RESEARCH

 

Exploring student midwives' experiences regarding completion of the midwifery register at a nursing college in Eastern Cape Province, South Africa

 

 

W N T Sogobile^I; S H Khunou^II

^IDiploma in Nursing Science (General, Community, Psychiatry) and Midwifery, BA Cur (Nursing Administration and Nursing Education), Advanced Diploma in Midwifery, Nursing Science and Neonatology, MA (Midwifery); Lilitha College of Nursing, Gqeberha, South Africa
^IIPhD (Nursing), MA (Nursing), BA Cur (Health Service Management and Nursing Education), Diploma in Nursing Science (General, Community, Psychiatry) and Midwifery Department of Health Studies, College of Human Sciences, University of South Africa, Pretoria, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND. The midwifery register forms part of basic nursing education. Notably, student midwives struggle with completion of the prescribed midwifery register.
OBJECTIVE. To explore and describe the experiences of student midwives regarding their completion of the midwifery register at a nursing college in Eastern Cape Province, South Africa.
METHODS. This qualitative study had an exploratory, descriptive, contextual design, and in-depth individual interviews were held. Tesch's method was used to analyse data.
RESULTS. Three themes emerged, i.e. positive experiences related to completion of the midwifery register; negative experiences regarding completion of the midwifery register; and factors that contributed to the lack of completion of the midwifery register.
CONCLUSION. The study findings recommend greater collaboration between different stakeholders to improve skills acquisition and completion of the midwifery register.

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During training, student midwives are obliged to complete a midwifery register - a critical requirement, as it provides evidence of successful skills performance. The midwifery register is a training record that reflects documentation of practical skills that student midwives should master.^[1] Successful completion of this register validates that the student midwife has met the minimum practical requirements as prescribed by the South African Nursing Council (SANC).^[2] Prescripts of the midwifery curriculum necessitate that the student midwife be deemed competent in a minimum of 16 procedures in a period of 1 000 hours,^[11 after which the register is endorsed by a registered midwifery lecturer as confirmation that the SANC-prescribed practical skills requirement has been met. Therefore, the student midwife must complete and document all stipulated skills in the midwifery register before graduation.

Problems with completion of the midwifery register have been directly linked to various factors related to inadequate experiential learning. The negative attitude of qualified midwives towards students has led to an ineffective acquisition of skills, which in turn impacts the completion of the register.^[3] Units that are overcrowded because of student midwives from different nursing education institutions (NEIs) and lack of time have also resulted in non-completion of skills.^[4,5] The increased number of midwifery students in maternity units has created a competitive atmosphere.^[5] Furthermore, student midwives' personal issues such as family responsibilities and transport problems have hindered experiential learning and the completion of the midwifery register.^[6] All these factors have impacted negatively on skills achievement and completion of the register. The experiences of student midwives with regard to their completion of a midwifery register need to be explored.

The researcher (WNTS) noted with great concern that student midwives battle to complete the midwifery register. Students only periodically update their incomplete register when they return from clinical allocations and before they exit the course. In most instances, clinical procedures are either incomplete or not documented in the register. Crucially, an incomplete midwifery register suggests a theory and practice gap that is detrimental to ensuring safe midwifery practices, as well as completion of training. The student midwife then has no option but to extend their training period and, consequently, delay their compulsory community service. Several studies have been conducted regarding the experiences of student midwives in various provinces of South Africa (SA) and in other countries.^[4,5,7] However, little empirical information has been documented on the completion of the midwifery register in Eastern Cape Province, SA. This knowledge gap encouraged the researchers to conduct their study in the Eastern Cape. The study aimed to explore and describe experiences of student midwives with regard to completion of the midwifery register at a nursing college in the Eastern Cape.

 

Methods

Study design

A qualitative, exploratory, descriptive design was used. This research design was chosen because little was known about student midwives' experiences regarding completion of the midwifery register.

Population and sampling

The population comprised R425 level-four student midwives who were studying at the selected college.^[2] The non-probability purposive sampling method identified 10 student midwives for the study. Only student midwives who were in their fourth-year level of training and who had been allocated to maternity units for a period of12 months were eligible to participate in the study.

Study setting

The study was conducted at a nursing college in Nelson Mandela Bay district in the Eastern Cape. The college is situated on one of five main campuses in the Eastern Cape, which is accredited by SANC and services five subsidiary campuses in the province. In the 2021 academic year the campus had a total of 267 students registered for the R425 diploma course.

