The nursing and midwifery shortage has been occurring on a global scale since 2000.1 Based on a report by the United Nations Population Fund and the International Confederation of Midwives, the World Health Organization has declared a major shortage in the midwifery workforce in 73 countries.2 Most of these countries are African, Asian and Latin American which have 96% of the global burden of maternal deaths, 93% of newborns deaths and 91% of stillbirths, but have only 42% of the world's midwives, nurses and doctors.2 The severe shortage of midwifery care needs to be addressed as midwives’ roles are crucial in determining the wellbeing of mothers and newborns. The global shortage has to be addressed by governments at a local level to implement strategies to manage the domestic nursing and midwifery workforce.2
“The transition period of new midwives is defined as a period of learning and adjustment after the completion of a recognized midwifery education program to work as registered midwives.”3(p.155) Transition period is described as a period of adjustment.4 Transition period is also identified to have an impact on job satisfaction and staff retention, which influence the midwifery profession shortage globally.3,5 Internationally, in both the nursing and midwifery contexts, the transition period from students to practice is recognized as a stressful and critical period.6 New graduate midwives are facing new opportunities and challenges in giving real and optimum-quality midwifery services for better health outcomes.7,8 The first year of practice is considered a period of transition that requires support for and adjustment by graduates.6,9 Entry to practice for graduates needs to prepare them to be ready with their new responsibility to work as health professionals.8 However, during their experience in the first year of transition period, many fresh graduate midwives feel ill-equipped and lack confidence, which influences their performance of midwifery services.7,10 The confidence levels of new graduate midwives related to decision making skills in their transition period have been shown to be low.9 As cited by Roxburgh et al.,6 the phenomenon of transition period issues in nursing context globally has been reported since 1999 in the United Kingdom, according to Holland, 2000 in Australia, according to Greenwood, 2003 in Canada, according to Ellerton and Gregor, and 2004 in South Africa, according to Moeti et al. Thus, examining the experiences of new graduate midwives in their first year of practice in this systematic review may assist institutions to provide support for new midwives.
Transition support programs are programs established to help new graduates develop their confidence and competence in their transition period.5 In the nursing context, transition support programs are defined as “new graduate programs to support the safe and effective transition into a new clinical practice area”.5(p.40) Transition support programs include preceptorship, mentorship, supernumerary time and specific orientation.11 “Preceptorship” is a term used in the United Kingdom, and “orientation programs” is the term used in the United States of America.11 In the Australian context, the three main approaches of supporting new midwives are “mentorship”, “preceptorship” and “clinical supervision”. Direct entry undergraduate midwifery has been offered in Australia since 2002.12,13 In Australia, two different paths of midwifery education are single and double degree (Bachelor of Midwifery and Bachelor of Nursing/Bachelor of Midwifery). Both approaches provide models of support to prepare graduate midwives to undertake midwifery services.12 This systematic review will include all transition support programs offered to graduate midwives in all midwifery healthcare settings.
Social support includes resources that help individuals to manage stress.14 The components of social support are appraisal support (having someone to talk to about their problems), self-esteem support (having a positive comparison when evaluating oneself against others), belonging support (having people to do things with) and tangible support (having someone to provide material aid).15 Social support has been found to be a protective role and plays an important stress-buffering function.14 Furthermore, social support helps individuals to cope with a stressful experience by fostering a more positive interpretation and perception of the event. This can help them decrease their experiences of anxiety and stress,15 which further increases their confidence. The transition from a new graduate to a professional has been described as a critical and stressful period for new midwives.16 Thus, the positive experiences of social support during the first year of midwifery practice has a vital role in helping new graduate midwives improve their level of confidence.
A supportive environment, effective transition support programs and an understanding of social support during the transition period increase new graduate midwives’ confidence levels. In turn, their confidence levels affect their performance. Gaining a thorough understanding of midwives’ experiences of social support during their first year working as midwives is likely an early step in optimizing support for new graduate midwives in their transition period. Qualitative aggregation is a method that attempts to address the same question or topic area from an accumulation of qualitative studies. The findings of a number of qualitative studies are integrated to inform, enhance and extend the evidence base. A systematic review undertaking a meta-aggregative approach is transparent in that it presents the whole range of relevant findings on a particular research topic and lends breadth and depth to the qualitative literature.16 Furthermore, this systematic review study provides a vital tool to inform policy and practice, and support the decision making.17-19
A preliminary search undertaken in the JBI Database of Systematic Reviews and Implementation Reports, CINAHL, PubMed and MEDLINE revealed no existing systematic review related to new graduate midwives’ experiences during their transition period. There was one approved JBI protocol on a similar topic in the nursing context, titled, “The experiences of newly qualified nurses during the role transition period following qualification”.20(p.4) However, none could be found that explicitly focused on the graduate midwife. The midwifery education program has been recognized to prepare graduate midwives for their autonomous role; however, it is essential to investigate the experiences of new graduate midwives in relation to transition support programs and social support during their transition period, as this may influence the quality of service provided by new graduate midwives.
For the purpose of this review, the following definitions will apply:
- Transition period: first year post-qualifying as a midwife or first year of employment following the registration after the completion of a recognized midwifery education program.
- Graduate midwife: a person who has completed either a recognized undergraduate or postgraduate midwifery education program.
