Explaining Midwifery Students’ Experience of Their First Attendance in Clinical Skill Centers: A Content Analysis Study

Clinical education constitutes the basis of any education program in medical sciences (1). Students have to acquire professional knowledge, skills, and attitudes during their medical studies; hence, a large amount of time is devoted to their clinical practice period so that they can acquire adequate clinical skills (2). Learning clinical skills on “real patients” not only endangers patient safety but also raises many ethical concerns. This has resulted in the establishment of Clinical Skill Centers (CSCs) in medical colleges where the students practice and learn different aspects of medical skills and knowledge (3). Thanks to their teaching aids, models, and manikins, these centers provide an opportunity for students to enhance their clinical and communication skills in a relaxed, controlled environment with minimal stress (4). CSCs have been reported to eliminate students’ emotional stress in their initial encounter with the patient (which often results from lack of sufficient skills and fear of error and failure) and prepare them for the first experience of visiting a real patient (5). Ali et al. quoting Bradley et al., wrote that CSCs cannot replace training with real patients, but instead, they gradually introduce ways of interacting with the patient and the highly sensitive patient community (6).

Experiences obtained from clinical settings should be taken into consideration when developing readiness and skills in functional professions training programs since this is one of the most effective factors contributing to education, if not the most effective one (7). Redmond et al. investigated the experience of nursing students at CSC and the hospital. They found that from the participant’s perspective, the difference between nursing laboratories and other scientific laboratories (physiology, microbiology, etc.) could be attributed to the following factors: The slower process of learning skills in CSC nursing, facilitation of learning skills in CSC by mentors, other learning facilitators, and the existence of some barriers to learning (8). Thunes and Sekse aimed to get a better understanding of the midwifery students’ first encounter with the maternity ward and of what was essential to them in the learning environment. They conducted a qualitative study using in-depth interviews with six students during their first clinical practice at a maternity ward. The findings show that the students needed to feel their presence was desired and that they wanted to be included in the activities in the ward. The authors argued that learning should be based on the student’s expectations, understanding, and previous experiences. The most important factor influencing the students’ well-being and learning was their relationship with their mentors. In conclusion, learning in a clinical setting requires more than just motivated students (9). Shahoei et al. also examined midwifery students’ experience in clinical settings, and the key concepts or themes revealed in their study included learning facilitators and inhibitors. The former included sub-themes of mentors’ performance, student satisfaction, and pre-clinical training. At the same time, the latter involved a lack of environmental facilities, a lack of coordination in educational programs, and the behavior of healthcare personnel (10). Ahmadi et al. argued that the majority of the midwifery students (69.8%) had a positive view about learning in CSCs. They mostly believed that the old and poor-quality models were the most important problems they encountered (66.7%). Despite students’ satisfaction with clinical skill centers, shortcomings and inappropriate behaviors can affect their interest and motivation (11). According to Ashrafnia et al., one of the challenges of the undergraduate educational program in midwifery was the lack of educational facilities and equipment, including the mismatch between the number of students and educational facilities and adequate equipment (specialized and advanced models). According to one of the participants in their study: “The models we have at the clinical skills center are very old and do not have many of the capabilities of the new models, and if we had better equipment, we could address some of the clinical deficiencies in college.” (12). The findings of Chesser indicated that a warm welcome by the clinical staff on the first day had a positive effect on the student’s sense of self-confidence. This promoted the integration of the learned theories and practicing them in the clinical setting with the help of qualified staff. Chesser found that acquiring basic clinical skills had to be considered first in order to ensure that B.A. students were appropriately prepared for clinical work and that socialization is one of the important processes in the development of B.A. curricula (13). Aliakbari et al. also found that the participants in their research had different experiences of their first presence in the delivery room. Some of these experiences were reported to be personal and partly related to the training and educational conditions, the environment, the mentor, etc. Generally, their participants considered a former negative mentality as one of the important factors influencing their first experience of being in the delivery room. Moreover, they reported that after entering the delivery room, confrontation with real situations played a crucial role in their experience of attending the delivery room. They believed that psychological unpreparedness, practical unpreparedness, stressful behavior of the mentor, fear of childbirth risks, lack of independence, and the unpleasant environment of the delivery room were among the important factors forming their first experience of attending a delivery room. They highlighted two main themes in the experiences of their participants: (1) Changing previous beliefs and (2) stressful childbirth internships (14). According to Aliakbari et al., fear is one of the emotions that students experience when entering a new clinical environment, and it can have negative effects on learning. Ahmadi et al. conducted a qualitative analysis aimed at determining the experience of fear and its consequences among midwifery students during their undergraduate program. The midwifery students’ fear consisted of the following subcategories: Fear of harming, fear of encountering their first childbirth, and fear of penalties. In their study, fear not only raised the students’ stress levels (leading to physical and psychological issues) but also hindered the adoption of their professional role (15).

