- Email: [email protected]
Students' and lecturers' perceptions of support in a UK pre-registration midwifery programme
Nurse Education in Practice 13 (2013) 578e583
Contents lists available at SciVerse ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education
Students’ and lecturers’ perceptions of support in a UK pre-registration midwifery programme Annette Elizabeth McIntosh*, Janice Gidman 1, Andrea McLaughlin 2 Faculty of Health and Social Care, University of Chester, Riverside Campus, Castle Drive, Chester CH1 1SL, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 13 January 2013
This paper reports on a study that explored the perceptions of students and lecturers regarding support within a pre-registration midwifery programme in one Higher Education Institution in England. A mixed method design was used: questionnaires were completed by first year and third year students and lecturers, complemented by focus groups with each of the three sets of participants. The findings showed that there are multi-focal challenges for student midwives in undertaking their programme of study. The main theme that emerged was of the difficulties involved in maintaining an appropriate workelife balance, especially within what was seen as a relatively inflexible programme structure. The value of peer support was also highlighted as a key factor in helping the students succeed in their studies. There were a number of implications for midwifery educators to consider in optimising support for students. These include ensuring that students have realistic expectations at the outset of their studies, formalising peer support mechanisms and reviewing programmes to provide more flexibility to better underpin the maintenance of an appropriate workelife balance. Further study is warranted to explore perceptions of support in practice and to identify the factors that help students to persevere in their studies. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Midwifery education Student support Peer support Workelife balance
Introduction and literature review Within educational pre-qualifying healthcare programmes, student support can come from a range of sources and encompass academic, clinical and personal contexts (McIntosh and Gidman, 2011). Studies have shown that students’ perceptions of quality relating to their educational experiences, and to their success, include social and emotional support systems addressing such elements as childcare, peer networks and specific units for student support (Hill et al., 2003; Robbins et al., 2004). Lauder et al. (2008), in a large scale Scottish study, showed that students rated family and peer support as highest in quality, with Higher Education Institution (HEI) and mentor support as the lowest quality; the research team opined that the more informal support systems such as that from family and peers are not often built into the design of curricula and could be an undervalued and relatively untapped asset. Peer support and mentoring within both academic and clinical environments have been highlighted as being valuable and beneficial in the education of healthcare students, although care is
* Corresponding author. Tel.: þ44 01244 513386. E-mail addresses: [email protected] (A.E. McIntosh), j.gidman@ chester.ac.uk (J. Gidman), [email protected] (A. McLaughlin). 1 Tel.: þ44 01244 513384. 2 Tel.: þ44 01244 512260. 1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.01.015
required in selecting and preparing peer mentors for the role (Aston and Molassiotis, 2003; Gilmour et al., 2007). Smith (2007) considered that lecturers are optimally placed to provide the individual support that students need in the academic setting, with the focus of support ranging from academic writing to pastoral care. The imperative of effectively supporting students in practice is well recognised, with the key role being that of the mentor (LevettJones et al., 2009; Steele, 2009). Some studies focus on the challenge of enhancing student retention and support in midwifery, although there are more relating to student nurses where similar findings are evident. A study by Green and Baird (2009) showed that the main issues which led participants, including midwifery students, to leave their studies were family issues, tensions between theory and practice and falling levels of motivation. The workload and the demands of the programme, together with unrealistic expectations, were also commonplace reasons for leaving, as were travelling times and finance (Green and Baird, 2009). Fowler and Norries’ (2009) findings were similar to those of Green and Baird (2009), although Fowler and Norrie (2009) also found that full-time nursing and midwifery students were more likely to finish the programme than part-time, as were students gaining higher grades for ‘A’ levels. Stress has long been highlighted as contributing to attrition (Dimond, 2002). Pryjmachuk and Richards (2008) identified stress predictors for student midwives
A.E. McIntosh et al. / Nurse Education in Practice 13 (2013) 578e583
and recommended that good communication skills and active listening on behalf of the HEI are needed, with effective academic and pastoral support systems being provided. In the United Kingdom (UK), managing the attrition and retention of student midwives is currently a source of concern. The effects of high attrition can be extensive and have an impact on the availability of qualified midwives in a profession which has an ageing workforce (Royal College of Midwives, 2011). The Midwifery 2020 report on the future of the profession alerts HEIs that programmes may require to be adapted to meet the needs of students who have family commitments, or who wish to study part-time, in order that a valuable resource is not lost (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). Identifying factors that may increase attrition and developing strategies to manage them is paramount in order to maintain viable numbers of qualified midwives. Like many other academic providers, the HEI reported here has experienced varying degrees of attrition, with one particularly high rate recorded prior to this study. The research team were interested in exploring factors regarding student support and to identify and implement strategies which could be utilised to lessen attrition and enhance progression. Aim The aim of this small-scale study was to investigate the perceptions of student midwives and lecturers in relation to support within a three year pre-registration programme of study in one UK University. Methods The study used a mixed method, exploratory approach. Questionnaires were designed to elicit students’ and lecturers’ perceptions of student support. Focus groups were undertaken to explore the issues arising from the questionnaire data. The definition of student support was situated within a wide context; anything that the participants perceived as supporting students’ study and progression. The populations for the study were: 1. The first year student cohort, approaching the six month point in their programme (n ¼ 31); 2. The third year student cohort, in the final six months of their programme (n ¼ 22); 3. The midwifery lecturing staff (n ¼ 8). A questionnaire was designed using Likert scales and open questions. The questions addressed the following areas: the need for support; sources of support; additional support mechanisms; intention to quit the programme; programme satisfaction; the challenges and the best aspects of the students’ learning experiences. The questionnaires were customised for the three groups where necessary e e.g. the first years being asked what they thought might be the case, the third years asked what had been the case for them and lecturing staff what they thought generally. Pilot work, carried out with a sample of students (n ¼ 15) and lecturers (n ¼ 5) indicated that the data would be valid, although some refinements were made regarding the wording of questions to improve clarity. Ethical approval Ethical approval was granted by the Faculty ethics committee. Participation was voluntary. Data collection was undertaken by a research assistant rather than academic staff, in order to avoid undue influence being exerted on participants. Full information
