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Transition to Independent Practice Survey Results

In October 2020, the College of Midwives of Ontario conducted a survey on the experiences of new midwives. We sought this information to inform new strategies on how we could support them to develop confidence and competence as a primary care provider as they transition to independent practice.

The survey was open to all midwives or resigned midwives who have practised in Ontario for 5 years or less. It was sent to 437 midwives and former members, and we  received 121 responses.

Midwives were asked to respond to quantitative questions using a 5 point Likert scale from strongly agree to strongly disagree, with the option of neutral, as well as open-ended questions that sought to understand:

  • the factors that contribute to gaining confidence and those that undermine confidence
  • the factors that helped consolidate clinical skills and those that prevented them from consolidating their clinical skills.
  • what might support a better transition to practice

Table 1: Demographic data
(Note: where numbers don’t add up, the remaining percentages were “prefer not to answer”)  

Current RegistrationGeneral 65 (67%)General w/ conditions 18 (18%)Supervised 1 (1%)Inactive 9 (9%)Resigned 3 (3%)
Years of ExperienceLess than 1 14 (14%)3-5 42 (42%)   
Practice LocationUrban 78 (78%)Rural 16 (16%)Rural & remote 3 (3%)  
Practice sizeMore than 20 14 (14%)5-14 71 (71%)4 or less 11 (11%)  

Quantitative responses

The majority of respondents (62%) either somewhat or strongly agreed that their first year of practice provided them with a broad range of clinical experiences. 67% somewhat or strongly agreed that their first year of practice provided them with exposure to a broad range of non-clinical professional experiences. And while 80% somewhat or strongly agreed that it was easy to meet the birth requirements, only 59% agreed that their first year of practice exposed them to all the experiences necessary to build their confidence as a primary care provider.

When asked if their first year of practice provide them with all the skills needed to practise as a midwife in Ontario, 69% somewhat or strongly agreed. We asked if supervised practice or new registrant requirements should be based on a minimum number of births, 63% felt it should be. Yet in a separate question, 52% felt supervised practice or the new registrant year should be based on a broad range of clinical skills. Just over half of all respondents (52%) somewhat or strongly agreed that they wouldn’t change anything about their first year of practice, leaving almost half of respondents disagreeing with this statement.

Qualitative responses

In all responses – the most important factors contributing to the experiences in the supervised or new registrant (NR) year were:

  • Having (or not) an adequate mentor
  • Belonging to healthy midwifery practice group
  • The hospital environment (including staff)

The overwhelming majority of responses show that a mentor is one of the keys to gaining confidence, skills and transitioning to practice. Responses show that a mentor must be:

  • Well-trained
  • Assigned to one NR through a formalized relationship
  • On-call when the NR is on-call to answer questions
  • Invested in the NR and not the money
  • Consider having a mentor who is not affiliated with the practice to ask questions and not be evaluated,
  • more structured feedback and regular chart reviews

The positive effects of a mentor were also shown in the survey responses where 62% somewhat or strongly agreed that it would have helped them to work with an assigned mentor.

The practice environment is also critical to the experiences of new midwives. Respondents described a range of practices with various ways of managing NRs. The following were seen to be important factors that influenced an NR’s experience in a practice:

  • Midwives must be supportive and provide constructive feedback
  • The practice must have protocols
  • Organized and transparent practice
  • The practice culture must be safe and supportive (adhere to guidelines about time allowed on call, take call when NR is exhausted)
  • There should be enough caseload that NR can do full case load but not everyone’s caseload
  • The practice should have a stable call model and consistent staffing. NR should not be going to a practice that  is taking them on because they are poorly staffed and need someone to fill in the gaps
  • The NR’s experience should be about consolidating skills and not about what they practice needs of them
  • Support from practice when conflicts occur
  • More support for sleep

The hospital was mentioned less frequently than the midwifery practice, but the same general issues were described. A hospital and its staff can positively contribute to midwives’ experiences and provide them with support and mentorship. Alternatively, it can be a very negative influence with strained relationships, little or no support, and no inter-professional collaboration.

Supportive factors reported for a healthy transition to practice:

  • Exposure to a wide range of experiences (high volume births, multips and primips, full scope, intrapartum emergencies)
  • Repetition and volume– lots of clinic, full caseload
  • Allow independence but with support – don’t treat like a student
  • Don’t have big lag time until births happen – need to start working shortly after graduating and go into practice and not wait 4 months for births.
  • Pay – getting paid during your time, get paid for a training period, on call day one at practice with no orientation, Payment plan for CMO fees.
  • Orientation and training to practice and hospital, orientation to community standards and guidelines
  • Opportunity for regular care reviews
  • Better interprofessional relationships (you walk into whatever relationships exist between the hospital and your practice so if the relationships are poor then it is hard to change this)
  • not to be treated like a student but like a NR
  • a checklist of skills and experiences
  • Understanding how funding and pay work, how practices are funded, when to start applying for GR jobs

Factors the undermine a health transition to practice

  • Poor relationships with practice (being bullied came up in several responses)
  • Not being trusted, by clients and midwives, because you are new
  • No assigned mentor, practice conflict over who will look after you
  • Lack of support
  • Unhelpful mentor
  • High volume of births because of poor practice management
  • Disconnect between what you are and how you treated (supposed to be primary care provider but not treated like one)
  • Racism
  • Lack of skills gained in the MEP/Deficits from final year of MEP
  • Anxiety about managing emergencies
  • Taking outcomes personally
  • Sleep deprivation/exhaustion/no time off call or vacation
  • Bad midwifery practice group dynamics
  • Having to look after students (because you are in a shared care pod or otherwise)
  • Lack of practice protocols
  • No voice in the practice
  • Questioned about skills and knowledge
  • Clients want experienced midwives

Recommendations

Survey responses make it clear that the experiences of new registrants and supervised midwives are dependent on the relationships they have with their mentor/supervisor, and with their practice and hospital.

It is also clear that how this first year of practice is implemented is inconsistent between practices. As a result, new midwives receive differing levels of supervision, mentorship, experience, and support. It seems to be simple luck if the new midwife ends up in a suitable practice where they are able to consolidate their skills and gain confidence.

If this period of time in an established practice/supervised practice is a requirement, then there must be minimum standards about what is expected and ways to address this when the practice (and mentor) or the new registrant/supervised midwife fall below these standards. The College needs to oversee this process, or set stricter criteria. There also needs to be one assigned mentor who is trained and responsible and accountable to the College.

In addition, thought should be given to new registrants being paid when they enter practice and receive a period of off-call time to get oriented to the community, the practice, and the hospital—perhaps attending a birth or two as an observer to familiarize themselves with the systems in the community. Thought must also be given to how caseload should be assigned to new registrants, and whether they should be working in primary or shared care.

These issues are not necessarily within the College’s control; work needs to be done with our partner organizations to make sure that these concerns are addressed by relevant organizations.