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Nurse Education in Practice 13 (2013) 578e583

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Nurse Education in Practice

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Midwifery education

Students’ and lecturers’ perceptions of support in a UKpre-registration midwifery programme

Annette Elizabeth McIntosh*, Janice Gidman 1, Andrea McLaughlin 2

Faculty of Health and Social Care, University of Chester, Riverside Campus, Castle Drive, Chester CH1 1SL, United Kingdom

a r t i c l e i n f o

Article history:Accepted 13 January 2013

Keywords:Midwifery educationStudent supportPeer supportWorkelife balance

* Corresponding author. Tel.: þ44 01244 513386.E-mail addresses: a.mcintosh@chester.ac.uk (

chester.ac.uk (J. Gidman), a.mclaughlin@chester.ac.uk1 Tel.: þ44 01244 513384.2 Tel.: þ44 01244 512260.

1471-5953/$ e see front matter � 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.nepr.2013.01.015

a b s t r a c t

This paper reports on a study that explored the perceptions of students and lecturers regarding supportwithin a pre-registration midwifery programme in one Higher Education Institution in England. A mixedmethod design was used: questionnaires were completed by first year and third year students andlecturers, complemented by focus groups with each of the three sets of participants. The findings showedthat there are multi-focal challenges for student midwives in undertaking their programme of study. Themain theme that emerged was of the difficulties involved in maintaining an appropriate workelifebalance, especially within what was seen as a relatively inflexible programme structure. The value of peersupport was also highlighted as a key factor in helping the students succeed in their studies. There were anumber of implications for midwifery educators to consider in optimising support for students. Theseinclude ensuring that students have realistic expectations at the outset of their studies, formalising peersupport mechanisms and reviewing programmes to provide more flexibility to better underpin themaintenance of an appropriate workelife balance. Further study is warranted to explore perceptions ofsupport in practice and to identify the factors that help students to persevere in their studies.

� 2013 Elsevier Ltd. All rights reserved.

Introduction and literature review

Within educational pre-qualifying healthcare programmes,student support can come from a range of sources and encompassacademic, clinical and personal contexts (McIntosh and Gidman,2011). Studies have shown that students’ perceptions of qualityrelating to their educational experiences, and to their success,include social and emotional support systems addressing such el-ements as childcare, peer networks and specific units for studentsupport (Hill et al., 2003; Robbins et al., 2004). Lauder et al. (2008),in a large scale Scottish study, showed that students rated familyand peer support as highest in quality, with Higher EducationInstitution (HEI) and mentor support as the lowest quality; theresearch team opined that the more informal support systems suchas that from family and peers are not often built into the design ofcurricula and could be an undervalued and relatively untappedasset. Peer support and mentoring within both academic andclinical environments have been highlighted as being valuable andbeneficial in the education of healthcare students, although care is

A.E. McIntosh), j.gidman@(A. McLaughlin).

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required in selecting and preparing peer mentors for the role(Aston and Molassiotis, 2003; Gilmour et al., 2007). Smith (2007)considered that lecturers are optimally placed to provide the in-dividual support that students need in the academic setting, withthe focus of support ranging from academic writing to pastoralcare. The imperative of effectively supporting students in practice iswell recognised, with the key role being that of the mentor (Levett-Jones et al., 2009; Steele, 2009).

Some studies focus on the challenge of enhancing studentretention and support in midwifery, although there are morerelating to student nurses where similar findings are evident. Astudy by Green and Baird (2009) showed that the main issueswhich led participants, including midwifery students, to leave theirstudies were family issues, tensions between theory and practiceand falling levels of motivation. The workload and the demands ofthe programme, together with unrealistic expectations, were alsocommonplace reasons for leaving, as were travelling times andfinance (Green and Baird, 2009).

Fowler and Norries’ (2009) findings were similar to those ofGreen and Baird (2009), although Fowler and Norrie (2009) alsofound that full-time nursing and midwifery students were morelikely to finish the programme than part-time, as were studentsgaining higher grades for ‘A’ levels. Stress has long been highlightedas contributing to attrition (Dimond, 2002). Pryjmachuk andRichards (2008) identified stress predictors for student midwives

Table 1Profile of students.

