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J Res Med Sci 2016,  21:68

The facilitators and impediment factors of midwifery student's empowerment in pregnancy and delivery care: A qualitative study

1 Department of Midwifery, Faculty of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Adult Nursing, Faculty of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission12-Feb-2016
Date of Decision25-Apr-2016
Date of Acceptance25-May-2016
Date of Web Publication01-Sep-2016

Correspondence Address:
Nikoo Yamani
Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1735-1995.189649

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Background: The organizational environment and its existing context may deeply affect on empowerment of individuals. In educational institutions as well as other organizations, students are going to be powerful when opportunities for growth and achievement of power are provided for them in learning and educational environments. This study has been carried out to explain the facilitators and impediment factors of midwifery student's empowerment in pregnancy and delivery care. Materials and Methods: The current qualitative study has been conducted with participation of 15 midwifery senior students, 10 midwifery academic teachers, and 2 employed midwives in educational hospitals. The given data were collected through individual and group semi-structured interviews, and there were analyzed using directed content analysis method. Results: Three main categories of opportunity for acquisition of knowledge, opportunity for acquisition of clinical skills and opportunity for acquisition of clinical experiences formed structure of access to opportunity in the course of an explanation of facilitators and impediment factors for midwifery student's empowerment in pregnancy and delivery care. Conclusion: To prepare and train the skilled midwives for giving care services to mothers during pregnancy and on delivery and after this period, the academic teachers and clinical instructors should pay due attention to providing the needed opportunities to acquire the applied knowledge and proficiency in the required skills for clinical work and the necessary clinical experiences in these individuals during college period.

Keywords: Delivery, empowerment, midwifery, power (psychology), prenatal care

How to cite this article:
Janighorban M, Yamani N, Yousefi H. The facilitators and impediment factors of midwifery student's empowerment in pregnancy and delivery care: A qualitative study. J Res Med Sci 2016;21:68

How to cite this URL:
Janighorban M, Yamani N, Yousefi H. The facilitators and impediment factors of midwifery student's empowerment in pregnancy and delivery care: A qualitative study. J Res Med Sci [serial online] 2016 [cited 2020 Sep 25];21:68. Available from: http://www.jmsjournal.net/text.asp?2016/21/1/68/189649

  Introduction Top

Following to pregnancy and delivery in 2013, 289,000 women lost their life. [1] Mortality of mother is the most regretful and serious accident during pregnancy period, but it is estimated that more than 20 women would suffer from the related adverse-effects to pregnancy and delivery caused by disease, physical impairment, and disability per one death occurs due to pregnancy and delivery. [2] The incidence of severe complications and requirement for using wide and special intervention represents failure of healthcare medical systems in the presentation of favorable services to pregnant mothers. [3] Mortality of mother will be followed by adverse consequences for family and community. Moreover, many women, who have rescued and survived after the given severe traumas during their pregnancy and delivery period, may suffer from physical, mental, and social destructive effects of this process that may influence the quality of their life. [4],[5] To improve health status in mothers and newborns, the presence of skilled birth attendant as well as in sustainable development plan after 2015 is also included in the international accepted goals. [6],[7] Surveillance on maternal death occurred at Azerbaijan Province, Iran during years from 2002 to 2011 indicates medial errors and substandard care at all levels, especially hospitals are the most important factors for these deaths, respectively. [8] The midwives may play a key and vital role in achieving high-quality and cost-effective services for countries. [9] The resultant findings from studies in educational programs of some countries may draw the existing gap among existing status and international standards and inadequacy of trainings for education of the related forces as skillful personnel in this field. [10],[11] There are also several barriers in Iran against path toward achieving appropriate training that has made it uneven. Inappropriateness of clinical environments, [12],[13] lack of acquisition of skill of experience in some cases of the minimum level of learning, [14] the problems relating to students (great quantity, lack of interest, motive, and self-confidence), [12],[15],[16] interference among educational curricula of different student groups, [14] the problems concerning the instructors (few numbers, defective knowledge and experience, teaching methods in clinical field, and method of treating with students), [15],[16],[17] and lack of coordination between the theory lessons learned with clinical activities [18] are some of these problems.

According to the opinion of Kanter, power and opportunity are two structural characteristics of an organization that may influence in the empowerment of personnel in achieving the relevant empowerment sources to their jobs. The power means access to resources, support, information, and opportunity means access to challenge, growth, and development. [19] The perspective of a person from growth and mobility in an organization; sense of challenge, learning chance, advancement forward to upgrade individual knowledge, and skills may reflect the structure of opportunity in the given organization. The sense of access to opportunity through motivation by making an effort for learning and investment in profession is led to individual growth and development. In contrast, lack of opportunity may lower self-esteem in personnel, sense of weakness, and reduction of their commitment to the organizational goals. [20],[21]

Therefore, this study was designed according to Kanter's theory and by aiming at deep exploration of facilitators and impediment factors in midwifery student's empowerment for pregnancy and delivery care based on the attitude of midwifery students, academic teachers, and the employed midwives.

