Executive summary
Feedback from the learners at this meeting continued to highlight a variable experience within midwifery however, there were some notable improvements compared to the visit undertaken in January 2024.
The following are areas identified during this visit that are working well or showed improvement:
- There was a notable change in the culture across both sites, with learners reporting that they had felt a change in the behaviours and support from most of the team.
- Learners reported positive interactions with the leadership team within the department, advising that they are approachable and visible.
- Support from the midwifery team has improved, with feedback from learners that if they needed help, support has been received.
- Learners reported that the process for requesting translators is clear and interpretation services are being used in situations where they would expect them to be present.
- Learners shared an increased awareness of the mechanisms for raising concerns.
There were reports of ongoing concerns which require further improvement:
- Orientation to the clinical areas was an issue raised by the learners across both sites, with reports that there is no formalised consistent process that appears to be in place.
- Across both sites, learners continued to report a lack of learning opportunities to fulfil competencies in some clinical areas due to capacity and being asked to support service provision.
- Ongoing difficulties with receiving feedback on performance and completion of electronic portfolios was shared by learners at both sites due to a lack of time and capacity for practice supervisors and assessors.
- There were some reports of a small number of midwives displaying poor behaviours towards learners, with particular examples shared.
In addition to the above, the following new areas of concern which require action were noted:
- A potential patient safety concern was raised at Good Hope Hospital regarding a lack of re-orientation into the postnatal ward impacting on a learner not being able to retrieve emergency equipment independently after a patient suffered a maternal collapse.
- Whilst the learners’ awareness of how to raise concerns had improved, feedback from the trust and/or department to learners regarding the management of issues raised was inconsistent.
- The timeliness of rotas being released across both sites of the trust were a source of frustration for the learners.
- Learners at Good Hope Hospital perceived an inequity in learning opportunities and support compared to other trust sites. Despite acknowledging improvements, they felt they were missing out on opportunities due to their location at Good Hope.
We would like to thank all learners and trust colleagues who engaged with the visit. The feedback provided highlights that improvements have been made, and that further work is still required in some areas. Learner awareness of the visit report from January 2024 was inconsistent, although the volume of work being delivered by the trust to improve the clinical learning environment was recognised. Of the 34 pre-registration midwifery learners that we met with, all recommended the trust as a place to train, and 32 out of the 34 learners would be happy to work within the trust following their registration.
Based on the improvements observed, the panel will be recommending this item is reduced from an Intensive Support Framework (ISF) category 3 to an ISF category 2. This is to ensure that the required improvements are fully implemented and that the outstanding areas are addressed. A trust improvement plan will be required against the mandatory requirements outlined in this report.
Review overview
Background to the review
This quality intervention was held as a follow-up to the January 2024 learner educator meeting to test progress against the trust’s active improvement plan for pre-registration midwifery training.
Who we met with
Learners
- Learners undertaking the pre-registration midwifery programme
Educators
- Practice supervisors and assessors within midwifery
Education team and senior team
- Chief Nurse (feedback summary only)
- Director of Midwifery (feedback summary only)
- Head of Midwifery (feedback summary only)
- Head of Pre-registration Education
- Head of School of Nursing, AHPs and Midwifery (feedback summary only) Practice Placement team
- Lead Support and Education Matron
- Lead Educator for Pre-registration Midwifery Education
Review panel
- Panel Chair, Sheran Oke, Assistant Director of Clinical Leadership & Education (Nursing and Midwifery)
- Specialty Expert, Jo Hadley, Midwifery Quality and Professional Development Lead
- Quality Representative, Amelia Harbon, Quality Deputy Manager
Review findings
Culture and support
Overall, learners across both sites reported improvements to the culture within midwifery when compared with the January 2024 visit. They shared that they felt the clinical environments are welcoming and they felt part of the team. Learners felt supported clinically, are comfortable to ask for help and are confident that the midwives will help if they are needed.
All learners, practice supervisors and assessors praised the efforts of the Practice Placement Team, recognising the Practice Support Midwives (PSMs) for the support they have provided since being in post.
In addition, learners at Heartlands Hospital reported positive interactions with the leadership team. They advised that the team are approachable, visible, and that they undertake regular walk arounds within the clinical areas to speak to learners.
Learners based at Good Hope Hospital reported that increased visibility of the PSMs and Leadership team on site would be beneficial. It was felt that those in practice support roles spent most of their time at Heartlands Hospital. The Education team later shared that they are progressing with plans to deliver equitable support to midwifery learners across sites.
