Professional development in midwifery: findings from a longitudinal study of midwives' careers

Professional development in midwifery: findings from a longitudinal study of midwives’ careers Sarah Robinson

Although much importance is attached to continuing professional education for nurses, midwives and health visitors, there is a paucity of empirical studies on the subject. This article reviews research in continuing education for midwives and adds to the body of literature by reporting on findings on continuing education obtained in the course of a longitudinal study of midwives’ careers. The original impetus for the study was concern about attrition from the profession; the method chosen to examine the problem was a longitudinal study in which two large cohorts of midwives were followed-up by means of questionnaires sent to them at regular intervals from qualification onwards. Information has been obtained on the relationship to retention of career intentions, careers followed and many aspects of life as a midwife. Those aspects relating to continuing professional education and development include obtaining post-basic qualifications, opportunities for in-service education, professional development during breaks for child care, support and feedback from senior colleagues and views on the importance of continuing education and support in relation to retention.

INTRODUCTION Continuing professional education for nurses, midwives and health visitors has been the focus of much attention over the last 2 years, following the publication of the United Kingdom Central Council’s (UKCCs) document on the Post-registration Education and Practice Project (UKCC 1990) and then the English National Board’s (ENBs) Framework for Continuing Education

Sarah Robinson BSc, Senior Research Fellow, Nursing Research Unit, Kings College, Cornwall House, Waterloo Road, London SE1 8TX, UK (Requests for offprints to SR) Manuscript accepted 27 October 1993

and Training (ENB 1990). The thinking and discussion that culminated in these two reports were a response to concerns that continuing education provision is uneven throughout the country and its relationship to service needs and individual careers is somewhat haphazard. The cornerstone of both reports is the belief that high quality care for patients and clients depends on the continuing education of those responsible for its delivery. Moreover, both reports recognise the effect that a planned programme of continuing education may have on individual career development and job satisfaction, and the influence that these in turn may have on staff retention. These sentiments have of course featured in a number of previous publications emanating from government departments and 161

162

NURSE EDUCATION

TODAY

professional

organisations

(for example

Commiteee

1972,

Commission

National

Health

Committee

Royal Service

1981,

1979,

UKCC

recent reports however,

National

1984).

schemes

whereby

tinuing

education

achievements

to career progress

in a formally

ENB

which

profiles

Award

stresses the importance

certified

in furthering Support

recommends registered

a period

the knowledge of

number

in order

The

eduis also

in that it

for all newly

these include

about after

includes

continuing

this initial

a mandatory

subject. those

for

continuing

eduperiod;

5 study days within

to midwives,

research

relating

to

of

followed

continuing

First,

however,

a com-

comment,

there

continuing

in the literature,

is no

professional

and they go on to of those that do exist.

This showed that whereas most definitions

refer

to developing

after

and expanding

initial registration,

knowledge

they differ

taken

to categorising

These

include

in the approach

aspects

distinguishing

of this process. between

informal

each 3 year period

and a system of continuing

activities such as reading

education

as part

and formal activities like course attendance;

‘credits’

progressions.

Although

the UKCC greater

differing

and the ENB

degree

career

in detail, both

wish to see a much

of planning

the provision

of planned

and coordination

of continuing

education

in

than has

In these two documents, have addressed that continuing practitioners

as in many others that

the subject, professional

enhances

it is taken as given education

of health

both the quality of care

review of the literature paucity

of

(Barriball empirical

on continuing

other

definitions

studies

on

the

a

subject.

Consequently, little is known about nurses’ perceptions of their own continuing education needs, how many have attended courses, factors that facilitate or militate against doing so, and what effect, if any, continuing education has on patient care and individual

careers.

and

and the service. Two

concerning

education

continuing

are relevant

in this article.

Firstly, (following

rence

the

1989)

provided

study

and those which service

the needs of the individual

distinction

by employers

pro-

to the findings Rogers

& Law-

between

courses

and/or other

organis-

ations which do not lead to nationally and post-basic

recognised

qualifications

which

do lead to the award of such certificates.

Secon-

dly, the phrase

education

et al 1992) has revealed

and self-directed

between courses which service the

needs of the employer

certificates

that they deliver and their own career development. However, a recent and comprehensive for nurses

distinguishing

fessional

been the case hitherto.

by pro-

used in the article. As

et al (1992) definition

on the

of the midwives’

are then described,

provide a useful summary a

Lon-

professional

available

development.

education

of

at the

Unit of King’s College,

currently

project

Barriball

pro-

studies

The article begins by outlining

findings

agreed

is part of a

in progress

The aims and methods

fessional

were of two

research

of longitudinal

ment on the terminology

to consolidate

document

of suggestions opportunities

Research

don University.

careers

The

and skill base gained by the time

qualification.

cation

of support

practitioners

of

outcomes

practitioners

project

funded

followed by a review of existing

enable

of support for

document,

The

health service staff, currently

development

some

that

a study of the careers

of a series

opportunities

learning

for

gramme

by presenting education

of Health

courses would

exist

of midwives.

the developand

does

continuing

Department

Nursing

way.

their continuing

in the UKCC

cohorts

by

of con-

by the Board.

cation and in demonstrating highlighted

during

that contribute

time

a Higher

in practice.

obtained

two

to gain the qualification

document

practitioners

on

can

recognised

modular

in

individuals

findings

forward,

advocates

approved

programmes successful

professional

document

of ENB

that

Staff

individuals

personal

The

research

the UKCC and the ENB

develop

ment

This article seeks to add to the small volume of

the

In these

have sought to move the discussion outlining

Briggs on

‘continuing

cation’ is sometimes continuing

professional

edu-

used interchangeably

professional

development.

with In

the

careers research programme at NRU, the former has been regarded as one component of the latter. While education may well be the main focus of professional development, other activities are also an important part of this process; these include

support

for staff by means

of a

NURSE EDUCATIOFU’ -lWDA\

mentor or preceptor system, regular appraisal or performance review of work, career guidance, and further academic study that may enhance analytic and critical skills.

