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The continuing professional education needs of midwives
The continuing
professional education needs of midwives Mary Mitchell
Mary Mitchell MEd, CertEd, ADM, RM, University of the West of England, Faculty of Health and SocialCare, Blackberry Hill, Stapleton, Bristol, UK (Requests for offprints to MM) Manuscript accepted 14 February 1996
The philosophy behind Post Registration Education and Practice (PREP) dictates that continuing professional education (CPE) must be tailored to the needs of the individual and relevant to the practice environment. The study is set within the context of PREP and other changes that are currently affecting midwives and midwifery educational establishments. This study sought to explore the CPE needs of midwives. The main objective of the study was to seek information on a number of issues that would assist with the planning and implementation of continuing education programmes to meet the needs of midwives. The study takes the form of a descriptive survey. Questionnaires were sent to 696 midwives employed by 7 National Health Service Trusts in the South-West of England. A 4 5 % response rate was achieved. Seven midwife managers were also interviewed to gain insight into their perspectives of CPE and to enhance the findings from the questionnaire. Results show that midwives use a variety of strategies to identify their CPE needs. One of the more significant seems to be through interaction with colleagues. 'Professional issues' and 'management topics' were the categories identified by both midwives and managers alike to be the greatest need. There is a demand for part-time and distance learning. The format and timings that would ensure that midwives find it easy to attend CPE events were identified. Findings illustrate how midwifery managers and educationalists can facilitate midwives with their CPE and career development.
Nurse EducationToday(1997) 17, 394-402 © 1997PearsonProfessionalLtd
INTRODUCTION Midwives are currently facing many changes which have major implications for practice and continuing professional education (CPE). To meet the requirements of Post Registration Education and Practice (PKEP) and the challenges of Changing Childbirth (Doll 1993), midwives must be able to identify their CPE needs and explore strategies to help them meet those needs. Within the financial constraints of midwifery, educationalists must provide a quality service that meets the needs of its customers in a consistent and coordinated manner. Green et al (1984) agree that one of the major components of quality in CPE programmes is the detection and analysis of needs in establishing priorities for the provision of educational programmes. This is the philosophy that underpins this study. A further rationale for undertaking the study concerns the lack of empirical evidence relating to the CPE of midwives. Robinson (1994) indicates that there is a substantial degree of dissatisfaction amongst midwives with the provision of CPE. The main aims of the study were to explore how midwives identify and meet their CPE needs, to identify the current CPE needs of midwives and to discover how the midwifery education department can facilitate the CPE and career development of midwives.
LITERATURE REVIEW The term 'continuing professional education' is used in many ways. It is acknowledged that midwives keep their knowledge and skills up-to-date in many ways but to assist the GPE providers in identifying needs, planning and implementing CPE programmes the definition given by the American Nurses Association was accepted: CPE consists of planned educational activities intended to build upon the educational and experiential basis of the professional nurse for the enhancement of practice, education, administration, research or theory development to the end of improving the health of the public (cited by Barriball et al 1992). Only three published studies have addressed the specific needs of midwives. Clarke & Rees (1989) undertook a survey of CPE needs of midwives in one region. A total of 176 midwives was targeted. The response rate was 56% but the night staff were under-represented in the results. The greatest interests lay in topics related to clinical practice, teaching and assess-
Continuing education needs of midwives 395
ment and communication skills and issues relating to personal development. Parnaby's (1987) study highlighted the differences in priorities of content given by course tutors and the midwife participants. The research also demonstrated the importance of asking midwives what they want if their educational needs are to be met. In a longitudinal study of midwives' careers, Robinson (1994) addressed the issue of professional development in relation to career pattern and satisfaction at work. Participants were asked about future CPE needs. Clinical updating was cited most frequently. Management topics, research and legal issues were desired by less than 10%. The relevance of these findings to present-day midwives is questionable. Phase 2 of the project was concerned with professional development. Questionnaires were administered in 1986; considerable changes have taken place since then which have influenced midwives' practice. Although phase 3 of the project intended to address the area of professional development, another major area of interest had emerged and the researchers focused on this, leaving little opportunity to explore professional development to the depth originally intended. Many factors may influence whether or not health professionals participate in CPE. Even when a need has been identified, there may be obstacles that prevent professionals meeting that need. Shortages of staff, time and funding are consistently referred to by many practitioners as hindering their uptake of CPE (Larcombe & Maggs 1991). The extent to which an individual is encouraged or supported by their manager to participate in CPE events is also important. A considerable portion of the respondents in Larcombe & Maggs' (1991) study fek their managers were unsupportive or had negative attitudes towards CPE. However, Allen (1989) found that even when individuals are given the time and funding to attend CPE, they still cite lack of support as a factor affecting attendance. These studies suggest that it may be the differing perspectives held by managers and individual practitioners that contribute to this lack of support. Managers are required to consider the needs of the service as a whole whilst individual practitioners may be more concerned with their own needs. Many midwives have clear reasons for attending CPE programmes. A number of studies have demonstrated that career intentions are significant motivational factors which influence participation in CPE (Mackereth 1989, Rogers & Lawrence 1989). There is little discussion in the literature of what practitioners need in the way of course
timing, length and location to ensure that attendance is possible without compromising personal responsibilities. Perhaps this demonstrates a lack of awareness or empathy towards practitioners who find that there are many other things in life that compete for their time and energy. It is clear from the literature that the personal needs of nurses and midwives are not always met, and as White et al (1991) suggest, this failure has implications for the efficiency and effectiveness of CPE. It is possible to take this argument a step further to conclude that failure to meet individuals' needs has implications for the quality of service offered and therefore to the efficiency and effectiveness of the National Health Service (NHS) as a whole.
METHODOLOGY
The main approach of the study is that of a descriptive survey. Questionnaires were the chosen method for phase i of the study. The main advantage to the use of questionnaires is the ability to target a large number of people easily (Cohen & Manion 1989). Other advantages cited by Treece & Treece (1982) include the ease with which analysis and interpretation of the data can be accomplished, and the fact that reliability and validity can be ensured. The limitations of questionnaires are also acknowledged. Respondents may omit or disregard questions without explanation, and those individuals who return the questionnaires may not be representative of the total population (Moser & Kalton 1971). The questionnaire was designed with both open and closed questions. The closed questions were designed with fixed alternative answers. This form of questioning ensures ease of analysis (Bell 1989). However, to avoid irritation, in case respondents felt that none of the fixed alternatives was suitable, space was left for comments and the respondents were encouraged to use this. Open questions were also included to allow respondents freedom to express themselves, whilst giving some flame of reference to work within as advocated by Oppenheim (1994). The response rate was 45%. Participants in the study included the total population of qualified midwives (n = 696) employed by 7 NHS trusts in the South-West of England. Targeting the total population ensures the elimination of sampling error which Oppenheim (1994) believes to be the main constituent of bias in many studies. The second phase of the study involved interviewing midwife managers about their perceptions of the CPE needs of midwives and how they help staff to identify and meet their
396 NurseEducationToday CPE needs. Interviewing enables the researcher to build a rapport with those involved and allows explanation, probing of responses and further exploration o f major issues or themes that emerge as the research progresses (Cohen & Manion 1989). Seven out of a total of 11 midwife managers were interviewed. The managers were chosen to reflect the different areas in which midwives practise. A pilot study was carried out. A number o f important issues in the design o f the questionnaire were identified and corrected accordingly. The semi-structured interview schedule was also piloted by interviewing a number of colleagues. These preliminary interviews served as a means of highlighting issues to be discussed in the interviews proper and gave the researcher an opportunity to practise questioning and probing techniques. A semi-structured interview format was chosen for the interviews. The interviews were not tape-recorded. Key words and sentences were written during the course of the interview. Immediately following the interview, more notes were made of the main issues and themes that emerged.
