Executive summary
Feedback from the learners at this meeting highlighted a learning experience within midwifery which is improving when compared to the previous visit undertaken in July 2023.
All pre-registration midwifery learners at the Burton Hospital site shared that the clinical environment is welcoming and supportive, and that they are enjoying their learning experience. Whilst there are still some reported areas of improvement required at the Royal Derby Hospital (RDH) site, overall, learners shared that they felt as though they are part of a team and that their education is valued.
There are areas that are working well, and improvements that have taken place since the July 2023 review, these include:
- Learners undertaking the undergraduate midwifery programme who had recently joined the trust for their practice placement reported receiving a robust departmental induction.
- Learners reported feeling part of the team in a supportive and welcoming environment.
- It was shared that there had been development of a Student Council to support implementation of the NHS England Safe Learning Environment Charter and to deliver improvements across the clinical learning environment.
- It was reported by learners that newly qualified midwives can now access the electronic practice assessment system and submit evidence to support learner proficiencies.
- Learners shared examples of good multi-disciplinary and simulation learning experiences including obstetric emergency training, home birth study days, theatre team placements and community emergency training.
- An initiative which was termed ‘team of the shift’ was praised by learners at both sites of the trust. This approach allows learners to introduce themselves on the shift, to share their learning needs and feel part of the team.
There were reports of ongoing concerns which require improvement:
- Learners shared that intensive workloads for the midwives at the RDH site continue to impact on opportunities to learn due to maintaining service provision.
- Not all learners were familiar with the formal mechanisms to escalate their concerns with the trust. There were also inconsistencies in the awareness of the Freedom to Speak Up Guardian role and the support that they could offer across both hospital sites.
- Learners continued to share challenges with practice supervisors and assessors evidencing and signing off proficiencies within their electronic portfolio. This was reported to be due to workload pressures for the midwives and a lack of any consistency in their allocated practice supervisor.
In addition to the above, new items for improvement were noted in the following areas:
- An incident was reported whereby a first-year learner was asked to support a birthing person without the appropriate level of supervision.
- Learners undertaking the shortened midwifery programme reported that they had not received an induction into the department.
- Learners reported that whilst the department encourages sharing of feedback, there are inconsistencies in providing reassurance or sharing the outcome to the issues raised.
It should be noted that we were unable to speak with practice supervisors or assessors due to significant workload and capacity issues within the trust.
Overall, we recognised a clear commitment to cultural change through the implementation of trust-wide initiatives, including a compassionate and inclusive leadership programme, to continually improve the experience of those learning and working within the organisation.
To ensure that the required improvements are fully implemented, and that the outstanding areas are addressed, the Intensive Support Framework (ISF) category 1 rating for this concern will be maintained. 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 July 2023 learner educator meeting to test progress against the trust’s active improvement plan for pre-registration midwifery training.
Who we met with
Learners
- Pre-registration midwifery learners
Education team and Senior team
- Director of Midwifery
- Director of Learning and Education
- Practice Learning Support Unit Lead
- Clinical Educator
Review panel
- Jackie Brocklehurst, Assistant Director of Clinical Leadership & Education (Nursing and Midwifery)
- Lucy Johnson, Midwifery Quality and Professional Development Lead
- Molly Yeardsley, Midwifery Leadership Fellow
- Amelia Harbon, Quality Deputy Manager
Review findings
Induction
Across both sites of the trust, learners who have started the undergraduate midwifery programme since the Workforce, Training and Education directorate (WT&E) visit in July 2023 reported receiving an in-person departmental induction. Learners in the other cohorts recognised this change, reporting that they had previously received an online induction which was not effective in preparing them for their roles in the department. Learners who received the latest induction reported that this was ‘helpful’ and covered all the relevant aspects of training.
Learners undertaking the shortened midwifery programme reported that they had not received an induction into the department. Learners felt that there is an assumption made by the department that they are familiar with the clinical areas from having previous healthcare roles, and therefore do not need the same level of induction as other learners. Learners reported that this has been highlighted to the Practice Learning Support Team at the trust.
At the July 2023 visit, it was also recognised that an induction handbook was shared by the community teams to prepare learners for placement. During this visit, whilst the learners were not aware of the handbook. The Education team reported that this is due to be actioned in the near future.
Supportive environment
Learners at both sites of the trust reported feeling supported by the midwifery team. All learners at Burton Hospital recommended the site as a place to train, sharing that they enjoyed their placement and that the midwives included them in clinical activities to support their proficiencies. Those placed at RDH also shared that staff are welcoming of learners.