CONTINUING PROFESSIONAL DEVELOPMENT IN MIDWIFERY Post-basic qualifications available for midwives include certificates, diplomas or degrees in education some at postgraduate level leading to UKCC registration as a teacher of midwifery. The National Boards offer a number of courses relevant to midwifery practice and education and a variety of courses such as Diplomas in Counselling and Certificates in Antenatal Education are also available. Many midwives have f-urthered their professional development by taking bachelor and/or masters degrees, usually in departments of nursing or education. Kecent years, however, have seen the introduction of degrees in midwifery itself, at both undergraduate and masters level (Pendleton 1990), and a growing number of- midwives have been awarded a doctorate for a dissertation on an aspect of midwifery practice or education (National Perinatal Epidemiology Unit 1991). Midwives have differed from nurses and health visitors in that they are statutorily required to undertake refresher courses in order to continue in practice. Up until 1987 these always took the form of a 5 day course once every 5 years; since then two other options are also available, namely 7 accumulated study days in 5 years or a 2 week planned period of clinical practice with theoretical input. As noted earlier, the UKCC is now seeking to introduce a mandatory component into continuing education for nurses and health visitors as well (UKCC 1990). In addition to statutory refresher courses, in-service courses on a range of topics relevant to midwifery are offered by university departments, the Koyal College of Midwives, organisations such as MIDIRS, maternity units, individual health authorities, and NHS Trusts. Updating courses for those who are returning after a break are available in some areas and a recent innovation is the production of a distance

163

learning programme for midwives who have been out of practice for a while (University of the South Bank 1992). Research published to date on opportunities for midwives to continue their professional development is relatively scant. Existing studies focus on the provision and uptake of post-basic and in-service courses and on their content and structure. Little information is available on the extent to which midwives’ needs are met, or on the impact, if any, that continuing education has on quality of care and individual career progress. In this respect the situation is similar to that found in relation to continuing education in nursing by Barriball et al (1992). Turning first to post-basic qualifications, then the Midwife Teacher’s Diploma has been the focus of two published research projects (Kilty & Potter 1975, Balch 1982). The first of these was commissioned in response to concerns about the examination failure rates of students in the early 1970s (Kilty & Potter 1975). Following discussions with an ‘expert group’, the authors identified several areas that might be relevant to the low pass rate, four of which were then investigated in the course of a multi-method project. Firstly, by means of questionnaires completed by midwives attending a refresher course (n = 33), midwives attending a practical teachers course (n = 22) and interviews with groups of midwife teachers (n not stated), potential deterrents to course application were identified. These included the high failure rate, difficulties in obtaining secondment, lack of guidance about teaching as a career, lack of information. about the course and problems in combining course attendance with family commitments. Secondly, interviews with small groups (numbers not given) of senior midwife teachers, course tutors, MTD students and examiners, together with observation of the oral part of the final examination showed that many of the changes occurring in the midwife’s role in the 1960s and 1970s were reflected in course aims and objectives, but that the same was not true of the written and oral examinations. The content of both examinations was in some respects poorlv matched to course objectives. The third part of the project focused on the

164

NURSE EDUCATION

TODAY

examination itself. Analysis of written material and observation at oral examinations, demonstrated that the marking scheme was weighted towards failure and that lack of agreed criteria led to inconsistency of marking between examiners. Finally the possible relationship of student variables to pass rates was studied by means of examining records for 77 students from 3 colleges. These data revealed no significant association of pass rates with age or previous midwifery experience. However, interviews with tutors revealed concerns that some students embarked on the course with inadequate basic midwifery knowledge and that this contributed to the high failure rate. The Kilty & Potter project is noteworthy because of the way in which it addressed many aspects of the MTD course, particularly those that might have a bearing on the course pass rate. Many of the ensuing recommendations were implemented, in particular those concerning the content and conduct of the examination system, the need for a longer course and one with a greater emphasis on educational as opposed to professional subjects, and the need for greater pre-course preparation. The second published research project on the Midwife Teacher’s Diploma focused on views and experiences of those who had taken the course at the Royal College of Midwives during the period 1975-79 (Balch 1982). Questionnaires were sent to 60 midwives who had taken the course and subsequently worked as tutors; and 80% (48) were returned. Findings showed that enjoyment of teaching was specified most frequently (23) as the reason for taking the course. When asked about their expectations of the course, learning about teaching and increasing professional knowledge were each mentioned by the same number of respondents (29). The author commented in particular on the latter finding, given that the course emphasis was ostensibly educational. However, given the prominence of professional as opposed to educational topics in the course (Kilty & Potter 1975), it is perhaps not surprising that a majority of Balch’s respondents perceived that attendance would increase their professional knowledge. 28 of the respondents felt that the course

had prepared them well for the role of teacher, with a further 16 having found the preparation adequate. Most respondents had found teaching practice stressful in some way but this was outweighed by various benefits such as seeing the attitude of tutors (17), seeing a school function (15), relating theory to practice (10) and seeing the role of the tutor (13). When respondents were asked to recommend changes to the course, two of the five that came up most often corroborated Kilty & Potter’s conclusions: namely the need for a period of pre-course preparation and for the course itself to be lengthened. Concern about the paucity of post-basic midwifery courses available in Wales led Maclean (1980) to undertake a survey of midwives’ views as to the importance of continuing education generally and their experiences of the availability and uptake of both post-basic and in-service courses. Information was obtained from a questionnaire sent to a 10% random sample of midwives in practice in Wales plus all the midwifery tutors working there; an 88% response rate overall was achieved (n = 147). Findings demonstrated a lack of available courses in some areas, but also inaccurate knowledge as to what was available. The view that their own professional education was not complete, and that continued study was of benefit to career development and to the quality of care delivered were expressed by over 80% of respondents. The published findings do not provide an overall figure for the number of midwives in practice who had attended an in-service and/or a postbasic course since qualifying, but do show that the number who had attended each kind of course was small, ranging from 37% for Family Planning Appreciation courses to 2% for the Advanced Diploma in Midwifery (Maclean 1980). Respondents in Maclean’s study were asked to specify the kinds of course for which they felt the need was most urgent, and short courses on keeping up-to-date were cited most frequently (52%). Some of the recommendations that Maclean made on the basis of this study were well ahead of their time; most notably that each midwife needs a planned professional develop-

