Midwifery 59 (2018) 94–99
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Experiences of the graduates of the first baccalaureate midwifery programme in Pakistan: A descriptive exploratory study
MARK
Arusa Lakhani, RN, RM, MScN Assistant Professora, Rafat Jan, RN, RM, PhD Professorb,1, Marina Baig, RN, RM, BScN Senior Instructora, Kiran Mubeen, RN, RM, MScN Instructora, Sadia Abbas Ali, RN, RM, BScN Senior Instructora, Shahnaz Shahid, RN, RM, MScN Senior Instructora, Karyn Kaufman, RN, CNM, DrPH Dr Professor Emeritusc a b c
The Aga Khan University School of Nursing and Midwifery (AKUSoNaM), Stadium Road, Karachi 74800, Pakistan National University of Medical Sciences (NUMS), Islamabad, Pakistan Mc Master University, Canada
A R T I C L E I N F O
A BS T RAC T
Keywords: Higher education Midwifery Bachelors Students Pakistan
Background: in 2012 the Aga Khan University in Karachi, Pakistan opened the country's first bachelor's degree program in midwifery for women who held diplomas in nursing and midwifery. The principal aims were to prepare midwives who would be competent to provide full-scope practice. For quality assurance, the programme was continuously monitored and assessed. As part of this ongoing evaluation process we sought in-depth feedback from the first graduates about their student experiences. Objective: this study aimed to explore the experiences of the first graduates of a Bachelor of Science in Midwifery (BScM) program to deepen our understanding of their views of the program's strengths and difficulties and to obtain their suggestions for change. Design and Methods: This qualitative descriptive exploratory study used universal sampling to collect data from all 21 of the first graduates of the BScM Program. Data collection involved focus group discussions using a semi structured interview guide and content analysis. The study was approved by Institutional Ethics Review Committee. Findings: three main themes emerged from the data: (1) Competence acquisition, (2) Attitude transformation, and (3) Strengths and limitations of the program. Conclusions: the study findings highlighted that the degree program in midwifery had a positive impact on graduates' perceptions of their knowledge, skills, attitudes and ability to implement evidence-based midwifery practice. The graduates regarded the university's environment, teaching-learning strategies, preceptorship model, self-directed learning and exposure to diverse clinical settings as major facilitators in achieving competence.
Introduction and background In 2012 the Aga Khan University in Karachi, Pakistan opened the country's first bachelor's degree programme in midwifery for women who held diplomas in nursing and midwifery (Jan et al., 2016). It is essential to continuously evaluate an educational programme to assess its relevance, performance, and success in achieving its goals. As part of this ongoing evaluation process, we sought in-depth feedback from the first graduates about their student experiences. Their perceptions are vital for assessing the programme's strengths and areas for improvement. This paper briefly sets forth background information relevant to
midwifery in Pakistan and goals of the new university programme since the context is important for understanding the graduates’ feedback. The Maternal Mortality Ratio (MMR) of Pakistan is 276/ 100,000 live births, a rate that remains high despite many interventions since the initiation of the Millennium Development Goals (NIPS - National Institute of Population Studies, Pakistan, Macro International Inc, 2008). The majority of these maternal deaths could be prevented by universal access to adequate reproductive health services. There is international consensus on the significant role of midwives in reducing maternal deaths. Current estimates are that, a 10% increase in skilled health workers leads to a 5% reduction in maternal deaths (UNFPA,
E-mail addresses:
[email protected] (A. Lakhani),
[email protected] (R. Jan),
[email protected] (M. Baig),
[email protected] (K. Mubeen),
[email protected] (S.A. Ali),
[email protected] (S. Shahid),
[email protected] (K. Kaufman). 1 The Aga Khan University, School of Nursing and Midwifery, Stadium Road Karachi, 74800 https://doi.org/10.1016/j.midw.2018.01.008 Received 16 August 2017; Received in revised form 28 November 2017; Accepted 12 January 2018 0266-6138/ © 2018 Elsevier Ltd. All rights reserved.
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were represented since the experiences could differ according to the province of origin.
