Lived experiences of undergraduate nursing students in midwifery practice at selected rural hospitals of South Africa

Abstract

Background

Midwifery practice is a requirement in the integrated undergraduate nursing programme which includes general, midwifery, community, and psychiatric nursing disciplines. Students are placed in these clinical areas for learning experiences. Students’ experiences in midwifery practice are mostly overwhelming due to the nature of the services rendered. This makes them have mixed feelings of anxiety and excitement. These experiences might hinder or enhance learning.

Objective

The study sought to explore student nurses’ experiences during placement in midwifery practice.

Methods

A phenomenological, qualitative approach was used to obtain the experiences of students in midwifery practice. Nonprobability purposive sampling was used to sample midwifery practice areas and nursing students. Measures to ensure trustworthiness were ensured. Ethical considerations were ensured. Data was collected through focus groups of 6–7 members each and analysed using Tesch’s open coding method. Data was collected over a period of nine months. Data was collected until saturation was reached.

Results

Two main themes that emerged from the findings are: positive and negative experiences which both impacted their clinical learning.

Conclusion

Findings revealed that students view midwifery training as fascinating as they were the first people to hold babies at birth. However, there are challenges like fear of not meeting learning outcomes and fear of making errors which require the support of professional nurses.

Keywords:

• Clinical learning
• clinical environment
• lived experiences
• midwifery practice
• nursing students

REVIEWING EDITOR:

• May Cheng, Education University of Hong Kong, Hong Kong

SUBJECTS:

• Nurse Education and Management
• Ethics and professional values
• Nursing research
• Midwifery

Introduction

The R425 integrated training curriculum for the undergraduate nursing program in South Africa, includes midwifery practice, general nursing, community and mental health. Students are placed in midwifery clinical areas for two academic years in their third and fourth levels of training (Act 33, 2005). These clinical areas are hospitals, clinics, and health centres. The training includes the theoretical component which is acquired from nursing education institutions and the practical component which is achieved from the clinical learning areas. The component of midwifery practice includes care of the woman during pregnancy, childbirth, and afterbirth including care of the baby (Act 33, 2005).

During a clinical placement in midwifery practice, students are placed under the guidance and supervision of professional nurses (Act 33, 2005). During midwifery practice, students are expected to develop competency in the management of pregnant women, labour and delivery, and postnatal and neonatal care. In the first year of midwifery practice, students’ competencies are on the management of uncomplicated midwifery whereas in the second year, they do complications related to midwifery. Clinical learning in midwifery slightly differs from other sections due to the nature of the care that is provided which might be potential risks to the mother and baby and an element of unpredictability in the childbirth process (Rahimi et al., 2019). During midwifery practice, students are expected to develop competency in the management of a pregnant woman through all the stages before and after delivery. The minimum period of hours to be acquired in midwifery practice is 1000. The aim of such a period is to ensure that on completion of training, newly qualified midwives are skilled and competent to provide prenatal, natal, and postnatal and neonatal care, evidence-based midwifery care in any setting. Considering the time spent until the students acquire those hours, there will be a lot of experiences gathered in the period spent. It is in this light that the researcher wished to explore those experiences. The study needed to explore the lived experiences as these might impact the outcome of the midwifery training. When students have positive experiences, the likelihood of achieving their learning objective is much higher. It is therefore empirical to ensure that student have positive learning experiences to take along in their future practice.

Background

Experiences of students in clinical learning practice are stressful, whereby sources of stress may be related to fear of making mistakes, self-pressure to be competent, and high expectations from supervisors (Atakro, 2017; Gomathi et al., 2017). Sources of student stress in the clinical learning areas may be caused by continuous fear. According to Ahmadi et al. (2018). students in clinical learning areas might experience intense fear leading to post-traumatic stress disorder, manifesting in triggering memories of the traumatic events that were experienced before. Students in midwifery clinical learning are subjected to even more stress due to the nature of the ward activities. The sentiment is affirmed by a study by Rezaei et al. (2020) in Iran which concluded that students in midwifery science learning have enormous stress. The authors further indicate that sources of stress could be related to fear of doing harm, experiencing the first childbirth, fear of punishment if they do wrong, inadequate training facilities, and the poor support of students by clinical supervisors. Midwifery experience can be psychologically exhausting and draining to students during the provision of care to a woman in labour. This is confirmed by a study by Coldridge and Davies (2017) in the United Kingdom which found that students are psychologically affected by thoughts of protecting the mother and baby from less positive outcomes of pregnancy and childbirth.