NURSE EDUCATION

ment

profile,

newly qualified

first year programme that post-basic by

means

courses of

midwives

of regular should

distance

also be provided

learning

been

focusing

each

for midwives

area (Sugarman

1988,

on in-service

59

study was prompted

about decreasing

staff

district; cated

findings

precluded

in

one

but that respondents

continuing

Northern

Ireland,

the participation

indi-

as useful were often

by short staffing

to a very

might

well reflect

for a set programme rather

more

compulsory

attendance.

attendance

respondents

education,

likely to support

than voluntary

previous

said there was a need

of continuing

Findings

showed

that

overall had attended

for

last year, but that this varied by grade;

hospital so. com-

munity

staff the

midwives and newly qualified

,411 respondents

were given a list of five broad

topic areas and asked forming

on

midwives

(1989)

of midwifery

midwives in formal continuing

cation

the content courses.

respondents in

investigated

to rate them from

of future

Clinical

1980

findings

oppor-

interest’

in

interest’ The

topics

were 62% for teaching

to

Maclean’s

respect.

other

edu-

was the topic

supports

this

rating

‘of a

relation to

continuing

practice

and

(84%),

respondents

sisters and staff education

of

sisters were most likely to have done

great deal of interest’ to ‘no interest’in

the lack of information

McCrea

on

63%

a course in the

most likely to be cited as ‘of greatest

education

a lack of

least likely.

by family responsibili-

ties and, to a lesser extent,

about

health

from the 42 who replied

from attending

for

were sent to the

employed

their wards. In a study to redress

by

specifically

the study days were perceived

and enjoyable

&

levels of attendance

Questionnaires

midwives

attributable

rate from night staff, which as the

comment,

and were

district/

1989, Clarke

at a series of study days provided staff midwives.

was primarily

access to courses for this group. Findings showed

have also

in one health McCrea

Rees 1989). Sugarman’s concerns

This

low response

that nearly all respondents scale studies

education

56%.

authors

packages

(Maclean 1980). A number of smaller undertaken,

need a

study days, and

165

TODA\r

$

of

as ‘of great

and assessment,

54% for communication

skills, 37% for manage-

tunities, such as courses and study days, as well as

ment

personal

time spent reading journals

(Clarke

Responses

from

72% return

43

from

board in Northern had

attended

courses. that

family

militated

representing

a

in one area health

Ireland,

showed that only 13

other

like Sugarman

responsibilities

against

respondents

midwives,

a sample

courses,

McCrea,

and using libraries.

course

and

than

refresher

(1988)

found

staffing

attendance;

levels

but many

also said that encouragement

from

and

36%

The priority ing

clinical

courses

development

that respondents topics

in

give to includ-

continuing

was also demonstrated

midwives’

views on the

courses (Parnaby to concerns (Mander senior

for

& Rees 1989).

content

of refresher

1987) undertaken

about the usefulness teachers

in response

of these courses

1986). Questionnaires

midwife

education

by a survey of

were sent to all

in England

(n = 149)

managers to attend courses was not always forthcoming. The majority of respondents said

and all midwives attending

that continuing

total of 45 topics and asked to rate their import-

profession, (1980),

education

although

found

was important

McCrea,

that a minority

lacked motivation

to personally

like

for the Maclean

(n = 119); both groups

attend courses.

midwifery

Clamorgan should meet staff needs, Clarke & Rees (1989) sought information from the

content.

district’s

(90%),

education

with a

ance for inclusion in the refresher course curriFindings from respondents ( 14 1 culum. members)

continuing

course

were presented

of respondents

In order that a proposed programme of continuing education for midwives in South

178 midwives

one refresher

on their experiences

of

to date and views about

which topics would be of most use in future courses. The overall response rate was low at

teachers

and

117 refresher

50% or more as being essential was rules

course

showed that 14 topics were rated by for curriculum

The most highly rated topics of the 14

‘recent

changes

in

midwifery

and this was followed of

statutory

bodies

practice’

by new policies/ (83%)

and

new

government legislation on reports related to midwifery practice (83%). The majority (88%) of

166

NURSE EDUCATION

TODAY

both groups said that refresher courses should offer participants a choice of sessions. Parnaby proposed three solutions as to how this could be achieved: by parallel sessions on existing courses; by offering specialist refresher courses, or by allowing midwives to chose a number of separate courses that they perceived as relevant to their continuing education needs (Parnaby 1987). As noted earlier, the last option and other alternative modes of refreshment have now been introduced as an alternative for those who do not wish to attend a course of 5 consecutive days. The view that continuing education has a positive impact on patient care is stressed in the recent documents produced by the UKCC (1990). However, as Barriball et al (1992) conclude from their review of the continuing education literature, few studies exist that have attempted to examine the veracity of this assertion. One notable exception in the research literature on midwifery education is MurphyBlack’s study of the effect that a course on had on participants’ antenatal education teaching styles (Murphy-Black 1985, 1991). The course philosophy emphasised the value of group work and interactive teaching methods and the research sought to determine whether expectations of course members were met and to assess course outcome by means of an observation study of participants pre- and post-course teaching styles. Expectations were studied by means of questionnaires given to course members (n = 65) at two centres: responses from a 94% pre-course return and a 78% post-course return showed a high degree of satisfaction, with most participants saying they had learnt about teaching, leading a group and communicating with women. The observation study was carried out with a third of the course members and used Flanders Interaction Analysis Categories (Flanders 1970). Findings showed a small post-course increase in interactive teaching and this difference reached a significant level for those members who had chosen to go on the course as opposed to being sent. This finding may have important implications for selection of participants, if resources invested in course provision are to be cost-effective. Murphy-Black argues

that evaluation studies comprising process measures only are useful to identify strengths and weaknesses of a course, but satisfaction with a course, does not necessarily mean there will be any subsequent change in practice. Outcome studies are needed to assess whether or not this is the case (Murphy-Black 1991). An area neglected until relatively recently is the continuing education needs of practitioners who are not working for reasons such as child care or a period of unemployment. Recognising the potential importance that opportunities for continuing education, may have on encouraging a return to work, the Department of Health (1988) has recommended the implementation of ‘keeping in touch’ schemes. Views of non-working midwives in this respect have recently been explored in a small scale interview study (n = 10) by Midgeley (1993). The findings showed that 9 members of the group would be interested in a ‘keep in touch’ programme for midwives, and that learning methods favoured were learning packages (8), attending midwives’ study days (8), loan of videos (7) and tutorial groups with clinical and teaching staff (6). 9 respondents said that it would be important for such a programme to attract credit accumulation. Finally, research on aspects of professional development for midwives, such as mentorship and career guidance, is notable by its absence, although a number of unpublished studies are recorded in the Midwifery Research Database (National Perinatal Epidemiology Unit 1991).