  Methodology Top

This study is a qualitative research that was conducted based on naturalistic paradigm and using directed content analysis method. This study was carried out in the Faculty of Nursing and Midwifery at Isfahan University of Medical Sciences. The participants were chosen through purposive sampling technique. The maximum variation was considered in the selection of academic teachers regarding age, working background, educational background and in students from aspect of empowerment in pregnancy, and delivery care (weak, fair, and strong). In addition, the employed midwives were chosen from two different main educational hospitals for pregnancy and delivery cares to midwifery students. A number of midwifery senior students were individually interviewed (n = 9) and to increase depth and richness of data by the aid of group interaction, a group interview was conducted with 6 midwifery student as well. [22] Midwifery teachers (n = 10) and 2 employed midwives in educational hospitals were also individually interviewed. The period of interviews varied from 36 to 92 min. To conduct this study, primarily senior students were informed about this investigation in a student meeting and then by attendance in training site of students (hospital, health center, and faculty), one of the researchers implemented the interview with them after acquiring their consent and agreement for participation. After saturation of data, academic teachers, and the employed midwives were interviewed in their workplace. Sampling was terminated when no new information was found in interviews with teachers and midwives. Data collection and analysis lasted from March to November in 2014. The interviews were done in semi-structured form. Initially, interview started by an open-ended question. These questions included: How do you evaluate your function in giving pregnancy and delivery care? And which factors have been effective in your experiences for the acquisition of empowerment in obstetric and delivery care? (Students) How does an empowered student act in pregnancy and delivery care and what factors may influence in the acquisition of empowerment of midwifery students in these cares? (Academic teachers and midwives). Then, the interview was continued with purposeful questions regarding already predicted categories according to Kanter's theory. Interviews were conducted by one of the researchers who was an experienced midwifery teacher working in faculty and hold a master's degree in midwifery. In addition, she is a PhD student of reproductive health. She had close interactions with students, midwifery teachers, and midwives. The voice of participants was recorded by voice-recorder. After conducting any interview, the recorded voice by researcher was transcribed word-by-word using Office Word software and simultaneously with qualitative content technique, the data were analyzed. According to Kanter's structural theory, the opportunity and power structures were designed as basic categories and initial operational framework. The operational definitions in any category were extracted using this theory and with respect to definitions and aspects of above structures, the text of interview was reviewed several times until semantic unit was formed. Then, the important phrases and sentences were determined and were named as codes. Similar codes were merged and then based on the conceptual similarity we put them next to each other in categories. As a result, the primary categories formed. These categories were merged again in each other and formed the final categories. At the end, the basic categories of theory were formed by these final categories. The initial analysis was done by the first researcher but regarding the accuracy of extracted codes, primary categories, and the final categories agreement was achieved between the members of the research team. The various strategies were taken to ensure from precision and rigor of findings. In the course of improving the credibility of this study, the participants were chosen with the maximum variation and various methods of data collection were adapted. Data accuracy and extracted codes were revised by participants and it was corrected if needed. Data were explored by the supervisor teachers including a teacher with PhD in curriculum planning and another PhD in nursing to ensure from consistency of categories with remarks of participants, the precision of formation of minor categories within framework and definition of predetermined categories of theory as well as setting aside ideas and presuppositions. Data were continually studied and examined in parallel with rising dependability. The related activities to quality of data collection and analysis were perfectly and constantly recorded. Some samples of method of extraction of meaning units and codes were proposed to the external supervisor teachers from the text of interviews for each of categories. To increase transferability, the given results were presented to some of persons with the same specifications of participants who did not attend in this study and their judgment was evaluated about the presence of similarity among research results with their experiences. To increase confirmability, some of interviews and extracted codes and categories were presented to researcher colleagues who were familiar with method of analysis of qualitative researches that they have not participated in this study and it was agreed on the given results. This study was approved under code No 393373 by the Ethics Committee of Isfahan University of Medical Sciences. The ethical considerations were taken into account by obtaining participants' informed consent and offering freedom to withdraw from the study whenever they wished. All the participants were informed about the method and goals of the study. The students and other participants were ensured that their remarks will remain confidential.