ANALYSIS OF THE DATA The Statistical Package for the Social Sciences (SPSS) was used to analyse the data from the questionnaires. The responses were entered by the researcher. The computer identified where there were entry discrepancies, and these were then corrected. To further ensure accuracy, the entries o f a random sample were checked. Only one error was noted. The open questions were postcoded prior to entry into the computer. The method used to categorize and code the open questions and interview transcripts was an adapted version o f Burnard's method (1991). Burnard's methods were developed from the grounded theory literature. The aim was to produce a detailed and systematic recording of themes and issues found in the data and to link these to a category system. Much of the literature written on the analysis of qualitative data stresses the inherent problem o f the researchers applying their own perceptions onto the findings (Burnard 1991). In an attempt to reduce this, transcripts were read through and notes were made as themes emerged. The aim was to become fully immersed in the data. As Burnard (1991) points out, 'the process o f immersion is used to attempt to become more fully aware of the "life world" o f the respondent'. Once the data were assembled into category systems, a colleague was asked to review the system. Some minor discrepancies were corrected.
DISCUSSION Findings from this study highlight many important issues related to the CPE o f midwives. Also, a significant amount of information was gained that could be used for advanced planning o f CPE offerings in terms of content, format, timing and preferred location. The majority of respondents (60%) were hospital midwives, 32% were communitybased and 9% were integrated to cover both hospital and community areas. More than onethird (36%) o f respondents worked part-time and a further 14% worked mainly night duty. A number o f studies have shown that part-time and night duty staff are disadvantaged when it comes to opportunities for CPE (Parker 1990, Larcombe 8: Maggs 1991, MacDonald 1994). Many comments from the midwives would seem to indicate that this is still a problem. However, the perceptions o f the managers differed. T w o o f the managers suggested that part-time and night duty staff assume that obtaining study leave or funding would be difficult and therefore do not put themselves forward for CPE events. If in the past, these midwives' needs had not been considered; this may explain the subsequent lack of motivation. Three o f the managers said they tried to be fair and provide equal opportunities for CPE regardless of employment status. One manager reported the part-time staff as attending more CPE events as they had more time. Only in one centre did they appear to be disadvantaged. Night duty staff were rescheduled to day duty if they wished to attend courses, and parttime staff were 'steered' towards those courses which required the least time away from clinical practice. O f those who responded to the question about career intentions, 48% saw themselves remaining in clinical practice. Only 18% anticipated promotion to a higher grade. There were many comments on the difficulty of obtaining promotion. A very small proportion anticipated a move to management, teaching or research. These findings are in contrast to Mackareth's (•989) study which found that 25% o f all staff anticipated promotion within 3 years and only 5% saw themselves in the same role. These findings reflect the changes in economic climate and in the organization o f the N H S that have taken place since Mackareth's study. These findings may have implications not only for CPE providers but for the job satisfaction and retention o f staff. A number o f studies have found that career intentions and promotion is the most frequently cited reason for attending CPE events (Mackareth 1989, Rogers 1987, Urbano et al 1983). Indeed
Continuingeducationneedsof midwives 397 intrinsic to the concept of PtLEP and the Higher Award is the concept that CPE should take place within the context of planned career development. Fifty-eight per cent of the respondents had obtained a further qualification after initial registration, but only 13% held a diploma or degree. Many of the midwives and managers expressed their concerns about the current emphasis on academic attainment and about the lack of availability of courses for non-academics or those who do not want to accumulate credits towards a degree. Indeed, since the English National Board for Nursing, Midwifery and Health Visiting (ENB) short courses have been incorporated into the Higher Award and are now assessed at diploma and degree level, many midwives are finding it difficult to achieve this level. At the time of the enquiry, only 3% of respondents were studying at diploma or degree level. There seems to be a reluctance among midwives to study at higher education level, perhaps because traditionally, midwifery has been regarded as a practicebased profession. However, this argument no longer holds true as the benefits of higher education for both midwives and managers have been demonstrated (Kirkham 1994). Further analysis of the data revealed that the majority of respondents who had gained further qualifications or were currently studying were grade G, had practised for 5 years or more, worked full-time and on day duty. This supports the longitudinal study of midwives' careers undertaken by Robinson (1994). A significant proportion (21%) of respondents were studying with the Open University (OU). The degree of flexibility offered by the O U must surely be the main advantage for midwives. Different shift timings and on-call rotas make the attendance at set course timings difficult to achieve for many midwives. The managers also felt there was a need for a variety of formats, including distance learning. The concept of open and distance learning in the midwifery profession has gained momentum in recent years. For midwifery education departments to compete with the OU, a sufficient variety of open and distance learning packages would need to be developed. However, it is wise to consider the implications of such a move. Distance and open learning require the practitioner to study alone with a limited number of contacts with educationalists or other students. There may be the tendency to revert to the acquisition of formal abstract knowledge and to neglect the knowledge that arises from practice. Both the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and ENB agree that a model of learning from practice should become
the centrepiece of CPE for nurses, midwives and health visitors. Cerevro (1990) discusses a number of methods through which practitioners can be helped to develop their knowledge from practice. These include discovery learning, case studies and peer coaching. All of these assume that learning is enhanced through social interaction and that the construction of knowledge takes place within the context of practice. The design of distance learning programmes then, should take this into consideration.
HOW MIDWIVES IDENTIFY AND M E E T T H E I R CPE N E E D S The data reveal that midwives use a variety of strategies to identify their CPE needs and this supports the work of Larcombe & Maggs (1991) whose work demonstrated that the methods used for identification of needs ranged from ad hoc discussions to formal appraisal. The strategies that midwives use most frequently to identify CPE needs include discussion with colleagues, changing practices and attending study days. Discussion with colleagues was cited by 92% of respondents as a strategy used sometimes or frequently to identify needs. This strategy seems to be the most significant for midwives and there are a number of implications from this finding. If the identification of CPE needs through discussion with colleagues is to be enhanced, there needs to be an awareness among practitioners that this process is taking place. There is a case for peer assessment and coaching as suggested by Cerevro (1990) and Hargreaves & Dawe (1990) to enhance learning from practice and from each other. A climate conducive to learning must be fostered in the organization. Since the identification of needs may involve the practitioner admitting to a gap in knowledge or skills, openness, mutual respect and trust, support and collaboration are all factors that must be addressed to achieve this (Green et al 1984). Discussion with managers, students and clients as a strategy to identify needs was used less often by midwives. Only 8% of respondents cited using their manager frequently to help identify their needs. Larcombe & Maggs (1991) emphasized the centrality of the manager's commitment to professional development. Other studies have identified the ward manager as a key figure in creating a learning environment and as a role model for staff (Marson et al 1990). Only two of the managers in this study talked about being accessible or approachable when asked how they help midwives identify their CPE needs.
