Introduction
As with all sectors of education, midwifery has been greatly affected by the lockdown
measures imposed by governments throughout Europe. Despite the COVID-19 period, all
students were expected to acquire professional midwifery competencies, according to
the European Union (EU) Directive ("Directive 2005/36/EC," 2005), the European Qualifications
Framework ("The Council of the European Union," 2017), as well as the International
Confederation of Midwives’ (ICM) Global Standards for Midwifery Education ("International
Confederation of Midwives," 2013). This Directive aims to ensure that midwifery education
attains minimum standards and provides a European framework for midwifery education
(Vermeulen et al., 2018) and practice including a quantitative description of the
tasks the midwife should carry out (Fleming et al., 2011). One of the biggest challenges
has been how to continue to provide the hours required under the EU Directive 2005/36/EC
so that students may transition to midwives without penalty. However there are equally
difficult but less obvious hurdles to overcome. This article provides a reflective
account from three experienced midwives in different European countries, one working
in education, one in clinical practice and one in research as to some of the major
issues that are emerging in undergraduate midwifery education programmes.
The theoretical component
The most profound changes occurred in midwifery education as national lockdowns saw
the closure of universities with staff and students working from home (Antonakou,
2020). Initially some institutions considered postponing all their programmes, but
many came round to offering the theoretical component of their teaching via online
platforms. As up until this point most education had taken place face-to-face this
change meant that rapid digitalisation of the curriculum and teaching had to take
place. For some lecturers this represented a huge challenge, while others with prior
experience managed the transition easily. Thus, the disruptions caused by COVID-19
have had more impact on digitalisation of midwifery education than some educational
advisors had had during the last decades. A few students, however, were without the
necessary hardware, and university libraries had to remain open, reopen, or provide
additional support to provide the workspaces and equipment for those who did not have
their own.
While a positive development in many ways, the transition to distance learning was
being achieved concurrently with timetable changes as clinical areas were struggling
to deal with the crisis and to cope with the added burden of students. Some institutions,
such as those of one of the authors, had to move theory blocks from the next semester,
taking students out of practice altogether, while others have made minor adjustments.
The organisation of assessing students has also been challenging to educators. Diverse
approaches have been utilised, with officials in some countries deciding to use an
aggregate system based on previous marks and clinical practice, but some moved to
an on-line approach when exams rather than essays or short answers are required. Such
formats of exams were suitable for some required competencies, such as analysis, critical
thinking, or synthesis, but less so for scenarios that involve clinical skills. This
is addressed below.
The practice component
In an initial flurry of activity some students working clinically were sent home from
practice areas. In some cases clinical managers suggested that educators behave irresponsibly
towards the student by sending them in practice, and increasing their exposure to
the virus ("Health Education England," 2020). However, in some countries, clinical
placements and teaching in practice have gone on as usual. In others, clinical placements
were put on hold, with no prospect of when they can be resumed (Furuta, 2020). All
international placements were cancelled, which not only cause financial losses for
students, but also lead to missed opportunities of acquiring additional competencies
gained in an foreign health-care system (Ahmed et al., 2020).
Once things began to settle, a number of models have emerged regarding placing students
in practice. In some countries, midwifery students have been recruited to support
clinical staff in practice, upon agreement of both institutions. In others, even after
the initial flurry of activity, midwifery students have not been allowed to continue
their clinical placements during the COVID-19 pandemic. Others still have contracts
for final year students to work as health care assistants ("Nursing and Midwifery
Council," 2020). A positive development is that some students have been able to work
more clinically, in interprofessional teams, and gaining an experience that they previously
would not have (Walton, 2020).
Completing the programme and becoming midwives
Obviously anxiety amongst final year students as to when they can complete their programmes
has been to the fore. In some countries this is only after they have passed a final
examination, which is subject to the constraints outlined above. In others a sign
off is required by a clinical mentor and/or a senior member of the academic staff.
Yet others require a clinically based examination. What is common to all is the EU
Directive's requirement for certain tasks and the required number of hours to be completed.
In some areas this has led to students completing their programmes before their expected
dates as the EU Directive had been reinterpreted allowing completion after three academic,
rather than calendar, years if all other targets had been achieved. In such cases
midwives were thus able to enter the workforce early. Others, conversely, have been
held back, as placements were suspended and students were not able to acquire the
professional midwifery competencies, which might lead to students’ graduation being
postponed.
Challenges for the near future and longer term
The teaching of specific midwifery skills remains a clear challenge. Universities
are beginning to open up again across Europe and the important question arises as
how to guarantee contact-free education and social distancing, while educating midwifery
students. One common theme is the need for personal protective equipment for staff
and students as social distancing is mainly not possible in midwifery work. Another
highly relevant question is whether or not to replace real clinical learning with
simulation with some arguing that some components of the EU Directive might partially
be replaced by simulation (for example replacing 100 effective antenatal examinations
with 90 and 10 simulated). The degree to which simulation can replace the genuine
situation, however, will be affected by a number of variables, such as the skill level
already achieved by individual students, the quality of the simulation experience
available and the history crafted around each simulation experience. In the short
term it may be used without such attention to detail but if it were to become a permanent
feature, the burden on the academic stuff needs to be considered as well as the experience
of the students.
One of the biggest remaining challenges is the mental health of students and academic
staff, now and in the near future. What is the impact of the lockdown, the social
distancing, staying at home or working with potentially infected women on students?
Some have suggested that about one in five students feel more anxious or depressed
than in the period before COVID-19 ("University Ghent," 2020). The digitalisation,
which is an obvious necessity at this time, may create a loss of collaborative experiences
that has the potential to be a significant detriment to education (Rose, 2020). Many
may be missing their social network, and have lost the connection with their peers
and lecturers, despite on-line encounters. Some may also have difficulties in balancing
tasks for the university with additional tasks, including educating their own children
at home. Both students and lecturers are processing the new situation, while searching
for a new normality.
Conclusion
The prescribed national lockdowns in most European countries has led to a disruption
that caused rapid, dramatic changes in the nature of midwifery education. In the short
term different approaches have been adopted to mitigate the impact on current midwifery
students’ theoretical and clinical education and seek the best approaches for both
midwifery students and lecturers during the COVID-19 pandemic (Furuta, 2020).
Some challenges, however, have emerged as chances to be grasped in taking midwifery
education forward for the next cohorts of students. Throughout Europe, the changes
of increased digitalisation and distance learning can definitely be highlighted as
opportunities to improve the current ways of delivering midwifery education. These
changes might also extend to a diverse population, such as potential students who
are looking for part-time education.
Lots of challenges however also remain. As Bick noticed, “life during the pandemic
is on hold, the things we all took for granted, no longer an option”- and comfort
zones had to be left (Bick, 2020). Many of these challenges are still ahead of us.
We still have only a limited overview of what students have experienced and what directions
the virus is taking us in as policy makers grapple with decisions that will affect
us all. Despite the pandemic however, as always, midwifery educators will do their
utmost to guarantee that the competencies needed and skill acquired will be achieved
at the same level as before the disruption.
Ethical approval
N/A
Funding sources
None declared
Declaration of Competing Interest
None declared.