Formulating the review questions

The SPIDER method (Table 1) was utilized, this acronym helped to develop the review questions, create keywords, assist in listing both the inclusion and exclusion criteria (Table 2), and guide the literature search¹³. Both authors discussed and agreed on these elements for this IR.

Keywords (Table 1) were sought with the help of the medical subject heading (MeSH) database. Consequently, the following three review questions were formulated to help guide the literature search: ‘What are the experiences and feelings of NQMs when caring for women in the maternity setting?’, ‘What may influence the NQM experiences on the job?’, and ‘What strategies may enhance the NQM’s new role?’. Before commencing the literature search, the keywords were combined with the Boolean operators AND and OR, with an asterisk (*) used at the end of certain truncated words to search for all possible endings, and the use of the question mark (?) to replace or represent more than one letter¹⁴.

Systematic search and selection of literature

An extensive literature search was completed by the first author, between December 2021 and the end of July 2022 by combining the keywords presented in Table 1. The following eight databases were used to search the literature: Academic Search Ultimate, Cinahl Complete, Medline Complete, PSYch INFO, BioMed Central, Cochrane Database of Systematic Reviews, PubMed, PubMed Central, and the use of the Google Scholar search engine. All quantitative, qualitative, and mixed-method studies addressing the review questions, were considered for inclusion in this review. No limiters such as the location of keywords, full text, original articles, language, and sample were set during the main search. Limiters were not used since an initial quick literature search indicated that studies published on the topic were few. Hence, to avoid missing any important studies, all that was available was taken into consideration. This was also applicable for the time limit; since no relevant publications dating further back than the year 2000 were 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 exclusion¹⁵.

Figure 1

PRISMA flow chart

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. Table 4 gives 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.

Analysis and synthesis

To get a better understanding of the topic, comprehensive methods of data analysis were implemented for this IR, which allowed recasting, combining, reorganizing, and integrating concepts across a body of literature¹⁶. Data analysis was conducted by deconstructing the articles into their simplest elements¹⁷. To efficiently analyze the articles, three review matrices were constructed, each representing a review question¹². The three analysis-matrices used in this review were thoroughly scrutinized for recurrent patterns, and the formation of themes was guided by the review questions¹². These processes were done by the first author under the supervision of the second author. Both authors discussed and agreed on the findings. Using the Braun and Clarke¹⁸ six-phase process helped to identify the following three themes: Shocking truth, Beginner’s crisis, and Moving on. This process included familiarizing with data where the article was read multiple times and notes were listed as codes for potential themes; generating initial codes, the data formed from the previous coding was organized into interesting codes; searching for themes, the codes were placed into potential themes and subthemes; reviewing themes where themes were refined by gathering items for each theme and a thematic map was developed (Table 5); defining and naming themes, the aspects of the data each 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 midwifery¹⁹. In one study, this philosophy of midwifery referred to the combination of learned theory, accumulated clinical practice during studentship, and individual experiences of childbirth¹⁹. 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^20-23. However, this changed over time, once they embarked on the journey of truly becoming a midwife²⁰. 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 role¹⁹.

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 subordinate⁸. NQMs indicated that the clinical placement could not compare to the midwifery philosophy they believed in²⁴. 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 woman-centered 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 care²⁴.

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 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 hospital-based setting expressed negative feedback about their experience².

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 university²⁰, stepping into the unknown²⁹ 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 situations³⁰. 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 care²⁶. 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 shielding²³. 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 registration². 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 counterparts²². This led to deep frustration, knowing that their ability to transition into their new role would be much slower than they anticipated³². 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 employment²⁰. 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 endured²⁸. 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, Norris²⁸and Wain⁴ 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 Maputle³³ 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 doing⁸.

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 duty²⁸. 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 them²⁸. Such findings also emerged from a study²² 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, Hobbs²² explains that NQMs tend to overlook their wellbeing since midwifery is a female-dominated 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 confidence⁸, 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 experience⁴. 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 labour²⁵. 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 care²¹. However, these participants had been given their midwifery training in a caseload midwifery setting, which differs from a hospital-based maternity setting, and hence, their feelings might have been accentuated by this fact²¹.

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 them²⁸ 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 care¹. 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 action¹. 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 demands¹. 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 midwives¹⁹.

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 equipment³⁰, 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 practice⁸.

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^23-25,29,31. Naqshbandi 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 anxiety²⁴. Fitting in and feeling accepted and not judged was an inspirational goal for NQMs^28,34. NQMs 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 concerns³⁵. 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 own³⁵ or taking over their work³⁰. Senior midwives must become aware that their positive support encourages NQMs to remain in employment²⁷, especially with the increasing concern of the availability of an insufficient number of midwives for future staffing³.

Apart from being supported, debriefing was also found to be vital for NQMs to survive and move on in their midwifery role⁸. 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 consideration⁴. Being placed in a shift that is made up of mixed levels of staffing experience⁸ 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 equipment³⁰, 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 belonging²⁵. Feeling appreciated and being acknowledged by the system as a contributing professional was perceived positively by NQMs⁸.