398 Nurse Education Today Sixty-one per cent of respondents found that working with students helped them to identify their needs. No other research has explored this issue. It seems that being involved with the teaching and assessment of students enables midwives to identify gaps in their own knowledge or skills. Cited the least frequently as strategies for identifying needs were: discussion with educationalists; keeping a portfolio; individual performance review; the job description; and following a role change or promotion. It is unfortunate that midwives do not make use of the educationalists to help identify their educational needs since these are the people who should have the skills to facilitate identification of needs. Rogers & Lawrence's (1989) study also found that very few practitioners used tutorial stafffor help. The reduction in teacher numbers and the move of educational establishments into universifies has resulted in a lack of contact between teachers and clinical staff. Indeed, none of the managers referred to the role of midwife teachers in facilitating the identification of needs. This is surprising in that the U K C C (i990) and the ENB (1990) envisage the manager, educationalist and individual practitioner working together to ensure that CPE needs are identified and an appropriate programme of professional development planned for the individual practitioner. Both midwives and midwife teachers need to explore strategies through which contact and c o m m u nication could be enhanced. Once the respondents had identified a need for CPE, they then adopted a variety of strategies to meet that need. Responses to the question of h o w midwives meet their CPE needs revealed similar trends to those strategies that midwives use first to identify their needs. Managers and educationalists were used infrequently; colleagues were cited most frequently. Reading appropriate literature featured high on the list. This supports other studies which report that midwives use journals and literature to keep up-to-date (Allen 1989, Clarke & Rees 1989). As small libraries are moved from the clinical sites, midwives may find it increasingly difficult to have access to a wide range of relevant journals. Midwives will have to be motivated to travel to distant library sites or to rely on colleagues and such innovations as journal clubs if they are to remain updated through reading. Eighty-five per cent of respondents sometimes or frequently attend study days. This is a higher proportion than the respondents of the aforementioned studies. The increased provision of ENB-approved study days and the
heightened awareness of the importance of CPE in recent years may explain this finding.
MIDWIVES' CPE NEEDS Midwives were asked to indicate their present level of need from an extensive range of topics divided into categories. The greatest level of need fell into the category of 'professional issues'. Topics in this category included all those which did not fit into the specific areas of midwifery practice, e.g. counselling, ethics, law, grief and bereavement. This finding is in sharp contrast to the majority of other studies that have addressed the present or future CPE needs of midwives (Parnaby 1987, Clarke & Rees 1989, Robinson 1994). Midwives in these studies reported that their greatest need was for clinical updating. Midwives in these studies were also supplied with a list of topics. From the reports it is not possible to comment on the extent of the topic lists. Other researchers have also found emphasis on clinical updating but are more wary of the fact that what respondents want and what they need may be different (Orme & Trickett 1982). The topic list in this survey was extensive. The topics were generated following discussion with educationalists, managers, clinical experts, practitioners and clients. Midwives had much choice and could relate the topics to their present area of practice. Robinson (1994) used open questions in her survey to identify midwives' future CPE needs. Open questions tend to be answered less well than structured questions (Cohen & Manion 1989). It would have been difficult for midwives to think of such an extensive range of topics in a limited time period and therefore the reliability of her findings could be questioned. Topics that midwives reported a great need for reflect the changes that are currently affecting midwifes' practice. 'Law and the midwife', 'implementing research into practice' and 'maternity services of the future' featured high on the list of priorities. O f the categories, topics listed under 'management issues' were the most favoured. This finding is again in contrast to that of Robinson (1994) where only 10% of respondents required management courses in the future. This finding may reflect the increased managerial responsibilities devolved to F and G grade staff in the changing management structures. Fifty-one per cent of respondents held an F grade or above. The least popular of the categories was 'postnatal issues'. Despite postnatal care forming a large part of the midwives' work, postnatal services have never attracted the level of
Continuingeducationneedsof midwives 399 attention or resources as other areas in the maternity services (Ball 1987). Recently, however, there has been an upsurge of interest in this field, particnlarily in women's health following childbearing, and midwives need to become more aware of and sensitive to this field. The managers' responses were similar, discussing the need for professional and management topics. These findings demonstrate that midwives are in tune with their o w n educational needs and that their requests for CPE reflects an awareness of their real needs. This finding supports the view of Dodwell (1984) and those who believe that true professionals should be capable of identifying their o w n educational needs (Jarvis 1983, Houle 1984).
H O W C A N M ID W IVES BE HELPED T O IDENTIFY A N D MEET CPE NEEDS? The concern that midwives felt regarding the move of the educational establishments from the clinical sites was apparent from many of the responses. An accessible and approachable department was a high priority of both midwives and managers. The importance of having educational staff available to the clinical staff cannot be underestimated. The development of informal support systems relies heavily on good relationships between educational and clinical staff who are accessible to one another. T o ensure that the practice d e m e n t in the education of student midwives is not devalued, it is vital that strong links are maintained with clinical staff. Indeed, respondents felt that the clinical link rotor should be more available in the clinical area, as this would enhance communication and would also help practitioners with their CPE needs. Other suggestions included more written information and early notification of courses and study days. Research findings have consistently demonstrated that course attendance is strongly influenced by early notification of events (Smddy & Hunt 1980). Other studies show that nurses and midwives are not always aware of what is available if there is insuflficient marketing of courses (Rogers 1987, Rogers & Lawrence 1989). The demand for flexibility and variety in the provision of courses is also reflected in the responses to a question covering course format and timings. Only 24% favoured full-time study. Attendance for a full day for either a study day or a course was the most favoured option. Some suggested that the timing should fit in with school hours. Evening sessions between 19:00-21:00 would also
enable 34% of respondents to attend. These two findings probably relate to the ease with which midwives with young children have in making childcare arrangements. Since only 3.5% cited the provision ofchildcare as a factor that would faciltiate attendance, it may be inferred that midwives can make their own childcare arrangements given the option of attending at a time that suits their own personal circumstances. Less than one-quarter of respondents would be prepared to spend a full weekend attending a course, although 49% would attend on a Saturday. Sunday was the least favoured day to attend. Informal courses for personal and professional development were also popular options. Open days, discussion groups, lunchtime meetings and update sessions were all suggestions put forward. The popularity of informal sessions may reflect the importance that midwives place on continual learning. An informal approach to CPE may fulfil an educational need without the stress of course assessments which are obligatory for any educational experience leading to a recognized award. In Mackareth's (1989) study, nurses expressed high levels of anxiety about taking examinations. This could be a &motivating factor affecting participation in more formal CPE. With the introduction of the ENB Higher Award, all short courses are n o w validated to offer credits at degree and diploma level. A preference for an informal approach to CPE may indicate that midwives lack confidence and self-esteem in their academic abilities or are concerned with fear of failure. T w o of the managers also expressed concern over the continuing emphasis on academic qualifications. These managers reported that the midwives are stressed, anxious and opt out of studying. There must be recognition of the demands that present work and possibly the home lives of midwives place on an individual. The changing work practices, the responsibilities of being a midwife, the requirement to develop and maintain a portfolio, notwithstanding domestic and family commitments place a heavy workload on today's midwives. It is not surprising then that midwives feel that time away from the workplace should be for themselves and their families. Indeed, Houle (1984) argues that there must be a balance between an individual's personal and professional life and suggest that it is impossible to distinguish learning that occurs in the different domains. With these findings in mind, it is important then to develop flexible learning systems that midwives can work through at their own pace. However, adequate support mechanisms must