THE MIDWIVES’ CAREERS PROJECT: AIMS AND METHODS The studies reviewed above have all focused solely on continuing education for midwives and/or other aspects of their professional development. Data on these topics have also been obtained in the course of the Nursing Research Unit’s project on careers of midwives; they were not, however, the only focus of the project which has in fact provided information on many aspects of life as a midwife. In this section the aims and methods of the project are described in order to provide a context for the

KUKSE

findings

on continuing

professional

develop-

EDU(:A-I-ION

was felt that information

167

TOD.4\

from these two cohorts

about their post-qualification

experiences

two cohorts of midwives from the time of qualifi-

usefully

understanding

cation

factors

ment.

The

project

onwards;

has followed the

first

the careers

cohort

of

qualified

in

contribute associated

1979, the second in 1983. To date three phases

relevant

of data collection

registration.

fourth

planned

have been undertaken

with a

educational,

lish whether

was

in that it sought to estab-

extending

midwifery

training

from

12 to 18 months led to the ‘hoped for’ increase qualified

midwives feeling

to practise,

adequately

and in the number

do so (Stewart

qualifying

prepared

1981). Questionnaires

course,

representing

that

year.

in

who intended

to 932 midwives who qualified month

to

were sent

in 1979 after a 12 a quarter

Then

the

of those

same

ques-

and for some demographic not practised

why this had been practised

the case.

and courses

views and experiences of retention,

and

years later in 1989, out.

All those

after

tionnaire

A national method

survey

of choice

numbers

were

significant career

intentions.

required

for

differences

in relation

also rep-

by questionnaire several

needed

cohorts

course,

of the year’s qualifiers. reasons.

existed A

between

national

Large the two

sample

and was

to militate against biases that

since

intentions

for

information with

and demographic

1973,

feasible

method

were the only given

the

studies

lems of method; tiveness

each

phase

pose

possible

loss of representa-

with

of respondents et al

& Manion

(Douglas 1978,

1980).

Bc Blomfield 1979.

Consequently

every

questionnaire

the

and

letter, response

Phases 2 and 3 originally

with the intention

two cohorts

further

tion. Concern 1980s

onwards

was not

undertaken

of following-up

the

in the years after qualifica-

had been growing however,

about

from the early attrition

from

the nursing and midwifery workforce (Royal College of Midwives 1985). In response to this, it

was made to maximise following:

tionnaires

developing

response

reliability of addresses;

feedback

reports

reminder

letters and duplicate

to maintain

responded members

length;

enclosing interest;

ques-

that they

and of acceptable

checking

every known address,

rates in included

testing

with a pilot group to ensure

were valid, reliable

at

Goldstein

Strategies

rates of 84% (782) and 89% (828) were achieved for the two cohorts respectively.

prob-

that of attrition

Hoinville

Cohen

considerable

in particular

Phases 2 and 3 of the project.

1 of the project

taken career

details.

effort

Phase

about

future

numbers involved and the geographical dispersion of the two cohorts. Following the initial and one reminder

in

again and sent a ques-

together

Longitudinal

school.

collection

3 was

Attrition and representativeness

training

of data

asked

1986,

might result from only including particular catchment areas of students and types of Questionnaires

intentions.

whether

to views about training

in order

career

various aspects of posts held and courses

was the

to determine

that

details of individual

who had responded

in 1983

18 month

taken,

Phase 3 of the project

Phase 2 were contacted

an

who had

in relation to the problem

future

was sent to 93 1 midwives who qualified a quarter

Those

that asked for various

post held

carried

If they had

as midwives were then sent a second

questionnaire each

as a midwife

details.

as a midwife they were asked to say

tionnaire resenting

of both cohorts asking for details

of their activities since qualifying

focus of the first phase of the project

of

that would be

and all members

were sent a short questionnaire

Phase 1 primarily

with attrition

might

in 1986, Phase 2 of the project

was undertaken

The

an

to all midwives, whatever their route to

Consequently

for the near future.

to

short

sending

questionnaires

to

and asking those who had

if they could help us to contact their set who were non-

of

respondents. Response

rates for longitudinal

studies can be

presented as a proportion of- the total cohort eligible to reply or as a proportion of those

168

NURSE EDUCATION

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Table 1 Response rates at Phases 1,2 and 3 of the Midwives’ Phase 1 197W983 Number in cohort Number returning the questionnaire Phase 1 response rate

Careers Project

at qualification

Phase 2(a) 1986 Number sent Phase 2(a) questionnaire Number returning questionnaire Response rate as proportion of cohort Number returning a Phase 1 and a Phase 2 questionnaire Response rate as proportion of Phase 1 respondents who returned a Phase 2 questionnaire Phase 2(b) 1987 Number who had practised midwifery by 1988 and sent a Phase 2(b) questionnaire Number returning questionnaire Response rate as proportion of number sent