- New midwife: a graduate midwife during their first year of practice.
Types of participants
The current review will consider studies that include new midwives or graduate midwives who have been working as registered midwives for one year. To be included, study participants must have completed their midwifery education program at both an undergraduate (single or double degree) and postgraduate level. This systematic review will include all transition support programs offered to graduate midwives in all midwifery healthcare settings.
Phenomena of interest
The current systematic review will include studies that explore the experiences of new midwives with transition support programs including preceptorship, mentorship or other transition support programs (i.e. clinical supervision and orientation program) and social support in the working place during their first year of practice.
The current qualitative review will consider all midwifery healthcare settings (i.e. hospitals, birth centers and other public or community health settings).
Types of studies
The review will examine qualitative studies including, but not limited to, phenomenology, grounded theory and ethnography. Studies that do not provide examples of participant voices will be excluded.
The search strategy aims to find published and unpublished studies on new midwives’ experience of transition support during the first year of practice. A three-step search strategy will be utilized in this review. An initial limited search of CINAHL will be undertaken followed by analysis of the text words in the title and abstract, and the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. The issue related to the transition period of graduates in nursing profession started being reported in 1999 and the beginning of 2000.6 Thus, the search will be restricted to international studies published from 2000 onward as the studies published before 2000 may not be relevant to the phenomenon of interest of this review. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies in English language only will be included.
Published literature will be searched in the following databases: Scopus, PubMed and CINAHL.
Unpublished literature will be searched in: Dissertation and Thesis Collection and ProQuest Dissertations and Theses Global. Key search terms will include “graduate midwives” OR “new midwives” OR “student midwives” OR “newly qualified midwives,” combined with “experience” OR “perception” OR “feeling,” combined with “social support” OR “mentorship” OR “perceptorship” OR “graduate program” OR “fellowship,” and “transition” OR “transition period” OR “change” OR “culture shock.”
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Appendix I: Appraisal instruments
QARI appraisal instrument
Appendix II: Data extraction instruments
QARI data extraction instrument
1. Kline DS. Push and pull factors in international nurse migration. J Nurs Sch
2003; 35 2:107–111.
3. Clements V, Davis D, Fenwick J. Continuity of care: supporting new graduates to grow into confident practitioners. Int J Childbirth
2013; 3 1:3–12.
4. Melbourne; 2002; Government VS. Victoria Department of Human Service. Graduate nurse program guidelines.
5. Levett-Jones T, FitzGerald M. A review of graduate nurse transition programs in Australia. Aust J Adv Nurs
2005; 23 2:40–45.
6. Roxburgh M, Lauder W, Topping K, Holland K, Johnson M, Watson R. Early findings from an evaluation of a post-registration staff development programme: The Flying Start NHS initiative in Scotland, UK. Nurs Educ in Practice
2010; 10 2:76–81.
7. Fullerton JT, Thompson JB, Johnson P. Competency-based education: the essential basis of pre-service education for the professional midwifery workforce. Midwifery
2013; 29 10:1129–1136.
8. Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ
2011; 45 11:1081–1089.
9. Young N. An exploration of clinical decision-making among students and newly qualified midwives. Midwifery
2011; 28 6:824–830.
10. Gerrish K. Still fumbling along? A comparative study of the newly qualified nurse's perception
of the transition from student to qualified nurse. J Adv Nurs
2000; 32 2:473–480.
11. Lennox S, Skinner J, Foureur M. Mentorship, preceptorship and clinical supervision: three key processes for supporting midwives. N Z Coll Midwives J
2008; 39 7:7–12.
12. McKenna L, Gilmour C, Biro MA, McIntyre M, Bailey C, Jones J, et al. Undergraduate midwifery students’ sense of belongingness in clinical practice. Nurs Educ Today
2013; 33 8:880–883.
13. Heslop L, McIntyre M, Ives G. Undergraduate student nurses’ expectations and their self-reported preparedness for the graduate year role. J Adv Nurs
2001; 36 5:626–634.
14. Cohen S, Hoberman HM. Positive events and social supports as buffers of life change stress. J Appl Soc Psychol
1983; 13 2:99–125.
15. Cohen S, Wills TA. Stress, social support
, and the buffering hypothesis. Psychol Bull
1985; 98 2:310.
16. Steele R. Gaining competence and confidence as a midwife. Br J Midwifery
2009; 17 7:441–447.
17. Garg AX, Hackam D, Tonelli M. Systematic review and meta-analysis: when one study is just not enough. Clin J Am Soc Nephrol
2008; 3 1:253–260.
18. Higgins J, Green SP. Qualitative research and Cochrane reviews. Cochrane handbook for systematic reviews of interventions version 510. The Cochrane Collaboration. 2008; Available from: http://www.cochrane-handbook.org
. [Updated March 2011; cited January 15, 2016].
19. Sandelowski M, Barroso J. Toward a metasynthesis of qualitative findings on motherhood in HIV-positive women. Res Nurs Health
2003; 26 2:153–170.
20. Tseng K, Hsu H, Hwu Y, Liu H, Chiang H, Chen Y. The experiences of newly qualified nurses during the role transition period
following qualification: a review of the qualitative evidence. JBI Lib Syst Rev
2011; 9 (32 Suppl):1–11.