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was given, consent obtained and confidentiality maintained throughout. Data were stored securely, made available only to the research team and computer-based data were password protected. Data collection and analysis Questionnaires were distributed to each of the groups during time in their academic study block. The focus groups were held at a location and time which was convenient for the participants and lasted for approximately 1 h. The interviews were audio-recorded with the participants’ consent. The questionnaire data were tabulated and quantitatively analysed using Excel spreadsheets to produce descriptive statistics (closed questions) and qualitatively analysed to produce themes (open questions). The focus group interviews were transcribed verbatim and the process of analysis undertaken in line with the interrelated elements developed by Miles and Huberman (1994): data reduction; data display and conclusion drawing. Findings The questionnaire produced response rates of first year students (87%, n ¼ 27), third year students (95%, n ¼ 21) and lecturers (75%, n ¼ 6). All participants were female and full-time, with the first year students undertaking a degree programme and the third year students completing a diploma programme; this difference was due to programme re-validation in response to commissioning and national requirements. Table 1 shows details of the student profiles. Three focus groups were facilitated with volunteers who had completed the questionnaires, with first year students (n ¼ 8), third year students (n ¼ 8) and midwifery lecturers (n ¼ 6) taking part. The findings from the questionnaire data are discussed in relation to the focus of the questions. The focus group findings address areas that further emerged from the discussions and centre on the areas of workelife balance, peer support and overall perceptions. Perceptions of students’ need for support The participants were asked to indicate what support they felt they would need (first year students) or had needed (third year students) using a five point Likert scale ranging from strongly agree to strongly disagree. The academics were asked what support they thought students needed. Fig. 1 shows the three groups’ perceptions of the need for support; the figures represent the percentage strongly agreeing or agreeing. Table 1 Profile of students.
Age
Marital status
Number of children
Years 17e20 21e30 31e40 40e50 Single Married In relationship Divorced/separated None One Two Three Four Eight
First year students n (%)
Third year students n (%)
4 (15) 10 (37) 11 (41) 2 (7) 11 (41) 9 (33) 6 (22) 0% (Nil return ¼ 1) 5 (19) 5 (19) 12 (44) 2 (7) 2 (7) 1 (4)
1 11 7 2 11 5 3 2
(5) (52) (33) (10) (52) (24) (14) (10)
10 4 4 3 0 0
(48) (19) (19) (14) (0) (0)
580
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the academics (83%, n ¼ 5) were of the opinion that students would access these. To contextualise the above data, the participants were also asked to indicate which support sources they would access for a range of specific elements within the programme. Module leaders were seen as the main support source by all groups for academic writing and exam support (78% (n ¼ 21) of first years, 76% (n ¼ 16) of third years and all of the academics (n ¼ 6)). Placement support was seen as coming chiefly from the mentor (93% (n ¼ 25) of first year students, 95% (n ¼ 20) of third year students and all of the academic staff (n ¼ 6)). Personal issues were perceived as being supported mainly by other students (85% (n ¼ 23) of first year students, 76% (n ¼ 14) of third years and all of the academics). Additional support mechanisms Fig. 1. Perceptions of elements requiring support.
Academic writing was perceived by the highest number of first year students as an element requiring support, with 63% (n ¼ 17) either agreeing or strongly agreeing that this was the case, followed by support for exams (56%, n ¼ 15). These were the highest for the third year students, albeit in reverse order (77% (n ¼ 16) exams and 72% (n ¼ 15) academic writing). All of the academic staff (n ¼ 6) opted for these two elements. The aspect seen as requiring support by the lowest number of first year students (26%, n ¼ 7) was personal issues (although 41% (n ¼ 11) were undecided), with 48% (n ¼ 10) of the third year students agreeing that they had required support with personal issues. All of the academic staff (n ¼ 6) felt that students would need help with personal issues. Sources of support The students were asked to indicate their main sources of support, using a five point Likert scale, while the academics were asked to indicate where they thought students accessed support from during their programmes. All of the first year students thought (strongly agree or agree) that they would access support from other students, as did the majority of the third year students (90%, n ¼ 19). However, all of the academics (n ¼ 6) felt that the module leader was the most likely source of general support. Fig. 2 shows the collated results for the three groups; the figures represent the percentage strongly agreeing or agreeing. The LSS and SSG categories in the table refer to the University learning support and student guidance sources which, as can be seen, were rated less likely support mechanisms by students, although the majority of
Fig. 2. Key sources of support.
The students were asked what specific mechanisms of support they would benefit from or would have benefitted from during their programme from a given list using a five point Likert scale. The academics were asked to indicate the areas they thought students generally would benefit from. The most popular (either strongly agree or agree) support mechanisms for development for the first year students, in order of popularity, were e-support (58%, n ¼ 12), a bespoke statement of their learning needs and goals (44%, n ¼ 12) and 1e1 tuition (41%, n ¼ 11). The third years had two of these elements in common with the first year students: e-support (57%, n ¼ 12) and a bespoke statement of their learning needs and goals (39%, n ¼ 8). However, rather than 1e1 tuition, 53% (n ¼ 11) of the third years thought that an assigned study partner would enhance their learning experience. For the academic staff there were two top answers; 100%, (n ¼ 6) thought that help with 1e1 tuition and childcare would be of value to students; the latter aspect of childcare received the lowest percentage of agreement from both the first year and the third year students. Fig. 3 shows the data in diagrammatic form; the figures represent the percentage strongly agreeing or agreeing. Intention to leave the programme The students were asked if, throughout their studies to date, there had been times that they had considered leaving the programme and to indicate the reason(s). The majority of first year students indicated that they had not considered leaving within their first few months although 26% (n ¼ 7) had. For the third year students, 90% (n ¼ 19) reported that there were times that they had thought about leaving the programme. The issue of workelife balance was the main reason given by both groups, followed by personal and support issues, financial pressures and academic challenges.