First yearstudentsn (%)

Third yearstudentsn (%)

Age Years17e20 4 (15) 1 (5)21e30 10 (37) 11 (52)31e40 11 (41) 7 (33)40e50 2 (7) 2 (10)

Marital status Single 11 (41) 11 (52)Married 9 (33) 5 (24)In relationship 6 (22) 3 (14)Divorced/separated 0% (Nil

return ¼ 1)2 (10)

Numberof children

None 5 (19) 10 (48)One 5 (19) 4 (19)Two 12 (44) 4 (19)Three 2 (7) 3 (14)Four 2 (7) 0 (0)Eight 1 (4) 0 (0)

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and recommended that good communication skills and activelistening on behalf of the HEI are needed, with effective academicand pastoral support systems being provided.

In the United Kingdom (UK), managing the attrition andretention of student midwives is currently a source of concern. Theeffects of high attrition can be extensive and have an impact on theavailability of qualified midwives in a profession which has anageing workforce (Royal College of Midwives, 2011). The Midwifery2020 report on the future of the profession alerts HEIs that pro-grammes may require to be adapted to meet the needs of studentswho have family commitments, or who wish to study part-time, inorder that a valuable resource is not lost (Chief Nursing Officers ofEngland, Northern Ireland, Scotland and Wales, 2010). Identifyingfactors that may increase attrition and developing strategies tomanage them is paramount in order to maintain viable numbers ofqualified midwives.

Like many other academic providers, the HEI reported here hasexperienced varying degrees of attrition, with one particularly highrate recorded prior to this study. The research teamwere interestedin exploring factors regarding student support and to identify andimplement strategies which could be utilised to lessen attrition andenhance progression.

Aim

The aim of this small-scale study was to investigate the per-ceptions of student midwives and lecturers in relation to supportwithin a three year pre-registration programme of study in one UKUniversity.

Methods

The study used a mixed method, exploratory approach. Ques-tionnaires were designed to elicit students’ and lecturers’ percep-tions of student support. Focus groups were undertaken to explorethe issues arising from the questionnaire data. The definition ofstudent support was situated within a wide context; anything thatthe participants perceived as supporting students’ study and pro-gression. The populations for the study were:

1. The first year student cohort, approaching the six month pointin their programme (n ¼ 31);

2. The third year student cohort, in the final six months of theirprogramme (n ¼ 22);

3. The midwifery lecturing staff (n ¼ 8).

A questionnaire was designed using Likert scales and openquestions. The questions addressed the following areas: the need forsupport; sources of support; additional support mechanisms;intention to quit the programme; programme satisfaction; thechallenges and the best aspects of the students’ learning experi-ences. The questionnaires were customised for the three groupswherenecessaryee.g. thefirst years being askedwhat they thoughtmight be the case, the third years asked what had been the case forthem and lecturing staff what they thought generally. Pilot work,carried out with a sample of students (n ¼ 15) and lecturers (n ¼ 5)indicated that the data would be valid, although some refinementswere made regarding the wording of questions to improve clarity.

Ethical approval

Ethical approval was granted by the Faculty ethics committee.Participation was voluntary. Data collection was undertaken by aresearch assistant rather than academic staff, in order to avoidundue influence being exerted on participants. Full information

was given, consent obtained and confidentiality maintainedthroughout. Data were stored securely, made available only to theresearch team and computer-based data were password protected.

Data collection and analysis

Questionnaires were distributed to each of the groups duringtime in their academic study block. The focus groups were held at alocation and time which was convenient for the participants andlasted for approximately 1 h. The interviews were audio-recordedwith the participants’ consent.

The questionnaire data were tabulated and quantitatively ana-lysed using Excel spreadsheets to produce descriptive statistics(closed questions) and qualitatively analysed to produce themes(open questions). The focus group interviews were transcribedverbatim and the process of analysis undertaken in line with theinterrelated elements developed by Miles and Huberman (1994):data reduction; data display and conclusion drawing.

Findings

The questionnaire produced response rates of first year students(87%, n ¼ 27), third year students (95%, n ¼ 21) and lecturers (75%,n¼ 6). All participants were female and full-time, with the first yearstudents undertaking a degree programme and the third yearstudents completing a diploma programme; this difference wasdue to programme re-validation in response to commissioning andnational requirements. Table 1 shows details of the student profiles.

Three focus groups were facilitated with volunteers who hadcompleted the questionnaires, with first year students (n¼ 8), thirdyear students (n ¼ 8) and midwifery lecturers (n ¼ 6) taking part.

The findings from the questionnaire data are discussed in rela-tion to the focus of the questions. The focus group findings addressareas that further emerged from the discussions and centre on theareas of workelife balance, peer support and overall perceptions.

Perceptions of students’ need for support

The participants were asked to indicate what support they feltthey would need (first year students) or had needed (third yearstudents) using a five point Likert scale ranging from strongly agreeto strongly disagree. The academics were asked what support theythought students needed. Fig. 1 shows the three groups’ percep-tions of the need for support; the figures represent the percentagestrongly agreeing or agreeing.

