raduates ’ perceptions of their midwifery training during the four year comprehensive nursing diploma

Sam evatting Since its inception in 1986, the Comprehensive Nursing Diploma has received many criticisms from registered nurses, who graduated from the pre-existing programmes. This study attempts to examine the perceptions of gradu­ ates from this training programme, towards their mid­ wifery education in terms of its adequacy in preparing them for midwifery practice. Twenty-nine graduates of the four year Comprehensive Nursing Programme completed self-administered questionnaires. Data was analysed by means of descriptive and inferential statistics, namely the paired t-test and the Wilcoxon test for matched pairs. Qualitative data was analysed to determine emerging themes and patterns. Differences in competence ratings on entry into midwifery units and those a year later, were significant at p = 0.0001. It was found that graduates appear to have a positive per­ ception of the midwifery component of their training pro­ gramme. They found the theory aspect to be more than adequate in preparing them for their professional roles. However, with regards to clinical exposure, it was felt that the time period was too short and needed to be extended in order for them to attain clinical proficiency. Sedert die instelling van die omvattende Verpleegkunde D ip lom a in 1986, is d it d ikw els g ek ritisee r deur g e reg is tree rd e verp leegk und ig es w at binne die voorafbestaande programme gekwalifiseer het. Hierdie studie poog om die persepsies van persone wat binne die huidige program gekwalifiseer het, te ondersoek ten opsigte van die akademiese voorbereiding vir praktisering as ‘n verloskundige. Nege en twintig gegradueerdes van die vierjarige omvattende Verpleegkunde program het self geadministreerde vraelyste voltooi. Data is geanaliseer deur m iddel van beskryw ende en inferensiele statistiek naamlik die gepaarde t-toets en die simmetrie toets van Wilcoxon. Kwalitatiewe data is geanaliseer om ontluikende temas en patrone to bepaal. Verskille in vaardigheidskoerse by toetrede tot verloskunde-eenhede en na een jaar later, was beduidend teen p = 0.0001. Daar is gevind dat gekwalifiseerde verpleegkundiges ‘n positiewe persepsie van die verloskundigekomponent van hul opleidings-program het. Hulle bevind die teorie-aspek meer as voldoende om hulle vir hul professionele rolle voor te berei. Met betrekking tot kliniese blootstelling was daar egter ‘n gevoel dat die tydsduur te kort is en dat dit uitgebrei behoort te word ten einde hulle in staat te stel om kliniese vaardig te word.


Introduction
The Comprehensive Nursing Diploma has been in existence for a period of almost ten years now.At ward level there have been many complaints and criticisms levelled at the gradu ates of this programme, from professional nurses who gradu ated from the pre-existing training programmes, namely the three and a half year integrated programme and the one year post-basic midwifery programme.Since its inception a few studies have been undertaken by various members of the nursing profession to examine this training programme.Gwele and Uys (1995) carried out a study amongst nurse educators in South Africa to examine their perceptions towards the Comprehensive Basic Nursing Pro gramme (CBNP).In their findings most respondents recog nised the need for the CBNP in South Africa.Gwele and Uys (1995), cite three respondents as having made particular men tion of the inadequate preparation afforded by the CBNP, in areas of midwifery and psychiatric nursing.Nkosi (1988) examined the attitudes of black professional nurses towards the Comprehensive Nursing Diploma at Themba Hospital in Mpumlanga.The findings revealed that a high percentage of professional nurses seemed to be nega tively disposed to the Comprehensive Nursing Diploma.