Fig. 3. Perceptions of beneficial additional support mechanisms.
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Satisfaction levels The students were asked to indicate their satisfaction levels in a five point Likert scale ranging from very satisfied to very dissatisfied. A positive picture emerged, with 78% (n ¼ 21) of first year students and 86% (n ¼ 18) of third year students indicating that they were either very satisfied or satisfied with their programmes.
Challenges and the best aspects of the students’ learning experiences Two open questions asked the students about their perceptions of the challenges and best elements of their programme. It was evident that while the students felt generally well supported, there were particular challenges that they experienced, particularly maintaining an appropriate workelife balance. Both groups also highlighted the difficulties of trying to achieve the academic standards and the course work involved in the programme. Comments included: Maintaining a work-life balance and juggling child care. These are all mild points though! (First year student MS18) Juggling home, work, children and study as a mature student (Third year student MF17) The best aspects of their educational programme for the first year students proved to be placement experiences, followed by social elements, gaining confidence, knowledge and skills, meeting career/personal aspirations, the course content and peer support. For the third year students, the same aspects were mentioned though the meeting and making new friends was the most frequently mentioned best aspect of their programme. Comments from the two groups included: Practice! Although the course has been difficult and the workload was quite high. I have enjoyed my practice (Third year student MF12) Becoming more competent and feeling that the theoretical aspects of the course are beginning to make sense in the practice area (First year student MS17) Meeting new people and making friends who want me to succeed and motivate me to stay (First year student MS7) Meeting new people and making life-long friends (Third year student MF20)
Focus group findings The transcripts from the focus groups were not coded individually but the following quotes have been extracted from the transcripts to be representative of the sample and are from different participants. The findings from the focus groups supported the main themes emerging from the questionnaire data. The overriding issues were the difficulty in juggling workload and maintaining an appropriate workelife balance. There was recognition from the students that the Nursing and Midwifery Council (NMC) framework and professional requirements had to be met within the programme, but felt that more flexibility could still be employed. Comments included: I’ve got lots of friends in Uni and they are always asking me to do things because they hardly have any lectures but I just can’t. I don’t have time and people don’t understand and it’s so hard and there is so much work to do (First year student)
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My partner was seriously ill in hospital and I didn’t dare take any time off .I think this is the main reason why 99% have thought about quitting and I think that’s really sad because most of the people who do the other university courses never think like that. I know when you come into it you know its going to be hard but until you actually do it you just don’t realise how tiring and exhausting it is.. and how little leeway there is if something happens (Third year student) To a point not all of the blame rests on the university because it is the NMC that specifies..there doesn’t seem to be any flexibility that life does go on, things do happen (Third year student) The midwifery lecturers were aware of the difficulties the students experienced with achieving a balance between their work and personal lives, but opined that, to offset this, the expectations of the programme were made clear to students from the outset and that it was important to explain the impact of the programme, particularly for mature students: It starts even before they arrive. the need to give a very realistic picture of what this programme involves (Midwifery lecturer) These points were reported by the lecturers to be re-inforced at interview and during induction week. Staff noted that students were given a fixed timetable for their three years to facilitate forward planning. However, the lecturers recognised that it was not possible to plan for every eventuality and that issues that arose for students had to be dealt with flexibly, although it was recognised that the requirements of the programme sometimes made this challenging. In addition, the staff considered that effective timemanagement strategies were important for students in trying to balance home life and studies. The students re-iterated the value of peer support in the focus group discussions: Like the tutors say if you have any kind of problem. but the truth is you’re going to talk to your friends about it (First year student) So the best support you have is the girls because you are all in the same boat and you all know what you’re going through (Third year student) Peer support was also reported positively by the midwifery lecturers who felt that the students benefitted from this: Students support each other really well. though this is not formal really (Midwifery lecturer) The midwifery staff felt that formalising these buddy mechanisms and arrangements would be beneficial to students, acknowledging that: Information from students can be more powerful than that from lecturers (Midwifery lecturer) Overall, it was evident that the findings reflected some commonalities and differences between the groups regarding elements of student support. These are discussed further in relation to current literature. Discussion It is recognised that the findings from this small-scale study will not have general applicability due to its limitations in size, locality and the relative homogeneity of the sample group. However, the findings may have resonance for others in midwifery education;
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they have helped inform the thinking of the midwifery team who participated in the project. The findings mainly echo the previous research in this area and offer further insights regarding the support of student midwives in their programmes of study. The quantitative findings on the perceptions regarding students’ need for support showed that the students had similar views and experiences, highlighting that their perceived needs were mainly to do with assessments and academic writing. Support for personal issues was not seen by many of the students as something they would, or had, needed, running counter to the literature showing that support for social and emotional aspects are particularly required and valued by students (Hill et al., 2003; Robbins et al., 2004). The midwifery lecturers felt that support would be required with all elements of the programme, including academic, clinical and personal aspects, as identified by McIntosh and Gidman (2011). There were considerable differences between the responses of lecturers and both student groups in relation to the perceived needs for support across all the elements presented. The quantitative data indicated that the lecturers had an unrealistic view of student support needs, particularly in relation to personal issues and finances. However, in the student focus groups, the importance of personal support for the students emerged more and was considered a crucial element in their achievements. The source that students reported they would generally access for support was