Data collection

The researcher conducted unstructured individual interviews between 15 April and 25 September 2021. Interviews were conducted in English. The researcher posed a broad question: 'What is your experience regarding completion of the midwifery register in maternity units?' Several probing questions were also asked to obtain additional information on the topic being studied. The interviews lasted between 60 and 90 minutes and were audio recorded, while field notes documented non-verbal responses.

Measures to ensure trustworthiness

The researcher used Lincoln and Guba's model as a guide to sustain the trustworthiness of the study.^[8] The following trustworthiness measures were employed to guarantee accuracy of the study findings, i.e. credibility, dependability, transferability and confirmability. The researcher remained in the field until data saturation was reached to ensure credibility. Experts in the midwifery field thoroughly examined the study to guarantee dependability. An independent co-coder was sought to ensure confirmability of the data. The principle of transferability was confirmed through description of the study objectives, design, methods and setting.

Data analysis

Data analysis was based on Tesch's steps data analysis method.^[8] Verbatim transcription of each interview was done after the researcher had listened to each recording. Similar topics were assembled and coded. Those that were not similar were grouped, after which distinct thoughts reflected in the margins were recorded. Clustering of similar concepts was done. The list was then condensed to a grouping of related themes, subthemes and categories.

Ethical considerations

Ethical approval was obtained from Department of Health Studies Research Ethics Committee, University of South Africa (ref. no. REC-24081052). Permission to conduct the study at the nursing college was provided by the Eastern Cape Province Department of Health. The individual student midwives voluntarily signed consent forms before taking part in the interview sessions. Participants were given codes instead of names to ensure their anonymity. To ensure confidentiality, transcripts were made accessible only to the researchers. The student midwives were given the choice to

withdraw and discontinue the interviews at any point.

 

Results and discussion

Table 1 recaps the demographic data of the student midwives who participated in the study. The study results are summarised in Table 2.

 

 

 

 

Demographic characteristics of the participants

All 10 of the study participants were in their fourth level of training; the majority had completed their antenatal and postnatal cases, whereas only 2 had completed their delivery cases (Table 1). Significant themes that emerged from the analysis of the participants' responses are structured in accordance with student midwives' experiences regarding their completion of the midwifery register: (i) positive experiences related to completion of the midwifery register; (ii) negative experiences regarding completion

of the midwifery register; and (iii) factors that contributed to the lack of completion of the midwifery register (Table 2).

Theme 1. Positive experiences related to completion of the midwifery register

Participants highlighted that they had positive experiences, as they were adequately guided to complete the midwifery register.

• Adequate guidance regarding completion of the midwifery register

The participants indicated that time spent in antenatal care and the midwife obstetric unit (MOU) was fruitful, as they could easily fill in the midwifery register. Clinical midwives were willing to teach, mentor and supervise them on how to deliver a baby and to record the delivery in the midwifery register:

'My first delivery was at MOU ... So, they sat down, guided us how to fill in the register, also about the rules of the college that you need to observe the patient for two hours before you write the patient.' [Participant 4]

To close the theory-practice gap, student nurses need to be adequately mentored, as mentoring is crucial to enhance skills acquisition and competency.^[9] In this study, the midwifery students were guided and supported to complete the midwifery register. Lack of support and supervision from qualified nurses in the wards can lead to a negative experience and incompetency.^[10] Adequate guidance would result in the student midwives knowing how to complete the midwifery register and making fewer mistakes.

Theme 2. Negative experiences regarding completion of the midwifery register

Student midwives described negative experiences regarding the completion of the midwifery register.

• Self-blame and anger

Participants felt that they were responsible for their failure to complete the midwifery register. As a result, they were angry and blamed themselves for non-compliance:

'I feel disappointed, on myself and I feel very angry at myself ... because at the end of the day I have no one else to blame, like I had opportunities.' [Participant 6]

Student nurses are expected to take full responsibility for the achievement of clinical learning outcomes.^[11] It is understandable that participants developed a sense of self-blame, guilt and anger, which could be related to overwhelming stress. Similarly, self-blame was associated with stress, criticising and blaming themselves for things that happened.^[12,13] The use of self-blame as a coping strategy could be attributed to their unawareness of coping strategies such as confiding in lecturers and mentors.^[13] Emotional support would be beneficial to alleviate guilt among student midwives.