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NurseEducation Today be intrinsic to the concept o f these flexible learning programmes. This support mechanism must help to prepare practitioners for study at advanced level and should include opportunities for participants to meet with peers and tutors in an effort to boost confidence and self-esteem. In response to the question that addressed factors that facilitate attendance at a CPE event, it was significant that only a minority o f respondents rated the content as important. It could be inferred from this that no matter h o w attractive or relevant the content o f a course, there are barriers that midwives must overcome to allow attendance. If these issues are neglected, there is a danger that the providers o f CPE may go to considerable efforts to design attractive events with the content designed to meet the needs o f practitioners, only to find there is minimal uptake. This could be the reason that MacDonald (1994) found initial enthusiasm for in-service education was not always followed through by attendance at events. The location o f the CPE event was sited most frequently as a factor that influenced attendance, with the overwhelming majority of respondents favouring a local site. A local centre would reduce the cost to the individual practitioner or to the manager. The cost o f a CPE event and whether managers gave study leave or financial assistance also featured high on the list of factors that influenced attendance. These findings support those of Mackareth (1989) and McCrea (1989). Midwives with domestic and family commitments may find it difficult to meet the cost of a CPE event plus the additional cost o f travel, time away from work and perhaps childcare. Rogers' (1987) survey identified that family commitments can hinder uptake o f CPE. The costs of CPE are increasing since the providers now function in a climate where income generation is allimportant. It is hardly surprising, then, that the support of managers facilitates attendance. Indeed, Heath (1980) found that attendance at staff development activities was heavily dependent on the support of service managers. There were many comments related to the cost o f CPE events. The expense that CPE entails was highlighted by a number of comments that demonstrate the difficulties that some midwives face if their employers do not share the responsibility for assisting their staff with meeting their CPE needs. However, there seems to be a greater willingness by midwives to contribute to the cost of CPE. Nearly 58% o f respondents in this study said they would be willing to attend in their own time. In a study by Clarke &tLees (]989), only 24% said they would attend in their own time. Eighty per cent also said they would be pre-
pared to contribute to the cost of an event. Many of the respondents felt that if they paid, the manager should give the time or vice versa, demonstrating a belief that the responsibility for CPE should be shared between manager and practitioner. This supports the findings of Allan (1989) who explored the question o f who is responsible for CPE. All but two o f the managers were extremely limited by the amount o f resources available to them. The managers reported that in the majority of cases it was possible to reach a compromise when faced with their staffs requests for support. If money was not available then study leave may be given or an attempt would be made to find a CPE event that did not cost, such as those offered by the training departments. Some argue that managers will choose the cheapest option without always giving full consideration to whether needs are being met (Casdedine 1992). Indeed, it does seem that for managers, cost is the bottom line. Midwives are encouraged to undertake courses run by training departments. Midwife managers in the study by Larcombe & Maggs (1991) reflected similar sentiments in that the statutory requirements for refresher courses used up all the available money. The managers recognized the importance of CPE and its contribution to both personal and professional growth and in meeting the service needs o f client care. The personal philosophy o f the managers was orientated towards seeing themselves as facilitators, helping midwives to recognize and fulfil their CPE needs. Nevertheless, all the managers believed that tlxe ultimate responsibility for professional development lay with the individual practitioner. The needs of the organization was an important factor that managers took into consideration in the decision of whether or not to support their staff. This assumed priority, with the needs of the individual taking second place for all but one of the managers. There did not seem to be any recognition that the needs of the organization and those o f the individual could be met at the same time. The managers felt that the midwives did not always appreciate the needs of the organization and the importance of feeding back into the unit the learning that had taken place as a result o f a CPE event. Moores (1984) also found that recognition of the value o f meeting individual and organizational needs simultaneously in terms o f resources had not filtered through to midwives. It seems then that little has changed in the last decade. The influence of a leading figure such as the manager is very important in supporting a learning environment, one which is conducive to change and open to experimentation (Carpentino 1990). Only two of the managers
Continuing education needs of midwives
discussed the importance o f n u r t u r i n g a climate conducive to change. Clinical staffin a study b y Larcombe & Maggs (1991) felt that managers were n o t supportive towards CPE. Allen (1989) highlighted that even w h e n managers allowed study leave and finance, this was n o t always equated with support. T h e r e must then be another element to support, that surely is the climate and culture o f an organization c o n ducive to learning. Hargreaves and D a w e (1990) discuss the importance o f a collaborative culture w i t h i n an organization if individuals are to learn from practice, from colleagues and be motivated towards professional development. Individuals w i t h i n such organizations display qualities such as trust, support and sharing. There needs to be overt praise and recognition o f achievement. T h e climate o f change and uncertainty over j o b security, and m a n a g e m e n t d o m i n a t e d b y financial priorities does n o t lend itself easily to this collaborative culture. Managers need to realize that a c o m m i t m e n t to C P E does n o t distract from getting the j o b done b u t enhances it. Staff d e v e l o p m e n t has b e e n equated with organizational efficiency ( U n s w o r t h - W e b b 1990). M o t i v a t i o n and sarisfaction w i t h w o r k is increased. There is a reduction i n costly staff t u r n o v e r (Basford & D o w n i e 1991). Indeed, H a n d y (1989) believes that education is the most important investm e n t that can be made.
CONCLUSION T h e findings from this study reinforce those o f other studies that have explored c o n t i n u i n g professional education for midwives. A n u m b e r o f other findings have n o t b e e n identified previously in the literature and this study highlights the value o f a local needs assessment if the midwifery education department is to meet the needs o f its clients. Perhaps one o f the most significant implications to arise from this study is the need for a collaborative approach to C P E b e t w e e n practitioners, managers and educationalists to ensure that an individual's needs are identified and met. W i t h the m o v e o f midwifery education into the realms o f universities, it is imperative that the difficulties that midwife teachers face in m e e t i n g their clinical c o m m i t m e n t s are addressed to ensure that educationalists are available to clinical staff. It is evident that support for midwives to c o n t i n u e their professional education is required from managers, educationalists and peers. In the present climate o f financial restraint, a collaborative effort is required to enable the practitioner to develop profession-
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ally and personally. This will also ensure that organizational needs are met, individual needs are recognized and practitioners can achieve satisfaction and fulfilment from their work. O n e way to fulfil this aim is to foster a climate conducive to learning, where individuals feel valued and change is encouraged.