Phase 3 1989 Number who had pracbsed midwifery by 1986 and sent a Phase 3(a) questionnaire Number returning questionnaire Response rate as proportion of number sent Number who had not practised midwifery by 1988 and sent a Phase 3(b) questionnaire Number returning questionnaire Response rate as proportion of number sent

responding at the previous phase. Both of these are shown for this project in Table 1. In Phase 3 it was considered wasteful of time and money to send questionnaires to those who had not replied in Phase 2 and so only those who had done so were sent a Phase 3 questionnaire. At certain phases of longitudinal studies different questionnaires are sometimes sent to particular subgroups, whose subsequent response rates may then vary. In this project those known to have practised midwifery by 1986 were sent a slightly different questionnaire in Phase 3 to those known not to have done so; response rates are shown separately for the two groups. Some information was obtained from the UKCC database about non-respondents in order to assess the representativeness of respondents. Taking the cohort as a whole, this showed that 66% of the 1979 cohort known to have practised midwifery by 1986 had responded and that the

1979 cohort 932 782 84%

1983 cohort 931 828 89%

932 536 58% (536/932) 490 63% (490/782)

931 629 68% (8291931) 581 70% (581/828)

394

524

319 87% (3191394)

431 82% (431/524)

394

524

288 73% (288/394) 96

407 78% (4071524) 57

80 83% (80196)

38 67% (38/57)

corresponding figure for the 1983 cohort was 79%. Table 1 shows that a high proportion of the Phase 2 respondents who had practised midwifery, responded in 1989 at Phase 3. Confidence can therefore be placed in the reliability of findings relating to experiences as a midwife.

Questions on continuing professional development Phase 2 of the project explored many aspects of life as a midwife including continuing professional development in the years since qualification. Some of the questions in this respect were also included in the questionnaire used for Phase 3 in 1989. By this time however, another major focus of interest had come to the fore: namely the problem of combining work as a midwife with family responsibilities and keeping in touch

NURSE EDUCATION

Table 2 Post/basic

qualifications

169

TODAY

obtained and sought

Qualifications

Column 1 Obtained since qualifying 1979 1983 cohort cohort (n = 319) (n = 431)

Column 2 Plan to study for in the future 1979 1983 cohort cohort (n = 101) (n =120)

Midwifery Advanced Diploma in Midwifery Midwife Teacher’s Diploma (or PGCEA)

19 9

6

24 5

55 15

Health visiting Health visitor’s certificate

41

26

13

30

6 2

3 8 1

2 -

-

6 6 1

7 2 -

3 6 -

6 7 -

7

4

2

19

16

Nursing Registered Sick Children’s Nurse Registered Mental Nurse Registered Nurse for Mentally Handicapped District Nurse Certificate Diploma in Nursing Registered Clinical Nurse Tutor Bachelors Degree in Nursing Masters Degree in Nursing

1

Degrees in subjects other than nursing or midwifery Bachelor Masters

2 -

with professional break

from

developments

full-time

keep the questionnaire and

maximise

response

while taking

employment.

In order

to a manageable

chances

of

length

maintaining

rates it was not feasible

a to

high

to include

all

FINDINGS Obtaining post-basic qualifications In Phase

2 of the project,

asked

qualifications

listed in Table

by this time. Consequently

The numbers

who had done so (column

on continuing

some of the findings

professional

development

relate

whether

respondents

the Phase 2 questions in the Phase 3 questionnaire, in addition to the new ones indicated

they had obtained

table) show that the Health

2 since qualifying. Visitor’s

to Phases 2 and 3, whereas others relate to Phase

was the most likely qualification

2 or Phase 3 only. The six topics explored

obtained;

were:

post-basic

2 and 3) 2. Opportunities (Phase 2) 3. Undertaking

qualifications

(Phases

obtained

the Advanced

1 of the

Certificate

to have been

by 41 of the 1979 respondents

of the 1983. 19 members 1. Obtaining

were

any of the

and 26

of the 1979 cohort had Diploma in Midwifery,

9

of whom had then taken the Midwife Teacher’s for

in-service

education

Diploma. qualified

part-time

study (Phase 2)

development 4. Professional for child care (Phase 3) with support 5. Satisfaction from senior colleagues

during

breaks feedback

(Phase 2)

1983

cohort

having

only been

to have attained the ADM and none had practised long enough to have completed the Midwife Teacher’s

and

of continuing 6. Views on the importance education and support in relation to retention (Phases 2 and 3).

The

for 3 years by this time were less likely

Diploma.

In a subsequent question all respondents were asked if they planned to study for any qualifications in the future.

Those

who said ‘yes’ (32% of

the 1979 respondents and 29% of the 1983) were then asked in an open-ended question to specify

170

NURSE EDUCATION

the qualifications

TODAY

they had in mind. Column

Table 2 shows the number the qualifications

listed in the earlier

and in both groups Midwifery

the Advanced

occurred

2 of

who specified each of

most

question;

Diploma

frequently.

Health

visiting was still more likely to be specified any of the branches are translated

of nursing

into practice,

in

than

and if intentions

then each of the two

as midwife

teachers.

Again

show if these numbers All

respondents

successfully

further

increase

were

completed

asked any

courses since qualifying

years since they qualified respondents

to have been taken were Special

hours

asked

their

health

reasons

visiting,

and the opportunity

greater

degree

for leaving

more

suitable

to practise

of autonomy

were

with a

mentioned

most often. The

number

of respondents

who said they

wanted to study for a degree is of interest. time of Phase

2 (1986)

there

tunities

for midwives

to pursue

degree

level, although

the need

degree

was advocated

& Adams

At the

were no oppormidwifery

to

degree

level

further

with

wanted

that

201120 for the 1983 cohort. a number

postgraduate

degrees

who

to do so at

a corresponding

of this paper,

figure

of

how many

members

in midwifery

are

of the two cohorts

or plan to obtain,

courses had been taken, but

each by four or less respondents.

Special

Intensive

and

Planning

Care

of

the

Newborn

were also the two ENB

likely to be specified

and

Family

courses

most

as those that respondents

would like to take in the future.

Opportunities education

for in-service

In Phase 2 all participants

were asked whether

they had attended

any in-service since qualifying

now

these courses were defined as those organised

have

a place on one of

made by respondents

to Phase

1 of the project

perceived

shortage

raised

wide range of other ENB (in

some cases JBCNS)

drew attention

of midwifery

teaching

1986). Concern

by Standon-Batt

teachers

for student

and a

midwives

about a shortage (1979)

to a

were

who calculated

courses

rel-

as midwives; by

respondent’s hospital or employing the authority, but which received no nationally recognised

certificate.