Fig. 1. Perceptions of elements requiring support.

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Academic writing was perceived by the highest number of firstyear students as an element requiring support, with 63% (n ¼ 17)either agreeing or strongly agreeing that this was the case, followedby support for exams (56%, n ¼ 15). These were the highest for thethird year students, albeit in reverse order (77% (n ¼ 16) exams and72% (n ¼ 15) academic writing). All of the academic staff (n ¼ 6)opted for these two elements. The aspect seen as requiring supportby the lowest number of first year students (26%, n ¼ 7) was per-sonal issues (although 41% (n ¼ 11) were undecided), with 48%(n ¼ 10) of the third year students agreeing that they had requiredsupport with personal issues. All of the academic staff (n ¼ 6) feltthat students would need help with personal issues.

Sources of support

The students were asked to indicate their main sources ofsupport, using a five point Likert scale, while the academics wereasked to indicate where they thought students accessed supportfrom during their programmes. All of the first year studentsthought (strongly agree or agree) that they would access supportfrom other students, as did the majority of the third year students(90%, n ¼ 19). However, all of the academics (n ¼ 6) felt that themodule leader was the most likely source of general support. Fig. 2shows the collated results for the three groups; the figures repre-sent the percentage strongly agreeing or agreeing. The LSS and SSGcategories in the table refer to the University learning support andstudent guidance sources which, as can be seen, were rated lesslikely support mechanisms by students, although the majority of

Fig. 2. Key sources of support.

the academics (83%, n¼ 5) were of the opinion that students wouldaccess these.

To contextualise the above data, the participants were alsoasked to indicate which support sources they would access for arange of specific elements within the programme. Module leaderswere seen as the main support source by all groups for academicwriting and exam support (78% (n ¼ 21) of first years, 76% (n ¼ 16)of third years and all of the academics (n ¼ 6)). Placement supportwas seen as coming chiefly from the mentor (93% (n ¼ 25) of firstyear students, 95% (n ¼ 20) of third year students and all of theacademic staff (n ¼ 6)). Personal issues were perceived as beingsupported mainly by other students (85% (n ¼ 23) of first yearstudents, 76% (n ¼ 14) of third years and all of the academics).

Additional support mechanisms

The students were asked what specific mechanisms of supportthey would benefit from or would have benefitted from duringtheir programme from a given list using a five point Likert scale.The academics were asked to indicate the areas they thought stu-dents generally would benefit from. The most popular (eitherstrongly agree or agree) support mechanisms for development forthe first year students, in order of popularity, were e-support (58%,n¼ 12), a bespoke statement of their learning needs and goals (44%,n ¼ 12) and 1e1 tuition (41%, n ¼ 11). The third years had two ofthese elements in common with the first year students: e-support(57%, n ¼ 12) and a bespoke statement of their learning needs andgoals (39%, n¼ 8). However, rather than 1e1 tuition, 53% (n¼ 11) ofthe third years thought that an assigned study partner wouldenhance their learning experience. For the academic staff therewere two top answers; 100%, (n ¼ 6) thought that help with 1e1tuition and childcare would be of value to students; the latteraspect of childcare received the lowest percentage of agreementfrom both the first year and the third year students. Fig. 3 shows thedata in diagrammatic form; the figures represent the percentagestrongly agreeing or agreeing.

Intention to leave the programme

The students were asked if, throughout their studies to date,there had been times that they had considered leaving the pro-gramme and to indicate the reason(s). The majority of first yearstudents indicated that they had not considered leaving withintheir first few months although 26% (n ¼ 7) had. For the third yearstudents, 90% (n¼ 19) reported that there were times that they hadthought about leaving the programme. The issue of workelifebalance was the main reason given by both groups, followed bypersonal and support issues, financial pressures and academicchallenges.

Fig. 3. Perceptions of beneficial additional support mechanisms.

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Satisfaction levels

The students were asked to indicate their satisfaction levels ina five point Likert scale ranging from very satisfied to verydissatisfied. A positive picture emerged, with 78% (n ¼ 21) of firstyear students and 86% (n ¼ 18) of third year students indicatingthat they were either very satisfied or satisfied with theirprogrammes.