There was also an acknowledgement by learners based at the Heartlands Hospital site that there has been a positive change in the culture of the maternity department over recent months. All learners shared that they could access support from both a clinical and wellbeing perspective if they needed to and recognised the work of the trust in creating a safe environment for the team.
The trust shared that they have nominated student ambassadors who work closely with the leadership team at the trust. They also represent learners as members of the maternity education group (MEG). In addition, student ambassadors participate in the internal ‘bronze’ meetings. Members of this meeting have co-produced and had oversight of the ongoing trust improvements, as well as having input into the Maternity and Neonatal Improvement Programme.
Most of the midwives at Heartlands Hospital were described as supportive however, there were still some reports of poor behaviours being displayed by some individuals at the site. We recognised that whilst the concerns do not appear to highlight an ongoing theme of bullying across the department, the trust needs to address the behaviours of individuals directly. This is to ensure an equitable educational experience, as these behaviours can have an adverse impact on all learners.
During our last visit, learners at Heartlands Hospital reported that translators did not appear to be used in situations where they would expect them to be present. At this visit, learners shared that they now have clear access to a system which supports the process for requesting a translator, and that translators are being offered as required.
Induction
All learners reported receiving a trust and departmental induction however, when discussing induction to the clinical areas, feedback from learners was variable. It was shared that on arrival to a new placement area, it is usually the allocated practice supervisor that provides a clinical orientation for the learner. Learners explained that this does not consistently take place and can depend upon the midwife and/or the capacity of the clinical area on the day. In addition, there does not appear to be a checklist or guidance provided to the midwife regarding the content that should be covered during the orientation. This was reported by learners to impact on their preparedness for their placement.
The trust confirmed that it is the joint responsibility of both the practice supervisor / practice assessor and the learner to ensure that the orientation has been completed. This is because the learner electronic portfolio indicates that local orientation to placement areas should be completed by the learner in every placement, in addition to the wider induction.
An example of this was an incident reported by a learner at Good Hope Hospital whereby a patient on the postnatal ward experienced a maternal collapse and two learners were asked to retrieve the emergency equipment. Both learners had been on a placement in the department previously but had not completed a re-orientation to the department upon their return and therefore could not locate the correct equipment. They returned with a cardiac box, which contained the required equipment, and no harm was caused to the patient. However, had they completed a re-orientation they would have been able to locate the correct emergency equipment sooner.
When we met with the practice supervisors and assessors, they shared that they will regularly undertake the orientations to the placement area. They also shared that there is an induction pack which can be accessed by learners to help with becoming familiar with each clinical area.
Positive feedback was also shared by learners who had recently experienced the induction process. They reported having the opportunity to meet and speak with their peers in other cohorts who had been placed at the trust. The learners shared that they had valued these conversations and would like to see this implemented permanently for future cohorts.
Learning opportunities
Across both sites, learners continued to report a lack of learning opportunities to fulfil competencies due to capacity and being asked to support service provision. This was attributed to short term sickness across the midwifery workforce and high workloads for the maternity teams on shift. Learners shared several examples where they felt they had not been seen as supernumerary. This included where they had been asked to discharge patients, support the workload of the induction bay, and act as the ‘nursery nurse’ or Midwifery Support Worker in the clinical area which they felt was to fill workforce gaps. Learners from both sites felt that this has impacted on them being able to access other learning opportunities to support their proficiencies.
Where learners had been able to access opportunities, they were described positively. Learners spoke highly of the Learner Led Clinical Environment, currently based at Heartlands Hospital. Learners shared that it provided them with opportunities to lead, be autonomous, and develop in confidence in a safe environment. Learners based at Good Hope recognised the positive feedback from their peers at Heartlands, and shared that they also want to be given these opportunities to embed their skills and confidence in the clinical environment. The education team shared that the opportunity for cross site working is available but that uptake to date has been limited and further work to expand uptake for cross site exposure is currently being progressed to enable all learners to experience the environment at Heartlands Hospital.
When asked about access to wider placement opportunities such as simulation and multidisciplinary learning, it was shared that the trust’s Practice Placement Team has a WhatsApp channel which provides a list of these training opportunities. It appeared that not all learners were aware of the channel and advised that they would contact the Practice Placement Team to sign up.