Less than half had in fact

done so; 41% of both cohorts.

Some of the comments

(Robinson

(47). An extremely

evant to midwifery

these courses.

lack of clinical

and Intensive

(44) and Family Planning

and

As noted in section 2

of undergraduate

available and later phases of the study will show obtained,

Care of the Newborn

as long ago as 1979 (Ward

a total of 26 of the 101 1979 respondents to study

The two courses most likely

for a masters

1979). This study shows however,

planned

A quarter

so in the 3 years

visitors.

for

had

Board

and 13% (57) of the

had done

since they qualified.

When

they

had done so in the 7

cohorts would have produced just over 50 health midwifery

if

National

as a midwife.

(79) of the 1979 respondents 1983

phases will

over time.

proportion but

smaller

(1988)

than that found than

and Clarke

All respondents was a need

those

This is a larger

by McCrea

found

(1988)

by Sugarman

& Rees (1989). were asked if they felt there

for greater

provision

of in-service

courses for midwives, whether or not they them-

that the number of tutors qualifying each year was 23 short of the number needed and as noted,

selves had attended

Kilty SC Potter (1975) had earlier looked at deterrents to recruitment to the course and

ded in-service who had not

factors related

greater provision of such courses. This finding indicates the importance attached to continuing

ination.

to high failure rates in the exam-

Findings

from

the Midwives’

Careers

a course. Table 3 shows that

over 70% of those respondents

who had atten-

courses and over 70% of those done so perceived a need for

Project show that if the Table 2 column 2 figures are translated into practice then 14 midwives

education by midwives and supports those of other studies (Maclean 1980, McCrea 1979,

from the 1979 cohort would have teachers and 15 from the 1983. The

Clarke & Rees 1989). Respondents who

become Phase 3

findings show that by 1989 14 of the 1979 cohort and five of the 1983 cohort were in fact working

had

attended

in-service

courses were asked to specify the main topics of each; these were then grouped into the catego-

NLTKSE EDU(:A’I‘IOK

Table 3 Attendance

at in-service courses for midwives

171

TOI)4k

by views on need for greater provision of such courses

Greater provision needed of in-service courses for midwives

1979 cohort who had: attended not attended courses courses No % No %

1983 cohort who had: attended not attended courses courses % No % No

Yes No No answer Total

74 17 9 100

74 14 12 100

97 22 12 131

Table 4 in-service courses: subjects of courses attended

Subject of course (A) Clinical updating Generally Technology in particular (B) Specific aspects of care Antenatal Parent craft Care in pregnancy Ultra-sound

77 15 8 100

129 26 13 168

27%

Care in labour Induction/acceleration Epidurals Other pain relief Intravenous infusions Continuous fetal monitoring Episiotomykuturing Resuscitation and intubation Types of delivery, Le Boyer, Active birth etc

10

1%

2 -

35 16 4

53% 1

4%

1 11 6 10 7 13 5 7

36%

47 18 12 9 16 2 4 5 9 -

164 31 37 232

Column 2 Respondents wanting courses 1979 cohort 1983 cohort (n = 226) (n = 295) No No

1 24 5 19 15 14 18 6

Postnatal care Feeding Family planning Neonatal deaths Child abuse Special care (C) Other topics Management Midwifery/nursing process Counselling Communication Education (learning, teaching, assessment) Health education Research Legal issues Aids Extending the midwife role

71 13 16 100

and courses wanted

Column 1 Respondents attending courses 1979 cohort 1983 cohort (n = 131) (n = 176) No No 8%

131 24 21 176

38%

66 23 19 8 8

7%

103 17

53%

9 9 6

11%

-I

110 47

33 19 12

1

6 -

20 -

19 _

8 8 27 23

16 16 17 23

18 9 1 27 -

27 8 -

16 4 26 15 10

15 ._

9%

29 3 37 15 3

-

-

-

3 6 15 -

17 13 14 6

30 8 15 20

In this table, % are only shown for those items to which attention is drawn in the text.

172

NURSE EDUCATION TODAY

ries shown in Table 4. The figures in column 1 show that for both cohorts, management courses were the most likely to have been attended, followed by parent craft. All respondents were asked to specify the topics that they would like to see addressed at future courses. As in Maclean’s (1980) study, this was an open ended question; respondents were not provided with a list of possible topics to rate in terms of importance for inclusion, as were those who participated in the studies by Parnaby (1987) and Clarke & Rees (1989). Topics specified for future courses were also allocated to the categories shown in Table 4, and the number of respondents listing topics in each category is shown in column 2. Taken together, the two colums reveal some interesting differences between the frequency of topics of courses taken and those desired in future. Management courses had been taken by just over a third of each group but desired in future by less than 10%. Very few respondents had attended courses concerned with clinical updating (8% of the 1979 group and 1% of the 1983), this however was the topic listed by far the most frequently as desired in the future; by just over half of both groups of respondents. This accords with findings from other studies in which midwives have been asked what topics they would like included in future courses (Maclean 1980, Parnaby 1987, Clarke & Rees 1989). This is perhaps not surprising given the rapid developments in the management of childbirth and the new policies and procedures with which midwives need to become familiar. Moreover, the research literature on continuing education for

Table 5 Satisfaction

nurses, similarly reveals an emphasis on clinical practice topics when respondents are asked for their views about future course content (Barriball et al 1992). Midwives’ satisfaction with the provision of in-service education in each midwifery post held since qualification was also explored in this study. Each midwife was sent a separate set of questions for each post held, and these asked about various aspects of life as a midwife including in-service education. A 5 point rating scale was provided (1 = very dissatisfied to 5 = very satisfied) and the option of not applicable, was included when appropriate. A mid point (3) of ‘neither satisfied or dissatisfied’, was included so that respondents who were not satisfied, were not forced to express dissatisfaction. As experiences and views often varied considerably from post to post it would have been meaningless to have worked out an average for each respondent for the rating given to each aspect listed. Percentages in Table 5 therefore relate to ‘posts held’ and not ‘individual’; findings are presented separately for first post and subsequent posts. Although the figures do not reach a majority, they do indicate a substantial degree of dissatisfaction; with totals of 48%, 34%, 40% and 35% for being ‘very’ or ‘fairly dissatisfied’ with the provision of in-service education in first and subsequent posts held by the two cohorts. These figures are consistent with other findings on in-service education from this project; namely less than half of the respondents having attended a course, and 70% saying that there should be greater provision.