  Results Top

Fifteen students at ages (22-29) have participated in this survey and they were all female with majority of single ones. The midwifery teachers were at ages 29-53 with periods of working background ranged from 2 to 26 years and they had master's degree in midwifery or doctoral degree in reproductive health. The participant midwives were at age 34 and 8 and 10 years of working background and had Bachelor of Science in midwifery. This article presents the results in opportunity structure regarding two structural dimensions of opportunity and power. Three major categories of knowledge acquisition, clinical skill acquisition, and clinical experiences acquisition formed in parallel with explanation of facilitator and impediment factors of empowerment in pregnancy and delivery care within the structure of achievement of opportunity [Table 1].
Table 1: The facilitators and impediment factors for structural empowerment

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Access to opportunity

Opportunity for acquisition of knowledge

The opportunity for knowledge acquisition is one of the foremost factors in access to empowerment for pregnancy and delivery care. Knowledge is deemed as prerequisite for empowerment. "I could not do anything practically as long as I do not know it well" (participant student number 1).

In contrast, weakness in knowledge acquisition that may be due to several factors such as educational problems and motivational and spiritual - mental barriers may lead to failure in achieving adequate readiness to enter clinical environment, lack of potential for making decision, and weakness in clinical management. In addition, theoretical subjects should be presented in applied and clinical form in academic classrooms. "If student knows theoretical lessons is applicable it is possible to create motive for her and this causes students to become more enthusiastic" (participant student number 15).

Paying more attention to the quality of lesson instead of its quantity was a factor to which all of participants have referred. Presentation of updated educational content as well as adaptation of modern, efficient teaching methods instead of traditional techniques through compelling students for thinking and participation may lead to contemplative, retained, and active learning and also the achievement of students at higher levels of learning.
"Management of our classes often includes lecture this may be useful for some units of classes, but it is not adequate since student is not actively involved in this process" (participant teacher number 23).

Some factors such as lack of updated educational content, presentation a great volume of contents within a short period of time at classroom along with applying traditional teaching methods, shortage of clinical experiences of teacher regarding the taught subjects, improper use of educational aid instruments have led to poor quality of teaching and acted as an impediment factor in achievement of empowerment.
"Two chapters of our book were taught only within the same session and we had neither time to propose our questions and nor an opportunity to think about this topic enough" (participant student number 5).

Developing scientific empowerment in midwifery subjects is a result of continuous study of various textbooks. If student is only sufficed with reading handouts and educational slides this trend may prepare the ground for student not to achieve stable, deep, and contemplative learning and it is led to nonacquisition of empowerment to attend in clinical environments. "When we were student we did not know how much this textbook would be applicable for us. So, after graduation and entering into workplace, we see that we should know all of these contents to the extent that at present, we encounter no problem in our workplace" (participant midwife number 26).

The textbook should be noticed as the main reference in the evaluation of students and it should be avoided from sufficing only with contents of handouts in assessments.
"From the beginning, we read the handouts. The contents of examinations were mainly selected from these handouts" (participant student number 13).

Opportunity for acquisition of clinical skills

The opportunity for acquisition and improvement of clinical skills through doing the given task perfectly and independently are considered as effective factors in empowerment for giving care to pregnant mothers. Assignment of doing task perfectly along with supervision over it through improving self-reliance in the given person and coping with fear may also provide the ground for satisfaction and potential for self-assessment. "When I do personally all of tasks related to the patient, I have better sense and even I just notice what I know and what I do not know and at time anyone may feel sense of satisfaction" (participant student number 11).

The presence of fewer students in educational groups at clinical environment may prepare the condition for more clinical opportunities to exercise the given skills and improvement of efficiency. "Learning pair-by-pair is much less efficient than when someone learns the skills alone in working on a patient" (participant student number 1). Alternately, the presence of great number of students in educational groups, reduced statistical number of natural deliveries is considered as barriers against exercising skills and acquisition of experience.

Having responsibility and being responsive versus the conducted task acts as a drive for effort and acquisition of empowerment in skills and in contrast nondelegation of task to student causes lack of motive for improving clinical skills and nonachievement of educational goals. "At the last year of study when we passed our shift alone as we saw that we were only responsible for this task we were careful the uterus not to be in tetanic state and fetal heart rate to be ok and mother's bladder not to be filled and then we should be careful to escort the mother toward delivery room with great care" (participant student number 15).

Opportunity for clinical experiences

The opportunity for confrontation to clinical situations is one of the effective factors in acquiring empowerment for pregnancy and delivery care.
"When two my patients delivered child on hospital bed then I noticed when I should take the patient to the delivery room for childbirth. I read it but I had not seen it and I could not because I had not worked in this field" (participant student number 2).

The findings show that the midwifery students may not acquire adequate clinical experiences in some fields such as clinical participation in emergency units, taking some specific procedures and cases of midwifery work, working in difficult situations, and making decision independently in clinical field, and doing team work.
"I think I could not overcome to handle an emergent case such as post-partum hemorrhage because I have not ever seen this case" (participant student number 10).

The cases such as being stressed, mental upsetting, weakness in clinical management, and failure in playing role in care for high-risk pregnancies, unfavorable management of difficult deliveries and midwifery emergencies are the consequences of inadequate clinical experiences.