• Student midwives used as workforce

Student midwives performed non-nursing duties and consequently felt overworked. This factor also contributed to the non-performance of procedures and difficulties in completing the midwifery register. The following participants explained their frustration:

'They want us to work, as a workforce then go, they don't care about our

register.' [Participant 3]

Another participant echoed as follows:

'There were no general assistants at times and we are mopping floors. Come delivery time you have to run to the sluice room to clean a dirty trolley first.' [Participant 5]

The use of midwifery students as part of the workforce in maternity units prevented them from concentrating on their learning outcomes, resulting in non-completion of the midwifery register. This could be attributed to a shortage of support staff and qualified midwives. Another study confirmed that student midwives were seen as a division of workforce, as they were expected to manage pregnant women without supervision.^[6,14] In this regard, students absented themselves, as they did not want to be used as part of the workforce in the units.^[6] It is imperative that every unit should be provided with clinical learning outcomes so that the learning needs of students are always taken into consideration.

• More midwifery students than delivery cases

The majority of participants raised the fact that limited learning opportunities had a negative impact on completion of the midwifery register. This was caused mostly by the presence of student midwives from other institutions:

'You have to share obviously with other students ... and university students are also there ... and at times we don't get a lot of patients that come in and deliver ... It is not easy to complete the midwifery register.' [Participant 7]

Participants stated that there were too many students compared with the number of available midwifery cases. This situation produced difficulties in performance of procedures and completion of the midwifery register. The problem was further exacerbated by the placement of other students, such as doctors and advanced nursing students from other academic institutions.^[10] Lack of suitable clinical placement sites leads to overcrowding in available areas and creates competition for cases and resources between the students.^[15] In trying to control the overcrowding of student midwives during clinical allocation, a collaboration between different education institutions and maternity units should be formed. This collaboration should include joint planning and appropriate shared placements and other resources.

• Limited experiential learning due to COVID-19

Most students lamented the fact that they could not complete the midwifery register because of limited experiential learning opportunities due to COVID-19:

'Now due to this Covid it's become too complicated you cannot be allocated as many as before so there is no time ... due to this Covid-19 it is difficult to do 1 000 hours.' [Participant 8]

Clinical learning was adversely affected by the COVID-19 pandemic when it was declared a worldwide public health problem.^[16] Lockdown restrictions were imposed on NEIs, as limited numbers of midwifery students were allocated to the maternity units. To curb the spread of COVID-19, worldwide experiential learning was cancelled, which had dire consequences because of missed opportunities for students' clinical learning.^[17] Midwifery students also had to adhere to the COVID-19 regulations, which subsequently led to incomplete midwifery registers.

Theme 3. Factors contributing to incompletion of the midwifery register

• Inadequate lecturer/student ratio

Proper teaching and supervision regarding completion of the midwifery register became difficult due to the large number of student midwives in relation to the limited number of lecturers:

'I haven't seen any lecturer in the units coming to assist us with the skills and midwifery register. Some classes have 100 students which is a lot and they had also post basic students.' [Participant 9]

To provide quality clinical education and supervision, the ratio of student nurses and lecturers should be manageable.^[18,19] This study found that lecturer numbers were far lower than those of the student midwives, which negatively affected teaching/learning and completion of the midwifery register. Consistently, the supervisor/supervisee ratio of 1:35 had an adverse effect on quality clinical supervision.^[20] In this situation, it was difficult for the student midwives to obtain individual attention and support with completion of their midwifery register. To that effect, preceptors should be hired to collaborate with lecturers and midwives to amply equip students with skills and completion of the midwifery register.^[21]

• Inadequate teaching and practice resources

It was clear from the evidence obtained from the participants that there was a lack of vital delivery equipment and inadequate teaching resources:

'Uhm ... there is always not enough equipment to accommodate all patients in labour wards ... You must wait for other people to finish their patients and then you start with yours which in a way will delay completion of the midwifery register' [Participant 9]

Students who practised in a well-equipped hospital were more likely to have a favourable attitude towards clinical practice.^[22] Participants indicated that shortage of resources affected clinical teaching and completion of the midwifery register. A shortage of clinical teaching resources has been highlighted, in particular in rural settings in SA.^[14,23] In these situations, only partial teaching and learning took place, which resulted in challenges regarding completion of the midwifery register.

