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

Sarah Robinson

Although much importance is attached to continuing professional education for nurses, midwives and health visitors, there is a paucity of empirical studies on the subject. This article reviews research in continuing education for midwives and adds to the body of literature by reporting on findings on continuing education obtained in the course of a longitudinal study of midwives’ careers.

The original impetus for the study was concern about attrition from the profession; the method chosen to examine the problem was a longitudinal study in which two large cohorts of midwives were followed-up by means of questionnaires sent to them at regular intervals from qualification onwards. Information has been obtained on the relationship to retention of career intentions, careers followed and many aspects of life as a midwife. Those aspects relating to continuing professional education and development include obtaining post-basic qualifications, opportunities for in-service education, professional development during breaks for child care, support and feedback from senior colleagues and views on the importance of continuing education and support in relation to retention.

INTRODUCTION

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

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

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

featured in a number of previous publications

emanating from government departments and

161

162 NURSE EDUCATION TODAY

professional organisations (for example Briggs Commiteee 1972, Royal Commission on the National Health Service 1979, National Staff Committee 1981, UKCC 1984). In these two recent reports however, the UKCC and the ENB have sought to move the discussion forward, by outlining schemes whereby individuals can develop personal professional profiles of con- tinuing education achievements that contribute to career progress in a formally recognised way.

The ENB document advocates the develop- ment of ENB approved modular courses and programmes which in time would enable successful individuals to gain the qualification of a Higher Award certified by the Board. The document stresses the importance of support for practitioners in furthering their continuing edu- cation and in demonstrating learning outcomes in practice. Support for practitioners is also

highlighted in the UKCC document, in that it recommends a period of support for all newly registered practitioners in order to consolidate the knowledge and skill base gained by the time of qualification. The document includes a number of suggestions about continuing edu- cation opportunities after this initial period; these include a mandatory 5 study days within each 3 year period and a system of continuing education ‘credits’ as part of planned career progressions. Although differing in detail, both the UKCC and the ENB wish to see a much greater degree of planning and coordination in the provision of continuing education than has been the case hitherto.

In these two documents, as in many others that have addressed the subject, it is taken as given that continuing professional education of health practitioners enhances both the quality of care that they deliver and their own career develop- ment. However, a recent and comprehensive review of the literature on continuing education for nurses (Barriball et al 1992) has revealed a paucity of empirical studies on the subject. Consequently, little is known about nurses’ per- ceptions of their own continuing education needs, how many have attended courses, factors that facilitate or militate against doing so, and what effect, if any, continuing education has on patient care and individual careers.

This article seeks to add to the small volume of research that does exist by presenting some findings on continuing education that were obtained during a study of the careers of two cohorts of midwives. The project is part of a Department of Health funded research pro- gramme of a series of longitudinal studies of

health service staff, currently in progress at the Nursing Research Unit of King’s College, Lon- don University. The article begins by outlining opportunities for continuing professional development currently available to midwives, followed by a review of existing research on the subject. The aims and methods of the midwives’ careers project are then described, followed by those findings relating to continuing pro- fessional development. First, however, a com- ment on the terminology used in the article. As Barriball et al (1992) comment, there is no agreed definition of continuing professional education in the literature, and they go on to provide a useful summary of those that do exist. This showed that whereas most definitions refer to developing and expanding knowledge after initial registration, they differ in the approach taken to categorising aspects of this process. These include distinguishing between informal activities such as reading and self-directed study and formal activities like course attendance; and distinguishing between courses which service the needs of the employer and those which service the needs of the individual and the service. Two other definitions concerning continuing pro- fessional education are relevant to the findings in this article. Firstly, (following Rogers & Law- rence 1989) the distinction between courses provided by employers and/or other organis- ations which do not lead to nationally recognised certificates and post-basic qualifications which do lead to the award of such certificates. Secon- dly, the phrase ‘continuing professional edu- cation’ is sometimes used interchangeably with continuing professional development. In the careers research programme at NRU, the for- mer has been regarded as one component of the latter. While education may well be the main focus of professional development, other activi- ties are also an important part of this process; these include support for staff by means of a

NURSE EDUCATIOFU’ -lWDA\ 163

mentor or preceptor system, regular appraisal

or performance review of work, career guid-

ance, and further academic study that may

enhance analytic and critical skills.

CONTINUING PROFESSIONAL DEVELOPMENT IN MIDWIFERY

Post-basic qualifications available for midwives

include certificates, diplomas or degrees in edu- cation some at postgraduate level leading to

UKCC registration as a teacher of midwifery. The National Boards offer a number of courses

relevant to midwifery practice and education

and a variety of courses such as Diplomas in

Counselling and Certificates in Antenatal Edu- cation are also available. Many midwives have

f-urthered their professional development by

taking bachelor and/or masters degrees, usually in departments of nursing or education. Kecent years, however, have seen the introduction of

degrees in midwifery itself, at both undergra-

duate and masters level (Pendleton 1990), and a growing number of- midwives have been

awarded a doctorate for a dissertation on an

aspect of midwifery practice or education

(National Perinatal Epidemiology Unit 1991). Midwives have differed from nurses and

health visitors in that they are statutorily required to undertake refresher courses in order to continue in practice. Up until 1987

these always took the form of a 5 day course once every 5 years; since then two other options are

also available, namely 7 accumulated study days

in 5 years or a 2 week planned period of clinical practice with theoretical input. As noted earlier,

the UKCC is now seeking to introduce a manda- tory component into continuing education for nurses and health visitors as well (UKCC 1990).

