NEWLY QUALIFIED MIDWIVES
WORKING IN COMMUNITY SERVICES
– THEIR EXPERIENCES AND
CHALLENGES
Dr. Diana du Plessis
Midwifery Consultant &
Researcher
2012
Introduction
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System of compulsory community service as a strategy to cope
with the problems of human resources in the health sector.
Community service for health professionals: doctors (1999),
dentists (2000) and pharmacists (2001)
A further 7 professional groups followed in 2003 and in 2007 nurses.
The national Department of Health: responsible for the
placement of the health professionals into posts.
The process is finalized by September each year
Provide a “wish list” of areas of interest and places where they
would like to practice – placement according to need.
Maternity services
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Largely nurse-based public maternity health system
The provision of doctors and nurses fall well below
the threshold of 230:100,000 regarded by the World
Health Organization as necessary to achieve the
health-related Millennium Development Goals (World
Development Report, 2006).
Taking into account post vacancies, there were 23
doctors and 181 professional nurses per 100 000
uninsured (Health Systems Trust, 2008).
Maternity services continue
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The Saving Mothers’ report (2005-2007) :
found that almost 60% of maternal deaths were
avoidable (National Committee on Confidential
Enquiries into Maternal Deaths 2008)
Of these 9.3% were attributed to lack of personnel
and
lack of appropriately trained staff (8.9%).
The quality of perinatal care in district hospitals were
particularly bad, with over a third of perinatal deaths
due to avoidable health system failures.
Maternity services continue
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A 5-year review of the public health sector
concluded that the morale among nurses are
significantly low (Segal, 1999).
Nurses contributed the low morale to
overwork but Segal found that a sense of
neglect and lack of support was at the heart
of problems.
Community service for medical
professionals (Reid: 2002)
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Community service for medical professionals had
positive impact despite difficulties and frustrations.
Medical professionals experienced community
service positively, but:
kept to their original career plans
few remained in South Africa or in the rural
environment after completion of the community year.
Problem statement
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Numerous studies on the effectiveness of compulsory
community service by medical practitioners
Minimal research on the experiences of the newly qualified
registered nurse and midwife during the compulsory community
service years.
Personal, unstructured observation and informal discussions
Interacted via Facebook and electronic mail when they related
experiences.
It is clear from these stories that they all face similar situations
during the compulsory community year, especially when placed
in the maternity services.
The following questions arose:
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What are the experiences of newly qualified
midwives during their compulsory community
year in Maternity Services?
How can the compulsory community services
contribute to a positive experience?
RESEARCH GOALS/OBJECTIVES
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Explore and describe the newly qualified
registered nurses and midwives lived
experiences of compulsory community
service in public maternity care in Gauteng.
Understanding these experiences assisted
the researcher to formulate guidelines.
RESEARCH DESIGN
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A qualitative phenomenological approach explorative, descriptive and contextual
All participants provided midwifery care
during all aspects of ante natal care, labor,
birth and the post partum period in public
health services in Gauteng.
Phases of the research
Phase 1
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Individual phenomenological interviews
and naïve sketches
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Phase 2
Guidelines
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DATA COLLECTION
Population
All newly qualified midwives working in the public maternity unit during
the compulsory community service years.
Sampling
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Purposive sampling technique
All newly qualified midwives who graduated from a university in
Johannesburg and who had completed the system of compulsory
community services in a maternity unit (2007-2011)
Cellular phone, Facebook or electronic mail.
Interacted with them personally
Participants who relocated or emigrated agreed to write a naïve sketch
Data Analysis
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Tesch’s (Creswell, 1994: 188)eight steps
were used
Data analyzed by researcher and
independent coder
Ethical considerations
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Confidentiality and anonymity
Fair treatment, beneficence and
prevention from harm
Privacy
Findings: Theme 1:Positive experience
1.1 Rewarding
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Felt supported and protected
Practiced independently as peers and colleagues
Opportunity to improve their knowledge and skills
Able to apply knowledge and skills
Felt that their positive attitude, motivation and discipline
contributed to the experience
“They treated me like a colleague; I am crazy about them and
we feel like a family …. Why did they treat us [bachelor nurses]
so bad during training?”