Background
In 1652, when Jan van Riebeeck established a refreshment station at the Cape, midwifery services were purely domicili ary in nature (Searle 1965), with pregnant and labouring women being attended to by traditional birth attendants (Mellish 1990).Since then many changes have occurred within the nursing profession to bring about midwifery train ing as we know it today.For one to decide on the efficacy of a programme to produce graduates that are able to carry out their professional roles, it is imperative to evaluate the gradu ates' competence.
Perceptions and evaluations of competence of student nurses and graduates Mozingo et al. (1995) examined factors associated with per ceived competency levels amongst senior baccalaureate nurs ing students from one particular university in America.Their most important finding that is of particular relevance to this study, was that one of the most problematic areas was related to clinical skills.Students appeared to lack confidence in their clinical competency.A large percentage of students stressed the need for more chances to practise clinical skills, while in training.As clinical exposure was increased, students per ceived themselves to be more competent in the employment arena.
In another study, students also felt that clinical instructors and ward staff could improve the learning environment by being more understanding of student problems, both personal and academic (Durrheim 1993).Students also felt that lec turers need to show more confidence in them and that feed back should mostly be positive.Kelly (1996) looked at the pressures or problems that neo phyte graduates have to face when making the transition from student nurse to graduate.All subjects made mention of ex periencing stress in their new roles, which appeared to be related to role anxiety.Informants also appeared not to have confidence in their competence.Due to staff shortages gradu ates were often not given the chance to gain experience and feel comfortable in their roles before they were expected to manage wards.In agreement with this, Gwele and Uys (1995) found that nurse educators felt that graduates from the Comprehensive Basic Nursing Programme lacked experience.This factor lead to feelings of inadequacy and resulted in them needing more post-basic experience before they could feel confident.Durrheim (1993) found that student nurses found the mid wifery clinical learning environment to be pleasant and re laxing.One of the findings was that clinical nursing staff made more of an effort to make the labour and postnatal wards more conducive to learning, than the other areas involved in midwifery.Students also had more positive perceptions of professional nurses in the wards than of their clinical instruc tors.They also felt that theoretical knowledge gained in class, was relevant to clinical instruction.However, it appeared that clinical instructors were seldom available to students in need.In keeping with this, students perceived that nursing staff made more use of clinical learn ing olroblems can be resolved once the student attains the relevant experience.Respondents in the Gwele and Uys (1995) study also felt that graduates need more post-basic experi ence before they could feel confident.Durrheim (1993) con cluded that respondents view themselves to be competent to render midwifery care according to their scope of practice, as laid down by the South African Nursing Council.(1996), postulate that this could be related to the speed at which the course was put into effect.Due to the time con straints inadequate time was given to the preparation of the learning environment and working relationship between staff and students.

Perceptions of training
Gwele and Uys (1995) draws one's attention to a similar pic ture with regards to the Comprehensive Basic Nursing Pro gramme.They state (p.9): "A number of aspects were identified as features that would hinder the attainment of this objective.Amongst others, these were (a) fragmented clinical placements, (b) emphasis on a number of lectures and clinical hours instead of competen cies, (c) a packed and rigid curriculum with 'too many nice to knows ', and (d) enforced qualification in all four clinical areas."

Purpose of study
This study was conducted to specifically examine the percep tions of the four year programme graduates, regarding their midwifery education.In doing so, this study sought to attain the following objectives: (I) Assess the views of graduates regarding the adequacy of their education, in preparing them to function as midwives, (ii) To examine the views of the graduates regarding their competency in midwifery practice in the areas o f : (a) Funda mental midwifery procedures, (b) Therapeutic & diagnostic measures, and (c) Advanced therapeutic & diagnostic meas ures.

Definition of concepts
For purposes of clearly understanding this study and to main tain consensus between reader and researcher, it is necessary to define some of the concepts that will be used.
(1) fundamental midwifery procedures: For purposes of this study, fundamental midwifery procedures, refered to midwifery procedures/skills that are essential to the practice of midwifery, without which the midwife would be unable to render care to women during pregnancy, labour and delivery, and the post natal period.
(2) therapeutic and diagnostic measures: Therapeutic mid wifery measures were seen as those interventions aimed at the resolution of maternal, foetal and neonatal complications.Diagnostic measures include the midwifery skills aimed at distinguishing and differentiating among maternal, foetal and neonatal complications, as well as the curative skills.
(3) advanced therapeutic and diagnostic measures: Refers to those measures/skills that usually fall into the scope of prac tice of an advanced midwife, rather than an ordinary mid wife, as determined by the South African Nursing Council.

Methodology Design
This was a descriptive survey, aimed at the graduates of the Comprehensive Nursing Diploma, who were presently work ing as midwives in midwifery departments.For purposes of this study and for accessibility, the target population was from Based on information provided by these hospitals the number of respondents was calculated to be 44.This was too small for sampling and as such the total population was utilised.