In addition to statutory refresher courses, in-ser- vice courses on a range of topics relevant to midwifery are offered by university depart- ments, the Koyal College of Midwives, organis- ations such as MIDIRS, maternity units, individual health authorities, and NHS Trusts. Updating courses for those who are returning after a break are available in some areas and a recent innovation is the production of a distance

learning programme for midwives who have

been out of practice for a while (University of the

South Bank 1992). Research published to date on opportunities

for midwives to continue their professional development is relatively scant. Existing studies

focus on the provision and uptake of post-basic and in-service courses and on their content and structure. Little information is available on the

extent to which midwives’ needs are met, or on the impact, if any, that continuing education has

on quality of care and individual career pro-

gress. In this respect the situation is similar to

that found in relation to continuing education in

nursing by Barriball et al (1992).

Turning first to post-basic qualifications, then the Midwife Teacher’s Diploma has been the

focus of two published research projects (Kilty &

Potter 1975, Balch 1982). The first of these was commissioned in response to concerns about the

examination failure rates of students in the early 1970s (Kilty & Potter 1975). Following discuss- ions with an ‘expert group’, the authors identi-

fied several areas that might be relevant to the

low pass rate, four of which were then investi-

gated in the course of a multi-method project.

Firstly, by means of questionnaires completed by

midwives attending a refresher course (n = 33), midwives attending a practical teachers course (n

= 22) and interviews with groups of midwife teachers (n not stated), potential deterrents to

course application were identified. These included the high failure rate, difficulties in

obtaining secondment, lack of guidance about

teaching as a career, lack of information. about

the course and problems in combining course attendance with family commitments. Secondly, interviews with small groups (numbers not

given) of senior midwife teachers, course tutors, MTD students and examiners, together with

observation of the oral part of the final examin- ation showed that many of the changes occurring in the midwife’s role in the 1960s and 1970s were reflected in course aims and objectives, but that the same was not true of the written and oral examinations. The content of both examinations was in some respects poorlv matched to course objectives.

The third part of the project focused on the

164 NURSE EDUCATION TODAY

examination itself. Analysis of written material and observation at oral examinations, demon- strated that the marking scheme was weighted towards failure and that lack of agreed criteria led to inconsistency of marking between exam- iners. Finally the possible relationship of student variables to pass rates was studied by means of examining records for 77 students from 3 colleges. These data revealed no significant asso- ciation of pass rates with age or previous mid- wifery experience. However, interviews with tutors revealed concerns that some students embarked on the course with inadequate basic midwifery knowledge and that this contributed to the high failure rate.

The Kilty & Potter project is noteworthy because of the way in which it addressed many aspects of the MTD course, particularly those that might have a bearing on the course pass rate. Many of the ensuing recommendations were implemented, in particular those concern- ing the content and conduct of the examination system, the need for a longer course and one with a greater emphasis on educational as opposed to professional subjects, and the need for greater pre-course preparation.

The second published research project on the Midwife Teacher’s Diploma focused on views and experiences of those who had taken the course at the Royal College of Midwives during the period 1975-79 (Balch 1982). Ques- tionnaires were sent to 60 midwives who had taken the course and subsequently worked as tutors; and 80% (48) were returned. Findings showed that enjoyment of teaching was specified most frequently (23) as the reason for taking the course. When asked about their expectations of the course, learning about teaching and increas- ing professional knowledge were each men- tioned by the same number of respondents (29). The author commented in particular on the latter finding, given that the course emphasis was ostensibly educational. However, given the prominence of professional as opposed to edu- cational topics in the course (Kilty & Potter 1975), it is perhaps not surprising that a majority of Balch’s respondents perceived that atten- dance would increase their professional know- ledge. 28 of the respondents felt that the course

had prepared them well for the role of teacher, with a further 16 having found the preparation adequate. Most respondents had found teaching practice stressful in some way but this was outweighed by various benefits such as seeing the attitude of tutors (17), seeing a school func- tion (15), relating theory to practice (10) and seeing the role of the tutor (13). When respondents were asked to recommend changes to the course, two of the five that came up most often corroborated Kilty & Potter’s conclusions: namely the need for a period of pre-course preparation and for the course itself to be lengthened.

Concern about the paucity of post-basic mid- wifery courses available in Wales led Maclean (1980) to undertake a survey of midwives’ views as to the importance of continuing education generally and their experiences of the avail- ability and uptake of both post-basic and in-ser- vice courses. Information was obtained from a questionnaire sent to a 10% random sample of midwives in practice in Wales plus all the mid- wifery tutors working there; an 88% response rate overall was achieved (n = 147). Findings demonstrated a lack of available courses in some areas, but also inaccurate knowledge as to what was available. The view that their own pro- fessional education was not complete, and that continued study was of benefit to career develop- ment and to the quality of care delivered were expressed by over 80% of respondents. The published findings do not provide an overall figure for the number of midwives in practice who had attended an in-service and/or a post- basic course since qualifying, but do show that the number who had attended each kind of course was small, ranging from 37% for Family Planning Appreciation courses to 2% for the Advanced Diploma in Midwifery (Maclean 1980).