other students, and the value of this support mechanism was re-inforced in the qualitative data. This is in line with the findings of other studies (Aston and Molassiotis, 2003; Gilmour et al., 2007; Lauder et al., 2008) and further highlights the value and importance of peer support. In contrast, the midwifery lecturers had identified the module leader as the main support source generally, although there was recognition of peer support. All participants reported that systems of peer support and mentoring were currently unstructured, and would benefit from the development of a more formal framework. This would ensure that the peer mentor was carefully selected and prepared, as recommended by Aston and Molassiotis (2003) and Gilmour et al. (2007). There was general agreement between lecturers and students in relation to support provided by module and programme leaders, other students and mentors. However, it was interesting that students’ rating of Learning Support Services and Student Support and Guidance were considerably lower than those of lecturers. This finding does not equate to those in the studies of Hill et al. (2003) and Robbins et al. (2004), but it could be mitigated by the fact that the support units were not in close proximity to the teaching premises. In relation to specific support, all of the participants had reported that the module leader was the main source for the development of academic skills recognising this, in line with the thinking of Smith (2007), as a key component of the role and one which academics are optimally placed to fulfil. The data for all groups highlighted awareness of the need for maintaining an appropriate workelife balance, although the academic staff considered that this particular challenge was made clear to students at the outset. An area that emerged as a particular frustration for students was the inflexibility of the programme, although there was recognition that NMC requirements left HEIs little in the way of room in this respect. The students considered this a main contributor to workelife imbalance. The importance of this was underlined by the fact that difficulty in balancing work and study with personal life was reported as the reason most likely to lead students to consider leaving the programme. This was highlighted by Fowler and Norrie (2009) and Green and Baird (2009), as were the challenges of achieving the academic standards; these were also identified by this study’s participants in relation to the challenges of the programme. There were notable differences in
responses between lecturers and students in relation to the perceived benefits of additional support mechanisms. Whilst the two groups of students provided similar ratings, lectures overestimated the importance of these across all areas. This was particularly evident in relation to e-support, additional tutorial support and childcare. Problems with child care have been shown in various studies as an area that can lead to attrition from programmes (Fowler and Norrie, 2009; Green and Baird, 2009). It was interesting to note therefore, that unlike the academics, the student midwives in the study reported here generally did not perceive this as a particular need, despite the majority being mothers. The students identified similar elements when considering the best aspects of their learning experiences. Practice placements were evidently a highlight, and this, allied to the fact that mentors were seen as the main support source in practice, pointed to the operation of a robust system of mentorship as advocated by LevettJones et al. (2009) and Steele (2009). Other positive aspects for the students were the social elements, including making new friends, the peer support and the gaining of confidence and knowledge. This again highlighted the need for HEIs to ensure that these elements are enhanced and underpinned by appropriate support structures, in line with recommendations of previous studies (Hill et al., 2003; Lauder et al., 2008; Pryjmachuk and Richards, 2008; Robbins et al., 2004). Conclusion These findings showed that there are multi-focal challenges for student midwives in completing their programme. For the students in this study, particular difficulties concerned achieving an appropriate workelife balance, attaining the standards of the programme and meeting the requirements of the NMC within what was seen as a relatively inflexible framework. It was evident that other students were a valuable source of support in all elements, although the input of academic staff and mentors was also recognised. The midwifery lecturing staff are now reviewing the peer support mechanisms within the programme with the aim of optimising this resource. While the study uncovered factors that may lead to students considering leaving, the reasons that they stayed on the programme did not emerge from the data and were not specifically explored; this element is subsequently being investigated as part of a follow-up study. Conflict of interest statement The authors confirm that there are no conflicts of interest involved in the study. References Aston, L., Molassiotis, A., 2003. Supervising and supporting student nurses in clinical practice: the peer support initiative. Nurse Education Today 23 (3), 202e210. Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010. Midwifery 2020: Delivering Expectations. http://midwifery2020.org.uk/ documents/M2020deliveringexpectations-FullReport2.pdf. Dimond, B., 2002. Staffing, stress, bullying and the midwife. British Journal of Midwifery 10 (11), 710e713. Fowler, J., Norrie, P., 2009. Development of an attrition risk prediction tool. British Journal of Nursing 18 (19), 1194e1200. Gilmour, J.A., Kopeikin, A., Douche, J., 2007. Student nurses and peer-mentors: collegiality in practice. Nurse Education in Practice 7 (1), 36e43. Green, S., Baird, K., 2009. An exploratory comparative study investigating attrition and retention of student midwives. Midwifery 25 (1), 79e87. Hill, Y., Lomas, L., MacGregor, J., 2003. Students’ perceptions of quality in higher education. Quality Assurance in Education 11 (1), 15e20. Lauder, W., Watson, R., Topping, K., Holland, K., Johnson, M., Porter, M., Roxburgh, M., Behr, A., 2008. An evaluation of the fitness for practice
A.E. McIntosh et al. / Nurse Education in Practice 13 (2013) 578e583 curricula: self-efficacy, support and self-reported competence in preregistration student nurses and midwives. Journal of Clinical Nursing 17 (14), 1858e1867. Levett-Jones, T., Lathlean, J., Higgins, I., McMillan, M., 2009. Staffestudent relationships and their impact on nursing students’ belongingness and learning. Journal of Advanced Nursing 65 (2), 316e324. McIntosh, A., Gidman, J., 2011. Student support. In: McIntosh, A., Gidman, J., MasonWhitehead, E. (Eds.), Key Concepts in Healthcare Education. Sage, London, pp. 189e193. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis, second ed. Sage, Thousand Oaks.
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Pryjmachuk, S., Richards, D.A., 2008. Predicting stress in pre-registration midwifery students attending a university in Northern England. Midwifery 24 (1), 108e112. Robbins, S.B., Lauver, K., Le, H., Davis, D., Langley, R., 2004. Do psychosocial and study skill factors predict college outcomes? A meta-analysis. Psychological Bulletin 130 (2), 261e288. Royal College of Midwives, 2011. The State of Maternity Services. RCM, London. Smith, R., 2007. An overview of research on student support: helping students to achieve or achieving institutional targets? Nurture or de-nature? Teaching in Higher Education 12 (5), 683e695. Steele, R., 2009. Gaining competence and confidence as a midwife. British Journal of Midwifery 17 (7), 441e447.