• Negative attitude of midwives

The majority of participants expressed their concerns with regard to the negative attitude displayed by clinical midwives, which had a negative impact on completion of the midwifery register:

'At times these midwives make us feel that we are forward at times . they call us names like "Nomaphunga" [a person that is moving too fast or you think you are smart as a student].' [Participant 5]

Midwives should display a welcoming attitude to create a conducive environment for clinical learning to take place. The negative attitudes of midwives promoted absenteeism and students' dodging, which resulted in them missing clinical skills performed in that particular maternity unit. In another study, student nurses were called names, harassed and blamed for misconduct in the ward.^[24] Furthermore, students were belittled and degraded to such an extent that they wanted to discontinue their studies.^[25] It is important that midwives should provide emotional support to students to encourage and motivate them to achieve their learning outcomes. A student-friendly environment should be promoted to transform students' negative emotional experiences into positive experiences.^[10]

• Students' dodging and misuse of learning opportunities Participants mentioned the deliberate misuse of learning opportunities

and avoiding clinical placements. Ultimately, the effect of these behaviours reflected negatively on the midwifery register, as they missed the opportunity to practise midwifery procedures:

'I had more than enough time, but I wasted my time . I wasted my own time.' [Participant 6]

'For me ... I just go to work, but when I'm tired I just dodge.' [Participant 1]

Participants acknowledged that they missed opportunities through dodging and misuse of experiential learning time. This kind of behaviour has been perceived as lack of interest and commitment in clinical learning. ^[26] Therefore, students lacked the knowledge, skills and competency to properly complete the midwifery register. Moreover, students who absented themselves from clinical areas, missed important information on the procedures performed in that specific clinical area.^[6] It is imperative that students should take responsibility for their learning in the clinical area.^[27]

 

Conclusion

The study revealed that some participants expressed positive experiences that were linked to adequate support by clinical midwives in some midwifery units. Negative experiences also emerged from the study. Several factors contributing to incompletion of the midwifery register were highlighted by study participants.

Recommendations

There should be a collaborative effort between midwives, lecturers and preceptors to ensure adequate support of student midwives in the clinical learning environment.

• All stakeholders should have regular meetings as a means of addressing challenges regarding student midwives' problems and behaviour.

• The NEIs should provide the maternity wards with the students' learning outcomes to ensure that learning takes precedence over other non-nursing duties.

• The NEIs should plan the placement of students in clinical areas to prevent overcrowding and competition for midwifery cases.

• In-service training departments should empower professional nurses and midwives regarding their teaching and mentoring roles.

• Time management and professionalism should always be emphasised to encourage students to complete midwifery requirements on time.

Declaration. The research for this study was done in partial fulfilment of the requirements for WNTS's MA (Nursing Science) degree at the University of South Africa.

Acknowledgements. The authors thank the midwifery students for their participation in the study.

Author contributions. WNTS collected and analysed the data, and drafted the manuscript. SHK supervised the study and finalised the manuscript.

Funding. The study was funded by a University of South Africa (UNISA) postgraduate bursary.

Conflicts of interest. None.

 

References

1. South African Nursing Council. Regulation relating to the conditions under which registered midwives may carry out their profession. R2488, in terms of the Nursing Act 1978 (Act No. 50 of 1978, as amended). Pretoria: Government Printing Works, 1990.         [ Links ]

2. South African Nursing Council. Regulations relating to the education and guidance concerning the teaching of students in the program leading to registration. As a nurse (general, psychiatric, community nursing science) and midwifery. R425, in terms of the Nursing Act 1978 (Act No. 50 of 1978, as amended). Pretoria: Government Printing Works, 1985.         [ Links ]

3. Malwela T, Maputle SM, Lebese RT. Factors affecting integration of midwifery nursing science with clinical practice in Vhembe District, Limpopo Province as perceived by professional midwives. Afr J Prim Health Care Fam Med 2016;8(2):969. https://doi.org/10.4102/phcfm.v8i2.997        [ Links ]

4. Pama N. Factors affecting experiential learning for midwifery students at the public college of nursing in the Eastern Cape. MA (Nursing) thesis. Alice: University of Fort Hare, 2017.         [ Links ]

5. Vermeiden J, Persman W, Waegemans M, et al. Learning experiences of final-year student midwives in labor wards: A qualitative exploratory study. Eur J Midwifery 2019;15:1-8. https://doi.org/10.18332/ejm/111802        [ Links ]

6. Magobolo GN, Dube BM. Factors influencing high absenteeism rate of student nurses in clinical areas at a nursing college in the Lejweleputswa district. Curationis 2019;42(1):1985. https://doi.org/10.4102/curationis.v42i1.1985        [ Links ]

7. Rikhotso SR, Williams MJS, de Wet G. Student nurses' perceptions of guidance and support in rural hospitals. Curationis 2014;37(1):1164. https://doi.org/10.4102/curationis.v37i1.1164        [ Links ]

8. Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. 5th ed. USA: SAGE, 2018.         [ Links ]