Respondents in Maclean’s study were asked to specify the kinds of course for which they felt the need was most urgent, and short courses on keeping up-to-date were cited most frequently (52%). Some of the recommendations that Maclean made on the basis of this study were well ahead of their time; most notably that each midwife needs a planned professional develop-

NURSE EDUCATION TODA\r 165

ment profile, newly qualified midwives need a first year programme of regular study days, and that post-basic courses should also be provided

by means of distance learning packages (Maclean 1980).

A number of smaller scale studies have also been undertaken, each focusing on in-service education for midwives in one health district/ area (Sugarman 1988, McCrea 1989, Clarke & Rees 1989). Sugarman’s study was prompted by concerns about decreasing levels of attendance at a series of study days provided specifically for staff midwives. Questionnaires were sent to the 59 staff midwives employed in one health district; findings from the 42 who replied indi- cated the study days were perceived as useful and enjoyable but that respondents were often precluded from attending by family responsibili-

ties and, to a lesser extent, by short staffing on their wards.

In a study to redress the lack of information about continuing education for midwives in Northern Ireland, McCrea (1989) investigated the participation of midwifery sisters and staff midwives in formal continuing education oppor- tunities, such as courses and study days, as well as time spent reading journals and using libraries. Responses from 43 midwives, representing a 72% return from a sample in one area health board in Northern Ireland, showed that only 13 had attended courses, other than refresher courses. McCrea, like Sugarman (1988) found that family responsibilities and staffing levels militated against course attendance; but many respondents also said that encouragement from managers to attend courses was not always forthcoming. The majority of respondents said that continuing education was important for the profession, although McCrea, like Maclean (1980), found that a minority of respondents lacked motivation to personally attend courses.

In order that a proposed programme of continuing education for midwives in South Clamorgan should meet staff needs, Clarke & Rees (1989) sought information from the district’s 178 midwives on their experiences of continuing education to date and views about which topics would be of most use in future courses. The overall response rate was low at

56%. This was primarily attributable to a very low response rate from night staff, which as the authors comment, might well reflect a lack of access to courses for this group. Findings showed that nearly all respondents said there was a need for a set programme of continuing education, and were more likely to support compulsory rather than voluntary attendance. Findings on previous attendance showed that 63% of respondents overall had attended a course in the last year, but that this varied by grade; hospital sisters were most likely to have done so. com- munity midwives and newly qualified staff the least likely.

,411 respondents were given a list of five broad topic areas and asked to rate them from ‘of a great deal of interest’ to ‘no interest’in relation to forming the content of future continuing edu- cation courses. Clinical practice was the topic most likely to be cited as ‘of greatest interest’ to respondents (84%), and supports Maclean’s 1980 findings in this respect. The $ of respondents rating other topics as ‘of great interest’ were 62% for teaching and assessment, 54% for communication skills, 37% for manage- ment and 36% for personal development (Clarke & Rees 1989).

The priority that respondents give to includ- ing clinical topics in continuing education courses was also demonstrated by a survey of midwives’ views on the content of refresher courses (Parnaby 1987) undertaken in response to concerns about the usefulness of these courses (Mander 1986). Questionnaires were sent to all senior midwife teachers in England (n = 149) and all midwives attending one refresher course (n = 119); both groups were presented with a total of 45 topics and asked to rate their import- ance for inclusion in the refresher course curri- culum. Findings from respondents ( 14 1

midwifery teachers and 117 refresher course members) showed that 14 topics were rated by 50% or more as being essential for curriculum content. The most highly rated topics of the 14 was ‘recent changes in midwifery practice’ (90%), and this was followed by new policies/ rules of statutory bodies (83%) and new government legislation on reports related to midwifery practice (83%). The majority (88%) of

166 NURSE EDUCATION TODAY

both groups said that refresher courses should

offer participants a choice of sessions. Parnaby proposed three solutions as to how this could be

achieved: by parallel sessions on existing

courses; by offering specialist refresher courses,

or by allowing midwives to chose a number of

separate courses that they perceived as relevant to their continuing education needs (Parnaby

1987). As noted earlier, the last option and other alternative modes of refreshment have now been introduced as an alternative for those who do not

wish to attend a course of 5 consecutive days. The view that continuing education has a

positive impact on patient care is stressed in the

recent documents produced by the UKCC (1990). However, as Barriball et al (1992) con-

clude from their review of the continuing edu-

cation literature, few studies exist that have attempted to examine the veracity of this asser-

tion. One notable exception in the research literature on midwifery education is Murphy-

Black’s study of the effect that a course on

antenatal education had on participants’

teaching styles (Murphy-Black 1985, 1991). The course philosophy emphasised the value of

group work and interactive teaching methods

and the research sought to determine whether expectations of course members were met and to

assess course outcome by means of an observa-

tion study of participants pre- and post-course

teaching styles.