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41}2 NurseEducation Today Mackereth P 1989 An investigation of the developmental influences on nurses motivation for their continuing education. Journal of Advanced Nursing 14: 776-787 Mason S, Hardebnry M,Johnston R, Scammell B 1990 Managing People. Macmillan, London Moores Y 1994 Release and provision for continuing education. Nurse Education Today Moser C A, Kalton G 1971 Survey methods in social investigation. Gower, Aldershot Oppenheim A N 1994 Questionnaire design, interviews and attitude measurement (2nd edn). Pinter, London Orme L, Trickett M 1982 Identification of the training needs of sisters and charge nurses. Nursing Times 78(24): 30-32 Parker E M 1990 The attitudes and needs of trained staff for continuing education. Masters in Nursing Unpublished Dissertation, University of the West of England, Bristol Pamaby C M 1987 Surveying the opinions of midwives regarding the curriculum content of refresher courses. Nurse Education Today 3:133-142 Robinson S 1994 Professional development in midwifery:
findings from a longitudinal survey of midwives careers. Nurse Education Today 14:161-176 RogersJ 1987 Survey of continuing professional education for nurses, midwives and health visitors. Ashdale Press, Petersborough Rogers J, LawrenceJ 1989 Continuing professional education for qualified nurses, midwives and health visitors. Ashdale Press, London Studdy S, Hunt C 1980 Computerised survey of learning needs. Nursing Times 190une): 1084-1087 Treece E W, Treece J W 1986 Elements of research in nursing (4th edn). Mosby, St Louis United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1°00 Post registration education and practice project. UKCC, London Unsworth-Webb J 1990 Staff development equated with organisational efficiency. Nurse Education Today 10: 74-75 Urbano M, Jahns i, Urbano R 1983 What really motivates nurses to participate in mandatory professional continuing education? Jottmal of Continuing Education in Nursing 19(1): 38-43 White A, Crooke L, Smith V 1991 Forgetting midwifery. Senior Nurse 11(3): 3, 8
professional education needs of midwives Mary Mitchell
Mary Mitchell MEd, CertEd, ADM, RM, University of the West of England, Faculty of Health and SocialCare, Blackberry Hill, Stapleton, Bristol, UK (Requests for offprints to MM) Manuscript accepted 14 February 1996
The philosophy behind Post Registration Education and Practice (PREP) dictates that continuing professional education (CPE) must be tailored to the needs of the individual and relevant to the practice environment. The study is set within the context of PREP and other changes that are currently affecting midwives and midwifery educational establishments. This study sought to explore the CPE needs of midwives. The main objective of the study was to seek information on a number of issues that would assist with the planning and implementation of continuing education programmes to meet the needs of midwives. The study takes the form of a descriptive survey. Questionnaires were sent to 696 midwives employed by 7 National Health Service Trusts in the South-West of England. A 4 5 % response rate was achieved. Seven midwife managers were also interviewed to gain insight into their perspectives of CPE and to enhance the findings from the questionnaire. Results show that midwives use a variety of strategies to identify their CPE needs. One of the more significant seems to be through interaction with colleagues. 'Professional issues' and 'management topics' were the categories identified by both midwives and managers alike to be the greatest need. There is a demand for part-time and distance learning. The format and timings that would ensure that midwives find it easy to attend CPE events were identified. Findings illustrate how midwifery managers and educationalists can facilitate midwives with their CPE and career development.
Nurse EducationToday(1997) 17, 394-402 © 1997PearsonProfessionalLtd
INTRODUCTION Midwives are currently facing many changes which have major implications for practice and continuing professional education (CPE). To meet the requirements of Post Registration Education and Practice (PKEP) and the challenges of Changing Childbirth (Doll 1993), midwives must be able to identify their CPE needs and explore strategies to help them meet those needs. Within the financial constraints of midwifery, educationalists must provide a quality service that meets the needs of its customers in a consistent and coordinated manner. Green et al (1984) agree that one of the major components of quality in CPE programmes is the detection and analysis of needs in establishing priorities for the provision of educational programmes. This is the philosophy that underpins this study. A further rationale for undertaking the study concerns the lack of empirical evidence relating to the CPE of midwives. Robinson (1994) indicates that there is a substantial degree of dissatisfaction amongst midwives with the provision of CPE. The main aims of the study were to explore how midwives identify and meet their CPE needs, to identify the current CPE needs of midwives and to discover how the midwifery education department can facilitate the CPE and career development of midwives.
LITERATURE REVIEW The term 'continuing professional education' is used in many ways. It is acknowledged that midwives keep their knowledge and skills up-to-date in many ways but to assist the GPE providers in identifying needs, planning and implementing CPE programmes the definition given by the American Nurses Association was accepted: CPE consists of planned educational activities intended to build upon the educational and experiential basis of the professional nurse for the enhancement of practice, education, administration, research or theory development to the end of improving the health of the public (cited by Barriball et al 1992). Only three published studies have addressed the specific needs of midwives. Clarke & Rees (1989) undertook a survey of CPE needs of midwives in one region. A total of 176 midwives was targeted. The response rate was 56% but the night staff were under-represented in the results. The greatest interests lay in topics related to clinical practice, teaching and assess-
Continuing education needs of midwives 395
ment and communication skills and issues relating to personal development. Parnaby's (1987) study highlighted the differences in priorities of content given by course tutors and the midwife participants. The research also demonstrated the importance of asking midwives what they want if their educational needs are to be met. In a longitudinal study of midwives' careers, Robinson (1994) addressed the issue of professional development in relation to career pattern and satisfaction at work. Participants were asked about future CPE needs. Clinical updating was cited most frequently. Management topics, research and legal issues were desired by less than 10%. The relevance of these findings to present-day midwives is questionable. Phase 2 of the project was concerned with professional development. Questionnaires were administered in 1986; considerable changes have taken place since then which have influenced midwives' practice. Although phase 3 of the project intended to address the area of professional development, another major area of interest had emerged and the researchers focused on this, leaving little opportunity to explore professional development to the depth originally intended. Many factors may influence whether or not health professionals participate in CPE. Even when a need has been identified, there may be obstacles that prevent professionals meeting that need. Shortages of staff, time and funding are consistently referred to by many practitioners as hindering their uptake of CPE (Larcombe & Maggs 1991). The extent to which an individual is encouraged or supported by their manager to participate in CPE events is also important. A considerable portion of the respondents in Larcombe & Maggs' (1991) study fek their managers were unsupportive or had negative attitudes towards CPE. However, Allen (1989) found that even when individuals are given the time and funding to attend CPE, they still cite lack of support as a factor affecting attendance. These studies suggest that it may be the differing perspectives held by managers and individual practitioners that contribute to this lack of support. Managers are required to consider the needs of the service as a whole whilst individual practitioners may be more concerned with their own needs. Many midwives have clear reasons for attending CPE programmes. A number of studies have demonstrated that career intentions are significant motivational factors which influence participation in CPE (Mackereth 1989, Rogers & Lawrence 1989). There is little discussion in the literature of what practitioners need in the way of course
timing, length and location to ensure that attendance is possible without compromising personal responsibilities. Perhaps this demonstrates a lack of awareness or empathy towards practitioners who find that there are many other things in life that compete for their time and energy. It is clear from the literature that the personal needs of nurses and midwives are not always met, and as White et al (1991) suggest, this failure has implications for the efficiency and effectiveness of CPE. It is possible to take this argument a step further to conclude that failure to meet individuals' needs has implications for the quality of service offered and therefore to the efficiency and effectiveness of the National Health Service (NHS) as a whole.