In addition, Amoo and Enyan (2022) state that the experiences of nursing students in the clinical areas are influenced by attributes that are assumed to impact on students’ performance in the clinical learning areas. These attributes are many and varied and may include the physical environment, psychosocial and interpersonal factors, the organisational culture and teaching and learning component. The relationship and interpersonal factors between the students and other members in the clinical areas might impact on the experiences that learners have during placements (Lee et al., 2018). The authors further alludes that the negative attitudes of clinical staff towards nursing students made it difficult to establish a healthy working relationship between the two.

The study is underpinned by the theoretical framework of Benner’s Novice to Expert Model (1984). The model describes how students develop competency through theoretical training and clinical learning (Ozdemir, 2019). The five stages of the model are the novice, advanced beginner, competent, proficient, and expert phases. Midwifery training starts in the third level of training, at this stage students are in the novice stage as they will be given a theoretical background about midwifery science. Demonstrations are done in the simulation laboratory to prepare students for situations they will encounter in the midwifery practice (Thomas & Kellgren, 2017).

In the second advanced beginner stage, students first go to the midwifery clinical learning areas. In this stage, students are often anxious and learn by trial and error. In this stage, professional nurses and senior learners should mentor and support junior students with the integration of theory and practice (Ozdemir, 2019). The third stage of the model is the competent stage. At this stage, students are less anxious and perform with minimal mistakes. Competency is evaluated through practical assessments which are formative and summative (Ozdemir, 2019). Students still practice under the supervision of a professional nurse at a minimal scale.

The fourth stage is proficiency. Students are more confident in the provision of care to pregnant woman and their babies. Students in the fourth level of study who are doing midwifery for the second year are at the proficiency stage. Thomas and Kellgren (2017) elaborate that at this stage, students spend less time and energy stressing and planning as they simply know what needs to be done. Their experiences are of less stress but fulfilment. The final stage in Benner’s Novice to Expert Model is the expert stage. Students have developed more competency and confidence in midwifery practice. In addition, students still need guidance and support from professional nurses to help them develop expertise in midwifery practice. At this stage, students are confident to provide care to mothers and babies in midwifery practice under the indirect supervision of professional nurses. They feel free to practice without causing any harm to the mother and baby.

Purpose

The study aims to obtain in-depth information regarding the nursing students’ lived experiences of clinical learning during placement in midwifery practice.

Objectives

To explore and describe nursing students’ lived experiences of clinical learning during placement in midwifery practice

Methodology

A phenomenological approach was used to collect data from nursing students who were doing midwifery science. A phenomenological approach is an inductive descriptive qualitative methodology for the purpose of describing the experiences as they are lived by the participants. (Gray et al., 2016). The approach assisted the researcher in obtaining adequate information about the phenomenon as data was collected in real-life settings with students sharing their experiences in midwifery clinical practice as they lived them.

Setting

Four clinical learning areas in the province were purposely sampled. Students from the colleges and universities training for the undergraduate programme are allocated at these hospitals for clinical learning and experience.

Sample

Nonprobability purposive sampling was used to sample students in the undergraduate nursing programme from the universities and nursing colleges. The inclusion criteria were students training for the nursing undergraduate programme at colleges and universities in the province and those who have been allocated in midwifery practice. The exclusion criteria were learners in other nursing programmes like post basic courses and those registered for diploma in midwifery science. These categories were excluded from the study because some had previous training experiences therefore the researcher assumed that their expectations would differ from those who were in undergraduate programme. The research population constituted both male and female learners. Four Focus Group Discussion (FGDs) were formed. Each group had seven to eight participants. Ten participants were males and twenty were females. Their ages ranged from twenty to twenty-five. Learners in the third and fourth levels of study were included in the study.