Contents lists available at SciVerse ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education
Students’ and lecturers’ perceptions of support in a UK pre-registration midwifery programme Annette Elizabeth McIntosh*, Janice Gidman 1, Andrea McLaughlin 2 Faculty of Health and Social Care, University of Chester, Riverside Campus, Castle Drive, Chester CH1 1SL, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 13 January 2013
This paper reports on a study that explored the perceptions of students and lecturers regarding support within a pre-registration midwifery programme in one Higher Education Institution in England. A mixed method design was used: questionnaires were completed by first year and third year students and lecturers, complemented by focus groups with each of the three sets of participants. The findings showed that there are multi-focal challenges for student midwives in undertaking their programme of study. The main theme that emerged was of the difficulties involved in maintaining an appropriate workelife balance, especially within what was seen as a relatively inflexible programme structure. The value of peer support was also highlighted as a key factor in helping the students succeed in their studies. There were a number of implications for midwifery educators to consider in optimising support for students. These include ensuring that students have realistic expectations at the outset of their studies, formalising peer support mechanisms and reviewing programmes to provide more flexibility to better underpin the maintenance of an appropriate workelife balance. Further study is warranted to explore perceptions of support in practice and to identify the factors that help students to persevere in their studies. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Midwifery education Student support Peer support Workelife balance
Introduction and literature review Within educational pre-qualifying healthcare programmes, student support can come from a range of sources and encompass academic, clinical and personal contexts (McIntosh and Gidman, 2011). Studies have shown that students’ perceptions of quality relating to their educational experiences, and to their success, include social and emotional support systems addressing such elements as childcare, peer networks and specific units for student support (Hill et al., 2003; Robbins et al., 2004). Lauder et al. (2008), in a large scale Scottish study, showed that students rated family and peer support as highest in quality, with Higher Education Institution (HEI) and mentor support as the lowest quality; the research team opined that the more informal support systems such as that from family and peers are not often built into the design of curricula and could be an undervalued and relatively untapped asset. Peer support and mentoring within both academic and clinical environments have been highlighted as being valuable and beneficial in the education of healthcare students, although care is
* Corresponding author. Tel.: þ44 01244 513386. E-mail addresses: [email protected] (A.E. McIntosh), j.gidman@ chester.ac.uk (J. Gidman), [email protected] (A. McLaughlin). 1 Tel.: þ44 01244 513384. 2 Tel.: þ44 01244 512260. 1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.01.015
required in selecting and preparing peer mentors for the role (Aston and Molassiotis, 2003; Gilmour et al., 2007). Smith (2007) considered that lecturers are optimally placed to provide the individual support that students need in the academic setting, with the focus of support ranging from academic writing to pastoral care. The imperative of effectively supporting students in practice is well recognised, with the key role being that of the mentor (LevettJones et al., 2009; Steele, 2009). Some studies focus on the challenge of enhancing student retention and support in midwifery, although there are more relating to student nurses where similar findings are evident. A study by Green and Baird (2009) showed that the main issues which led participants, including midwifery students, to leave their studies were family issues, tensions between theory and practice and falling levels of motivation. The workload and the demands of the programme, together with unrealistic expectations, were also commonplace reasons for leaving, as were travelling times and finance (Green and Baird, 2009). Fowler and Norries’ (2009) findings were similar to those of Green and Baird (2009), although Fowler and Norrie (2009) also found that full-time nursing and midwifery students were more likely to finish the programme than part-time, as were students gaining higher grades for ‘A’ levels. Stress has long been highlighted as contributing to attrition (Dimond, 2002). Pryjmachuk and Richards (2008) identified stress predictors for student midwives
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and recommended that good communication skills and active listening on behalf of the HEI are needed, with effective academic and pastoral support systems being provided. In the United Kingdom (UK), managing the attrition and retention of student midwives is currently a source of concern. The effects of high attrition can be extensive and have an impact on the availability of qualified midwives in a profession which has an ageing workforce (Royal College of Midwives, 2011). The Midwifery 2020 report on the future of the profession alerts HEIs that programmes may require to be adapted to meet the needs of students who have family commitments, or who wish to study part-time, in order that a valuable resource is not lost (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). Identifying factors that may increase attrition and developing strategies to manage them is paramount in order to maintain viable numbers of qualified midwives. Like many other academic providers, the HEI reported here has experienced varying degrees of attrition, with one particularly high rate recorded prior to this study. The research team were interested in exploring factors regarding student support and to identify and implement strategies which could be utilised to lessen attrition and enhance progression. Aim The aim of this small-scale study was to investigate the perceptions of student midwives and lecturers in relation to support within a three year pre-registration programme of study in one UK University. Methods The study used a mixed method, exploratory approach. Questionnaires were designed to elicit students’ and lecturers’ perceptions of student support. Focus groups were undertaken to explore the issues arising from the questionnaire data. The definition of student support was situated within a wide context; anything that the participants perceived as supporting students’ study and progression. The populations for the study were: 1. The first year student cohort, approaching the six month point in their programme (n ¼ 31); 2. The third year student cohort, in the final six months of their programme (n ¼ 22); 3. The midwifery lecturing staff (n ¼ 8). A questionnaire was designed using Likert scales and open questions. The questions addressed the following areas: the need for support; sources of support; additional support mechanisms; intention to quit the programme; programme satisfaction; the challenges and the best aspects of the students’ learning experiences. The questionnaires were customised for the three groups where necessary e e.g. the first years being asked what they thought might be the case, the third years asked what had been the case for them and lecturing staff what they thought generally. Pilot work, carried out with a sample of students (n ¼ 15) and lecturers (n ¼ 5) indicated that the data would be valid, although some refinements were made regarding the wording of questions to improve clarity. Ethical approval Ethical approval was granted by the Faculty ethics committee. Participation was voluntary. Data collection was undertaken by a research assistant rather than academic staff, in order to avoid undue influence being exerted on participants. Full information