ICM, and WHO, 2014). Hence, in order to improve perinatal outcomes, midwives needs to be educated, regulated and licensed (Renfrew et al., 2014). It is also endorsed by the WHO (2014), which states that, sufficient and competent health care providers specifically those with ‘midwife or other midwifery skills’ are essential without which all other strategies to reduce maternal, neonatal and child mortality will never be achieved. Prior to 2012 there were three pathways to obtaining a midwifery qualification in Pakistan: become a Lady Health Visitor (LHV), or a nurse-midwife or a community midwife (CMW). The LHV pathway is a two year diploma programme, in which one year is public health nursing and one year is midwifery. The nurse-midwife pathway is a one year diploma programme following a three year nursing diploma. The CMW pathway of 18 months was launched by the government of Pakistan in 2007 for the improvement of primary maternity services in communities. Studies have highlighted the shortcomings of midwifery education delivered through these diploma programmes (Rukanuddin et al., 2007; Sarfraz and Hamid, 2014). Most of the graduates successfully acquire the basic midwifery knowledge but due to limited clinical experience they do not acquire the necessary midwifery skills, hence, are unable to demonstrate confidence and competence in clinical practice (Sarfraz and Hamid, 2014).The midwives who work in a hospital setting are relegated to the role of the assisting doctor, and are unable to carry out the full scope of practice of a qualified midwife. Almost 90% of registered nurses are trained in midwifery but only a few actually practice midwifery (Rukanuddin et al., 2007). Lack of development of the midwifery profession, the limited scope of practice and lack of career opportunities have fostered lack of acceptance and invisibility of midwives in Pakistan and in the larger South Asian region. This leads many young women to prefer the field of nursing rather than midwifery (Saleem et al., 2015; Jan et al., 2016). These challenges highlighted the need to actively change midwifery education to ensure that it meets the education standards of the International Confederation of Midwives (ICM, 2013) and that the future workforce better meets the needs of the population. In our preceding article (Jan, et.al., 2016), the Bachelor's in midwifery programme is discussed in detail. The programme launched in 2012 after receiving feedback on the curriculum from the Education Committee of ICM. The ICM graciously agreed to review the document as it was the first undergraduate degree program for South Asia. This two year programme has a balance of 40% theory including midwifery, science and research courses and 60% clinical practice. Total 21 students were admitted in the first cohort, with a minimum of five from each province of Pakistan. The principal aims were to prepare midwives who would be competent to provide full-scope practice confidently and independently and who also would be clinical leaders in upgrading midwifery practice throughout the country (Jan et al., 2016). This strategy is aligned with the experiences of LMIC such as Burkina Faso, Cambodia, Indonesia, and Morocco, who have opted, for a rapid scale-up of their midwife workforce and deploy competent midwives (Van Lerberghe et al., 2014). Our purpose in exploring the student experiences of the first cohort of graduates from the BScM Programme in Karachi, Pakistan was to deepen our understanding of their views of the programme's strengths and difficulties and to obtain their suggestions for change. As the first participants of the programme their views are very important in the ongoing assessment of its quality.
Data collection procedure Two Focus Group Discussions (FGDs) (n = 10 and 11 respectively) were conducted in November 2014. Krueger and Casey (1994) defined a focus group study as ‘a carefully planned series of discussions designed to obtain perceptions on a defined area of interest in a permissive, non-threatening environment’. FGDs generate deeper and richer data through social interaction within the group as compared to individual interviews (Thomas et al., 1995). Group size was determined considering the suggested optimal group size for FGD 6–12 people (Tong et al., 2007; Polit and Beck, 2008). Researchers ensured equal representation of all provinces in each group. The interviews were conducted within one week of their graduation to avoid any recall bias among the participants. At this point students had not initiated their clinical work. In this way researchers controlled any contamination of their student experiences with their work experience. Two educators from the same university who were not involved in direct teaching of these students were trained by the researchers to moderate the FGDs. Researchers developed a discussion guide (Box 1) for the moderators to ask and probe questions to increase the comprehensiveness of data collection (Wong, 2008). Each FGD lasted 60 to 90 minutes. The interviews were conducted in English language and were recorded in a digital voice recorder and field notes were obtained by the note taker accompanying each educator during FGDs. Notes were compared to the transcripts during analysis to increase data validity. Data analysis Data analysis was done manually and simultaneously along with data collection. After both the FGDs, the members of the research team did immediate debriefing with the observer who helped the researcher in taking notes and observing the non-verbal behaviors. The research team made debriefing notes; which included comments about the process of FGDs and the significance of data and its relationship to the phenomenon of interest. Then, the audio recordings were listened and data were transcribed on a MS word document with a pseudo file names. Moreover, the audio taped content were checked with the observer notes to take care of the non-verbal cues and behaviors. This helped the research team to understand the verbal statements better when incorporated with the nonverbal communication and gestures. The transcripts were distributed among three researchers who independently analyzed the data using Graneheim and Lundman (2004) analysis approach, which has three levels of coding the focus group data. In level one, the research team thoroughly read the transcripts line by line to look for meaning units (statements) that addressed the phenomenon of interest. In level two, data was compared for similarities and differences and were then coded accordingly. Similar data were clustered together into categories and data with differences were categorized separately. In level three, the clustered Table 1 Example of three levels of coding of theme one.