Data collection

Data was collected through focus group discussions (FGDs). Student nurses were recruited after obtaining permission from nursing education institutions. The first meeting was held with the students who were allocated to the midwifery clinical practice and were willing to participate in the study. The researcher introduced herself to the students and explained the purpose and the objectives of the study. The right to participate or not in the study, their right to withdraw from the study without any prejudice, the right to be treated fairly without any bias and discrimination, the right to protect their names and identity, and the right that they will not be harmed in any manner was explained. Willing participants gave informed consent and signed a consent to participate and were given invitation letters. Arrangements to collect data were made with participants to meet at their convenient time. The researcher was the main research instrument as she conducted the interviews. A voice recorder was used to capture data. The researcher collected descriptive field notes to document the date, time, and place of data collection and the behaviours of the participants. The statement was posed to participants to allow them to share their experiences. The statement said: ‘Kindly share your experiences of clinical learning during midwifery practice’. The researcher was taking field notes on important points at the same time observing the expressions of the participants. Probing was done to seek more clarity and gain more insight on the mentioned aspects. Data was collected until saturation was reached when no new information was shared during the discussions. Each FGDs lasted for 45–60 min.

Data analysis

Data was analysed through Tesch’s (1992) open-coded method. During data analysis, the researcher listened to the voice recorder and transcribed it verbatim. The researcher and the supervisor analysed data individually by reading through the transcripts and field notes to familiarize themselves with the collected data. Ideas that came to mind were written down. Similar topics were clustered together and coded. Coded data was reduced and examined for similarities and differences. Descriptive topics were turned into themes and subthemes (Creswell & Poth, 2016). A meeting was held between the two researchers wherein the developed themes and subthemes were compared and discussed, and a consensus was reached.

Measures to ensure trustworthiness

Trustworthiness refers to the degree of confidence qualitative researchers have in their data using the criteria of credibility, transferability, dependability, and confirmability (Polit & Beck, 2017). Credibility was ensured through prolonged engagement as data was collected over a period of nine months which encouraged the researcher and the participants to develop trust towards each other. For member checking, the researcher met with the participants after data collection to discuss preliminary findings. The researcher and the participants agreed on the findings presented. Rigorous methodology ensured transferability. All voice recordings, transcripts, and field notes were stored in case an audit trail is needed.

Ethical considerations

After obtaining ethical clearance from the University Research Ethics Committee (Project number SHS/19/PDC/04/1103), permission to collect data was granted. Participants were explained of the right to participate or not in the study, and the right to withdraw without any penalty. The privacy of the patient was ensured by protecting the identity of participants as they were coded. Participants were not exposed to harm in any manner, they were also treated fairly without bias. Participants voluntarily participated in the study and gave informed written consent.

Results

Characteristics of the participants

Participants were recruited from 4 clinical areas of midwifery practice. Their ages ranged between 20 and 25. Twenty-three (90%) were females and seven (30%) were males. The number of male students was much lesser than the females as nursing is predominantly female-dominated profession this is affirmed by Maputle and Mthombeni (2022), who found that female practitioners dominated midwifery practice.

Results indicated that students’ experiences in midwifery practice were both positive and negative. These experiences were influenced by personal experience, interaction with clinical staff, and work atmosphere. The themes that emerged are tabled in Table 1.

Table 1. Themes and subthemes that emerged from the study.

Themes	Subthemes
Positive experiences	Gaining competency in midwifery practice
	Discovering passion in midwifery practice
	Effective support from professional nurses
Negative experiences	Fear of harming patients
	Fear of failing midwifery science practice
	Overwhelmed by workload
	Poor support from professional nurses

Positive experiences

Findings revealed that students had positive experiences in midwifery practice. The experiences were feelings of achievement, fulfilment, and support from professional nurses in maternity units.

Gaining competency in midwifery practice

Students expressed that clinical placements in midwifery assisted them in gaining competency. They indicated that they gained skills important in midwifery practice. To the students, it meant a lot to safely help a woman deliver as it is their learning outcome. Competency in midwifery is a dream for every midwife. The subtheme is supported by:

Participant H

My experience was that I gained competency in midwifery. When I started, I was clueless about what to expect as I never witnessed any childbirth before. After my second clinical placement, I was competent, and I could say I was able to help the woman deliver the baby. I had the confidence to do it more often as I felt competent.