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was given, consent obtained and confidentiality maintained throughout. Data were stored securely, made available only to the research team and computer-based data were password protected. Data collection and analysis Questionnaires were distributed to each of the groups during time in their academic study block. The focus groups were held at a location and time which was convenient for the participants and lasted for approximately 1 h. The interviews were audio-recorded with the participants’ consent. The questionnaire data were tabulated and quantitatively analysed using Excel spreadsheets to produce descriptive statistics (closed questions) and qualitatively analysed to produce themes (open questions). The focus group interviews were transcribed verbatim and the process of analysis undertaken in line with the interrelated elements developed by Miles and Huberman (1994): data reduction; data display and conclusion drawing. Findings The questionnaire produced response rates of first year students (87%, n ¼ 27), third year students (95%, n ¼ 21) and lecturers (75%, n ¼ 6). All participants were female and full-time, with the first year students undertaking a degree programme and the third year students completing a diploma programme; this difference was due to programme re-validation in response to commissioning and national requirements. Table 1 shows details of the student profiles. Three focus groups were facilitated with volunteers who had completed the questionnaires, with first year students (n ¼ 8), third year students (n ¼ 8) and midwifery lecturers (n ¼ 6) taking part. The findings from the questionnaire data are discussed in relation to the focus of the questions. The focus group findings address areas that further emerged from the discussions and centre on the areas of workelife balance, peer support and overall perceptions. Perceptions of students’ need for support The participants were asked to indicate what support they felt they would need (first year students) or had needed (third year students) using a five point Likert scale ranging from strongly agree to strongly disagree. The academics were asked what support they thought students needed. Fig. 1 shows the three groups’ perceptions of the need for support; the figures represent the percentage strongly agreeing or agreeing. Table 1 Profile of students.
Age
Marital status
Number of children
Years 17e20 21e30 31e40 40e50 Single Married In relationship Divorced/separated None One Two Three Four Eight
First year students n (%)
Third year students n (%)
4 (15) 10 (37) 11 (41) 2 (7) 11 (41) 9 (33) 6 (22) 0% (Nil return ¼ 1) 5 (19) 5 (19) 12 (44) 2 (7) 2 (7) 1 (4)
1 11 7 2 11 5 3 2
(5) (52) (33) (10) (52) (24) (14) (10)
10 4 4 3 0 0
(48) (19) (19) (14) (0) (0)
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the academics (83%, n ¼ 5) were of the opinion that students would access these. To contextualise the above data, the participants were also asked to indicate which support sources they would access for a range of specific elements within the programme. Module leaders were seen as the main support source by all groups for academic writing and exam support (78% (n ¼ 21) of first years, 76% (n ¼ 16) of third years and all of the academics (n ¼ 6)). Placement support was seen as coming chiefly from the mentor (93% (n ¼ 25) of first year students, 95% (n ¼ 20) of third year students and all of the academic staff (n ¼ 6)). Personal issues were perceived as being supported mainly by other students (85% (n ¼ 23) of first year students, 76% (n ¼ 14) of third years and all of the academics). Additional support mechanisms Fig. 1. Perceptions of elements requiring support.
Academic writing was perceived by the highest number of first year students as an element requiring support, with 63% (n ¼ 17) either agreeing or strongly agreeing that this was the case, followed by support for exams (56%, n ¼ 15). These were the highest for the third year students, albeit in reverse order (77% (n ¼ 16) exams and 72% (n ¼ 15) academic writing). All of the academic staff (n ¼ 6) opted for these two elements. The aspect seen as requiring support by the lowest number of first year students (26%, n ¼ 7) was personal issues (although 41% (n ¼ 11) were undecided), with 48% (n ¼ 10) of the third year students agreeing that they had required support with personal issues. All of the academic staff (n ¼ 6) felt that students would need help with personal issues. Sources of support The students were asked to indicate their main sources of support, using a five point Likert scale, while the academics were asked to indicate where they thought students accessed support from during their programmes. All of the first year students thought (strongly agree or agree) that they would access support from other students, as did the majority of the third year students (90%, n ¼ 19). However, all of the academics (n ¼ 6) felt that the module leader was the most likely source of general support. Fig. 2 shows the collated results for the three groups; the figures represent the percentage strongly agreeing or agreeing. The LSS and SSG categories in the table refer to the University learning support and student guidance sources which, as can be seen, were rated less likely support mechanisms by students, although the majority of
Fig. 2. Key sources of support.
The students were asked what specific mechanisms of support they would benefit from or would have benefitted from during their programme from a given list using a five point Likert scale. The academics were asked to indicate the areas they thought students generally would benefit from. The most popular (either strongly agree or agree) support mechanisms for development for the first year students, in order of popularity, were e-support (58%, n ¼ 12), a bespoke statement of their learning needs and goals (44%, n ¼ 12) and 1e1 tuition (41%, n ¼ 11). The third years had two of these elements in common with the first year students: e-support (57%, n ¼ 12) and a bespoke statement of their learning needs and goals (39%, n ¼ 8). However, rather than 1e1 tuition, 53% (n ¼ 11) of the third years thought that an assigned study partner would enhance their learning experience. For the academic staff there were two top answers; 100%, (n ¼ 6) thought that help with 1e1 tuition and childcare would be of value to students; the latter aspect of childcare received the lowest percentage of agreement from both the first year and the third year students. Fig. 3 shows the data in diagrammatic form; the figures represent the percentage strongly agreeing or agreeing. Intention to leave the programme The students were asked if, throughout their studies to date, there had been times that they had considered leaving the programme and to indicate the reason(s). The majority of first year students indicated that they had not considered leaving within their first few months although 26% (n ¼ 7) had. For the third year students, 90% (n ¼ 19) reported that there were times that they had thought about leaving the programme. The issue of workelife balance was the main reason given by both groups, followed by personal and support issues, financial pressures and academic challenges.