The literature lends support to the importance of CSC in improving the learning level of medical students, eliminating the fear of encountering the patient, and increasing the safety level of patients. Therefore, improving the conditions of these centers is one of the duties of medical education study centers. Since the first encounters and experiences are often associated with permanent consequences, this qualitative study aimed to explore the first experience of midwifery students entering clinical skill centers. The results of this study could be used to remove the existing obstacles in this process and help the students have a pleasant experience for an informed and responsible entrance to the clinical setting.

This was a qualitative study designed and implemented using the content analysis method. The study population included all the second-semester midwifery students of Ahvaz Jundishapur University of Medical Sciences (n = 32) who had recently passed the course “Introduction to the Principles and Techniques of Patient Care” at Clinical Skill Centers (CSC). After the guest students (n = 2) were removed, all eligible midwifery students were invited to the Midwifery Department office and were introduced to the lead researcher by the secretary of the department. Then, each student entered the research interview room and was briefed on how to participate in the study and their right to participate or withdraw from the study. Then, their written informed consent was obtained. The interviewer was both a Ph.D. candidate in Medical Education and a faculty member with a notable background in midwifery. In this study, the principles of confidentiality of audio and handwritten information of the interviews were strictly observed. In-depth, non-structured individual interviews were conducted in the interviewer’s office to collect the data. This type of interview was selected due to its flexibility and in-depth data. Purposive sampling was first performed for the interview and continued until data saturation. In this type of sampling method, the participating groups are chosen according to pre-determined criteria for specific research questions (16). Furthermore, in this type of research, the number of samples varies, and the researchers continue sampling until they can arrive at a new idea (17). The inclusion of the students in the study was gradual. Transcription of the interviews and determination of meaning units were done immediately after each interview. After the eighth interview, no new concept was extracted. However, to ensure data saturation, three more interviews with three students were conducted, which confirmed data saturation.

The lead researcher conducted all interviews, and the interviews began with the main question, “How did you feel when you first entered the skill lab (clinical skill lab)?” Then, the interview unfolded based on the students’ responses and experiences with the environment and facilities. The length of the interviews ranged from 20 to 30 minutes. The data were analyzed using the conventional qualitative content analysis method. This analysis was performed by Mayring’s deductive category application (18) (Figure 1).

In the present study, the recorded interviews were first transcribed using this approach. The transcript of each student’s interview was reviewed and checked. The researcher read the transcripts several times, and the units of analysis, as well as semantic units or coding units, were specified. This involved reading the transcripts repeatedly with the researcher’s full attention to detail. Then, based on the similarities of the semantic units, the condensation, abstracting, and summarization of data were performed. Subsequently, re-reading and subjective analysis were performed through continuous comparisons, the distinction between the classes was specified, and coding was performed. According to Iman et al., coding and consequently categorizing content in conventional content analysis begins along with reading a transcript or interview without any background. Based on the topic, we systematically defined the semantic units and condensed them to determine the codes, and in case they had a common context, the codes were merged to form the categories. Then, the general concept resulting from the aggregation of these categories (themes) was obtained. The content was reviewed in two stages to maintain reliability: One after completing 5 to 10 percent of the categories and the other at the end of the process (19). In the present study, after the formation of the categories, sub-categories were formed, and we obtained themes by merging deduction and continuous analysis. The agreement percent index was used to check reliability (i.e., the agreement between the coders). In more detail, any given variable was measured or coded by two people independently of each other, and the degree of agreement or disagreement was determined in cases where there was no agreement. In case of serious disagreements, the opinion of the research team leader was sought and considered as the final result.