Data collection and analysis
The method of data collection used for this study, was the completion of questionnaires by respondents.The question naire listed 32 midwifery skills, which were further divided into the following categories : (a) Fundamental midwifery procedures, (b) Therapeutic/ diagnostic measures, and (c) Advanced therapeutic / diagnostic measures.
Respondents were asked to rate their perceived competence with regards to these skills: (a) when they first began work ing in the midwifery department and, (b) a year later, while still working in the midwifery department.A Likert type rat ing scale was designed by the researcher.The rating scale comprised of four categories as follows: Very competent = 4; Competent = 3; Fairly competent = 2; Not competent = 1.
Respondents were also asked to express their perceptions of the education that they received in order to prepare them to practise as midwives.
In order to test for content validity of the instrument, it was administered to five registered midwives, two of whom were involved in midwifery education and the remaining three who worked in a midwifery department.They were then requested to give their input regarding whether or not, (a) they agreed with the classification of the skills into the three categories, (b) all the relevant midwifery skills had been included and (c) all the skills listed were in fact pertinent to midwifery practice.
The test-retest reliability of the instrument was tested by ad ministering it to five members of the target population.How ever, only three completed questionnaires were returned.A week later the same questionnaire was administered to the same three respondents.The questionnaires, for these three respondents, from these two rounds were then compared, to check the consensus between the results.Results from these two rounds revealed an r value of 0.7, indicating the reliabil ity of the questionnaire to elicit the necessary information.
Questionnaires were then hand delivered to the different midwifery units at the three targeted hospitals.

Ethical considerations
Verbal consent was obtained from the participants by the re searcher when handing out the questionnaires.Anonymity was maintained since no specific personal details were being asked of participants.Confidentiality was maintained with regards to all details of participants obtained.

Findings
Perceptions of competence For all the skills listed in the questionnaire, the mean score for each skill was calculated using all 29 completed question naires.An average mean score was then calculated for each category.
For the category 'Fundamental Midwifery Procedures', re spondents rated their initial entry competence on average as 2.32 (SD=0.68),which fell closer to 'fairly competent' on the Likert rating scale.For competence a year later, a rating of Fairly competent 1 -1.4 Not competent 3.51 (SD=0.37)was obtained, placing their perceptions be tween 'very competent' and 'competent'.With regards to 'Therapeutic and Diagnostic Measures' re spondents rated their initial competence as 2.17 (SD=0.66).This meant that they viewed themselves as 'fairly competent'.Competence a year later was rated as 3.33 (SD=0.44),with respondents seeing themselves as 'competent'.
For the category 'Advanced Therapeutic and Diagnostic Meas ures' respondents rated their initial competence as 2.06 (SD=0.55),which meant that they saw themselves, as being 'fairly competent'.The scores for competence a year later, revealed an average of 3.26 (SD=0.53),which indicated that they saw themselves as being 'competent'.A paired t-test was used to ascertain the statistical signifi cance of the gather data.The paired t-test makes the assump tion of normality of distribution and should normally be used for n 30.In order to check the results obtained by the paired t-test the Wilcoxon test for matched pairs was conducted.This test was utilised since paired data was being analysed, rather than independent data.The Wilcoxon test for matched pairs, unlike the paired t-test, does not make the assumption of nor mality of distribution (Polit and Hungler, 1983).For all three categories of skills, the Wilcoxon test for matched pairs and the paired t-test were significant at p = 0.0001.Hence in all categories, perceptions of competence were found to improve over time.

Perceptions of educational preparation
By means of open-ended questions respondents were asked to comment on their midwifery training during the four year Comprehensive Nursing Diploma programme.Patterns emerging from comments were either positive or negative.
Themes that came to light from the positive comments were as follows.Inadequate practical experience.Eleven respondents stated that time spent in the practical field as students had been inadequate, therefore, they did not feel practically competent at the end of the course.One respondent also complained about the practical aspect being 'too rushed'.As a result more practice was needed before they could function as independ ent practioners.Another graduate reported that time spent in each unit in the midwifery department had been inadequate.She stated that just when 'proficiency' was attained, they were moved to new areas.As a result they had to relearn proce dures when they came back to work as qualified midwives in the midwifery department.One graduate felt that the South African Nursing Council's 15 delivery requirement for regis tration, was in fact inadequate for competence.