Expectations were studied by means of ques- tionnaires given to course members (n = 65) at two centres: responses from a 94% pre-course return and a 78% post-course return showed a high degree of satisfaction, with most partici-

pants saying they had learnt about teaching,

leading a group and communicating with women. The observation study was carried out with a third of the course members and used Flanders Interaction Analysis Categories (Flan- ders 1970). Findings showed a small post-course increase in interactive teaching and this difference reached a significant level for those members who had chosen to go on the course as opposed to being sent. This finding may have important implications for selection of partici- pants, if resources invested in course provision are to be cost-effective. Murphy-Black argues

that evaluation studies comprising process

measures only are useful to identify strengths

and weaknesses of a course, but satisfaction with

a course, does not necessarily mean there will be any subsequent change in practice. Outcome

studies are needed to assess whether or not this is the case (Murphy-Black 1991).

An area neglected until relatively recently is the continuing education needs of practitioners who are not working for reasons such as child

care or a period of unemployment. Recognising

the potential importance that opportunities for continuing education, may have on encouraging

a return to work, the Department of Health

(1988) has recommended the implementation of

‘keeping in touch’ schemes. Views of non-wor-

king midwives in this respect have recently been explored in a small scale interview study (n = 10) by Midgeley (1993). The findings showed that 9

members of the group would be interested in a ‘keep in touch’ programme for midwives, and that learning methods favoured were learning

packages (8), attending midwives’ study days (8),

loan of videos (7) and tutorial groups with clinical and teaching staff (6). 9 respondents said

that it would be important for such a programme

to attract credit accumulation.

Finally, research on aspects of professional development for midwives, such as mentorship

and career guidance, is notable by its absence, although a number of unpublished studies are

recorded in the Midwifery Research Database (National Perinatal Epidemiology Unit 1991).

THE MIDWIVES’ CAREERS PROJECT: AIMS AND METHODS

The studies reviewed above have all focused solely on continuing education for midwives and/or other aspects of their professional

development. Data on these topics have also been obtained in the course of the Nursing Research Unit’s project on careers of midwives; they were not, however, the only focus of the project which has in fact provided information on many aspects of life as a midwife. In this section the aims and methods of the project are described in order to provide a context for the

KUKSE EDU(:A-I-ION TOD.4\ 167

findings on continuing professional develop- ment. The project has followed the careers of

two cohorts of midwives from the time of qualifi- cation onwards; the first cohort qualified in 1979, the second in 1983. To date three phases of data collection have been undertaken with a fourth planned for the near future.

Phase 1

The focus of the first phase of the project was primarily educational, in that it sought to estab- lish whether extending midwifery training from 12 to 18 months led to the ‘hoped for’ increase in qualified midwives feeling adequately prepared to practise, and in the number who intended to do so (Stewart 1981). Questionnaires were sent to 932 midwives who qualified in 1979 after a 12 month course, representing a quarter of those qualifying that year. Then the same ques- tionnaire was sent to 93 1 midwives who qualified in 1983 after an 18 month course, also rep- resenting a quarter of the year’s qualifiers.

A national survey by questionnaire was the method of choice for several reasons. Large numbers were needed to determine whether significant differences existed between the two cohorts in relation to views about training and career intentions. A national sample was required in order to militate against biases that might result from only including particular catchment areas of students and types of

training school. Questionnaires were the only feasible method of data collection given the numbers involved and the geographical disper- sion of the two cohorts. Following the initial questionnaire and one reminder letter, response rates of 84% (782) and 89% (828) were achieved for the two cohorts respectively.

Phases 2 and 3

Phase 1 of the project was not undertaken originally with the intention of following-up the two cohorts further in the years after qualifica- tion. Concern had been growing from the early 1980s onwards however, about attrition from the nursing and midwifery workforce (Royal College of Midwives 1985). In response to this, it

was felt that information from these two cohorts about their post-qualification experiences might usefully contribute to an understanding of factors associated with attrition that would be relevant to all midwives, whatever their route to registration.

Consequently in 1986, Phase 2 of the project was undertaken and all members of both cohorts were sent a short questionnaire asking for details of their activities since qualifying as a midwife and for some demographic details. If they had not practised as a midwife they were asked to say why this had been the case. Those who had

practised as midwives were then sent a second questionnaire that asked for various details of each post held and courses taken, individual views and experiences in relation to the problem of retention, and future career intentions. 3 years later in 1989, Phase 3 of the project was carried out. All those who had responded in Phase 2 were contacted again and sent a ques- tionnaire that asked for information about

various aspects of posts held and courses taken since 1986, together with future career intentions and demographic details.

Attrition and representativeness

Longitudinal studies pose considerable prob- lems of method; in particular that of attrition at each phase with possible loss of representa- tiveness of respondents (Douglas Bc Blomfield 1973, Hoinville et al 1978, Goldstein 1979.

Cohen & Manion 1980). Consequently every effort was made to maximise response rates in Phases 2 and 3 of the project. Strategies included the following: developing and testing ques- tionnaires with a pilot group to ensure that they were valid, reliable and of acceptable length; checking reliability of addresses; enclosing short feedback reports to maintain interest; sending reminder letters and duplicate questionnaires to every known address, and asking those who had responded if they could help us to contact members of their set who were non- respondents.

