A mixed method study to explore competence based practice of midwives in Zimbabwe

Introduction and aim: In Zimbabwe, a one-year midwifery-training programme, based on a competency-based curriculum, aims to develop essential competencies for midwifery clinical practice and sound professional judgement, as required by the International Confederation of Midwives (ICM) Global Standards for Midwifery Education. This study aimed to explore midwives�€™ preparation for practice to the level defined by ICM core competencies in Zimbabwe. Methods: A critical realist mixed-method study included an exploratory correlational approach for the quantitative phase and classical grounded theory for the qualitative phase. In the quantitative phase, complete sampling was used to recruit a cohort of 85 midwives from three midwifery schools (School A, School C and School B; recruitment rate 53.8%) before they received the results of their state final examinations. Confidence and competence data were collected from participants, their ward supervisors/senior midwives, peers and clinical instructors using a 360° assessment tool developed for the study, based on one currently used for assessment at the participating schools. This consisted of a checklist of 20 ICM competencies each scored as a rating scale from 0-10 in six areas of midwifery care. Data were collected at initial recruitment, after the participants had received their examination results and after three months of clinical practice, with 58 from School A and School C providing data at the final time point (68.2% retention rate). The qualitative study used in-depth interviews to explore the knowledge views and practices of midwives regarding ICM core competencies, using theoretical sampling to recruit 36 participants (21 newly qualified midwives, 4 tutors, 5 ward supervisors, 3 clinical instructors, and 3 acting clinical instructors) from School A and School C until data saturation was reached. Data analysis: IBM SPSS Statistics 22 was used to analyse quantitative data. Cronbach�€™s alpha was used to estimate the internal consistency of subscales and the overall scale of the 360° assessment tool. Most analyses were descriptive, and Pearson�€™s chi-square, Fisher�€™s exact and the Mann-Whitney U test was used to compare data by school. Kendall�€™s correlation and multiple linear regressions were used to explore which variables were associated with total confidence and competence scores. Constant comparative analysis was used on the qualitative data to develop categories to build a grounded theory of social processes facilitating or hindering competence and confidence development in midwives. Results: The 360° assessment tool was reliable although some assessors appeared not to have observed the participant performing an episiotomy or resuscitating a new born. Participants�€™ confidence scores were generally higher than their assessors�€™ competence scores. Confidence and competence scores at School C generally increased over time, but confidence scores at School A fell after the midwives had spent three months in clinical practice. The number completing the quantitative phase limited the generalisability and precision of the multiple regressions but the main predictor of confidence and competence was school. The qualitative phase explained the difference between schools in terms of school policies, the way facilitators planned and organised clinical settings to facilitate student learning, and facilitator characteristics. Students at School A were allowed to pass assessments without reaching the required standard while those at School C were marked more harshly, but were subsequently appreciative of this approach, recognising its necessity for competence development. Following transduction, a Competence and Confidence Development Model was proposed to explain how the dualistic nature of an individual and their confidence and competence were related via a student learning typology combining individualism-collectivism and rate of learning with six phases of skill acquisition. Conclusions: Midwifery schools in Zimbabwe must consider policies, the training environment, student learning styles and the teaching processes required for students to acquire the clinical skills and theoretical knowledge necessary to become competent qualified practitioners.