Adequate theory component
Exposure to abnormal midwifery.Another area that war rants looking at according to 6 (21%) respondents, is that of abnormal midwifery.Respondents felt that while they were able to render care to patients with no complications, they would not have been able to render care to patients with com plications and abnormal conditions, after graduation.They instead needed more exposure after qualifying to be compe tent in this area.
Other negative comments.One or two respondents made mention of other negative aspects of the midwifery training.These were, (a) the volume of information was too vast for the course, (b) separation of modules by one year, lead to for getting, (c)the midwifery course being placed too early in the programme resulted in it being stressful and (d) not being able to get much 'hands on' experience in the neonatal inten sive care units.

Student recommendations
Finally respondents were asked what they would change about the programme, if they were given the power to do so.
Lengthen time spent in clinical field.A total of 12 (41%) respondents felt strongly that the course should allow more time in the clinical learning area.This would allow them to correlate theory with practice, and would give them more confidence since they would be better able to make decisions concerning patient care.Extending practical learning time would also enable students to assist with and learn about ab normal conditions and complications in midwifery.
Lengthen duration of entire course.Another 10 (34%) re spondents also mentioned extending the duration of the mid wifery component, so as to have more time all around.Four respondents felt that the course should last for one year rather than 6 months.If the course was extended, respondents felt that they would feel confident to carry out their duties once qualified.They also expressed that this would also enable them to perform their teaching function more efficiently as well.
Other recommendations.One respondent said that they would decrease emphasis on the midwifery clinical require ment register and instead promote learning through 'willing, active participation'.It was also suggested that the number of clinical teaching staff be increased to cater for students clini cal teaching needs.One respondent also highlighted the need for more home visiting to take place for continuity of care.Two graduates suggested combining the two modules in midwifery and not allowing for the time lapse as already men tioned.One respondent also suggested that midwifery should be done after the general nursing and psychiatric components in the four year Comprehensive programme.One graduates felt that more effort should be made to build confidence in students.It was also suggested, by one respondent, that the size of midwifery classes be decreased, so as to ensure that all students get more individual attention.

Discussion
Perceptions of competence One of the findings of the study, was that respondents rated themselves as 'fairly competent', with regards to 'fundamen tal midwifery procedures', upon entry into a midwifery unit as a qualified midwife.It would appear that graduates seemed to have little confidence in their clinical competence.Inad equate confidence with regards to clinical competence upon graduation was found in graduates of the Dalhousie Univer sity School of Nursing, Nova Scotia, Canada (Barrett et al. 1996).
The respondents were also asked to rate their competence with regards to the same skills, 'a year later'.It was found that they rated their competence as significantly higher.Clini cal competence was now perceived as falling between 'very competent' and 'competent'.It can be deduced that time spent in the 'working area', had a definite effect on the respondents perceptions of their competence.Barrett et al. (1996) found this phenomenon with their study in that graduates percep tions of their competence improved with more clinical expo sure gained after qualification.Hence, they (Barrett et al. 1996) concluded that more clinical experience was needed whilst in training for the graduate nurse to feel competent.In South Africa nurse educators have also observed that clinical expo sure after qualification helps to improve the four year Com prehensive Nursing Diploma graduate's confidence, as well as, clinical competence (Gwele and Uys 1995).
The same was asked of the respondents for the other two cat egories.As can be seen from the findings, perceptions of clini cal competence, improved in both categories, with clinical experience.It becomes clear that graduates appear to have little confidence in their clinical competency following gradu ation.However, exposure to the clinical area as qualified mid wives, seems to have helped them gain experience and al lowed them to feel more confident.This is further reinforced by their perceptions of the education that they received in preparation for their roles as midwives, which will be dealt with later.
On the whole one can conclude, that the four year Compre hensive Diploma programme offers a substantial midwifery training.This can be corroborated by the respondents ratings of their competence.Thus graduates of this programme ap pear to feel that they are able to carry out their professional roles as midwives, as outlined by their scope of practice, by the South African Nursing Council.