Methods Study design and participants We used a qualitative descriptive exploratory design for this study of student experiences. All 21 graduates were invited and agreed to participate in the study. This full participation provided a true representation of the sample and ensured that the different provinces 95
Level 1 Meaning Unit
Level 2 Categories
Level 3 Theme
Variety of teaching-learning strategies Diverse learning styles Faculty-student relationships Constant guidance Hands-on practice Self-directed learning Clinical facilitation Clinical portfolio
Theoretical learning
Competence Acquisition
Clinical learning
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Guest speakers were very inspirational and helpful in our learning. We were exposed to a different world of midwifery and we were able to compare midwifery practices in other parts of the world with our practices. It gave us motivation to bring positive change and to adopt best midwifery practices for the benefit of women (Student 2).
data were given a theme that represented the meaning units and categories. After individualized analysis of the transcripts, the group met to develop consensus on the final categories and themes emerged from the data. The following table is an example of the three levels of coding of theme one.
Almost all the students were satisfied with the classroom teaching and stated that healthy faculty-student relationships and constant guidance by the faculty helped to achieve their learning objectives. As one of the students said, ‘Faculty members supported us 24/7 hours. They were very helpful; we were even comfortable to discuss family/personal issues with them, which were disturbing our studies.”(Student 4).
Ethical consideration The Ethical Review Committee (ERC) of the Aga Khan University granted approval for the study. The participants were informed about the purpose of the study and were provided full autonomy to make independent decisions regarding their participation in the study. Consent to participate in the study was obtained from the participants before FGDs. Anonymity of the participants was maintained by assigning codes to individual participants (Table 1).
Sub-theme: Clinical learning Majority of the students reported satisfaction with their clinical experience. They became competent and confident in their skills because they had opportunities for hands-on practice. Most of the students thought that achieving the number of competencies would be a big challenge but all students were able to meet the requirement of the clinical expectations. ‘Clinical gave me the dimension of thinking independently and being a self-directed learner. I am happy that I got the chance to conduct 40 deliveries independently, now I am able to apply all the learnt skills in my community competently” (Student 4). Students identified several facilitators that supported their clinical skills learning. For example, faculty facilitation during clinical time was seen to be the major factor in giving students confidence while performing skills. Similarly, using a clinical portfolio to record cases helped them evaluate their improvement of skills. In addition, having positive group dynamics in the clinical area was reported by many students to be a source of support and encouragement for acquiring the needed level of skills. As one student said,
Findings The majority of the participants (76.2%) were between 26–35 years of age; five (23.8%) were more than 35 years of age. Most of the participants (61.9%) were single and 85.7% had worked in government facilities (Table 2). Overall, three main themes emerged from the data that provided a conceptual framework for understanding the students’ experiences: (1) Competence acquisition, (2) Attitude transformation, and (3) Strengths and limitations of the programme. Fig. 1 shows the classifications of themes and subthemes. Theme 1: Competence acquisition Sub-theme: Theoretical learning Use of a variety of teaching-learning strategies in the classroom enhanced student learning and also helped meet the needs of students with diverse learning styles. One of the students elaborated, ‘In the classroom setting, the teacher brought all types of learners together by utilizing various strategies such as use of Problem Based Learnings (PBL), demonstrations, presentations, small group discussions and activities, stories and case studies that were really helpful” (Student 8). Another student added, ‘With interesting teaching -learning strategies we were even happy to take full day workshops without feeling bored and losing interest” (Student 17). Students also said that national and international guest speakers helped expose them to different dimensions of midwifery and helped them relate to international trends and perspectives in midwifery practice.