Challenges and the best aspects of the students’ learning experiences

Two open questions asked the students about their perceptionsof the challenges and best elements of their programme. It wasevident that while the students felt generally well supported, therewere particular challenges that they experienced, particularlymaintaining an appropriate workelife balance. Both groups alsohighlighted the difficulties of trying to achieve the academic stan-dards and the course work involved in the programme. Commentsincluded:

Maintaining a work-life balance and juggling child care. Theseare all mild points though! (First year student MS18)

Juggling home, work, children and study as a mature student(Third year student MF17)

The best aspects of their educational programme for the firstyear students proved to be placement experiences, followed bysocial elements, gaining confidence, knowledge and skills, meetingcareer/personal aspirations, the course content and peer support.For the third year students, the same aspects were mentionedthough the meeting and making new friends was the mostfrequently mentioned best aspect of their programme. Commentsfrom the two groups included:

Practice! Although the course has been difficult and the work-load was quite high. I have enjoyed my practice (Third yearstudent MF12)

Becoming more competent and feeling that the theoretical as-pects of the course are beginning to make sense in the practicearea (First year student MS17)

Meeting new people and making friends who want me to suc-ceed and motivate me to stay (First year student MS7)

Meeting new people and making life-long friends (Third yearstudent MF20)

Focus group findings

The transcripts from the focus groups were not coded individ-ually but the following quotes have been extracted from the tran-scripts to be representative of the sample and are from differentparticipants. The findings from the focus groups supported themain themes emerging from the questionnaire data. The overridingissues were the difficulty in juggling workload and maintaining anappropriate workelife balance. There was recognition from thestudents that the Nursing andMidwifery Council (NMC) frameworkand professional requirements had to be met within the pro-gramme, but felt that more flexibility could still be employed.Comments included:

I’ve got lots of friends in Uni and they are always askingme to dothings because they hardly have any lectures but I just can’t. Idon’t have time and people don’t understand and it’s so hardand there is so much work to do (First year student)

My partner was seriously ill in hospital and I didn’t dare take anytime off .I think this is the main reason why 99% have thoughtabout quitting and I think that’s really sad because most of thepeople who do the other university courses never think likethat. I know when you come into it you know its going to behard but until you actually do it you just don’t realise how tiringand exhausting it is.. and how little leeway there is if some-thing happens (Third year student)

To a point not all of the blame rests on the university because itis the NMC that specifies..there doesn’t seem to be anyflexibility that life does go on, things do happen (Third yearstudent)

The midwifery lecturers were aware of the difficulties the stu-dents experienced with achieving a balance between their workand personal lives, but opined that, to offset this, the expectationsof the programmewere made clear to students from the outset andthat it was important to explain the impact of the programme,particularly for mature students:

It starts even before they arrive. the need to give a very real-istic picture of what this programme involves (Midwiferylecturer)

These points were reported by the lecturers to be re-inforced atinterview and during induction week. Staff noted that studentswere given a fixed timetable for their three years to facilitate for-ward planning. However, the lecturers recognised that it was notpossible to plan for every eventuality and that issues that arose forstudents had to be dealt with flexibly, although it was recognisedthat the requirements of the programme sometimes made thischallenging. In addition, the staff considered that effective time-management strategies were important for students in trying tobalance home life and studies.

The students re-iterated the value of peer support in the focusgroup discussions:

Like the tutors say if you have any kind of problem. but thetruth is you’re going to talk to your friends about it (First yearstudent)

So the best support you have is the girls because you are all inthe same boat and you all know what you’re going through(Third year student)

Peer support was also reported positively by the midwiferylecturers who felt that the students benefitted from this:

Students support each other really well. though this is notformal really (Midwifery lecturer)

The midwifery staff felt that formalising these buddy mecha-nisms and arrangements would be beneficial to students,acknowledging that:

Information from students can be more powerful than that fromlecturers (Midwifery lecturer)

Overall, it was evident that the findings reflected some com-monalities and differences between the groups regarding elementsof student support. These are discussed further in relation to cur-rent literature.

Discussion

It is recognised that the findings from this small-scale study willnot have general applicability due to its limitations in size, localityand the relative homogeneity of the sample group. However, thefindings may have resonance for others in midwifery education;

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they have helped inform the thinking of the midwifery team whoparticipated in the project. The findings mainly echo the previousresearch in this area and offer further insights regarding the sup-port of student midwives in their programmes of study.