Perceptions of educational preparation
A positive finding of this study, was that 72% of the popula tion of respondents felt that the midwifery education that they had received had been adequate in preparing them for their professional roles as midwives.After all, who better to judge the programme, than a product of that programme.An idea, fully supported by Barrett et al. (1996), who suggested that graduates be used to help to evaluate the curriculums in nurs ing schools.From this one can deduce that the negative feel ings towards the four year Comprehensive Diploma pro gramme by graduates of other pre-existing programmes, as described by Nkosi (1988) was not supported by the results of this study, with regards to educational preparation.Thus it can be thought to stem from other factors, not including the adequacy of the course.

Adequate theory foundation
Staying with positive perceptions of the respondents, it was also found that the respondents felt that they had been given adequate theoretical knowledge during their midwifery train ing.According to them, this sound theory base, helped them correlate their theory learnt to the practical situation.This finding correlates with data provided by respondents, from the Dalhousie University School of Nursing (Barrett et al. 1996).Not all respondents in the present study were happy with the theory component.It was felt that the volume was too great, with too much of emphasis on subjects such as pathology and physiology.Mozingo et al. (1995), also found that respond ents in their study felt the same way, with regards to anatomy and physiology.It was suggested that more emphasis be placed on learning to render care to patients, instead.Gwele and Uys (1995) also suggested that one of the factors that may be responsible for preventing students from meeting course ob jectives, may in fact be the curriculum.They describe the cur riculum as being, "packed and rigid" (p.9).As already mentioned by respondents, six months are allot ted to midwifery during the Comprehensive programme.
During this time students are expected to learn a vast amount of theory, as well as, gain clinical experience and skills.There fore, the author agrees with Armstrong (1993) on the idea that the teaching of basic nursing care should be undertaken in a separate nursing course.Due to the time constraint placed on the midwifery component, it becomes difficult to give time to the teaching of basic nursing skills that the student should have already acquired by this stage of their training.

Inadequate clinical experience
Respondents did, however, feel that their exposure to the clini cal learning area had not been adequate.They felt that time spent in each midwifery unit had been too short, and as a result did not allow them to be proficient in their midwifery skills.This is due to the fact that the duration of the mid wifery course within the four year Comprehensive Diploma programme, has been decreased from the one year of the post basic course to six months in the basic programme.This complaint can also be heard from graduates of other programmes, such as the baccalaureate programme at the Dalhousie University School of Nursing (Barrett et al. 1996) and baccalaureate programmes in America (Mozingo et al. 1995).It would seem that graduates need more clinical expo sure during their educational preparation, in order to feel con fident about their competency after graduation.This can also be borne out by the difference in the average mean scores of respondents at 'initial entry' as compared to those ' a year later'.Indicating that clinical exposure does in fact influence perceptions of competence positively.This correlates with findings by Gwele and Uys (1995), as well as, with findings by Barrett et al. (1996), that graduates seem to need some degree of clinical exposure after qualify ing, in order to feel confident about their competence and professional roles.
Contribution by ward/unit staff A few respondents mentioned the contribution by ward/unit staff towards their learning.These respondents felt that they learnt a lot from ward staff, even more than from clinical teaching staff.They saw the ward staff as being very knowl edgeable.In total contrast to findings of Lowane (1990).Re spondents also felt that more clinical teachers were needed in the practical field.Once again in contrast to Lowane (1990), no mention was made of the teaching methods of clinical teachers.Teaching by clinical teachers appears to be of good quality, but it was felt that clinical teachers needed to be more available to students.

Adequate clinical evaluation
Even though respondents felt that their clinical experience had been inadequate, they did not lack all confidence in their clinical preparation.This is due to the fact that they were extensively evaluated whilst in the clinical area of their train ing and education.

Separation of modules
The fact that the midwifery course is divided into modules appears to be beneficial to students in training.Respondents in this study felt that this division of normal and abnormal midwifery, helped them to learn subject content properly be fore moving on to learn new information.It also gave them a chance to correlate theory with practice before new informa tion was given.Therefore division of normal and abnormal midwifery seem to assist learning, by allowing the student to move progressively from easy to difficult study material.There appears to be two ways to solve this problem.Firstly, one can cut down on student numbers.This will allow stu dents to get adequate clinical experience, as well as, indi vidual attention.However, this may pose the problem of a shortage of qualified staff.The other option is to allow stu dent numbers to remain large and instead, increase the avail ability of clinical placements for these students, making more use of polyclinics and other primary health care settings.This has the added benefit of varying of clinical experiences and broadening the student's knowledge base.

