Newly qualified midwives’ experiences of caring for women in the maternity setting: An integrative review

INTRODUCTION This integrative review aims to explore the experiences of newly qualified midwives (NQMs) when caring for women in the maternity setting. METHODS An integrative review (IR) method was chosen based on a systematic approach using Cooper’s 1984 framework for transparency and rigorousness. A total of 2428 articles were located, duplicate records were removed, leaving 1428 records. All titles and abstracts were reviewed and 91 articles were then retrieved in full text. After applying inclusion and exclusion criteria, 22 studies were ultimately included in this IR. Appraisal tools were used for each study included in this review according to its research approach. RESULTS Literature demonstrated how NQMs’ wellbeing is at stake after registration as they go through a tumultuous period full of psychological stress, fear and other surges of negative emotions. The importance for NQMs to form new and trusting relationships with colleagues and women patients is highly evident in the literature. CONCLUSIONS Transitioning from a student to a midwife brings about stress and tension especially when NQMs take full responsibility for the women under their care, knowing that their decisions might have a direct impact on the outcome for women, newborns, and families. Literature shows that NQMs are a precious entity to healthcare as they are the future of midwifery and hence more research is recommended.


INTRODUCTION
Newly qualified midwives (NQMs) are valuable individuals as they represent the progression of midwifery 1 .Hence, the ability of these NQMs to effectively make the transition from a student midwife to a registered midwife affects both the midwifery profession and maternity health services 2 .A smooth transition is a key aspect of job retention, especially since many countries worldwide fear the availability of an inadequate number of midwives for future staffing requirements 3 .In the published literature, NQMs describe their transition from student midwives to qualified midwives as a 'reality shock' 4,5 which could leave NQMs devastated and unable to process and express their emotions after facing traumatic experiences that could present either 'too unexpectedly' or else 'too soon', caused by various factors like experiencing abuse from staff members or when facing obstetric emergencies, possibly leading to secondary post-traumatic stress 6 .Such issues highlight the importance of making the transition of NQMs a time that helps them develop confidence and competence 7 .
To qualify as a midwife, one must undergo a midwifery education program that fulfills the academic recognition stipulated by their country, whereby most midwifery courses need to be completed within three to four years to attain a diploma or degree in midwifery studies 8 .Attaining the relevant academic midwifery qualification equips a NQM with the necessary knowledge and skills to care for women during normal pregnancies and assist them in childbirth.Moreover, a NQM is also expected to have the ability to detect complications in both the mother and infant, take preventative measures for these complications and carry out emergency measures for complications that may arise during pregnancy, childbirth, and the postpartum period 9 .An NQM should also have acquired the general knowledge and skills to provide counselling and education on women's reproductive

Review paper
and sexual health and childcare to women and their families 9 .The international definition of a qualified midwife as stated by the International Confederation of Midwives (ICM) 9 is: 'A midwife is a person who has completed a midwifery education program that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education and is recognized in the country where it is located; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title 'midwife'; and who demonstrates competency in the practice of midwifery' 9 .
The experience of childbirth is a particularly important and emotional event in a woman's life; it will forever affect how she sees herself as a woman, and her relationship with her partner and other family members 10 .This highlights the importance of having NQMs who feel/are confident and competent while caring for women and that a midwife's well-being has a direct impact on the care provided to a woman 11 .Therefore, an integrative review was undertaken to investigate what NQMs experience as they embark on their new professional role and care for women in the maternity setting.

METHODS
An integrative review (IR) method combines research and draws inferences from various sources on a topic by looking at and taking into consideration all literature present during the search, being empirical, methodological, and theoretical 12 .As Toronto and Remington 12 suggest, for both transparency and rigorousness, this review was based on a systematic approach using Cooper's 1984 framework 12 , which consists of a six-step process that was implemented as guidance.These six steps include: formulating the purpose for the review and formulating a review question; executing a systematic search; selecting appropriate literature; performing a quality appraisal of the literature chosen; carrying out analysis and synthesis of the studies; and discussion, conclusion, and dissemination of the findings 12 .found, no time limit was set.Furthermore, the reference lists of the chosen articles were thoroughly scrutinized for any other relevant studies.The retrieved articles were retained according to the inclusion and exclusion criteria (Table 2) for this review.A total of 91 articles were retrieved in full text and, after applying the exclusion criteria, a total of 22 studies were retained for the review.Figure 1 displays the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing the number of records identified, included, excluded, and the reasons for exclusion 15 .

Quality appraisal
To determine if the results of the study were valid and could be used for further research studies, education, policies, or clinical practice, an evaluation for utility and quality was done using appraisal tools.Table 3 shows the appraisal tools used for each study included in this review according to its research approach.