The quantitative findings on the perceptions regarding students’need for support showed that the students had similar views andexperiences, highlighting that their perceived needsweremainly todo with assessments and academic writing. Support for personalissues was not seen by many of the students as something theywould, or had, needed, running counter to the literature showingthat support for social and emotional aspects are particularlyrequired and valued by students (Hill et al., 2003; Robbins et al.,2004). The midwifery lecturers felt that support would berequired with all elements of the programme, including academic,clinical and personal aspects, as identified byMcIntosh and Gidman(2011). There were considerable differences between the responsesof lecturers and both student groups in relation to the perceivedneeds for support across all the elements presented. The quanti-tative data indicated that the lecturers had an unrealistic view ofstudent support needs, particularly in relation to personal issuesand finances.

However, in the student focus groups, the importance of per-sonal support for the students emerged more and was considered acrucial element in their achievements. The source that studentsreported they would generally access for support was other stu-dents, and the value of this support mechanism was re-inforced inthe qualitative data. This is in line with the findings of other studies(Aston and Molassiotis, 2003; Gilmour et al., 2007; Lauder et al.,2008) and further highlights the value and importance of peersupport. In contrast, the midwifery lecturers had identified themodule leader as themain support source generally, although therewas recognition of peer support. All participants reported thatsystems of peer support and mentoring were currently unstruc-tured, and would benefit from the development of a more formalframework. This would ensure that the peer mentor was carefullyselected and prepared, as recommended by Aston and Molassiotis(2003) and Gilmour et al. (2007). There was general agreementbetween lecturers and students in relation to support provided bymodule and programme leaders, other students and mentors.However, it was interesting that students’ rating of Learning Sup-port Services and Student Support and Guidancewere considerablylower than those of lecturers. This finding does not equate to thosein the studies of Hill et al. (2003) and Robbins et al. (2004), but itcould be mitigated by the fact that the support units were not inclose proximity to the teaching premises. In relation to specificsupport, all of the participants had reported that the module leaderwas the main source for the development of academic skills rec-ognising this, in line with the thinking of Smith (2007), as a keycomponent of the role and one which academics are optimallyplaced to fulfil.

The data for all groups highlighted awareness of the need formaintaining an appropriate workelife balance, although the aca-demic staff considered that this particular challenge was madeclear to students at the outset. An area that emerged as a particularfrustration for students was the inflexibility of the programme,although there was recognition that NMC requirements left HEIslittle in the way of room in this respect. The students consideredthis a main contributor to workelife imbalance. The importance ofthis was underlined by the fact that difficulty in balancing work andstudy with personal life was reported as the reason most likely tolead students to consider leaving the programme. This was high-lighted by Fowler and Norrie (2009) and Green and Baird (2009), aswere the challenges of achieving the academic standards; thesewere also identified by this study’s participants in relation to thechallenges of the programme. There were notable differences in

responses between lecturers and students in relation to theperceived benefits of additional support mechanisms. Whilst thetwo groups of students provided similar ratings, lectures over-estimated the importance of these across all areas. This wasparticularly evident in relation to e-support, additional tutorialsupport and childcare. Problems with child care have been shownin various studies as an area that can lead to attrition from pro-grammes (Fowler and Norrie, 2009; Green and Baird, 2009). It wasinteresting to note therefore, that unlike the academics, the studentmidwives in the study reported here generally did not perceive thisas a particular need, despite the majority being mothers.

The students identified similar elements when considering thebest aspects of their learning experiences. Practice placementswere evidently a highlight, and this, allied to the fact that mentorswere seen as the main support source in practice, pointed to theoperation of a robust system of mentorship as advocated by Levett-Jones et al. (2009) and Steele (2009).

Other positive aspects for the students were the social elements,including making new friends, the peer support and the gaining ofconfidence and knowledge. This again highlighted the need forHEIs to ensure that these elements are enhanced and underpinnedby appropriate support structures, in linewith recommendations ofprevious studies (Hill et al., 2003; Lauder et al., 2008; Pryjmachukand Richards, 2008; Robbins et al., 2004).

Conclusion

These findings showed that there are multi-focal challenges forstudent midwives in completing their programme. For the stu-dents in this study, particular difficulties concerned achieving anappropriate workelife balance, attaining the standards of theprogramme and meeting the requirements of the NMC withinwhat was seen as a relatively inflexible framework. It was evidentthat other students were a valuable source of support in all ele-ments, although the input of academic staff and mentors was alsorecognised.

The midwifery lecturing staff are now reviewing the peer sup-port mechanisms within the programme with the aim of optimis-ing this resource. While the study uncovered factors that may leadto students considering leaving, the reasons that they stayed on theprogramme did not emerge from the data and were not specificallyexplored; this element is subsequently being investigated as part ofa follow-up study.

Conflict of interest statement

The authors confirm that there are no conflicts of interestinvolved in the study.

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