METHODOLOGY
The main approach of the study is that of a descriptive survey. Questionnaires were the chosen method for phase i of the study. The main advantage to the use of questionnaires is the ability to target a large number of people easily (Cohen & Manion 1989). Other advantages cited by Treece & Treece (1982) include the ease with which analysis and interpretation of the data can be accomplished, and the fact that reliability and validity can be ensured. The limitations of questionnaires are also acknowledged. Respondents may omit or disregard questions without explanation, and those individuals who return the questionnaires may not be representative of the total population (Moser & Kalton 1971). The questionnaire was designed with both open and closed questions. The closed questions were designed with fixed alternative answers. This form of questioning ensures ease of analysis (Bell 1989). However, to avoid irritation, in case respondents felt that none of the fixed alternatives was suitable, space was left for comments and the respondents were encouraged to use this. Open questions were also included to allow respondents freedom to express themselves, whilst giving some flame of reference to work within as advocated by Oppenheim (1994). The response rate was 45%. Participants in the study included the total population of qualified midwives (n = 696) employed by 7 NHS trusts in the South-West of England. Targeting the total population ensures the elimination of sampling error which Oppenheim (1994) believes to be the main constituent of bias in many studies. The second phase of the study involved interviewing midwife managers about their perceptions of the CPE needs of midwives and how they help staff to identify and meet their
396 NurseEducationToday CPE needs. Interviewing enables the researcher to build a rapport with those involved and allows explanation, probing of responses and further exploration o f major issues or themes that emerge as the research progresses (Cohen & Manion 1989). Seven out of a total of 11 midwife managers were interviewed. The managers were chosen to reflect the different areas in which midwives practise. A pilot study was carried out. A number o f important issues in the design o f the questionnaire were identified and corrected accordingly. The semi-structured interview schedule was also piloted by interviewing a number of colleagues. These preliminary interviews served as a means of highlighting issues to be discussed in the interviews proper and gave the researcher an opportunity to practise questioning and probing techniques. A semi-structured interview format was chosen for the interviews. The interviews were not tape-recorded. Key words and sentences were written during the course of the interview. Immediately following the interview, more notes were made of the main issues and themes that emerged.
ANALYSIS OF THE DATA The Statistical Package for the Social Sciences (SPSS) was used to analyse the data from the questionnaires. The responses were entered by the researcher. The computer identified where there were entry discrepancies, and these were then corrected. To further ensure accuracy, the entries o f a random sample were checked. Only one error was noted. The open questions were postcoded prior to entry into the computer. The method used to categorize and code the open questions and interview transcripts was an adapted version o f Burnard's method (1991). Burnard's methods were developed from the grounded theory literature. The aim was to produce a detailed and systematic recording of themes and issues found in the data and to link these to a category system. Much of the literature written on the analysis of qualitative data stresses the inherent problem o f the researchers applying their own perceptions onto the findings (Burnard 1991). In an attempt to reduce this, transcripts were read through and notes were made as themes emerged. The aim was to become fully immersed in the data. As Burnard (1991) points out, 'the process o f immersion is used to attempt to become more fully aware of the "life world" o f the respondent'. Once the data were assembled into category systems, a colleague was asked to review the system. Some minor discrepancies were corrected.
DISCUSSION Findings from this study highlight many important issues related to the CPE o f midwives. Also, a significant amount of information was gained that could be used for advanced planning o f CPE offerings in terms of content, format, timing and preferred location. The majority of respondents (60%) were hospital midwives, 32% were communitybased and 9% were integrated to cover both hospital and community areas. More than onethird (36%) o f respondents worked part-time and a further 14% worked mainly night duty. A number o f studies have shown that part-time and night duty staff are disadvantaged when it comes to opportunities for CPE (Parker 1990, Larcombe 8: Maggs 1991, MacDonald 1994). Many comments from the midwives would seem to indicate that this is still a problem. However, the perceptions o f the managers differed. T w o o f the managers suggested that part-time and night duty staff assume that obtaining study leave or funding would be difficult and therefore do not put themselves forward for CPE events. If in the past, these midwives' needs had not been considered; this may explain the subsequent lack of motivation. Three o f the managers said they tried to be fair and provide equal opportunities for CPE regardless of employment status. One manager reported the part-time staff as attending more CPE events as they had more time. Only in one centre did they appear to be disadvantaged. Night duty staff were rescheduled to day duty if they wished to attend courses, and parttime staff were 'steered' towards those courses which required the least time away from clinical practice. O f those who responded to the question about career intentions, 48% saw themselves remaining in clinical practice. Only 18% anticipated promotion to a higher grade. There were many comments on the difficulty of obtaining promotion. A very small proportion anticipated a move to management, teaching or research. These findings are in contrast to Mackareth's (•989) study which found that 25% o f all staff anticipated promotion within 3 years and only 5% saw themselves in the same role. These findings reflect the changes in economic climate and in the organization o f the N H S that have taken place since Mackareth's study. These findings may have implications not only for CPE providers but for the job satisfaction and retention o f staff. A number o f studies have found that career intentions and promotion is the most frequently cited reason for attending CPE events (Mackareth 1989, Rogers 1987, Urbano et al 1983). Indeed
Continuingeducationneedsof midwives 397 intrinsic to the concept of PtLEP and the Higher Award is the concept that CPE should take place within the context of planned career development. Fifty-eight per cent of the respondents had obtained a further qualification after initial registration, but only 13% held a diploma or degree. Many of the midwives and managers expressed their concerns about the current emphasis on academic attainment and about the lack of availability of courses for non-academics or those who do not want to accumulate credits towards a degree. Indeed, since the English National Board for Nursing, Midwifery and Health Visiting (ENB) short courses have been incorporated into the Higher Award and are now assessed at diploma and degree level, many midwives are finding it difficult to achieve this level. At the time of the enquiry, only 3% of respondents were studying at diploma or degree level. There seems to be a reluctance among midwives to study at higher education level, perhaps because traditionally, midwifery has been regarded as a practicebased profession. However, this argument no longer holds true as the benefits of higher education for both midwives and managers have been demonstrated (Kirkham 1994). Further analysis of the data revealed that the majority of respondents who had gained further qualifications or were currently studying were grade G, had practised for 5 years or more, worked full-time and on day duty. This supports the longitudinal study of midwives' careers undertaken by Robinson (1994). A significant proportion (21%) of respondents were studying with the Open University (OU). The degree of flexibility offered by the O U must surely be the main advantage for midwives. Different shift timings and on-call rotas make the attendance at set course timings difficult to achieve for many midwives. The managers also felt there was a need for a variety of formats, including distance learning. The concept of open and distance learning in the midwifery profession has gained momentum in recent years. For midwifery education departments to compete with the OU, a sufficient variety of open and distance learning packages would need to be developed. However, it is wise to consider the implications of such a move. Distance and open learning require the practitioner to study alone with a limited number of contacts with educationalists or other students. There may be the tendency to revert to the acquisition of formal abstract knowledge and to neglect the knowledge that arises from practice. Both the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and ENB agree that a model of learning from practice should become
the centrepiece of CPE for nurses, midwives and health visitors. Cerevro (1990) discusses a number of methods through which practitioners can be helped to develop their knowledge from practice. These include discovery learning, case studies and peer coaching. All of these assume that learning is enhanced through social interaction and that the construction of knowledge takes place within the context of practice. The design of distance learning programmes then, should take this into consideration.