Participant C said;

My experience is that when I was first allocated to maternity, I had doubts if I could be able to assist the woman in childbirth. With the theoretical background from the university and the support from clinical staff, I became competent in no time. The competency made me feel happy with my performance and I couldn’t stop bragging to my colleagues.

Discovering passion in midwifery practice

Students might have different experiences when observing childbirth for the first time. In this study, students were excited to be in that situation. Nursing is a caring profession with the expression of love for fellow humans and seeing someone coming to life makes it even more special. Participants alluded that maternity practice made them have a passion for midwifery which they never thought they had before. They stated that midwifery is very interesting as most of the time patients are ambulant and interactive. Others even went on to say that they consider specialising in midwifery practice.

Participant A

My experience when I was placed in midwifery was an interesting. When I had my first delivery, I was so excited when I heard the baby crying. I have never felt so happy. I started to develop passion and discovered myself in the process that I love midwifery practice. I think I will specialise in midwifery when I complete my undergraduate training.

Findings discovered that students view midwifery training as interesting making them to be fulfilled and developing love and interest in the discipline. This was alluded to by Participant D who said:

In my experience, helping a woman to safely deliver was an overwhelming experience. I felt like is something that I should be proud of. I felt so fulfilled as a person and made me discover that I actually love midwifery practice. The fulfilment goes beyond the maternity room as even when I meet the parents in town, they continue to thank me.

Being supported by professional nurses

Students expressed to have been supported by professional nurses and through that support, they were able to develop competency in midwifery practice. When student midwives are in the clinical learning areas, they need and depend on the support of registered midwives in the units. This improved their performance as positive experiences might lead to positive experiences. Sometimes male students find it difficult to adjust to midwifery practice as they feel that labour and childbirth are more feminine and are supposed to be done by women (Chinkhata & Langley, 2018), however, in the current study, one male student had a different opinion saying he enjoyed midwifery as he had support from professional nurses.

Participant A

I experienced support from the professional nurses in maternity the unit.

On probing, the researcher asked

May you please elaborate on the support that you are referring to.

As a male student, there were many things in midwifery practice that I was afraid of and uncomfortable to ask. I would hide behind my female colleagues, but the professional nurses would call me and delegate a patient and make sure that whenever I assess the patient, they are there to guide and assist. In their support I was able to learn and be competent.

In addition, Participant L said:

My experience in midwifery practice was good. When I was first allocated, I was clueless. Professional nurses helped me and reassured me that I should feel free to ask if I didn’t understand. They would always say midwifery is a closed book so if you don’t know ask. That made me feel that they want to assist me in learning, and I would ask whenever I didn’t understand.

Negative experiences

Though some students having positive experiences, others had negative experiences. Those experiences were influenced by fear of harming patients, fear of not meeting the learning needs, the overwhelming nature of the clinical environment and unsupportive professional nurses.

Fear of harming patients

Students indicated to have witnessed incidences where the outcome of childbirth was not as expected. That affected them as every time the woman was not progressing well, they feared the worst. In support of the subtheme, participants said:

Participant E

My experience in maternity was emotionally draining. I witnessed an unfortunate incident where the woman lost her baby. This affected me as every time I checked a woman, I would worry to say what if something wrong happens to this patient. I had this fear that things might go wrong. At times I would doubt my competency to say what if what I am doing will harm the mother.

Participant F

Maternity allocation is always stressful. What makes it worse is that a patient who is coming for delivery comes in smiling with expectations. Whenever you are providing care, you always have it in your mind that I don’t want anything bad happening to this patient. You are always on your nerves.

Overwhelmed by workload

Students shared experiences where they were overwhelmed by the amount of work in maternity practice. They indicated that wards are always busy and at the end of the shift they are physically and emotionally exhausted. Some indicated that they would go on without having proper lunch breaks in between due to the busy wards. Working long hours and heavy workloads can be a barrier to effective learning for students. To elaborate on that, participants said:

Participant B

In my experience maternity practices are very busy. In hospital X where I am allocated, the ward is so busy that the staff normalise not going for breaks on time. Some days are better but mostly the wards are busy. When I knock off, I am physically and emotionally exhausted and this affect my other activities like when I have an assignment.