9. Bweupe N, Ngoma CM, Sianchapa B. Clinical supervision of midwifery students at the University Teaching Hospital School of Nursing and Midwifery in Lusaka, Zambia. Open J Nurs 2018;8:372-389.         [ Links ]

10. Motsaanaka MN, Makhene A, Ally H. Student nurses' experiences regarding their clinical learning opportunities in a public hospital in Gauteng Province, South Africa. Health SA Gesondheid 2020;25:1217. https://doi.org/10.4102/hsag.v2510.1217        [ Links ]

11. Eastern Cape Department of Health. Lilitha College of Nursing in Association with Consortium of Universities (WSU, NMMU, UFH). Recruitment and Selection Policy. Bisho: Government Printing Works, 2019.         [ Links ]

12. Straud CL, McNaughton-Cassill M. Self-blame and stress in undergraduate college students: The mediating role of proactive coping. J Am Coll Health 2018;6:1-7. https://doi.org/10.1080/07448481.2018        [ Links ]

13. Masilamani R, Aung MMT, Othman H, et al. Stress, stressors and coping strategies among university nursing students. Malaysian J Public Health Med 2019;19(2):20-28.         [ Links ]

14. Thopola MK, Lekhuleni ME. Impediments of optimal midwifery experiential learning environments in maternity units of public hospitals. J Pregnancy Newborn Care 2019;2(1):1-5.         [ Links ]

15. Muthathi IS, Thurling CH, Armstrong SJ. Through the eyes of the student: Best practices in clinical facilitation. Curationis 2017;40(1):a1787. https://doi.org/10.4102/curationis.v40i1.1787        [ Links ]

16. Sogut S, Dolu I, Cangol E. The relationship between COVID-19 knowledge levels and anxiety states of midwifery students during the outbreak: A cross-sectional web-based survey. Perspect Psychiat Care 2020;57:246-252. https://doi.org/10.1111/ppc.12555        [ Links ]

17. Luyben A, Fleming V, Vermeulen J. Midwifery education in COVID-19-time: Challenges and opportunities. Midwifery 2020;89:102776. https://doi.org/10.1016/j.midw.2020.102776        [ Links ]

18. National Department of Health. The National Strategic Plan for Nursing Education, Training and Practice 2012/13 - 2016/17. Pretoria: Government Printing Works, 2017.         [ Links ]

19. South African Qualifications Authority. Act No. 58 of 1995. https://www.acts.co.za 2010 (accessed 4 September2022).         [ Links ]

20. Donough G, van der Heever M. Undergraduate nursing students' experience of clinical supervision. Curationis 2018;41(1):a1833. https://doi.org/10.4102/curationis.v41i1.1833        [ Links ]

21. Maphuti MJ. Challenges encountered by one-year student midwives in acquiring clinical skills at selected hospitals in Limpopo Province. MPH (Nursing) thesis. Polokwane: University of Limpopo, 2016.         [ Links ]

22. Aragaw Y, Sinishaw W, Daba W Attitude of Nursing and Midwifery Students Towards Clinical Practice and its Associated Factors in Northwest Ethiopia: A Cross-sectional Study. London: Biomedical Central Publishers, 2019:1-6.         [ Links ]

23. Baloyi OB, Mchunu GG, Williams C, et al. A road less travelled: Undergraduate midwifery students' experiences of a decentralised clinical training platform. Health SA Gesondheid 2020;25:a1473. https://doi.org/10.4102/hsag.v25i0.1473        [ Links ]

24. Atakro CA. Experiences of student nurses and midwives at selected hospital in the Volta Region of Ghana. J Educ Soc Behav Sci 2017;21(4):1-9. https://doi.org/10.9734/JESBS/2017/33976        [ Links ]

25. Fadana FP, Vember HF. Experiences of undergraduate nursing students during clinical practice at health facilities in Western Cape, South Africa. Curationis 2021;44(1):a2127. https://doi.org/10.4102/curationis.v44i1.2127        [ Links ]

26. Drasiku A, Gross JL, Jones C, et al. Clinical teaching of university-degree nursing students: Are the nurses in practice in Uganda ready? BMC Nurs 2021;20:4. https://doi.org/10.1186/s12912-020-00528-5        [ Links ]

27. Vuso Z, James S. Effects of limited midwifery clinical education and practice standardisation of student preparedness. Nurse Educ Today 2017;55:134-139. https://doi.org/10.1016/j.nedt.2017.05.014        [ Links ]

 

 

Correspondence:
S H Khunou
khunosh@unisa.ac.za

Accepted 17 May 2023