Response rates for longitudinal studies can be presented as a proportion of- the total cohort eligible to reply or as a proportion of those

168 NURSE EDUCATION TODAY

Table 1 Response rates at Phases 1,2 and 3 of the Midwives’ Careers Project

Phase 1 197W983 Number in cohort Number returning the questionnaire at qualification Phase 1 response rate

Phase 2(a) 1986 Number sent Phase 2(a) questionnaire Number returning questionnaire Response rate as proportion of cohort

Number returning a Phase 1 and a Phase 2 questionnaire Response rate as proportion of Phase 1 respondents who returned a Phase 2

questionnaire

Phase 2(b) 1987 Number who had practised midwifery by 1988 and sent a Phase 2(b)

questionnaire Number returning questionnaire Response rate as proportion of number sent

Phase 3 1989 Number who had pracbsed midwifery by 1986 and sent a Phase 3(a)

questionnaire Number returning questionnaire Response rate as proportion of number sent

Number who had not practised midwifery by 1988 and sent a Phase 3(b) questionnaire

Number returning questionnaire Response rate as proportion of number sent

1979 cohort 932 782 84%

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

394

319 87% (3191394)

394

288 73% (288/394)

96

80 83% (80196)

1983 cohort 931 828 89%

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

524

431 82% (431/524)

524

407 78% (4071524)

57

38 67% (38/57)

responding at the previous phase. Both of these

are shown for this project in Table 1. In Phase 3 it was considered wasteful of time and money to

send questionnaires to those who had not replied in Phase 2 and so only those who had done so were sent a Phase 3 questionnaire. At certain phases of longitudinal studies different ques-

tionnaires are sometimes sent to particular sub- groups, whose subsequent response rates may then vary. In this project those known to have practised midwifery by 1986 were sent a slightly different questionnaire in Phase 3 to those known not to have done so; response rates are

shown separately for the two groups. Some information was obtained from the

UKCC database about non-respondents in order to assess the representativeness of respondents. Taking the cohort as a whole, this showed that 66% of the 1979 cohort known to have practised midwifery by 1986 had responded and that the

corresponding figure for the 1983 cohort was

79%. Table 1 shows that a high proportion of the Phase 2 respondents who had practised mid-

wifery, responded in 1989 at Phase 3. Confi- dence can therefore be placed in the reliability of findings relating to experiences as a midwife.

Questions on continuing professional development

Phase 2 of the project explored many aspects of life as a midwife including continuing pro-

fessional development in the years since qualifi- cation. Some of the questions in this respect were also included in the questionnaire used for Phase 3 in 1989. By this time however, another major focus of interest had come to the fore: namely the problem of combining work as a midwife with family responsibilities and keeping in touch

NURSE EDUCATION TODAY 169

Table 2 Post/basic qualifications obtained and sought

Qualifications

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

Column 1 Column 2 Obtained since Plan to study for

qualifying in the future 1979 1983 1979 1983 cohort cohort cohort cohort (n = 319) (n = 431) (n = 101) (n =120)

19 6 24 55 9 5 15

Health visiting Health visitor’s certificate 41 26 13 30

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

6 3 2 2 8 - -

1 -

6 7 3 6 6 2 6 7 1 - - -

- - 7 4 1 -

Degrees in subjects other than nursing or midwifery Bachelor 2 2 19 16 Masters -

with professional developments while taking a break from full-time employment. In order to keep the questionnaire to a manageable length and maximise chances of maintaining high response rates it was not feasible to include all the Phase 2 questions in the Phase 3 ques- tionnaire, in addition to the new ones indicated by this time. Consequently some of the findings on continuing professional development relate to Phases 2 and 3, whereas others relate to Phase 2 or Phase 3 only. The six topics explored were:

1.

2.

3. 4.

5.

6.

Obtaining post-basic qualifications (Phases

2 and 3) Opportunities for in-service education

(Phase 2) Undertaking part-time study (Phase 2) Professional development during breaks for child care (Phase 3) Satisfaction with support and feedback from senior colleagues (Phase 2) Views on the importance of continuing education and support in relation to reten- tion (Phases 2 and 3).

FINDINGS

Obtaining post-basic qualifications

In Phase 2 of the project, respondents were asked whether they had obtained any of the qualifications listed in Table 2 since qualifying. The numbers who had done so (column 1 of the table) show that the Health Visitor’s Certificate was the most likely qualification to have been obtained; by 41 of the 1979 respondents and 26 of the 1983. 19 members of the 1979 cohort had obtained the Advanced Diploma in Midwifery, 9 of whom had then taken the Midwife Teacher’s Diploma. The 1983 cohort having only been qualified for 3 years by this time were less likely to have attained the ADM and none had prac- tised long enough to have completed the Mid- wife Teacher’s Diploma.

In a subsequent question all respondents were asked if they planned to study for any qualifica- tions in the future. Those who said ‘yes’ (32% of the 1979 respondents and 29% of the 1983) were then asked in an open-ended question to specify

170 NURSE EDUCATION TODAY

the qualifications they had in mind. Column 2 of Table 2 shows the number who specified each of the qualifications listed in the earlier question; and in both groups the Advanced Diploma in Midwifery occurred most frequently. Health visiting was still more likely to be specified than any of the branches of nursing and if intentions are translated into practice, then each of the two cohorts would have produced just over 50 health visitors. When asked their reasons for leaving midwifery for health visiting, more suitable hours and the opportunity to practise with a greater degree of autonomy were mentioned most often.