Inadequate abnormal midwifery
Respondents also complained that they gained adequate nor mal midwifery exposure, but lacked exposure to abnormal midwifery.If one follows through with the idea of increasing availability of clinical placements, then this problem would also be solved.In the primary health care setting, there is a decrease in the availability of doctors.Problems encountered have to be managed by the midwife, if possible.This will allow the student to observe and assist with the management of patients with problem or abnormal conditions.

Clinical register
One of the respondents suggested doing away with the mid wifery clinical register of requirements.The respondent felt that it in fact hindered learning rather than promoted it.This can be seen to be true since students tend to adhere strictly to the requirements stipulated in their registers.Since the regis ter is a requirement for registration as a midwife with the South African Nursing Council, it becomes the main focal point for students.As a result it can in effect prevent the stu dent from opening themselves up to new and beneficial expe riences that are not stipulated in the register.However, until a new method can be devised to ensure that student midwives get adequate clinical experience, the register remains one of the most effective ways of assessing students' clinical expo sure.

Recommendations
The main recommendation is to lengthen the training period for midwifery.This will allow the student midwives the op portunity to gain more practical experience.Staying with prac tical experience, another way of increasing exposure will be to include more clinical placements, so that these placements are not overcrowded with students.This will enable all stu dents to have access to practical exposure.
There is also a need for more clinical teachers, who can then give students more individual attention.Clinical teachers and ward staff also have to make an effort to involve students in more abnormal midwifery situations in the clinical field, as this area seems to be lacking.It is recommended that midwifery modules run consecutively, to avoid forgetting of information learned and to allow stu dents to correlate theory with practice.Finally, due to the limitations of this study, that of popula tion size, future research should extend the study to include more hospitals, in order to get a better picture of the mid wifery component of the four year Comprehensive Nursing Diploma.This type of study could also be extended to exam ine perceptions of the entire programme and not just of mid wifery.

Conclusions
Except for a lack of adequate clinical experience, the four year Comprehensive Nursing Diploma programme is afford ing adequate education and training to the student midwife, thus allowing the graduates to be able to fulfil their profes sional roles.Once adequate clinical experience during train ing is provided, graduates will also feel more confident upon qualifying.
Parker and Carlisle (1996) examined final year students' per ceptions of their training during the Project 2000 course in the United Kingdom.Negative perceptions towards the course related to the organisation of the course.Students found the course to be fragmented and variable.Parker and Carlisle

Table 1 :
M eans & Standard Deviation of G raduates' Com petencies in M idw ifery Skills

Table 2 :
Interpretation of the Likert Scale Scores ward staff were also responsible for making their educational preparation a success.According to one re spondent, ward staff were 'knowledgeable and always will ing to teach'.As graduates neared the end of their midwifery training they were given more opportunities to make deci sions concerning patient care, a special mention being made of labour ward in this regard.The following statement from one of the respondents demonstrates the benefit derived from ward staff.' The close supervision o f our clinical teaching department and the registered midwives o f the midwifery department, helped me tremendously.' 'The theoretical and practical knowledge imparted to me, by my tutors was extensive, very informative and interesting and therefore adequately prepared me fo r practice as a midwife ' Contribution by ward/unit staff.Only eight (28%) gradu ates reported that This time lapse appears to be detrimen tal to student learning.It allows for forgetting of information learnt and students then have to relearn information that has been forgotten.One can also see how this would lead to un necessary stress for the students.It also hinders the learners ability to correlate normal midwifery with abnormal mid wifery.Large student numbersFrom data collected it would seem that student numbers in fluence learning.Respondents complained that due to the large student numbers, they were not able to gain adequate clinical experience in the hospital setting.This also relates to the prob lem of availability of clinicians, that was discussed earlier.It would stand to reason that as student numbers increase, so to must the numbers of clinical teachers.Otherwise it becomes very difficult for students in training to get individual atten tion from their clinical teachers.
On the down side, one of the campuses separated module I (normal midwifery) from module II (abnormal midwifery) by a period of one year.