Participant G

Maternity wards are busy. In a day the numbers of deliveries are many and assisting in delivery and recording takes time. At the end of the shift, I didn’t want to look back as my feet were sore. In maternity going for lunch is a bonus. Most days you eat for 15 minutes and quickly come back.

Fear of failing midwifery science

Students brought to light the fact that midwifery practice is more difficult than other disciplines. They felt that the practice was complicated and needed someone who should be serious and want to learn. Having confidence in performing skills is essential for midwifery students because the profession is demanding, and students should be able to work independently with a scientific approach and professional responsibility.

The subtheme is supported by:

Participant D who said

I never had so much pressure in training like when I was in midwifery practice. The pressure comes from wanting to pass with good marks. Senior colleagues always told us that if you want to pass midwifery you must work very hard. Honestly midwifery differs from other clinical placements

On probing the researcher said

May you please share how midwifery practice differ from other clinical placements

The difference is that in midwifery practice procedures are more complicated than those in general nursing science. When you palpate a pregnant woman, you need to be accurate as the findings might affect the woman and the baby. You need to make sure that you have practiced thoroughly.

Discussions

The study explored the experiences of students during midwifery practice. These midwifery practices impact the learning outcome of students by creating learning opportunities and experiences. Depending on the milieu in the midwifery practice, the experiences might be positive or negative. Students’ experiences are often influenced by different factors in the clinical learning areas. In their journey, students need to be supported and guided so that the learning outcome is positive. The main aim of clinical practice is to equip the student with skills and ensure that the students develop competency before going to practice independently (Rahimi et al., 2019). Developing competency is crucial in midwifery practice in order to reduce the global maternal mortality ratio to less than 70 per 100,000 live births as indicated in sustainable development goals. In New Zealand, it was found that every midwife in practice is working towards being a ready practitioner guaranteeing that from their perspective they are competent to practice their profession and that they have the knowledge and skills required to function as competent midwives (Calvert et al., 2017). It is therefore significant that the clinical learning areas should foster positive experiences of students to enhance learning.

The findings of the study indicated that students had positive clinical learning experience which is a good thing as this positively affect their learning outcome and further practice in the profession. The findings are similar to a study in Israel on experiences of nursing student in the clinical learning areas which concluded that students were generally satisfied with the experiences that they had during such placements (Suliman & Warshawski, 2022). The positive experiences were influenced by the support that the students received from the clinical learning areas. According to Mafumo and Netshikweta (2022), students expect professional nurses in the clinical learning areas to support them as that impacts their learning outcomes. Supporting students in clinical practice is crucial as stated by Thunes and Sekse (2015) who found that students who had positive experiences and whose expectations were met and valued, experienced a high level of satisfaction. These findings are contrary to what was experienced by an Iranian student who was afraid and horrified by the pain the pregnant woman experienced (Ahmadi et al., 2018).

Students stated that negative experiences were related to fear of not meeting their learning outcomes. They regarded midwifery as more complex and complicated than other disciplines. Student midwives sometimes find it difficult, tough, and overwhelming to integrate theory into practice (Bäck & Karlström, 2020). In such instances students often find themselves doubting their competencies in midwifery practice. The concern is common as was found in a study in Turkey which concluded that when students are in the clinical learning areas, they are afraid of not meeting their learning outcomes wherein causes of this fear could be high expectations laid by the clinical facilitators (Arkan et al., 2018).

Students also had fears that they might harm patients during the provision of care. Midwifery is such a complex discipline where the probability of negative outcomes is always in the minds of care providers. This leads to students not relaxing and always agitated. The findings are similar to what was revealed by Panda et al. (2021) and Ahmadi et al. (2018) which described fear of harming patients as a common factor threatening the performance of students in the clinical learning areas.

In this study, another worrying factor in midwifery practice was found to be the busy units. In institutions where research was done, students often work 12-h shifts. The issue of working long shifts was shared by De Swardt et al. (2017) who alluded that excessive workload negatively impacts student learning. Students are often tired and exhausted at the end of the shift, and they find it difficult to do their assignments. The issue of fatigue in nursing students was reported by Fletcher et al. (2020) who indicated that nursing students usually work 6–12 h shifts which makes them to feel fatigued, especially during their first periods of training but the good thing about this long shifts was that there was no relation between medical errors and the number of hours worked.