The number of respondents who said they wanted to study for a degree is of interest. At the time of Phase 2 (1986) there were no oppor- tunities for midwives to pursue midwifery to degree level, although the need for a masters degree was advocated as long ago as 1979 (Ward & Adams 1979). This study shows however, that a total of 26 of the 101 1979 respondents who planned to study further wanted to do so at degree level with a corresponding figure of 201120 for the 1983 cohort. As noted in section 2 of this paper, a number of undergraduate and postgraduate degrees in midwifery are now available and later phases of the study will show how many members of the two cohorts have obtained, or plan to obtain, a place on one of these courses.

Some of the comments made by respondents to Phase 1 of the project drew attention to a perceived shortage of midwifery teachers and a lack of clinical teaching for student midwives (Robinson 1986). Concern about a shortage were raised by Standon-Batt (1979) who calculated that the number of tutors qualifying each year was 23 short of the number needed and as noted, Kilty SC Potter (1975) had earlier looked at deterrents to recruitment to the course and factors related to high failure rates in the exam- ination. Findings from the Midwives’ Careers Project show that if the Table 2 column 2 figures are translated into practice then 14 midwives from the 1979 cohort would have become teachers and 15 from the 1983. The Phase 3 findings show that by 1989 14 of the 1979 cohort and five of the 1983 cohort were in fact working

as midwife teachers. Again further phases will show if these numbers increase over time.

All respondents were asked if they had successfully completed any National Board courses since qualifying as a midwife. A quarter (79) of the 1979 respondents had done so in the 7 years since they qualified and 13% (57) of the 1983 respondents had done so in the 3 years since they qualified. The two courses most likely to have been taken were Special and Intensive Care of the Newborn (44) and Family Planning (47). An extremely wide range of other ENB (in some cases JBCNS) courses had been taken, but each by four or less respondents. Special and Intensive Care of the Newborn and Family Planning were also the two ENB courses most likely to be specified as those that respondents would like to take in the future.

Opportunities for in-service education

In Phase 2 all participants were asked whether they had attended any in-service courses rel- evant to midwifery since qualifying as midwives; these courses were defined as those organised by the respondent’s hospital or employing authority, but which received no nationally recognised certificate. Less than half had in fact done so; 41% of both cohorts. This is a larger proportion than that found by McCrea (1988) but smaller than those found by Sugarman (1988) and Clarke & Rees (1989).

All respondents were asked if they felt there was a need for greater provision of in-service courses for midwives, whether or not they them- selves had attended a course. Table 3 shows that over 70% of those respondents who had atten- ded in-service courses and over 70% of those who had not done so perceived a need for greater provision of such courses. This finding indicates the importance attached to continuing education by midwives and supports those of other studies (Maclean 1980, McCrea 1979, Clarke & Rees 1989).

Respondents who had attended in-service courses were asked to specify the main topics of each; these were then grouped into the catego-

NLTKSE EDU(:A’I‘IOK TOI)4k 171

Table 3 Attendance at in-service courses for midwives by views on need for greater provision of such courses

Greater provision needed of in-service courses for midwives

1979 cohort who had: 1983 cohort who had: attended not attended attended not attended courses courses courses courses

% No % No % No % No

Yes 74 97 77 129 74 131 71 164 No 17 22 15 26 14 24 13 31 No answer 9 12 8 13 12 21 16 37 Total 100 131 100 168 100 176 100 232

Table 4 in-service courses: subjects of courses attended and courses wanted

Subject of course

Column 1 Column 2 Respondents Respondents

attending wanting courses courses

1979 cohort 1983 cohort 1979 cohort 1983 cohort (n = 131) (n = 176) (n = 226) (n = 295)

No No No No

(A) Clinical updating Generally Technology in particular

(B) Specific aspects of care Antenatal Parent craft Care in pregnancy Ultra-sound

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

Active birth etc

Postnatal care Feeding Family planning Neonatal deaths Child abuse Special care

(C) Other topics Management Midwifery/nursing process Counselling Communication Education (learning,

teaching, assessment) Health education Research Legal issues Aids Extending the midwife role

8% 10

27% 35 16 4

1 1 11 24 6 5

10 19 7 15

13 14 5 18 7 6

36% 47 38% 66 7% 16 9% 29 18 23 4 3 12 19 26 37 9 8 15 15

16 8 10 3

2 - 4 3 5 6 9 15 - -

- - 17 30 13 8 14 15 6 20

1% 2 -

53%

1 103

17

4% 9 11% 33 9 19 6 12

1

20 -

8 8

27 23

18 27 9 8 1 -

27 15 - ._

53% -I

110 47

6 -

19 _

16 16 17 23

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

172 NURSE EDUCATION TODAY

ries shown in Table 4. The figures in column 1 show that for both cohorts, management courses

were the most likely to have been attended, followed by parent craft. All respondents were

asked to specify the topics that they would like to see addressed at future courses. As in Maclean’s

(1980) study, this was an open ended question; respondents were not provided with a list of

possible topics to rate in terms of importance for inclusion, as were those who participated in the

studies by Parnaby (1987) and Clarke & Rees

(1989). Topics specified for future courses were also

allocated to the categories shown in Table 4, and

the number of respondents listing topics in each

category is shown in column 2. Taken together, the two colums reveal some interesting differ-

ences between the frequency of topics of courses taken and those desired in future. Management

courses had been taken by just over a third of each group but desired in future by less than

