NEWLY QUALIFIED MIDWIVES WORKING IN COMMUNITY SERVICES – THEIR EXPERIENCES AND CHALLENGES

1. NEWLY QUALIFIED MIDWIVES WORKING IN COMMUNITY SERVICES – THEIR EXPERIENCES AND CHALLENGES Dr. Diana du Plessis Midwifery Consultant & Researcher 2012

2. Introduction • 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.

3. Maternity services • 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).

4. Maternity services continue • 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.

5. Maternity services continue • 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.

6. Community service for medical professionals (Reid: 2002) • 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.

7. Problem statement • 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.

8. The following questions arose: • 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?

9. RESEARCH GOALS/OBJECTIVES • 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.

10. RESEARCH DESIGN • 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.

11. Phases of the research Phase 1 • Individual phenomenological interviews and naïve sketches • Phase 2 • Guidelines

12. DATA COLLECTION Population • All newly qualified midwives working in the public maternity unit during the compulsory community service years. Sampling • 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

13. Data Analysis • Tesch’s (Creswell, 1994: 188)eight steps were used • Data analyzed by researcher and independent coder

14. Ethical considerations • Confidentiality and anonymity • Fair treatment, beneficence and prevention from harm • Privacy

15. Findings: Theme 1:Positive experience1.1 Rewarding • 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?”

16. 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”. • 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!”

17. 1.3 Sharing ideas and experiences • 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”.

18. 1.4 Different ethos: caring, respectandbeneficence • 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” “the midwives were empathetic and concerned for the wellbeing of both the new family and myself”.

19. 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.

20. 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”.

21. Mentoring continue • 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

22. Theme 2: Disillusionment :2.1 Management • 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”.

23. Management continue • 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”

24. Management continue • 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!”

25. Management continue • 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”

26. 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”

27. 2.3 Experienced stress in the clinical field: Interpersonal relationships • 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

28. Relationships continue • Strained relationship with some of the midwives. “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 ..”

29. 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”

30. 2.4 Overwhelmed • 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.

31. 2.5 Clinical setting: caring • 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]”

32. 2.6 Clinical setting: respect • 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

33. 2.7 Clinical setting: professional midwifery practice? • 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

34. Professional continue • Felt unsafe, unsure and angry: • “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.

35. Professional practice • 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.

36. 2.8 Multi-disciplinary team • 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.

37. SUMMARY • 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.

38. Summary continue • Verbalized an increase in their knowledge and skills subsequently • increasing their self-worth and • confidence levels.

39. Summary continue • 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.

40. Conclusions • 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.

41. Conclusion continue • 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 self-reflect, be accountable and to practice autonomously.

42. Conclusions continue • 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.

43. 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.”