Fig. 3. Perceptions of beneficial additional support mechanisms.
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Satisfaction levels The students were asked to indicate their satisfaction levels in a five point Likert scale ranging from very satisfied to very dissatisfied. A positive picture emerged, with 78% (n ¼ 21) of first year students and 86% (n ¼ 18) of third year students indicating that they were either very satisfied or satisfied with their programmes.
Challenges and the best aspects of the students’ learning experiences Two open questions asked the students about their perceptions of the challenges and best elements of their programme. It was evident that while the students felt generally well supported, there were particular challenges that they experienced, particularly maintaining an appropriate workelife balance. Both groups also highlighted the difficulties of trying to achieve the academic standards and the course work involved in the programme. Comments included: Maintaining a work-life balance and juggling child care. These are all mild points though! (First year student MS18) Juggling home, work, children and study as a mature student (Third year student MF17) The best aspects of their educational programme for the first year students proved to be placement experiences, followed by social elements, gaining confidence, knowledge and skills, meeting career/personal aspirations, the course content and peer support. For the third year students, the same aspects were mentioned though the meeting and making new friends was the most frequently mentioned best aspect of their programme. Comments from the two groups included: Practice! Although the course has been difficult and the workload was quite high. I have enjoyed my practice (Third year student MF12) Becoming more competent and feeling that the theoretical aspects of the course are beginning to make sense in the practice area (First year student MS17) Meeting new people and making friends who want me to succeed and motivate me to stay (First year student MS7) Meeting new people and making life-long friends (Third year student MF20)
Focus group findings The transcripts from the focus groups were not coded individually but the following quotes have been extracted from the transcripts to be representative of the sample and are from different participants. The findings from the focus groups supported the main themes emerging from the questionnaire data. The overriding issues were the difficulty in juggling workload and maintaining an appropriate workelife balance. There was recognition from the students that the Nursing and Midwifery Council (NMC) framework and professional requirements had to be met within the programme, but felt that more flexibility could still be employed. Comments included: I’ve got lots of friends in Uni and they are always asking me to do things because they hardly have any lectures but I just can’t. I don’t have time and people don’t understand and it’s so hard and there is so much work to do (First year student)
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My partner was seriously ill in hospital and I didn’t dare take any time off .I think this is the main reason why 99% have thought about quitting and I think that’s really sad because most of the people who do the other university courses never think like that. I know when you come into it you know its going to be hard but until you actually do it you just don’t realise how tiring and exhausting it is.. and how little leeway there is if something happens (Third year student) To a point not all of the blame rests on the university because it is the NMC that specifies..there doesn’t seem to be any flexibility that life does go on, things do happen (Third year student) The midwifery lecturers were aware of the difficulties the students experienced with achieving a balance between their work and personal lives, but opined that, to offset this, the expectations of the programme were made clear to students from the outset and that it was important to explain the impact of the programme, particularly for mature students: It starts even before they arrive. the need to give a very realistic picture of what this programme involves (Midwifery lecturer) These points were reported by the lecturers to be re-inforced at interview and during induction week. Staff noted that students were given a fixed timetable for their three years to facilitate forward planning. However, the lecturers recognised that it was not possible to plan for every eventuality and that issues that arose for students had to be dealt with flexibly, although it was recognised that the requirements of the programme sometimes made this challenging. In addition, the staff considered that effective timemanagement strategies were important for students in trying to balance home life and studies. The students re-iterated the value of peer support in the focus group discussions: Like the tutors say if you have any kind of problem. but the truth is you’re going to talk to your friends about it (First year student) So the best support you have is the girls because you are all in the same boat and you all know what you’re going through (Third year student) Peer support was also reported positively by the midwifery lecturers who felt that the students benefitted from this: Students support each other really well. though this is not formal really (Midwifery lecturer) The midwifery staff felt that formalising these buddy mechanisms and arrangements would be beneficial to students, acknowledging that: Information from students can be more powerful than that from lecturers (Midwifery lecturer) Overall, it was evident that the findings reflected some commonalities and differences between the groups regarding elements of student support. These are discussed further in relation to current literature. Discussion It is recognised that the findings from this small-scale study will not have general applicability due to its limitations in size, locality and the relative homogeneity of the sample group. However, the findings may have resonance for others in midwifery education;
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they have helped inform the thinking of the midwifery team who participated in the project. The findings mainly echo the previous research in this area and offer further insights regarding the support of student midwives in their programmes of study. The quantitative findings on the perceptions regarding students’ need for support showed that the students had similar views and experiences, highlighting that their perceived needs were mainly to do with assessments and academic writing. Support for personal issues was not seen by many of the students as something they would, or had, needed, running counter to the literature showing that support for social and emotional aspects are particularly required and valued by students (Hill et al., 2003; Robbins et al., 2004). The midwifery lecturers felt that support would be required with all elements of the programme, including academic, clinical and personal aspects, as identified by McIntosh and Gidman (2011). There were considerable differences between the responses of lecturers and both student groups in relation to the perceived needs for support across all the elements presented. The quantitative data indicated that the lecturers had an unrealistic view of student support needs, particularly in relation to personal issues and finances. However, in the student focus groups, the importance of personal support for the students emerged more and was considered a crucial element in their achievements. The source that students reported they would generally access for support was