10%. Very few respondents had attended courses concerned with clinical updating (8% of the 1979 group and 1% of the 1983), this

however was the topic listed by far the most

frequently as desired in the future; by just over

half of both groups of respondents. This accords with findings from other studies in which mid-

wives have been asked what topics they would like included in future courses (Maclean 1980,

Parnaby 1987, Clarke & Rees 1989). This is perhaps not surprising given the rapid develop- ments in the management of childbirth and the new policies and procedures with which mid-

wives need to become familiar. Moreover, the

research literature on continuing education for

Table 5 Satisfaction with the provision of in-service education

nurses, similarly reveals an emphasis on clinical practice topics when respondents are asked for

their views about future course content (Barri- ball et al 1992).

Midwives’ satisfaction with the provision of

in-service education in each midwifery post held since qualification was also explored in this

study. Each midwife was sent a separate set of questions for each post held, and these asked

about various aspects of life as a midwife includ-

ing in-service education. A 5 point rating scale was provided (1 = very dissatisfied to 5 = very

satisfied) and the option of not applicable, was

included when appropriate. A mid point (3) of

‘neither satisfied or dissatisfied’, was included so that respondents who were not satisfied, were

not forced to express dissatisfaction. As experiences and views often varied con-

siderably from post to post it would have been

meaningless to have worked out an average for each respondent for the rating given to each aspect listed. Percentages in Table 5 therefore relate to ‘posts held’ and not ‘individual’;

findings are presented separately for first post and subsequent posts.

Although the figures do not reach a majority,

they do indicate a substantial degree of dissatis-

faction; with totals of 48%, 34%, 40% and 35% for being ‘very’ or ‘fairly dissatisfied’ with the provision of in-service education in first and subsequent posts held by the two cohorts. These

figures are consistent with other findings on in-service education from this project; namely less than half of the respondents having atten-

ded a course, and 70% saying that there should

be greater provision.

Satisfaction ratings

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

Posts held by 1979 cohort 1983 cohort

First Subsequent First Subsequent % % % %

2 9 13 13 25 27 22

18 20 16 16 23 27 30 31

6 12 9 11 8 8 5

319 514 431 37:

NURSE EDUCATIOK TODA\ 173

Part-time study

Midwives were asked whether or not they had undertaken any part-time study since qualifying. A total of 26% (82) of the 1979 respondents had done so in the 7 years since qualifying, 63% of whom had taken two or more courses. 13% (58) of the 1983 respondents had studied part-time in the three years since they qualified, the majority of whom (46) had taken one course only. All these respondents were asked why they had taken the courses; interest in the subject was cited most frequently (over 70% in each instance), followed by relevance to longterm career objectives and then relevance to post held at the time. Most of these respondents held full-time midwifery posts while they were studying part-time; for 70% of courses attended, they had been allowed to do so during working

hours.

Keeping in touch while having a break for child care

Opportunities to keep in touch while having a break for a period of child care, and refresher courses to update skills and knowledge upon return are important aspects of continuing pro- fessional development for any health prac- titioner. Both strategies have been identified as important in encouraging a return to practice (Department of Health 1988). As noted earlier the issue of combining work as a midwife with

family responsibilities was explored in greater depth in Phase 3 of the project (1989) than in Phase 2 (1986). Respondents in Phase 3 were asked whether they had left midwifery for family reasons and then subsequently returned. Further questions, relevant to professional development, included whether employers had kept in touch during breaks about developments in the field, and whether respondents had subse- quently attended a refresher course.

By 1989, the 1979 respondents had taken a total of 129 completed periods of absence from midwifery, and the corresponding figure for the 1983 respondents was 157. Employers had pro- vided opportunities and facilities for midwives to

in less than 10% of these periods of absence; 6%

of those taken by the 1979 cohort and 9% of those taken by the 1983. Of those periods in which opportunities had not been available, for 52% of those taken by the 1979 cohort, respondents said that they would have liked some form of contact; the corresponding figure for the 1983 cohort was 64%. It appears there- fore that during the majority of breaks for child care, midwives did want to keep in touch with professional developments, but certainly up until 1989 little provision in this respect had been made.

In relation to 25% of the periods of absence taken by the 1979 cohort and 30% of those taken by their 1983 counterparts, respondents atten- ded a course to refresh their midwifery skills and knowledgejust before orjust after they returned to work. A substantial majority of those who had

not attended a course said that the break was not long enough for one to be necessary (86% for the 1979 cohort and 80% for the 1983).

Support and feedback for midwives

As the UKCC has recently reiterated, regular feedback on work from senior colleages is recog- nised as important for professional development and particularly for newly registered prac- titioners (UKCC 1990). Respondents in this study were asked therefore to rate their satisfac- tion with feedback received during each mid- wifery post held since qualification. Table 6 shows that although respondents were more likely to be satisfied than dissatisfied with feed- back, nonetheless there was a substantial mino- rity of posts for which this was not the case. For 27% of first posts held by the 1979 cohort and 31% held by the 1983, respondents had been ‘very’ or ‘fairly’ dissatisfied with feedback. Corresponding figures for subsequent posts were 2 1% and 22% for the two cohorts respec- tively.