Raising concerns
When comparing with the feedback from the visit in January 2024, there was a notable improvement in learners having an awareness of the mechanisms to raise concerns. At this visit, there was an understanding of the processes and that they could access Professional Midwifery Advocates (PMAs) and the Freedom to Speak Up Guardian if they needed support, as well as the Practice Placement Team and their education providers. Practice supervisors and assessors echoed this and shared that all learners are encouraged to escalate concerns through the multiple mechanisms which are available to them.
Some learners referred to the escalations of concerns pathway established by the trust, with those that had recently utilised this process sharing that their issues had been appropriately managed. However, overall knowledge of this pathway, and receiving feedback following raising of concerns did not appear to be consistent for all learners. An example of this was where a learner had raised concerns about a clinical incident that they had witnessed during their shift. After raising their concerns, the learner advised that they did not receive a debrief or feedback from the department and therefore is not aware about how their issues were resolved.
There appeared to be multiple mechanisms available for learners across both sites to share feedback about their learning experience. This included a learner experience form, accessible by QR code, which has been developed by the trust for learners to leave comments. In addition, all learners have access to regular learner forums where they are able to share feedback. However, learners based at Good Hope Hospital site advised that since the departure of the PSM they have not been aware of the biweekly forums that have been scheduled for their attendance.
Off duty (rotas)
Learners shared positive feedback about the approach to sharing the off duty within delivery suite at Heartlands Hospital. Learners told us that they receive their off duty via a spreadsheet, 3 – 4 months in advance of being on placement. In contrast, learners advised that the off duty being disseminated by the antenatal and postnatal wards is paper based.
Learners at Good Hope Hospital agreed with the views of their peers at Heartlands, citing inconsistencies in the approach of accessing the off duty between different areas as an issue. Multiple mechanisms were reported as being used across both sites including via a mobile instant messaging application and by hard copy which needed to be accessed in a folder on site or by ringing the wards. Learners shared that these inconsistencies have impacted on their ability to manage demands on their time outside of their education programme, including arranging childcare so that they complete their required placement hours.
Feedback and proficiency sign off
Learners continued to report challenges with receiving feedback on performance, with timely completion of their electronic portfolios being highlighted as an issue. Learners explained that this has impacted on the learning proficiencies they have been able to sign off, including the number of births they have conducted during their practice placement. Some practice supervisors and assessors agreed with the feedback provided by the learners, sharing that there are some wards where finding time to sign off proficiencies is challenging due to high workloads.
Some learners also shared that when they have followed up with the midwife who supervised them, some have said they do not recall working with the learner and therefore cannot sign off their electronic portfolios. Learners recognised that this issue has arisen because of a lack of time and capacity for midwives to fulfil their educational support roles.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
|
Culture and supportive environment In comparison to the January 2024 visit, learners reported a notable change in the culture across both sites. Learners reported that they had felt a positive change in support from the team. Improvements to attitudes and behaviours were particularly noted at Heartlands Hospital. Learners at Heartlands Hospital also reported positive interactions with the leadership team, advising that they are approachable and visible. |
1.1, 1.3 |
|
Clinical support During the January 2024 visit, learners shared instances of being left alone to provide one-on-one care for patients without any assistance. Improvements were noted at this visit, with learners sharing that if they asked for help it was available, and that they had no concerns about the support offered to them by the midwifery team. |
1.6, 3.5, 4.4
|
|
Patient consent Learners shared feedback that there are clear pathways for requesting translators when a patient’s first language is not English. It was also reported that translators are being offered and utilised appropriately by the midwifery team. |
1.5, 1.6 |
|
Raising concerns Overall, learners shared an awareness of the mechanisms to raise concerns. There was an understanding by learners of the routes for escalation and structures in place if they had an issue to raise. |
1.7 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
|
A learner at Good Hope Hospital reported a patient on the postnatal ward experienced a maternal collapse and two learners were asked to retrieve the emergency equipment. Both learners had been on a placement in the department previously but had not completed a reorientation to the department upon their return and therefore could not immediately locate the correct equipment. They returned with a cardiac box, which contained the required equipment, however, had they completed a re-orientation they would have been able to locate the correct emergency equipment. Whilst there was no harm to the patient on this occasion, had the cardiac box not contained the appropriate equipment, there could have been an impact on the timely delivery of patient care. |
A trust response has been requested and received to this Immediate Mandatory Requirement. |
IMR1 |
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
|
Culture and support Whilst improvements to culture within the department were recognised by learners, they continued to report some poor behaviours being displayed by some members of the Midwifery team. This can impact negatively on the learner’s ability to feel safe within the clinical environment. |
The directorate needs to continue to ensure that work is undertaken to encourage a positive culture where all team members are valued and where a compassionate and supportive approach is embedded. Assurance needs to be provided to evidence that there is a zero-tolerance approach to incivility of any kind, including individual instances of poor behaviours. |
MR1 1.1, 1.3 |
Induction Learners reported inconsistencies across the clinical areas in the completion of an orientation at the start of each placement. Learners also did not appear to be aware of the induction packs which are available in each clinical area. In addition, it was noted from the feedback we received that there does not appear to be a formal process in place to support practice supervisors and assessors to provide an orientation, including the content which should be covered. This can affect the ability for learners to effectively prepare for their placement. |
The trust needs to provide assurance that all learners receive an equitable start to their placement and that the delivery of an orientation is consistent. The trust should consider how support is provided for practice supervisors and assessors to deliver the orientation at the start of a placement.