1.2 Gratifying experience
“I kept on telling myself: I want to be here, I can make a
difference, I will take it as it comes”.
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Independent practitioner: enjoyable and satisfying and
expressed a true desire and eagerness to make a difference
Could apply their knowledge and skills and truly functioned
independently.
“I had to hit the road running, but [was] able to perform!” and “If
you can’t take the heat, you shouldn’t be in the kitchen …. Well,
I am in the kitchen and loving it!”
1.3 Sharing ideas and experiences
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Experienced midwives
Appreciated personal interest
“It was helpful [when she assisted] because I then learned how to
handle such a stressful situation.”
“I learned a lot from the doctors, they were surprised that I knew so
much and wanted to know where I trained.”
 Valued teaching opportunities (doctor’s rounds and in-service
training sessions)
“I like it when we can go to the in-service training of the doctors; I
try to learn as much as I could”.
1.4 Different ethos: caring, respect and
beneficence
Undergraduate training: pleasantly surprised to find
another ethos in the [new] public hospital:
“I thought all nurses in government are just plain rude
and insensitive, but that was not what I found”
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“the midwives were empathetic and concerned for the
wellbeing of both the new family and myself”.
1.5 Support and mentoring
The quality of nursing care is directly
influenced by the support midwives received
from peers while integrating roles and
responsibilities.
 The newly qualified midwives found most of
the senior staff members to be mature,
respectful, supportive and competent.
Mentoring continue
Appreciated input and time the older
practitioners would invest: “She showed me
what a good midwife looks like”.
 Worked as peers and colleagues.
 Felt appreciated when they were consulted.
“I really felt that my knowledge and skills were
appreciated” and “I had to go back to the
books, they expected a lot from me”.
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Mentoring continue
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Cangelosi (2005:10): the professional nurse who
accept the mentoring role will contribute to newly
qualified nurses to stay in nursing and find
satisfaction in the different options nursing offer.
Van der Merwe (2005:64): when the mentor
remembers why she started in the profession in the
first instance, she would be able to transfer this
positive image to newly qualified staff
Theme 2: Disillusionment :
2.1 Management
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Lack of structure and support
Lack of understanding regarding roles and
responsibilities
Felt bewildered in the clinical field
Hospital managers and clinical leaders were
unprepared to cope with “community service nurses
[said with scorn or in a sarcastic tone of voice]”.
Because of the fact that a scope of practice for
community service nurses was not in place, “they
made up a scope for me”.
Management continue
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Lack of co-ordination of their function and
orientation
“Skivvies” and were merely performing the duties
expected of a fourth year nursing student
Expected to take charge of a unit, managing staff
and co-coordinating patient care.
“My unit manager resigned on my first day; and there I
was, clueless, running the whole labour ward while
she is saying goodbye”
Management continue
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Health systems to be poorly organized (2011)
Structure and policies absent or not adhered
to:
“They did not know what to do with us and I
was only placed in maternity when I
threatened to go to the press!”
Management continue
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Some managers did not acknowledge that they were novices:
“I was thrown into the deep end, and this was quite
bewildering”.
“Making this transition was daunting … it is truly a new world
and you feel alienated”
Reality shock in the clinical field.
“Things are not always what they seem and no one is there to
prepare you for the shock you experience during the transition
from student to professional nurse”
2.2 Coping with Lack of support
Coped with this perceived lack of support by
management and clinical staff by withdrawal,
aggression and suppression of the
frustration:
“I just had to keep quite and quickly learned
what to say and when to talk”
2.3 Experienced stress in the clinical
field: Interpersonal relationships
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Disrespect
Difficult to work with older colleagues
Difficult to be assertive
Unclear roles and responsibilities
Difficult to work as part of a multi disciplinary
team
Relationships continue
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Strained relationship with some of the midwives.
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“I had to learn when to say what … it appeared
better not to say anything at all”.
Disappointment with the quality of the relationship:
“…I felt unwelcome and disappointed” and “I didn’t
know if she noticed I was actually helping her ..”