Professional development and retention

keep in- touch about professional developments One of the main objectives of the study at Phases

174 NURSE EDUCATION TODAY

Table 6 Setisfection with feedback on work from senior colleages

Satisfaction ratings

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

Posts held by 1979 cohort 1983 cohort

First Subsequent First Subsequent % % % %

11 6 9 7 16 15 22 15 28 19 27 19 36 37 31 35

7 19 10 17 3 4 1 6

319 514 431 379

2 and 3 was to obtain midwives’ views about strategies to encourage retention in the profes- sion. Of particular interest is the importance

accorded to continuing education and other

aspects of professional development in encouraging retention when compared with

other aspects of working as a midwife. In mid-

wifery, as in nursing (Barriball et al 1992) little empirical work exists on this subject. In this

study a list of possible strategies was identified from the literature and from pilot work; each

respondent was asked to circle all those that she felt to be relevant and then to list the five she

thought most important. The findings for Phases 2 and 3 were very similar for this question

and so Table 7 shows the Phase 3 findings only,

as these are the more recent views of the two

cohorts on this subject. Pay, staffing, lack of creche facilities and

flexible hours feature most prominently, both in the factors circled and those included in the five

most important. However, more than half of all respondents circled more support for newly qualified midwives and increased provision of in-service education, and just under half

included more refresher courses for updating of skills. Each of these aspects of professional development was regarded as one of the five most important by some respondents, in particu- lar more support for newly qualified midwives.

Findings from this study indicate that substan-

tial proportions of respondents do regard pro- fessional development as an important factor in encouraging retention. Given the range and complexity of issues that may surround a deci- sion to leave, the extent to which the availability of opportunities for professional development is

actually related to retention would, however, be very difficult to determine.

CONCLUSION

The Nursing Research Unit’s longitudinal study

of the careers of two large cohorts of midwives,

has produced a number of findings on con- tinuing professional development of interest to those in practice, education and management.

Obtaining post-basic qualifications (Table 2), attending in-service courses and combining part-time study with work had each been experi-

enced by a small proportion of midwives. In a

substantial minority of midwifery posts,

respondents were dissatisfied with the avail-

ability of in-service education (Table 5). More- over, more than 70% of both cohorts wanted a greater provision of in-service courses, relevant

to their work (Table 3) with clinical topics specified most frequently (Table 4). Some degree of dissatisfaction was evidenced in rela- tion to support and feedback for staff (Table 6).

Midwives who had taken a break in order to care for children, were unlikely to have been pro- vided with opportunities to keep in touch during this time, although the majority would have welcomed the opportunity to do so. At both Phases 2 and 3 (Table 7) the provision of

in-service education and support for newly qualified staff featured as important in encouraging retention in the profession. Many of the findings from the project support those from other studies of the subject.

Midwives have broadly welcomed the recent UKCC and ENB proposals for a more systematic

NURSE EDU(:ATION TODAY 175

Table 7 Views on factors thought to be important in encouraging midwives to stay in and/or return to midwifery

1979 cohort (n = 288) 1983 cohort (n = 407) % listing % listing reason in % circling reason in % circling 1 st five reason 1 st five reason

Professional development More support for newly qualified midwives from senior 37 62 35 67

staff Better promotion prospects 28 51 30 59 Increased provision of in-service education 17 51 15 58 More refresher courses for updating of skills 27 49 15 45

Professional responsibility Less involvement of medical staff in decision-making in

normal maternity care More opportunities to provide continuity of care Less technological intervention in childbirth A management structure that ensures midwifery

35 62 40 66

31 63 30 66 14 43 18 45 28 63 23 67

services are managed by midwives

Family commitments More flexibility in working hours to fit round family 63 83 61 82

commitments Creche facilities 51 83 54 87 Setting-up bank schemes 21 51 13 52

Conditions of service Increased levels of pay Increased pay for living in high cost areas Better staffing levels Better accommodation facilities provided by health

63 77 8 30

58 77 4 19

68

G 3

86 34 86 19

authority Car parking facilities 31 18

and relevant programme of continuing pro- fessional education and development (West 199 1, Sleep 199 1). For the midwifery profession in particular, continuing professional develop- ment may well increase in importance if the recommendations of the recent report of the Maternity Services Committee are implemented and midwives are able to practise with a greater degree of autonomy than in recent decades (House of Commons Select Committee 1992). To ensure that these programmes meet staff and service needs, however, a greater volume of empirically based studies on the subject is required than has been undertaken hitherto.

Although the volume of research in midwifery has increased substantially overall, education has been relatively neglected in comparison with practice and management (Robinson et al 1989). The usefulness of refresher courses, the content

of in-service courses, the value of a mentorship system, factors that militate or facilitate mid- wives in obtaining post-basic qualifications and attending in-service courses, and the provision of career guidance are all subjects that merit further investigation. Subsequent phases of the Midwive’s Careers Project will continue to add to the existing body of knowledge on some of these subjects, but a wider range of more detailed studies is also required.

Acknowledgements

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

176 NURSE EDUCATION TODAY

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