|
MR2 3.9 |
|
Learning opportunities Pre-registration midwifery learners shared that intensive workloads across both sites mean that opportunities for learning can be missed due to maintaining service provision. |
The trust must develop and embed its workforce solutions at all levels to ensure that there are adequate staffing levels to manage workload. Assurance is required to evidence that learners are not being counted within the numbers required for safe and effective care within the clinical area. The department also needs to review the opportunities available to preregistration midwifery learners, ensuring that time on shift contributes positively towards proficiencies and is equitable. Actions should include working with education provider partners to implement a clear strategy to ensure there is sufficient placement capacity and capability to appropriately deliver the pre-registration midwifery curriculum. |
MR3 5.1 |
|
Raising concerns Whilst there was a notable improvement to concerns being raised, there appeared to be inconsistencies in awareness of the trust escalation pathways. In addition, whilst some learners shared that after raising a concern, |
The trust needs to continue to embed any processes which have been developed to support raising of concerns. Where concerns have been escalated and managed, feedback should be provided to the learner as appropriate, |
MR4 1.7 |
|
their issues were managed and they were made aware of the outcome, others advised that they had not received feedback and were therefore unsure whether their concerns had been dealt with. |
to ensure that the communication loop is closed. |
|
|
Off duty (rotas) Learners reported that there was variation across placement areas in the format of receiving the off duty. This was reported to be dependent on the placement area, rather than there being a consistent approach across the department. This impacted on learners’ abilities to manage demands on their time outside of their education programme. |
The trust needs to consider and implement solutions which will allow effective delivery of the off duty. This should include considering how digital solutions can support this action to minimise the burden of additional work for the midwifery team. |
MR5 5.6 |
|
Feedback and proficiency sign off All learners shared challenges with being able to receive evidence towards, or sign off of, their proficiency documentation. This was attributed to a lack of time and capacity for midwives to fulfil their practice supervisor and assessor roles. |
The trust needs to ensure that formally recognised supervisors are appropriately supported to undertake their roles. Learners should be supported to complete their e-portfolio by all Practice Supervisors and Assessors. |
MR6 1.4, 3.7, 4.2 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
|
Learner support – Good Hope Hospital It was felt that those in practice support roles spent most of their time at Heartlands Hospital. The Education team later shared that they are progressing with plans to deliver equitable support to midwifery learners across sites. We would recommend considering how the department might increase engagement between learners and those in practice support roles whilst this equitable support is put in place. This may include hybrid options such as using virtual platforms to offer student forum sessions. |
3.1, 3.2 |
|
Induction Positive feedback was shared by learners who had the opportunity to meet and speak with their peers in other cohorts during the induction period. The learners shared that they had valued these conversations and would like to see this implemented permanently for future cohorts. |
3.9 |
|
Multi-disciplinary and simulation learning opportunities It was shared that the Practice Placement Team has created a channel which is accessible by learners that includes a list of the wider training opportunities available. Not all learners were aware of this channel, but those that were spoke positively of its development. We would recommend ensuring all learners are made aware of how to access the channel. The trust may also wish to monitor the number of learners who sign up and utilise the channel, to measure the success of its implementation. |
1.12, 5.4 |
Report approval
Report completed by: Amelia Harbon, Quality Deputy Manager
Review lead: Sheran Oke, Assistant Director of Clinical Leadership and Education (Nursing and Midwifery)
Date approved by review lead: 10 December 2024
NHS England authorised signature: Prof. Jonathan Corne, Regional Postgraduate Dean
Date authorised: 31 December 2024
Final report submitted to organisation: 3 March 2025