HOW MIDWIVES IDENTIFY AND M E E T T H E I R CPE N E E D S The data reveal that midwives use a variety of strategies to identify their CPE needs and this supports the work of Larcombe & Maggs (1991) whose work demonstrated that the methods used for identification of needs ranged from ad hoc discussions to formal appraisal. The strategies that midwives use most frequently to identify CPE needs include discussion with colleagues, changing practices and attending study days. Discussion with colleagues was cited by 92% of respondents as a strategy used sometimes or frequently to identify needs. This strategy seems to be the most significant for midwives and there are a number of implications from this finding. If the identification of CPE needs through discussion with colleagues is to be enhanced, there needs to be an awareness among practitioners that this process is taking place. There is a case for peer assessment and coaching as suggested by Cerevro (1990) and Hargreaves & Dawe (1990) to enhance learning from practice and from each other. A climate conducive to learning must be fostered in the organization. Since the identification of needs may involve the practitioner admitting to a gap in knowledge or skills, openness, mutual respect and trust, support and collaboration are all factors that must be addressed to achieve this (Green et al 1984). Discussion with managers, students and clients as a strategy to identify needs was used less often by midwives. Only 8% of respondents cited using their manager frequently to help identify their needs. Larcombe & Maggs (1991) emphasized the centrality of the manager's commitment to professional development. Other studies have identified the ward manager as a key figure in creating a learning environment and as a role model for staff (Marson et al 1990). Only two of the managers in this study talked about being accessible or approachable when asked how they help midwives identify their CPE needs.
398 Nurse Education Today Sixty-one per cent of respondents found that working with students helped them to identify their needs. No other research has explored this issue. It seems that being involved with the teaching and assessment of students enables midwives to identify gaps in their own knowledge or skills. Cited the least frequently as strategies for identifying needs were: discussion with educationalists; keeping a portfolio; individual performance review; the job description; and following a role change or promotion. It is unfortunate that midwives do not make use of the educationalists to help identify their educational needs since these are the people who should have the skills to facilitate identification of needs. Rogers & Lawrence's (1989) study also found that very few practitioners used tutorial stafffor help. The reduction in teacher numbers and the move of educational establishments into universifies has resulted in a lack of contact between teachers and clinical staff. Indeed, none of the managers referred to the role of midwife teachers in facilitating the identification of needs. This is surprising in that the U K C C (i990) and the ENB (1990) envisage the manager, educationalist and individual practitioner working together to ensure that CPE needs are identified and an appropriate programme of professional development planned for the individual practitioner. Both midwives and midwife teachers need to explore strategies through which contact and c o m m u nication could be enhanced. Once the respondents had identified a need for CPE, they then adopted a variety of strategies to meet that need. Responses to the question of h o w midwives meet their CPE needs revealed similar trends to those strategies that midwives use first to identify their needs. Managers and educationalists were used infrequently; colleagues were cited most frequently. Reading appropriate literature featured high on the list. This supports other studies which report that midwives use journals and literature to keep up-to-date (Allen 1989, Clarke & Rees 1989). As small libraries are moved from the clinical sites, midwives may find it increasingly difficult to have access to a wide range of relevant journals. Midwives will have to be motivated to travel to distant library sites or to rely on colleagues and such innovations as journal clubs if they are to remain updated through reading. Eighty-five per cent of respondents sometimes or frequently attend study days. This is a higher proportion than the respondents of the aforementioned studies. The increased provision of ENB-approved study days and the
heightened awareness of the importance of CPE in recent years may explain this finding.
MIDWIVES' CPE NEEDS Midwives were asked to indicate their present level of need from an extensive range of topics divided into categories. The greatest level of need fell into the category of 'professional issues'. Topics in this category included all those which did not fit into the specific areas of midwifery practice, e.g. counselling, ethics, law, grief and bereavement. This finding is in sharp contrast to the majority of other studies that have addressed the present or future CPE needs of midwives (Parnaby 1987, Clarke & Rees 1989, Robinson 1994). Midwives in these studies reported that their greatest need was for clinical updating. Midwives in these studies were also supplied with a list of topics. From the reports it is not possible to comment on the extent of the topic lists. Other researchers have also found emphasis on clinical updating but are more wary of the fact that what respondents want and what they need may be different (Orme & Trickett 1982). The topic list in this survey was extensive. The topics were generated following discussion with educationalists, managers, clinical experts, practitioners and clients. Midwives had much choice and could relate the topics to their present area of practice. Robinson (1994) used open questions in her survey to identify midwives' future CPE needs. Open questions tend to be answered less well than structured questions (Cohen & Manion 1989). It would have been difficult for midwives to think of such an extensive range of topics in a limited time period and therefore the reliability of her findings could be questioned. Topics that midwives reported a great need for reflect the changes that are currently affecting midwifes' practice. 'Law and the midwife', 'implementing research into practice' and 'maternity services of the future' featured high on the list of priorities. O f the categories, topics listed under 'management issues' were the most favoured. This finding is again in contrast to that of Robinson (1994) where only 10% of respondents required management courses in the future. This finding may reflect the increased managerial responsibilities devolved to F and G grade staff in the changing management structures. Fifty-one per cent of respondents held an F grade or above. The least popular of the categories was 'postnatal issues'. Despite postnatal care forming a large part of the midwives' work, postnatal services have never attracted the level of
Continuingeducationneedsof midwives 399 attention or resources as other areas in the maternity services (Ball 1987). Recently, however, there has been an upsurge of interest in this field, particnlarily in women's health following childbearing, and midwives need to become more aware of and sensitive to this field. The managers' responses were similar, discussing the need for professional and management topics. These findings demonstrate that midwives are in tune with their o w n educational needs and that their requests for CPE reflects an awareness of their real needs. This finding supports the view of Dodwell (1984) and those who believe that true professionals should be capable of identifying their o w n educational needs (Jarvis 1983, Houle 1984).
