduction to Curriculum Theory (Att organisera omvärlden. En introduktion till läroplansteori). Liber Förlag, Stockholm. Ohlen, J., Furaker, C., Jakobsson, E., Bergh, I., Hermansson, E., 2011. Impact of the Bologna process in Bachelor Nursing Programmes: the Swedish Case. Nurse Education Today 31 (2), 122–128. Oliver, R., Sanz, M., 2007. The Bologna process and health science education: times are changing. Medical Education 41 (3), 309–317. Raholm, M.B., Hedegaard, B.L., Lofmark, A., Slettebo, A., 2010. Nursing education in Denmark, Finland, Norway and Sweden—from Bachelor's degree to PhD. Journal of Advanced Nursing 66 (9), 2126–2137. Roxburgh, M., Watson, R., Holland, K., Johnson, M., Lauder, W., Topping, K., 2008. A review of curriculum evaluation in United Kingdom nursing education. Nurse Education Today 28 (7), 881–889. SFS, 1992:1434, updated 2006:173. Higher education act. Swedish Statues in Translation. SFS, 1993:100, updated 2006. Higher education ordinance Swedish statues in translation. SFS, 2003:460. The Swedish Act concerning ethical review of research involving humans (Lag (2003:460) om etikprövning av forskning som avser människor). http://www.notisum.se/rnp/sls/lag/20030460.htm. SoU, 1978:50. New Health Care Education: report from the committee of certain health care programmes in higher education; Vård 77 (Ny vårdutbildning: betänkande av Utredningen om vissa vårdutbildningar inom högskolan; Vård 77). Ministry of Education and Research, Stockholm. Spitzer, A., Perrenoud, B., 2006. Reforms in nursing education across Western Europe: implementation processes and current status. Journal of Professional Nursing 22 (3), 162–171. Swedish National Agency for Higher Education, 1996. Vårdutbildningar i Högskolan. En utvärdering. Swedish National Agency for Higher Education, Stockholm. Swedish National Agency for Higher Education, 2000. Utbildningar inom vård-och omsorg. En uppföljande utvärdering. Swedish National Agency for Higher Education, Stockholm. Swedish National Agency for Higher Education, 2007. Evaluation of Undergraduate Programmes in Medicine and Health Care at Swedish Universities and University Colleges . (No. 2007:23R) Ministry of Education and Research. The Swedish National Board of Health and Welfare, 2006. Description of competences for registered midwife (Kompetensbeskrivning för legitimerad barnmorska). The National Board of Health and Welfare, Stockholm. Thompson, J.B., Fullerton, J.T., Sawyer, A.J., 2011. The international confederation of midwives: global standards for midwifery education (2010) with companion guidelines. Midwifery 27 (4), 409–416. World Medical Association Declaration of Helsinki, 2008. Ethical principles for medical research involving human subjects. Zabalegui, A., Cabrera, E., 2009. New nursing education structure in Spain. Nurse Education Today 29 (5), 500–504.