other students, and the value of this support mechanism was re-inforced in the qualitative data. This is in line with the findings of other studies (Aston and Molassiotis, 2003; Gilmour et al., 2007; Lauder et al., 2008) and further highlights the value and importance of peer support. In contrast, the midwifery lecturers had identified the module leader as the main support source generally, although there was recognition of peer support. All participants reported that systems of peer support and mentoring were currently unstructured, and would benefit from the development of a more formal framework. This would ensure that the peer mentor was carefully selected and prepared, as recommended by Aston and Molassiotis (2003) and Gilmour et al. (2007). There was general agreement between lecturers and students in relation to support provided by module and programme leaders, other students and mentors. However, it was interesting that students’ rating of Learning Support Services and Student Support and Guidance were considerably lower than those of lecturers. This finding does not equate to those in the studies of Hill et al. (2003) and Robbins et al. (2004), but it could be mitigated by the fact that the support units were not in close proximity to the teaching premises. In relation to specific support, all of the participants had reported that the module leader was the main source for the development of academic skills recognising this, in line with the thinking of Smith (2007), as a key component of the role and one which academics are optimally placed to fulfil. The data for all groups highlighted awareness of the need for maintaining an appropriate workelife balance, although the academic staff considered that this particular challenge was made clear to students at the outset. An area that emerged as a particular frustration for students was the inflexibility of the programme, although there was recognition that NMC requirements left HEIs little in the way of room in this respect. The students considered this a main contributor to workelife imbalance. The importance of this was underlined by the fact that difficulty in balancing work and study with personal life was reported as the reason most likely to lead students to consider leaving the programme. This was highlighted by Fowler and Norrie (2009) and Green and Baird (2009), as were the challenges of achieving the academic standards; these were also identified by this study’s participants in relation to the challenges of the programme. There were notable differences in
responses between lecturers and students in relation to the perceived benefits of additional support mechanisms. Whilst the two groups of students provided similar ratings, lectures overestimated the importance of these across all areas. This was particularly evident in relation to e-support, additional tutorial support and childcare. Problems with child care have been shown in various studies as an area that can lead to attrition from programmes (Fowler and Norrie, 2009; Green and Baird, 2009). It was interesting to note therefore, that unlike the academics, the student midwives in the study reported here generally did not perceive this as a particular need, despite the majority being mothers. The students identified similar elements when considering the best aspects of their learning experiences. Practice placements were evidently a highlight, and this, allied to the fact that mentors were seen as the main support source in practice, pointed to the operation of a robust system of mentorship as advocated by LevettJones et al. (2009) and Steele (2009). Other positive aspects for the students were the social elements, including making new friends, the peer support and the gaining of confidence and knowledge. This again highlighted the need for HEIs to ensure that these elements are enhanced and underpinned by appropriate support structures, in line with recommendations of previous studies (Hill et al., 2003; Lauder et al., 2008; Pryjmachuk and Richards, 2008; Robbins et al., 2004). Conclusion These findings showed that there are multi-focal challenges for student midwives in completing their programme. For the students in this study, particular difficulties concerned achieving an appropriate workelife balance, attaining the standards of the programme and meeting the requirements of the NMC within what was seen as a relatively inflexible framework. It was evident that other students were a valuable source of support in all elements, although the input of academic staff and mentors was also recognised. The midwifery lecturing staff are now reviewing the peer support mechanisms within the programme with the aim of optimising this resource. While the study uncovered factors that may lead to students considering leaving, the reasons that they stayed on the programme did not emerge from the data and were not specifically explored; this element is subsequently being investigated as part of a follow-up study. Conflict of interest statement The authors confirm that there are no conflicts of interest involved in the study. References Aston, L., Molassiotis, A., 2003. Supervising and supporting student nurses in clinical practice: the peer support initiative. Nurse Education Today 23 (3), 202e210. Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010. Midwifery 2020: Delivering Expectations. http://midwifery2020.org.uk/ documents/M2020deliveringexpectations-FullReport2.pdf. Dimond, B., 2002. Staffing, stress, bullying and the midwife. British Journal of Midwifery 10 (11), 710e713. Fowler, J., Norrie, P., 2009. Development of an attrition risk prediction tool. British Journal of Nursing 18 (19), 1194e1200. Gilmour, J.A., Kopeikin, A., Douche, J., 2007. Student nurses and peer-mentors: collegiality in practice. Nurse Education in Practice 7 (1), 36e43. Green, S., Baird, K., 2009. An exploratory comparative study investigating attrition and retention of student midwives. Midwifery 25 (1), 79e87. Hill, Y., Lomas, L., MacGregor, J., 2003. Students’ perceptions of quality in higher education. Quality Assurance in Education 11 (1), 15e20. Lauder, W., Watson, R., Topping, K., Holland, K., Johnson, M., Porter, M., Roxburgh, M., Behr, A., 2008. An evaluation of the fitness for practice
A.E. McIntosh et al. / Nurse Education in Practice 13 (2013) 578e583 curricula: self-efficacy, support and self-reported competence in preregistration student nurses and midwives. Journal of Clinical Nursing 17 (14), 1858e1867. Levett-Jones, T., Lathlean, J., Higgins, I., McMillan, M., 2009. Staffestudent relationships and their impact on nursing students’ belongingness and learning. Journal of Advanced Nursing 65 (2), 316e324. McIntosh, A., Gidman, J., 2011. Student support. In: McIntosh, A., Gidman, J., MasonWhitehead, E. (Eds.), Key Concepts in Healthcare Education. Sage, London, pp. 189e193. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis, second ed. Sage, Thousand Oaks.
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Pryjmachuk, S., Richards, D.A., 2008. Predicting stress in pre-registration midwifery students attending a university in Northern England. Midwifery 24 (1), 108e112. Robbins, S.B., Lauver, K., Le, H., Davis, D., Langley, R., 2004. Do psychosocial and study skill factors predict college outcomes? A meta-analysis. Psychological Bulletin 130 (2), 261e288. Royal College of Midwives, 2011. The State of Maternity Services. RCM, London. Smith, R., 2007. An overview of research on student support: helping students to achieve or achieving institutional targets? Nurture or de-nature? Teaching in Higher Education 12 (5), 683e695. Steele, R., 2009. Gaining competence and confidence as a midwife. British Journal of Midwifery 17 (7), 441e447.