Total studies included in review (n=22)
Remaining studies from Databases and Registers (n=19) Remaining studies from other search methods (n=3)

Figure 1. PRISMA flow chart
theme captured were determined, and the story of each theme was studied to develop the final theme names; and producing the report where a report of the identified themes was developed.

Emergent themes
Shocking truth This theme brings out the stark realities NQMs experience when transitioning from the role of student to that of a registered midwife by looking at NQMs' perceptions of what midwifery entails and their views of their real job experiences.This theme represents the research question, 'What may influence the NQM experiences on the job?'.NQMs expressed a feeling of coming into the workforce proud of their graduation and achievements, and embracing the philosophy of midwifery 19 .In one study, this philosophy of midwifery referred to the combination of learned theory, accumulated clinical practice during studentship, and individual experiences of childbirth 19 .NQMs had an idea of what a midwife is, what the job involves, and the relationships they will build with their colleagues, the women they care for, and their families [20][21][22][23] .However, this changed over time, once they embarked on the journey of truly becoming a midwife 20 .Participants in many studies experienced a huge surprise when they started practicing in a professional setting, encountering many unexpected scenarios, from what they had been taught and their views on maternity care, to what was practiced in the clinical setting.Leading to a sense of frustration when they could not reach their expectations of their midwifery role 19 .
It emerged that the working environment is based on a medical setting where certain unneeded interventions take place, which led to NQMs looking at the midwifery role as being subordinate 8 .NQMs indicated that the clinical placement could not compare to the midwifery philosophy they believed in 24 .One study particularly showed that the initial feelings of NQMs as they cared for women, were of 'letting women down' 19 and not giving them the support, standard of care, and attention, they had envisioned 19,20 .NQMs felt that they were not able to provide proper womancentered care as they had intended 5,20,21,25,26 , leading to NQMs feeling guilty when they did not dare to speak up for women and stand up to other staff members when they felt that women were not receiving proper care 24 .
However, this could be based on the environment these NQMs were exposed to since in two studies, NQMs had the opportunity to work in caseload midwifery practice.This included student midwives caring for an assigned woman throughout pregnancy, birth, and the postnatal period.This resulted in these NQMs experiencing a completely different aspect of the job description once they were employed as midwives in a hospital-based maternity setting.This is one of the reasons that NQMs became disappointed after having different expectations from the role 20,21 .Whereas NQMs who worked their transition period within the midwifery continuity of care model regarded their experience as a positive one, describing it as having the opportunity to work closely with