with the provision of in-service education Posts held by

Satisfaction

ratings

Very dissatisfied Fairly dissatisfied Neither satisfied or dissatisfied Fairly satisfied Very satisfied No answer Total number of posts held

First % 2 18 23 6 8 319

1979 cohort Subsequent % 9 25 20 27 12 8 514

First % 13 27 16 30 9 5 431

1983 cohort Subsequent % 13 22 16 31 11 37:

NURSE EDUCATIOK

Part-time

in less than 10% of these periods of absence;

study

Midwives were asked whether undertaken

any part-time

or not they had

study since qualifying.

A total of 26% (82) of the 1979 respondents done so in the 7 years since qualifying, of the 1983 respondents three

majority

years

of whom

(46)

they

cited

most

instance),

career objectives at the

time.

full-time

one course

were asked why they (over

70%

by relevance of these

midwifery

studying part-time;

posts

in

each

to longterm

and then relevance

Most

the

interest in the subject was

frequently

followed

part-time

qualified,

had taken

only. All these respondents had taken the courses;

13% (58)

had studied

since

had

63% of

whom had taken two or more courses. in the

to post held

respondents

held

while

were

they

for 70% of courses attended,

they had been allowed to do so during

working

hours.

of those those

taken

taken

by the 1979 cohort

by the

1983.

which opportunities 52%

of

those

respondents

Of those

taken

by

for the 1983 cohort

the

they

some form of contact;

1979

would

Opportunities

to keep in touch while having a

for a period

courses

to update

return

are important

of child care, and refresher skills and knowledge aspects of continuing

fessional

development

titioner.

Both strategies

important

for

of Health

the issue of combining

any

health

proprac-

have been identified

in encouraging

(Department

upon

a return 1988).

to practice

As noted earlier

work as a midwife

family

responsibilities

depth

in Phase 3 of the project

as

was explored

with

in greater

(1989)

than in

Phase 2 (1986). Respondents in Phase 3 were asked whether they had left midwifery for family reasons

and

Further

questions,

development,

then

subsequently

returned.

relevant to professional included whether employers had

kept in touch during breaks about developments in the field, and whether respondents quently attended a refresher course.

had subse-

By 1989, the 1979 respondents had taken a total of 129 completed periods of absence from midwifery,

and the corresponding

figure for the

1983 respondents was 157. Employers had provided opportunities and facilities for midwives to keep in- touch about professional developments

in

was 64%.

for

cohort,

have

liked

the corresponding

fore that during the majority

figure

It appears

there-

of breaks for child

care, midwives did want to keep in touch with professional until

developments,

1989

but

little provision

certainly

up

in this respect

had

been made. In relation

to 25% of the periods

of absence

taken by the 1979 cohort and 30% of those taken by their

1983 counterparts,

ded a course to refresh knowledgejust

respondents

their midwifery

before orjust

to work. A substantial

Support

after they returned

majority of those who had (86% for the

and 80% for the 1983).

and feedback

As the UKCC feedback

atten-

skills and

a course said that the break was not

1979 cohort

having a

periods

had not been available,

said that

not attended

Keeping in touch while break for child care

6%

and 9% of

long enough for one to be necessary

break

173

TODA\

for midwives

has recently

reiterated,

regular

on work from senior colleages is recog-

nised as important

for professional

and

for

particularly

titioners

(UKCC

newly

1990).

wifery

post

shows

that

held

although

during

each mid-

qualification.

respondents

Table were

likely to be satisfied than dissatisfied back, nonetheless

in this

to rate their satisfac-

received since

prac-

Respondents

study were asked therefore tion with feedback

development

registered

6

more

with feed-

there was a substantial

mino-

rity of posts for which this was not the case. For 27% of first posts held by the 1979 cohort 31% ‘very’

held by the 1983, or

‘fairly’

Corresponding

respondents

dissatisfied figures

for

with

feedback.

subsequent

were 2 1% and 22% for the two cohorts tively.

Professional retention

development

One of the main objectives

and

had been posts respec-

and

of the study at Phases

174

NURSE EDUCATION

Table 6 Setisfection

TODAY

with feedback on work from senior colleages Posts held by

Satisfaction

ratings

Very dissatisfied Fairly dissatisfied Neither satisfied or dissatisfied Fairly satisfied Very satisfied No answer Total number of posts held

First %

1979 cohort Subsequent %

11 16 28 36 7 3

319

2 and 3 was to obtain midwives’ views about strategies to encourage retention in the profession. Of particular interest is the importance accorded to continuing education and other aspects of professional development in encouraging retention when compared with other aspects of working as a midwife. In midwifery, as in nursing (Barriball et al 1992) little empirical work exists on this subject. In this study a list of possible strategies was identified from the literature and from pilot work; each respondent was asked to circle all those that she felt to be relevant and then to list the five she thought most important. The findings for Phases 2 and 3 were very similar for this question and so Table 7 shows the Phase 3 findings only, as these are the more recent views of the two cohorts on this subject. Pay, staffing, lack of creche facilities and flexible hours feature most prominently, both in the factors circled and those included in the five most important. However, more than half of all respondents circled more support for newly qualified midwives and increased provision of in-service education, and just under half included more refresher courses for updating of skills. Each of these aspects of professional development was regarded as one of the five most important by some respondents, in particular more support for newly qualified midwives. Findings from this study indicate that substantial proportions of respondents do regard professional development as an important factor in encouraging retention. Given the range and complexity of issues that may surround a decision to leave, the extent to which the availability of opportunities for professional development is

6 15 19 37 19 4

514

First % 9 22 27 31 10 1

431

actually related to retention very difficult to determine.