H O W C A N M ID W IVES BE HELPED T O IDENTIFY A N D MEET CPE NEEDS? The concern that midwives felt regarding the move of the educational establishments from the clinical sites was apparent from many of the responses. An accessible and approachable department was a high priority of both midwives and managers. The importance of having educational staff available to the clinical staff cannot be underestimated. The development of informal support systems relies heavily on good relationships between educational and clinical staff who are accessible to one another. T o ensure that the practice d e m e n t in the education of student midwives is not devalued, it is vital that strong links are maintained with clinical staff. Indeed, respondents felt that the clinical link rotor should be more available in the clinical area, as this would enhance communication and would also help practitioners with their CPE needs. Other suggestions included more written information and early notification of courses and study days. Research findings have consistently demonstrated that course attendance is strongly influenced by early notification of events (Smddy & Hunt 1980). Other studies show that nurses and midwives are not always aware of what is available if there is insuflficient marketing of courses (Rogers 1987, Rogers & Lawrence 1989). The demand for flexibility and variety in the provision of courses is also reflected in the responses to a question covering course format and timings. Only 24% favoured full-time study. Attendance for a full day for either a study day or a course was the most favoured option. Some suggested that the timing should fit in with school hours. Evening sessions between 19:00-21:00 would also
enable 34% of respondents to attend. These two findings probably relate to the ease with which midwives with young children have in making childcare arrangements. Since only 3.5% cited the provision ofchildcare as a factor that would faciltiate attendance, it may be inferred that midwives can make their own childcare arrangements given the option of attending at a time that suits their own personal circumstances. Less than one-quarter of respondents would be prepared to spend a full weekend attending a course, although 49% would attend on a Saturday. Sunday was the least favoured day to attend. Informal courses for personal and professional development were also popular options. Open days, discussion groups, lunchtime meetings and update sessions were all suggestions put forward. The popularity of informal sessions may reflect the importance that midwives place on continual learning. An informal approach to CPE may fulfil an educational need without the stress of course assessments which are obligatory for any educational experience leading to a recognized award. In Mackareth's (1989) study, nurses expressed high levels of anxiety about taking examinations. This could be a &motivating factor affecting participation in more formal CPE. With the introduction of the ENB Higher Award, all short courses are n o w validated to offer credits at degree and diploma level. A preference for an informal approach to CPE may indicate that midwives lack confidence and self-esteem in their academic abilities or are concerned with fear of failure. T w o of the managers also expressed concern over the continuing emphasis on academic qualifications. These managers reported that the midwives are stressed, anxious and opt out of studying. There must be recognition of the demands that present work and possibly the home lives of midwives place on an individual. The changing work practices, the responsibilities of being a midwife, the requirement to develop and maintain a portfolio, notwithstanding domestic and family commitments place a heavy workload on today's midwives. It is not surprising then that midwives feel that time away from the workplace should be for themselves and their families. Indeed, Houle (1984) argues that there must be a balance between an individual's personal and professional life and suggest that it is impossible to distinguish learning that occurs in the different domains. With these findings in mind, it is important then to develop flexible learning systems that midwives can work through at their own pace. However, adequate support mechanisms must
400
NurseEducation Today be intrinsic to the concept o f these flexible learning programmes. This support mechanism must help to prepare practitioners for study at advanced level and should include opportunities for participants to meet with peers and tutors in an effort to boost confidence and self-esteem. In response to the question that addressed factors that facilitate attendance at a CPE event, it was significant that only a minority o f respondents rated the content as important. It could be inferred from this that no matter h o w attractive or relevant the content o f a course, there are barriers that midwives must overcome to allow attendance. If these issues are neglected, there is a danger that the providers o f CPE may go to considerable efforts to design attractive events with the content designed to meet the needs o f practitioners, only to find there is minimal uptake. This could be the reason that MacDonald (1994) found initial enthusiasm for in-service education was not always followed through by attendance at events. The location o f the CPE event was sited most frequently as a factor that influenced attendance, with the overwhelming majority of respondents favouring a local site. A local centre would reduce the cost to the individual practitioner or to the manager. The cost o f a CPE event and whether managers gave study leave or financial assistance also featured high on the list of factors that influenced attendance. These findings support those of Mackareth (1989) and McCrea (1989). Midwives with domestic and family commitments may find it difficult to meet the cost of a CPE event plus the additional cost o f travel, time away from work and perhaps childcare. Rogers' (1987) survey identified that family commitments can hinder uptake o f CPE. The costs of CPE are increasing since the providers now function in a climate where income generation is allimportant. It is hardly surprising, then, that the support of managers facilitates attendance. Indeed, Heath (1980) found that attendance at staff development activities was heavily dependent on the support of service managers. There were many comments related to the cost o f CPE events. The expense that CPE entails was highlighted by a number of comments that demonstrate the difficulties that some midwives face if their employers do not share the responsibility for assisting their staff with meeting their CPE needs. However, there seems to be a greater willingness by midwives to contribute to the cost of CPE. Nearly 58% o f respondents in this study said they would be willing to attend in their own time. In a study by Clarke &tLees (]989), only 24% said they would attend in their own time. Eighty per cent also said they would be pre-
pared to contribute to the cost of an event. Many of the respondents felt that if they paid, the manager should give the time or vice versa, demonstrating a belief that the responsibility for CPE should be shared between manager and practitioner. This supports the findings of Allan (1989) who explored the question o f who is responsible for CPE. All but two o f the managers were extremely limited by the amount o f resources available to them. The managers reported that in the majority of cases it was possible to reach a compromise when faced with their staffs requests for support. If money was not available then study leave may be given or an attempt would be made to find a CPE event that did not cost, such as those offered by the training departments. Some argue that managers will choose the cheapest option without always giving full consideration to whether needs are being met (Casdedine 1992). Indeed, it does seem that for managers, cost is the bottom line. Midwives are encouraged to undertake courses run by training departments. Midwife managers in the study by Larcombe & Maggs (1991) reflected similar sentiments in that the statutory requirements for refresher courses used up all the available money. The managers recognized the importance of CPE and its contribution to both personal and professional growth and in meeting the service needs o f client care. The personal philosophy o f the managers was orientated towards seeing themselves as facilitators, helping midwives to recognize and fulfil their CPE needs. Nevertheless, all the managers believed that tlxe ultimate responsibility for professional development lay with the individual practitioner. The needs of the organization was an important factor that managers took into consideration in the decision of whether or not to support their staff. This assumed priority, with the needs of the individual taking second place for all but one of the managers. There did not seem to be any recognition that the needs of the organization and those o f the individual could be met at the same time. The managers felt that the midwives did not always appreciate the needs of the organization and the importance of feeding back into the unit the learning that had taken place as a result o f a CPE event. Moores (1984) also found that recognition of the value o f meeting individual and organizational needs simultaneously in terms o f resources had not filtered through to midwives. It seems then that little has changed in the last decade. The influence of a leading figure such as the manager is very important in supporting a learning environment, one which is conducive to change and open to experimentation (Carpentino 1990). Only two of the managers
Continuing education needs of midwives
discussed the importance o f n u r t u r i n g a climate conducive to change. Clinical staffin a study b y Larcombe & Maggs (1991) felt that managers were n o t supportive towards CPE. Allen (1989) highlighted that even w h e n managers allowed study leave and finance, this was n o t always equated with support. T h e r e must then be another element to support, that surely is the climate and culture o f an organization c o n ducive to learning. Hargreaves and D a w e (1990) discuss the importance o f a collaborative culture w i t h i n an organization if individuals are to learn from practice, from colleagues and be motivated towards professional development. Individuals w i t h i n such organizations display qualities such as trust, support and sharing. There needs to be overt praise and recognition o f achievement. T h e climate o f change and uncertainty over j o b security, and m a n a g e m e n t d o m i n a t e d b y financial priorities does n o t lend itself easily to this collaborative culture. Managers need to realize that a c o m m i t m e n t to C P E does n o t distract from getting the j o b done b u t enhances it. Staff d e v e l o p m e n t has b e e n equated with organizational efficiency ( U n s w o r t h - W e b b 1990). M o t i v a t i o n and sarisfaction w i t h w o r k is increased. There is a reduction i n costly staff t u r n o v e r (Basford & D o w n i e 1991). Indeed, H a n d y (1989) believes that education is the most important investm e n t that can be made.
CONCLUSION T h e findings from this study reinforce those o f other studies that have explored c o n t i n u i n g professional education for midwives. A n u m b e r o f other findings have n o t b e e n identified previously in the literature and this study highlights the value o f a local needs assessment if the midwifery education department is to meet the needs o f its clients. Perhaps one o f the most significant implications to arise from this study is the need for a collaborative approach to C P E b e t w e e n practitioners, managers and educationalists to ensure that an individual's needs are identified and met. W i t h the m o v e o f midwifery education into the realms o f universities, it is imperative that the difficulties that midwife teachers face in m e e t i n g their clinical c o m m i t m e n t s are addressed to ensure that educationalists are available to clinical staff. It is evident that support for midwives to c o n t i n u e their professional education is required from managers, educationalists and peers. In the present climate o f financial restraint, a collaborative effort is required to enable the practitioner to develop profession-
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ally and personally. This will also ensure that organizational needs are met, individual needs are recognized and practitioners can achieve satisfaction and fulfilment from their work. O n e way to fulfil this aim is to foster a climate conducive to learning, where individuals feel valued and change is encouraged.
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