Studies
Appraisal tool

Qualitative studies
Avis et al. 29 Barry et al. 19 Barry et al. 1 Cazzini et al. 24 Clements et al. 2 Fenwick et al. 34 Griffiths et al. 21obbs 22 Kitson Reynolds et al. 20 Kool et al. 25 Naqshbandi et al. 27 Norris 28 Saliba 31 Sheehy et al. 8 Simane-Netshisaulu and Maputle 33 Skirton et al. 26 van der Putten 5 Wain 4 Watson and Brown 23 Young 35 The other midwives, sharing the same philosophy of care, and keeping women at the center of care.In contrast, those from the same study who were assigned to a hospitalbased setting expressed negative feedback about their experience 2 .
Beginners' crisis This theme highlights the difficulties found across the literature that NQMs experience in their new role as registered midwives in a maternity setting.This theme represents the research question: 'What are the experiences and feelings of NQMs when caring for women in the maternity setting?'.Literature indicates that it is quite common for NQMs to experience a surge of feelings and emotions, which may contribute to a lack of confidence and mediocre performance, making them vulnerable persons during an exceedingly difficult and stressful time of their professional career 8,27,28 .All included studies (n=22) revealed that NQMs experienced some form of stress, with two studies indicating that stress was linked to the phenomenon of sudden status change; from being a protected student to becoming a fully independent and accountable midwife 4,20 .The feeling of losing the shelter provided by their university 20 , stepping into the unknown 29 and starting to find out the true demands of midwifery was all about experiencing the reality of both sides of the profession, from happy/joyful moments to sad, heartbreaking situations 30 .NQMs revealed that they did not realize the responsibility of being a midwife while they were students and, therefore, found it stressful once they were employed in their new role, taking sole responsibility and decision-making for the women under their care 26 .Three studies show that this sense of responsibility was seen as overwhelming by the participants 5,23,31 .
Studies revealed the steep learning curve that was expected by employers, where NQMs were expected to increase their knowledge regarding certain skills and practices for which they had not been previously trained 8,22 .NQMs were mostly worried about being those who must act during emergencies without any shielding 23 .As students, NQMs never took decisions on their own while caring for women during labor while, once qualified, they were afraid of the heavy responsibility and that they would make a mistake that would cost them their registration 2 .Furthermore, participants put themselves under intense pressure due to increased expectations of their abilities to carry out tasks at the same pace as their senior counterparts 22 .This led to deep frustration, knowing that their ability to transition into their new role would be much slower than they anticipated 32 .Such issues surfaced mostly in birthing units, especially during vaginal examinations (VEs), the second stage of labor, and when interpreting cardiotocography (CTG) results 22,25 .
Participants felt that even though they were educated and trained on responsibility, accountability, and autonomy as students, they did not feel up to these in their first 12 months of employment 20 .NQMs went through so many conflicting ideologies when they tried to use the knowledge they acquired from school into practice, that it resulted in impeding their self-confidence 5,23,27 .Although studies mention that NQMs were conscious of their abilities in knowledge and skills, they mostly felt that their position as an NQM was subordinate, and this unfavorably affected their ability to be sufficiently assertive to deal with the events and tasks presented to them.NQMs described the role of the midwife as intense and emotionally demanding, while not finding the right support from colleagues, which proved to have a negative effect 8,32 .One study compared being accepted by senior midwives to an 'initiation period' 20 , meaning that they felt as if they had to pass a test to be accepted by their senior counterparts.Other NQMs described their struggle to be accepted by other midwives as a challenge that had to be endured 28 .NQMs felt continuously watched by colleagues, waiting to be judged on whether they stepped out of line and whether they can be trusted 2,21 .They felt that they were mostly seen as a burden, lacking skills, ability, and competence 8,21,23,24,30 .Studies by Kool et al. 25 , Norris 28 and Wain 4 have all described the dilemmas NQMs face when they need to ask for help from other midwives or refer women to obstetricians.Fearing that they would be seen as weak and incompetent, NQMs felt like a nuisance to ask for help/support, especially in busy environments and short-staffed circumstances, shattering their hopes of building a trusting relationship with colleagues 24,26 .Sheehy et al. 8 and Simane-Netshisaulu and Maputle 33 describe a bullying culture where NQMs feel belittled by a hierarchical system and autocratic personalities.This is also shown in the studies of Fenwick et al. 34 and Lennox et al. 30 where a pattern of inappropriate working culture was noted in some units, where midwives rank themselves according to seniority with NQMs placed at the bottom of the hierarchy, the well known 'pecking order' 30 .
Findings of one study revealed how participants felt helpless and did not know what to do to perform their role, with one of the participants expressing that she felt 'like a fraud' 30 while speaking to a mother who was continuously thinking that this woman should be speaking to 'a real midwife' 30 .On the other hand, in another study, a common expression by NQMs was 'fake it till you make it' 8 , which involved mimicking skills from other colleagues even though they were not aware of what they were doing 8 .
Most NQMs take all these fears, feelings, and emotions back to their own homes, worrying that they failed as midwives and believing that they did something wrong while caring for women 20,25 .Worst of all, they even compared themselves to others, which, eventually, may take a toll on their personal lives.Participants complained of not being able to sleep and constantly counting the days until their next duty 28 .Others commented on not taking any breaks during their duty or staying on after their duty ended, to see the outcome of the birth even though they were exhausted and needed to go home to their families 22,23 .Their coping skills and anxiety were based on how and if they would manage to complete the tasks assigned to them 28 .Such findings also emerged from a study 22 focusing on Bourdieu's notion of habitus, which is defined as 'our overall orientation to or way of being in the world; our predisposed ways of thinking, acting, and moving in and through the social environment' 22 .Hence, Hobbs 22 explains that NQMs tend to overlook their wellbeing since midwifery is a femaledominated profession and it is in their nature to give their 100% and more, which Bourdieu refers to as 'service and sacrifice' 22 .
Six of the studies included in this review 2,4,8,25,29,34 presented the experiences of NQMs when working on a rotation basis.This brought about instability in their confidence 8 , insecurity, and having to prove themselves to colleagues in an extremely limited period 24,25 .Time is needed in one clinical area to consolidate and gain knowledge and experience 4 .However, some conflicting ideas emerged between participants, such as in the study by Avis et al. 29 where some participants agreed with the negative effects of the rotation system, describing it as a 'roller coaster ride', while others described it as building their confidence since they had the opportunity to witness various scenarios from different ward settings.Similarly, in Clements et al. 2 , participants working in the continuity of midwifery care setting did not experience any feelings of stress, fear, or anxiety during their rotation.However, the findings of these studies could have been affected by organizational structures and dimensions, the geolocation of the studies, and personal character traits.Workload and time constraints were other factors that made it extremely difficult and stressful for NQMs to provide proper care and attention to women during labour 25 .Moreover, the inability to provide proper woman-centered care was yet another added concern for NQMs when assigned to shifts, as it made them feel that they lacked continuity of care 21 .However, these participants had been given their midwifery training in a caseload midwifery setting, which differs from a hospitalbased maternity setting, and hence, their feelings might have been accentuated by this fact 21 .