  Discussion Top

The findings indicated that the opportunity for acquisition of knowledge and skill in clinical work are deemed as the main efficient factors to achieve empowerment in pregnancy and delivery cares. Knowledge and self-confidence have been assumed as effective core factors in empowerment of nursing students in clinical work. [23] Possessing knowledge and clinical skills are one of the characteristics of a good midwife. [24] Lack of acquisition of adequate knowledge was the impediment factor against empowerment in pregnancy and delivery care that might be accompanied to weakness in clinical management of high-risk pregnancies as well. In study of McIntosh et al., midwifery students expected to acquire the needed knowledge and skills from educational programs. Lack of knowledge acquisition was followed by fear, anxiety, weak readiness for clinical task, and lack of sense of empowerment for them. [25] Presentation of theoretical subjects in applied form and within clinical cases along with applying participatory teaching methods in classrooms may lead to the effectiveness of teaching that is facilitator factors for empowerment. These findings are consistent with results of research done by Carolan-Olah and Kruger in which one of the concerns for midwifery students is this point that to what extent of theoretical learned knowledge in university might cover the expectations to be met in clinical environment. They have asked for further exercise and acquiring readiness in clinical skills and midwifery emergencies as well as being interested in remoteness from traditional educational approaches and moving toward interactive learning attitudes. [26]

After the acquisition of adequate knowledge, execution of task independently and fully should be repeated in various clinical environments and the related person should be responsible and accountable versus them, and this may act as a facilitator factor in empowerment for working. Acquisition of the needed and adequate skills to role playing in the field of midwifery has been proposed as an efficient factor in empowerment for midwifery work. [27] Assignment of work to other personnel in clinical environments and lack of doing independent and perfect work by midwifery student causes nonacquisition of the needed experience and lower speed in their responsiveness empowerment at clinical situations as well as inability to manage clinical situations. [28]

The results of the study showed that the opportunity for exposure to clinical situations and acquisition of experience resulting from such involvement in their situations and challenges are one of the efficient factors in achieving empowerment for pregnancy and delivery care. Despite of importance of adequate acquisition of clinical experiences as the facilitator factor to achieve the needed capabilities before graduation and entry of midwifery students as new workforces into clinical environments, the findings indicated that disregarding the importance of management of clinical cases by the academic teachers and students, poor clinical training, lower exposure to clinical cases due to the related problems to educational programs and facilities on the one hand and restriction of professional responsibility of midwives, weak inter-professional cooperation, and team working in educational centers on the other hand that have led to reduce opportunities to acquire the needed clinical experiences for midwifery students during the time of education is an impediment factor in achieving empowerment. Midwifery students in study of Skirton et al. have mentioned compressed period of midwifery course as an obstructive factor against acquisition of favorable clinical experiences. They have asked for further emphasis on clinical complications and cases and more practical work in educational courses. [28] The presence of great numbers of students in group is followed by reducing received feedback from instructor, lengthening of waiting time for attendance of instructor in clinical position, lack of access to instructor under emergency situations to give answers to the students questions, and helping them as well as increase in number of errors. This issue may lead to lose clinical opportunities for learning and acquisition of experience. [29] Identified role and field of activity for midwife regarding caregiving to mother, independence in doing of tasks and execution of works monitored, and guided by midwife personally are deemed as facilitator factors for the empowerment of the employed midwives in clinical environments. [27] Preparation of opportunity for the experience of clinical learning by inter-professional form may positively effect on learning in students. The interprofessional collaboration in clinical environment enables students in various disciplines to share their knowledge and experiences with each other and to acquire learning and experience along with these interactions. [30]

Limitation of this study is that the findings were more comprehensive if the issues related to midwifery student's empowerment in clinical environments were investigated from midwifery managers and pregnant women's perspectives too.

  Conclusion Top

The academic teachers and clinical instructors should pay special attention to providing the needed opportunities for acquisition of the knowledge, skill, and clinical experiences as facilitator factors for empowerment. It is suggested to use modern educational and evaluation methods both in theoretical classrooms and clinical environments, to emphasis and focus on management of high-risk pregnancies, and to prepare students adequately in laboratories of clinical skills by the aid of simulation, particularly in the field of clinical management of midwifery emergencies and creation of opportunity to acquire adequate clinical experiences despite of the problems and defects through strengthening of interdisciplinary collaborations in clinical environments.

Financial support and sponsorship

This study is funded by Isfahan University of Medical Sciences.

Conflicts of interest

The authors have no conflicts of interest.

  Authors Contribution Top

All authors contributed in conducting the study concept and design, acquisition of data, analysis and interpretation of data. MJ and NK contributed in drafting of the manuscript, revising the draft, and approval of the final version of the manuscript.

  References Top

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