Students expressed satisfaction regarding the support from professional nurses. Many studies have been done to explore the support of nursing students where findings were found to be positive and negative. The current study is affirmed by Pitkänen et al. (2018) who concluded that students support can be achieved through creating an environment conducive to learning, evaluating students’ performance and offering guidance during clinical learning. Registered midwives are not only responsible for providing a supportive and nurturing environment for students, but they are also responsible for providing clinical education to students to provide knowledge on midwifery practice (Arundell et al., 2018). According to Benner’s theory of learning, students in the earlier stages of learning need support from competent practitioners. Finally, it is important to ensure that clinical learning areas create opportunities for positive experiences for nursing students. When experiences are positive, the learning journey becomes healthy and fulfilling.

Limitations of the study

The study was conducted in rural areas where challenges of shortage of human and material resources are prevalent, and the limitation could be that if the study was in urban areas, it might have yielded different results. The urban areas have more human and material resources therefore the students’ experiences regarding working long hours and being overwhelmed might not necessarily be the same as in rural areas. In addition, in urban areas, the increased capacity of human resources could lead to students being better supported in their learning resulting in improved psychological well-being. However, conducting the study in rural areas could be seen as a positive thing as most research is conducted in urban areas where there are resources for conducting such. The study focused on undergraduate students, post-graduate experiences might yield different results. Postgraduates are already professional nurses therefore they do not depend more on other professional nurses for support, they have more knowledge than undergraduates.

Conclusion

Midwifery practice is mandatory in undergraduate training of students in South Africa. Students are exposed to the discipline so that when they qualify, they have the competency to provide such service. The clinical areas of midwifery practice should promote an environment where students are relaxed and free to learn. As indicated midwifery practice can be strenuous and demanding at times, therefore professional nurses should strive to create an environment that promotes positive experiences. In an environment where students have positive experiences, their learning outcomes will be affected positively. Supporting students’ midwifery practice journey not only makes their experiences positive but also gives the students the opportunity to ask questions and improve on their performance. Competent students make competent practitioners who will make midwifery practice a safe place for our communities.

Authors contributions

JLM was the main project leader responsible for conceptualization, writing methodology, data collection and analysis, sourcing funds, and drafting the manuscript. TRL assisted in drafting the manuscript and reviewing the manuscript, literature search, and data analysis.

Acknowledgments

The authors wish to thank the University and the University staff Development Programme (USDP) for their support during the research and all the students who participated in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Transcripts and audio recordings used to analyse data in the current study are available from the corresponding authors on request.

Additional information

Funding

The study was funded by the University research fund and the University Staff Development Program (USDP).

Notes on contributors

Julia Langanani Mafumo

Dr. Julia Langanani Mafumo is a senior lecturer at the Faculty of Health Sciences, Department of Advanced Nursing Science at the University of Venda, Limpopo Province, South Africa. She holds a Doctoral Degree in Nursing. She has an experience of 28 years in the higher education sector. She is the clinical coordinator for Undergraduate Nursing Programmes where her work entails coordinating student allocations in the clinical facilities and doing clinical accompaniment and support. She is passionate about clinical learning, competency and the professional socialisation of student nurses. Additionally, she has written published articles in peer-reviewed journals on clinical education topics. She also supervises students for Masters and Doctoral studies. She is an external examiner for other Universities in the country.

Takalani Rhodah Luhalima

Dr Takalani Rhoda Luhalima is a senior lecturer in the Faculty of Health Sciences, Department of Advanced Nursing Science at the University of Venda, Limpopo Province, South Africa. She holds a Ph.D. degree. She has worked for more than 14 years in Higher Education Institutions. Supervisors Honours, Masters, and Doctoral postgraduate students. Her research interest includes Nursing Management, Nursing Education, with an emphasis on leadership and inclusive education. Presents research papers locally and internationally, also published book chapters and articles on management and inclusive education in various national and international in peer-reviewed journals. She also evaluates book chapters and manuscripts from accredited journals.