Intra-subject agreement percentage = (number of agreements) ÷ total number of codes. If this index is more than 60%, coding has sufficient reliability (20).

Strategies to ensure credibility are prolonged engagement, persistent observation, triangulation, and member check (21). In this study, to ensure the reliability of the results, we used long-term engagement of researchers with data and member checks. Also, long data collection time (interviews) was avoided, and all participants were asked about the same topic.

In this study, 11 second-semester midwifery students were interviewed. The mean age of the students was 19.5 years. Most of them were Khuzestani and lived in dormitories. A total of 156 codes were extracted from the research data, which were organized into 9 categories and 28 subcategories after depleting and merging similar codes. Further analysis and classification led to the emergence of three main categories and nine sub-categories (Table 1).

Self-regulation was one of the strong themes extracted in this study. This term is used to describe the creation, maintenance, and motivation of students to perform professionally trained skills in CSC and to build and enhance self-confidence while performing CSC-trained procedures. The instructor acts as a role model for the students to reach a level of confidence to be capable of eliminating interfering emotions and tensions and pre-operative thinking at the end of this course. Cho et al. believe that the four areas in which one can adjust are cognition, motivation, behavior, and context (22). These four areas are exactly what the education system should follow in order to train a competent midwifery student. Among these, motivation is of unique importance. Arfaei and Soofi-Abadi believe that midwifery students are sufficiently motivated and aimed at choosing this discipline. The authorities should make the necessary efforts to enhance the educational level of talented students and to achieve maximum productivity through effective learning (23). According to Moores et al., the motivation of students to study midwifery in low-income countries can be classified into two forms, namely the personal and intrinsic form (including an interest in pregnancy and childbirth, feelings of altruism or willingness to help others and personal experience of pregnancy or birth), and the professional and extrinsic form (including job security, salary and wage, opportunities for continued professional development, and increased autonomy) (24). Moreover, most students in the studied population were sufficiently motivated to learn; hence, the teachers should enhance or maintain their motivation. One of the ways to increase students’ motivation is for teachers to be mindful of themselves as role models. In the study by Bluff and Holloway, a number of midwifery students and graduates cited two types of midwives as their models: The prescriptive midwives and the flexible midwives. The former strictly follow the regulations, and most of these regulations are related to the medical model mainly developed by doctors. Thus, doctors are the model of these midwives. They had been working in the hospital and were considered by the students in that study to be non-autonomous. In contrast, flexible midwives adapt to regulations to provide individual care to women. These midwives make their own decisions about the proper care of women and thus appear to be independent midwives from the viewpoint of students (25). In academic settings, professors are always intentionally or unintentionally observed and judged by their students, and the students follow their decisions as a model. Reuler and Nardone argue that models play an important role in determining how students graduate from college, transform into specialists, and become committed physicians. Their academic medical mission goes beyond their commitment to the needs of patients and the community generally, and physicians who teach must be a model for students (26). At CSC, as the first center for student exposure to practical tasks, manikins, and simulated patients (SPs) and a center for learning communication skills, the role of the instructors of the center and selection of the best and most experienced instructors seem necessary. Midwifery students enter the center on their first days of university. Each of them has come to university from a particular family and cultural background, and all have selected a single profession. This profession requires quick decisions, necessitating a high level of confidence in them. As Nomali et al. writes, students with lower levels of self-esteem are less likely to participate in school-related activities, and they like to sit in the back seats (27).