Moving on
The final theme in this review investigates several factors that NQMs identified as helping them accept, adapt, and move forward in their new role, representing the final research question: 'What strategies may enhance the NQM in her new role?'.Over time, participants started to feel more confident, obtained a clearer picture of what was expected of them 28 and were able to put their knowledge into practice 26,31 .One study explains that NQMs go through three stages while transitioning from students to qualified midwives to provide woman-centered care 1 .These three stages include: being centered on developing their personal qualities, developing an understanding of outside influences that may impact their practice, and moving through a process to support change through their plan of action 1 .The feeling of belonging to the profession and their role as a midwife helped NQMs not only to provide the best care to mothers but also set boundaries to help themselves survive.These included working autonomously, gaining professional recognition, respecting their family commitments, and supporting their emotional demands 1 .Other factors that encouraged NQMs to retain their profession, and achieve job satisfaction and motivation were the ability to work within the full scope of midwifery practice and building a good relationship with the women in their care 8,25 .Receiving positive feedback and trust from the women they cared for was considered an important job resource, which instilled a feeling of empowerment in new midwives 19 .
Another factor that helped NQMs cope with their transition, was being assigned to work in clinical areas where they previously trained as students helping them to adapt faster in their role due to the familiarity with the ward setting and workforce 8,24,31 .It also helped them in the steep learning curve and to provide better care to women 8,24,31 .
Additionally, two studies point out that the structure of clinical placements previously familiar to student midwives directly influences NQMs once they start to work 21,26 .Hence, being oriented with the clinical setting and equipment 30 , whilst being informed about ward/hospital protocols and guidelines, gave NQMs a feeling of security, knowing what is expected of them in the early days of their employment 8,29 .Likewise, organizational structures within the hospital helped NQMs to work to the full scope of the midwifery practice 8 .
Five studies show that when NQMs were supervised or assigned to a senior midwife, facilitator or preceptor during duties, NQMs' confidence increased, giving them a sense of security 4,24,25,29,31 emphasizing that being surrounded by support from colleagues was deemed crucial and helpful [23][24][25]29,31 . Naqshandi et al. 27 add that supportive colleagues help NQMs to adapt faster, have a smooth transition, increase confidence, and make them more likely to retain their profession.This support offered NQMs positive learning experiences in practice 8,28 and helped with stress and anxiety 24 .Fitting in and feeling accepted and not judged was an inspirational goal for NQMs 28,34 . NQs also expressed that being in the company of colleagues during duties and breaks, team building activities and socializing during out of duty hours were all assets in building relationships and enhancing their work practice 8,24,25 .
NQMs' decision-making skills were developed when they were assigned to another colleague and were given the possibility to speak about their concerns 35 .Moreover, decision-making skills were also improved when senior midwives dedicated time to explain and discuss with NQMs the rationale behind a decision rather than leaving them to fend on their own 35 or taking over their work 30 .Senior midwives must become aware that their positive support encourages NQMs to remain in employment 27 , especially with the increasing concern of the availability of an insufficient number of midwives for future staffing 3 .
Apart from being supported, debriefing was also found to be vital for NQMs to survive and move on in their midwifery role 8 .Participants explained that having the space to vent their feelings about their experiences and challenges, helped them to relieve their anxiety, learn, and progress 8,30 .Furthermore, having a friend who is going through the same experience also helped in relieving anxiety 23,24 .Additionally, having the possibility of assigning NQMs to a one-to-one woman-care ratio during the first few months of work is deemed to be a beneficial consideration 4 .Being placed in a shift that is made up of mixed levels of staffing experience 8 and is considered supernumerary 23,24 was also seen as an important strategy for learning and safety in practice.
Another factor found to enhance the transition phase of NQMs was having good organizational support, which was shown to be an asset for NQMs.This support translates to having sound induction programs allowing NQMs to orient themselves with units and equipment 30 , be introduced to policies and guidelines 8,29 , be assigned to preceptors, have supervision, and be assigned over and above the staff requirement of the clinical area 8,23 .These provided NQMs with a smooth transition into the workforce.The organization should endeavor to support and empower NQMs to further their studies to allow them to expand their knowledge, and stay up-to-date with the latest evidence-based literature, besides keeping them motivated and giving them a sense of belonging 25 .Feeling appreciated and being acknowledged by the system as a contributing professional was perceived positively by NQMs 8 .