Learners at both sites of the trust also advised that the department is utilising a ‘team of the shift’ tool. This allows learners to introduce themselves and share the learning opportunities they need for their proficiencies. All learners that had experienced this approach praised the team for its implementation and recommended that this is consistently utilised across all clinical areas in the maternity departments at both sites.
Whilst interactions with the midwives at RDH were reported to be positive, examples were shared where learners had raised concerns about the negative behaviours of the medical team towards themselves and the midwives. Examples were given whereby obstetricians had ‘shouted at’ midwives and had belittled learners when they had shared their clinical opinions.
When raised with the Education team, this feedback was already known and identified to be a small number of locum doctors being used by the trust to cover shifts. We were provided with assurance that the concerns reported by the learners had been escalated by the department through the relevant processes and addressed appropriately.
When discussing the support offer within the clinical learning environment, the Education team shared that the counselling service for staff had been extended to learners for them to use. The team also advised that there are a number of Professional Midwifery Advocate (PMA) posts currently vacant within the departments. It is expected that once recruited to, the PMAs will have an active role in supporting learners.
Involving the learner in quality improvement
During this visit, learners recognised the creation of the Student Council and shared that there was an ongoing action plan to support improvements. This was echoed by the Education team, who reported that the council started in July 2024, and they now have learner representatives from each of their education provider partners. Whilst it is recognised that the council is in the early stages of development, it was reassuring to hear how the trust is providing opportunities for learners to take an active role in quality improvement initiatives and to be part of the team driving change.
Workload – learning opportunities
Learners continued to share that high workloads for the midwives at the RDH site mean that learning opportunities are lost due to maintaining service provision.
Examples were shared by learners about ‘overwhelming issues’ in the department, including a specific concern raised about the midwife to patient ratio on postnatal ward. An example described included 1 midwife having 16 service users and their babies to care for during their shift. Learners felt that where the workload is too high for the midwives, they are being allocated tasks to support service provision such as completing observations. Whilst learners recognised this as a chance to provide additional patient care, they felt this regularly impacted on opportunities to meet their proficiencies.
The Education team shared that they are aware of the concerns regarding workload and reported that midwives may be moved from the postnatal ward to support on delivery suite to ensure safe care for birthing people. The team advised that to address the concerns they are currently undertaking recruitment of midwives to increase capacity.
Practice supervision and assessment
Following the last visit, we noted an improvement that newly qualified midwives are now able to support learners by providing evidence towards proficiencies using the electronic practice assessment systems. However, although NQMs can now submit evidence, learners are still reporting challenges with gaining evidence and proficiencies from practice supervisors.
Learners attributed this issue to a lack of consistency in allocation of practice supervisor at both sites of the trust and because of a high workload for the midwives at the RDH site.
In addition, at this visit an incident was reported whereby a first-year learner was asked to support a birthing person without the appropriate level of supervision. The birthing person was receiving an oxytocin infusion to support induction of labour and had also received an epidural.
The learner reported being checked-in with hourly however, given the complexity of the birth, it was not appropriate for a first-year learner to be left unsupervised. It is understood that the learner raised their concerns locally at the time with the labour ward co-ordinator and a member of the practice learning team, however, received no further feedback about how their concerns were managed more widely.
Raising concerns
Learners continued to report that they were not aware of the formal mechanisms to raise concerns. There also continued to be inconsistencies in the awareness of the Freedom to Speak Up Guardian and the purpose of their role.
In addition, where learners had raised concerns, there were inconsistencies in the way in which they felt their issues had been managed. Whilst some learners felt their concerns had been managed appropriately, others reported that after they had shared their feedback, they did not receive a response from the department, or they had to chase for support. Another group of learners shared that whilst they had received a response, some of the comments from the department were inappropriate or unhelpful, with specific examples shared about issues with car parking and childcare.
The Education team also shared that there are policies and processes in place to support learners to raise concerns within the department which are shared regularly.
Multi-disciplinary and simulated learning opportunities
When comparing to our visit in July 2023, multi-disciplinary and simulated learning opportunities at both sites of the trust were reported to have improved. Learners shared that they had attended in-house obstetric emergency drills, external community emergency training, homebirth study days and had opportunities to interpret cardiotocography (CTG) results with the support of the medical team.