1983 cohort Subsequent % 7 15 19 35 17 6

379 would, however,

be

CONCLUSION The Nursing Research Unit’s longitudinal study of the careers of two large cohorts of midwives, has produced a number of findings on continuing professional development of interest to those in practice, education and management. Obtaining post-basic qualifications (Table 2), attending in-service courses and combining part-time study with work had each been experienced by a small proportion of midwives. In a substantial of midwifery posts, minority respondents were dissatisfied with the availability of in-service education (Table 5). Moreover, more than 70% of both cohorts wanted a greater provision of in-service courses, relevant to their work (Table 3) with clinical topics specified most frequently (Table 4). Some degree of dissatisfaction was evidenced in relation to support and feedback for staff (Table 6). Midwives who had taken a break in order to care for children, were unlikely to have been provided with opportunities to keep in touch during this time, although the majority would have welcomed the opportunity to do so. At both Phases 2 and 3 (Table 7) the provision of in-service education and support for newly staff featured as important in qualified encouraging retention in the profession. Many of the findings from the project support those from other studies of the subject. Midwives have broadly welcomed the recent UKCC and ENB proposals for a more systematic

NURSE EDU(:ATION

Table 7 Views on factors thought to be important

in encouraging

Professional responsibility Less involvement of medical staff in decision-making normal maternity care More opportunities to provide continuity of care Less technological intervention in childbirth A management structure that ensures midwifery services are managed by midwives Family commitments More flexibility in working hours to fit round family commitments Creche facilities Setting-up bank schemes Conditions of service Increased levels of pay Increased pay for living in high cost areas Better staffing levels Better accommodation facilities provided by health authority Car parking facilities

and

relevant

fessional

programme

education

of continuing

and

development

199 1, Sleep 199 1). For the midwifery in particular, ment

continuing

may well increase

recommendations Maternity

Services Committee

develop-

of autonomy

than

(House

of Commons

Select

report

To ensure that these programmes

has increased been

the volume of research substantially

relatively

neglected

28 17 27

51 51 49

30 15 15

59 58 45

35

62

40

66

31 14 28

63 43 63

30 18 23

66 45 67

63

83

61

82

51 21

83 51

54 13

87 52

63 8 58 4

77 30 77 19

68

86 34 86 19

G 3

of in-service system,

18

courses,

factors

wives in obtaining attending

post-basic

midand

courses,

guidance

are all subjects

investigation.

and the provision

Subsequent

that merit

phases of the

Project will continue

the existing body of knowledge subjects,

or facilitate qualifications

in-service

Midwive’s Careers

1992).

the value of a mentorship

that militate

but a wider

range

to add to

on some of these of more

detailed

studies is also required.

meet staff and

than has been undertaken

Although

67

further

service needs, however, a greater volume empirically based studies on the subject required

35

of career

decades

Committee

62

if the

with a greater

in recent

37

of the

are implemented

and midwives are able to practise degree

pro(West

in importance

of the recent

1983 cohort (n = 407) % listing reason in % circling 1st five reason

31

profession

professional

in

175

midwives to stay in and/or return to midwifery 1979 cohort (n = 288) % listing % circling reason in 1st five reason

Professional development More support for newly qualified midwives from senior staff Better promotion prospects Increased provision of in-service education More refresher courses for updating of skills

TODAY

Acknowledgements

hitherto. in midwifery

overall, education in comparison

practice and management (Robinson The usefulness of refresher courses,

of is

has with

et al 1989). the content

Thanks are due to the Department of Health who funded the research. all the midwives who have completed questionnaires, Heather Owen, the prqject’s research associate, for assistance in data collection and analysis, Keith Jacka for the computing work, and colleagues at the Nursing Research Unit, for commenting on drafts of this article.

176

NURSE EDUCATION

TODAY

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proceedings for 1992. Department of Nursing, University of Manchester, UK Murphy-Black T 1991 Antenatal education: Evaluation of a post-basic training course. In: Robinson S, Thomson A, eds. Midwives, research and childbirth. Vol2. Chapman and Hall, London National Perinatal Epidemiology Unit 199 I Miriad: Midwifery research database. National Perinatal Epidemiology Unit, Oxford National Staff Committee for Nurses and Midwives 1981 Recommendations on the organisation and provision of continuing in-service education and training. National Staff Committee for Nurses and Midwives, London Parnaby C 1987 Surveying the opinions of midwives regarding the curriculum content of refresher courses. Midwiferv 3(3): 133-142 Pendleton S 1990 Degrees and diplomas for registered midwives: some new initiatives. MIDIRS Information Pack 15 December. MIDIRS, Bristol Robinson S 1986 Midwifery training: the views of newly qualified midwives. Nurse Education Today 6(2): 49-59 Robinson S, Thomson A, Tickner V 1989 Midwives’ views on directions and developments in midwifery research. In: Robinson S, Thomson A, eds. Research and the midwife conference proceedings for 1988. Nursing Research Unit. Kings College, London Univerztv, UK Rogers J, Lawrence J 1989 Continuing professional education for aualified nurses. midwives and health visitors. Ashdaie Press, Oxford, UK Royal Commission on The National Health Service 1979 Report of the Royal Commission on The National Health Service Cmnd 7615. HMSO, London Sleep J 1991 More refreshing changes for midwifery practice: MIDIRS. Midwifery Digest l(2): 127-128. MIDIRS, Bristol South Bank University 1992 Midwifery update modules 1-9. Distance learning centre. South Bank University, London Sugarman E 1988 The case of the disappearing midwives. Nursing Times 84(8): 35-36 Standon-Batt M 197% Where are’the tutors? Midwives Chronicle and Nursing Notes 92 (1,100): 304 Stewart A 1981 The present state of midwifery training. Midwife. Health Visitor and Community Nurse 17(7): 270-272 UKCC 1984 Code of Professional conduct for the nurse. midwife and health visitor. UKCC, London UKCC i990 The report of the post-registration education and practice project. UKCC, London Ward E, Adams M E 1979 A masters degree in midwifery. Midwives Chronicle and Nursing Notes 92 (1093): 37-38 West S 1991 Refreshing changes for midwifery practice. MIDIRS Midwifery Digest l(1): 3-4. MIDIRS, Bristol