DISCUSSION
This review aimed to explore the experiences of NQMs when caring for women in the maternity setting.The literature demonstrated how NQMs' wellbeing is at stake after registration, as they go through a tumultuous period full of psychological stress, fear, and other surges of negative emotions since the role of the midwife is very intense and emotionally demanding 8 .This difficult period is linked to the new responsibilities of their role, especially when it comes to decision-making, which may influence their confidence and competency 20 .The sudden change of role to a more demanding and responsible one might come to what was explained by Kramer in 1974 4,5 , as a 'reality shock', where what was expected and envisioned as students becomes shattered once they join the workforce [20][21][22] .Participants felt helpless in the early days of their professional role as they did not have the understanding or the experience to perform their roles effectively and efficiently 30 .Feelings of incompetence and lack of self-confidence had an increased influence on the stress levels of NQMs, causing a psychological impact on them since they had become the sole-accountable person for the mother and baby under their care.Most were afraid to assume this newly acquired responsibility out of fear of making a serious mistake, which would cost them their midwifery licence 2 .All these emotions, together with lofty expectations and the lack of support from colleagues, were taking a toll on their personal lives, which could lead to compassion fatigue, which is known as the 'cost of caring' 6 , especially when exposed to obstetric emergencies, leading to less compassion satisfaction 36 .These emotions were mostly dependent on the different settings NQMs were enrolled in since participants felt less psychologically affected and more at ease when they were not assigned to birthing units in a hospital-based setting but worked in caseload midwifery practice 2 .
Most of the literature reviewed also highlights the transition phase from being a student to becoming a midwife 1,2,4,8,[19][20][21][22][23][24][25]27,28,30,31,34,35,37 . The findings from th studies concur with a three-phase gradual transition where, primarily, NQMs felt the loss of what was familiar to them; teachers, school colleagues, mentors, and the shelter provided by their university 20 , whilst stepping into a whole new world and a role of uncertainty 29 .This IR also showed the importance for NQMs to form new and trusting relationships with colleagues and women patients, trying to fit in and carry out the necessary skills needed to perform tasks.Finally, it became evident that as time passed, participants were finally reaching the stage where they wanted to be, in the 'promised land' 28 .In this new phase of adaptation, although still scary and risky, NQMs now feel they have a clearer vision of what is expected of them 28 and start to apply all the knowledge they already possess with that they continue to acquire from their new experiences 1 .They are ready to let go of what passed and try to adapt to their new role and environment as more autonomous midwives 28 , leading to job satisfaction where they feel they are finally truly helping women 8,25 .Senior midwives were found to play one of the biggest roles in guiding and helping NQMs succeed 25,29,31 .When senior midwives were readily available to explain, guide, and help without any form of judgment or exercise of superiority, this was the ideal situation for NQMs to learn and advance in their practice 2,21,25,27,29,31 .Kitson Reynolds 20 and Cazzini et al. 24 emphasized the importance of giving NQMs time and space for debriefing and considered this to be instrumental for all healthcare professionals.Debriefing should not only be available after an emergency or traumatic experience but for anyone who needs it 20 .

CONCLUSIONS
Transitioning from a student to a midwife brings about stress and tension, especially as NQMs take full responsibility for the women under their care, knowing that their decisions can have a direct impact on the outcome for women, newborns, and families.Literature shows that the factors that influence NQMs include the working environment, especially when working in birthing units, the support given by colleagues, and the organization in which they are employed.It is therefore very important that NQMs find the needed support to be able to overcome this trauma before it is aggravated and leads to secondary post-traumatic stress.NQMs are a precious entity in healthcare, as they are the future of midwifery.Yet, research is still extremely limited, and, to date, the focus has mostly been on the transition to practice and on supportive programs such as preceptorship.Further research focusing on more holistic experiences of NQMs is warranted to enable a deeper understanding of their professional development.

Table 1 . SPIDER method for developing keywords used for the literature search Component Explanation Term
Table4gives a summary of the final 22 studies used in this integrative review, showing the authors, year of publication, methodology, sample size and sampling, the participants, and the data collection methods used.It also indicates the region/country where the study was done, giving a cultural context perspective that could reflect cultural implications in the results.The studies were appraised by the first author, and the processes were reviewed by the second author.The outcomes were discussed and agreed upon by both authors.