Permanent staff members
Unsure of the roles and responsibilities
 Would expect them to know everything,
despite the fact that they were newly
qualified, felt insecure and lacked
confidence.
“Along with the title comes huge
responsibilities and the expectation from your
colleagues are high, as they expect you to
know everything”
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2.4 Overwhelmed
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Responsibility
Expectation to perform (“because I was the only
degree nurse there”)
Left unsupported and unmentored
When mistakes occurred: sarcastic or in a language
that she could not understand.
This particular participant said that this experience
made her wanting to leave nursing as soon as
possible.
2.5 Clinical setting: caring
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Brooker, Waugh, Van Rooyen & Jordan
(2009:205) identifies warmth, positive regard
and guineness to be essential in the clinical
setting.
These components were found to be lacking.
“I did not feel them caring about me at all”
and “it took a lot of self motivation and
discipline to make this transition by myself
[self underlined]”
2.6 Clinical setting: respect
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Change-of-shift report handover: “I asked her to
change to English, but she just laughed and
continued… the other staff members laughed too!”
Global consensus: the need for nurses is greater
than ever.
When relationships are not consciously valued in the
workplace, the culture becomes dehumanized and
retention of staff becomes impossible
2.7 Clinical setting: professional
midwifery practice?
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Based on tradition and convention:
Policies, guidelines or procedures
The nursing process not used
Partograms were completed after the
delivery.
Correct interpretation of the cardio-tocograph
was minimal – thus acted too late
Professional continue
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Felt unsafe, unsure and angry:
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“I found myself constantly enquiring of procedure
and processes in order to perform my duties as a
professional nurse …. It almost makes you afraid of
making an error”.
The central notion in the principle of ‘do no harm’,
includes adhering to appropriate policies, procedures
and techniques – this will ensure quality midwifery
nursing care.
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Professional practice
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Did not report lack of professional practice
Found it difficult to be assertive especially of
the perception that the older midwife “knows
better”.
If they then found that the midwife lacked the
particular skills or knowledge, they would be
hesitant to correct her.
2.8 Multi-disciplinary team
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Experienced stress and discomfort when communicating with
the doctors:
They did not question or challenge them and
the interaction was limited and non-assertive.
Lacked the confidence and skills to participate during patient
rounds and often felt ignored.
As the time passed, the experience became more positive.
Some researchers (Parsons & Griffiths 2007:32) believe that
the standards of conformity and obedience were the result of
the professional socialization process during their training.
SUMMARY
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Newly qualified midwives in compulsory
community service related positive
experiences especially when
they are able to identify with the ethos and
philosophy of the unit,
they were acknowledged and
mentored by the more senior staff members.
Summary continue
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Verbalized an increase in their knowledge
and skills subsequently
increasing their self-worth and
confidence levels.
Summary continue
3.
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Barriers to effective practice included
disillusion with management,
interpersonal challenges and
the fear of making mistakes due to a lack of
adherence to policies or guidelines based on
the best available practice.
Conclusions
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The newly qualified midwives who participated in this
study faced complex, ambiguous situations during
the compulsory community service year, while being
acutely aware of their novice status and [self]
perceived lack of knowledge.
Despite these constraints, many of them verbalized
their personal and professional growth and
development during this period.
Conclusion continue
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The sub-ordination of the newly qualified staff
deprives midwives of the ability to make decisions
based on the best available research evidence.
The fact that the newly qualified midwife did not
question or challenge the medical practitioners or
senior midwives should be of concern to midwifery
leaders as these findings undermine the principles of
professional practice that include the ability to selfreflect, be accountable and to practice
autonomously.
Conclusions continue
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A properly structured, mentored service experience
can have a positive impact on newly qualified
midwifes and may provide benefits to the
communities served.
Despite the positive responses to the compulsory
community year, the inequalities of maternity health
care (rural/urban) can not be addressed when the
newly qualified registered nurse is placed in the
urban area only.
The End
Cangelosi (2005:8) stated:
“Nurses are eating the young”….. the
“miserable” treatment given to new
colleagues deprive the workforce of a
motivated and passionate staff member.”