It was also reported that doctors at RDH will try to maximise the teaching that they can offer to learners. An example was given of doctors utilising handover as an opportunity to teach preregistration midwifery learners. Anaesthetists at Burton Hospital were also praised by learners for their interactive teaching approach during theatre placements.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
|
Supportive environment – Midwifery Team – Royal Derby Hospital and Burton Hospital It was reported by learners that clinical midwifery staff are invested in education and consider the needs of the learner when offering opportunities. The learning environment across both sites of the trust was reported to be welcoming, despite the overwhelming workload for staff at RDH. |
1.3, 3.8 |
|
Practice supervision – newly qualified midwives – RDH and Burton Hospital At this visit, it was identified that newly qualified midwives are now able to submit evidence on the electronic practice assessment portfolios to support pre-registration midwifery learners’ completion of proficiencies. |
4.3, 4.6 |
|
Multi-disciplinary and simulated learning opportunities – RDH and Burton Hospital Learners across both sites reported that access to multi-disciplinary and simulated learning opportunities are good and were able to describe several training sessions they had been able to attend. This included in-house obstetric emergency drills, external community emergency training, homebirth study days and had opportunities to interpret cardiotocography (CTG) results with the support of the medical team. |
1.3, 1.12, 3.8, 5.4 |
|
Learners praised the approach of doctors at RDH and the anaesthetists at Burton Hospital for their approach and for valuing their training. |
|
Good practice
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
|
Involving the learner in quality improvement- Student Council – RDH and Burton Hospital As part of the improvements implemented by the trust to address the concerns following the July 2023 visit, a Student Council has been formed. The council have created an action plan to effectuate positive change across the clinical learning environment and to support the implementation of the NHS England Safe Learning Environment Charter. |
1.1, 1.9 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and domain(s) and standard(s) |
|---|---|---|
Practice supervision incident – Royal Derby Hospital. An incident was reported whereby a first-year learner was asked to support a birthing person without the appropriate level of supervision. The birthing person was receiving an oxytocin infusion to support induction of labour and had also received an epidural. They were being checked-in with hourly however, given the complexity of the birth, it is not appropriate for a firstyear learner to be left unsupervised. | The trust has responded to this immediate mandatory requirement. This will now form part of the trust improvement plan. | IMR1 3.5, 3.6, 4.4 |
Mandatory requirements
| Review findings | Required action | Reference number and domain(s) and standard(s) |
|---|---|---|
|
Induction – RDH and Burton Hospital Learners on the shortened midwifery programme reported that they did not receive a departmental induction, which was required to adequately prepare them for placement. |
The trust needs to provide assurance that all learners receive an equitable start to their placement and that the delivery of a departmental induction is consistent for all groups. |
MR2 3.9 |
|
Workload – learning opportunities – RDH Pre-registration midwifery learners continued to share that intensive workloads for staff mean that opportunities for learning and to receive feedback are missed due to maintaining service provision. | The trust must continue to develop and embed its workforce solutions at all levels to ensure that there are adequate staffing levels to manage workload. The department needs to review the opportunities available to preregistration midwifery learners, ensuring that time on shift contributes positively towards proficiencies. Assurance is required to evidence that learners are not being counted within the numbers required for safe and effective care within the clinical area. 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 preregistration midwifery curriculum. |
MR3 1.1, 1.4 |
|
Practice supervision and assessment – completion of electronic practice assessment portfolio and feedback – RDH and Burton Hospital All learners shared challenges with being able to receive evidence towards, or sign off of their proficiency documentation. This was attributed to having a different midwife supporting their practice supervision on each shift and staff having high workloads, particularly at the RDH site. |
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. |
MR4 1.4, 3.6, 3.7 |
Raising concerns – RDH and Burton Hospital There continued to be inconsistencies in the awareness of how to raise a concern, and the role of the Freedom to Speak Up Guardian. In addition, some learners felt that when they had raised concerns with the department, that they did not receive feedback or a response to provide reassurance that they had been listened to and their issues had been appropriately managed. |
The trust needs to ensure consistent and close dialogue with learners to understand any issues and provide updates on any resulting changes, or where change is not possible. The trust should engage with learners to help with solutions to ensure that feedback is shared with them. The trust might look to utilise the Student Council to support improvements in this area. |
MR5 1.7 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
|
‘Team of the shift’ – RDH and Burton Hospital Learners praised an initiative being adopted across the maternity department which they referred to as ‘team of the shift’. This allows learners to introduce themselves and share the learning opportunities they need for their proficiencies in preparation for their shift. Learners shared that whilst this was being mostly adopted across the department, there were some areas which were not consistently utilising the model. Following the positive feedback that we heard from learners about this approach, we recommend that the trust looks to adopt this consistently across all clinical areas. |
1.1, 1.3 |
Report approval
Report completed by: Amelia Harbon, Quality Deputy Manager
Review lead: Jackie Brocklehurst, Assistant Director of Clinical Leadership & Education (Nursing and Midwifery)
Date approved by review lead: 15 December 2024
NHS England authorised signature: Prof. Jonathan Corne, Regional Postgraduate Dean
Date authorised: 24 December 2024
Final report submitted to organisation: 26 February 2025