Sometimes I became exhausted from continuously hunting for the opportunities to accomplish the desired numbers and I tended to sit back. But then, I found someone standing behind me and persuading me to get up and move. This support from faculty and peers enabled me to keep going and at last I succeeded. (Student 10).
Themes and Subthemes
Competence Acquisition
Attitude Transformation
Strengths and Limitations of the Program
Table 2 Demographic characteristics of participants. Total (N = 21) Characteristics Age 26–30 31–35 > 35 Marital status Single Married Province Sindh Punjab Baluchistan KPK Kabul Job status Government Employee Private Employee
n
%
89 8 5
38.1 38.1 23.8
13 8
61.9 38.1
5 4 6 5 1
23.8 19.0 28.6 23.8 4.8
18 3
85.7 14.3
Theoretical learning
Personal and professional development
Clinical sites and supervision
Clinical learning
Image of midwife
Curriculum content
Academic Environment and other related activities
Feedback and evaluation Fig. 1. Classification of Themes and Subthemes.
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helpful in achieving midwifery competencies. Most of the students found the clinical experience at Gilgit Baltistan2 Aga Khan Health Service, Pakistan best enabled them to become competent and confident in their skills because there was opportunity for hands on practice in a midwifery led model of care with competent midwives and LHVs.
Students also reported challenges. Some found that long hours e.g. with a woman in labour, were very challenging. They faced difficulty in managing assignments although simultaneously meeting the expectations of clinical practice. ‘We were upset with the clinical hours and it was difficult to manage clinical hours and assignments side by side. Though it was very challenging, we enjoyed the clinical”. (Student 15). Some students noted that working with physicians in clinical sites was the biggest challenge. Initially, obstetricians and other postgraduate medical doctors did not accept the students in labour rooms and did not give them a chance to learn and perform skills independently. All the students said that it would be helpful if obstetricians were flexible and would support students in their learning process.
Gilgit is the best site for midwifery students; it gave us an excellent opportunity to practice so all the students must get chance to visit Gilgit because we were able to observe and practice in an ideal midwifery led model of care and learned the concepts of normality during childbirth. (Student 11). All students found the clinical teachers (LHVs and senior midwives) to be very cooperative, well organized and supportive of having students focus on areas that met their learning needs. Using a preceptorship model proved to be very effective; students reported satisfaction with preceptors and found them very helpful. As one of the student reported, ‘Clinical preceptors were very helpful for us, they were there with us all the time and they helped us to adjust in the challenging clinical environment” (Student 9). Another student said, ‘Clinical preceptors gave us new learning and should be continued. We were able to focus on our learning objectives because of 1:1 preceptorship.” (Student 13).
Some doctors really gave us a hard time; they were not ready to accept our role as a midwife but they expected us to be their assistant. But, gradually when they observed us working and being involved in the care of women they gained an understanding of our roles. (Student 18). Theme 2: Attitude transformation Sub-theme: Personal and professional development The findings revealed that the BScM programme helped students grow personally and professionally in various ways such as improving communication skills, being an advocate, being a reflective and selfdirected learner, applying evidence-based knowledge to their practice, developing information technology skills, acquiring knowledge of gender issues and learning to be a mentor. As one of the student expressed,
Sub-theme: Curriculum content Almost all the students were satisfied with the courses included the curriculum. However, a few students suggested the inclusion of theoretical content about leadership and management and teaching and learning.
We are taught ways to become independent learners. Now we know sufficient ways to access learning resources and move forward.” (Student 5). Another student said, ‘Now I know how to reflect; reflection will help me in lifelong learning as once we reflect it remains in our mind. (Student 11).
I felt that leadership management theory was too short and we never did clinical in this course. Like other midwifery subjects it should be taught as a course so that we can understand leadership concepts in detail and apply them when we go back. (Student 8). The faculty provided a four-week enrichment programme (preparatory programme) prior to the first semester for students who were not able to meet the cutoff score of the entry test, however met the criteria for the enrichment programme. The preparatory weeks helped them with Basic English computer skills, and basic midwifery knowledge. Those who were included found it very helpful and thought it should be the part of programme for all students. In terms of the distribution of theory and clinical time, most students felt that there should be a better balance between theory and clinical hours because they found theory time very short in comparison to the required clinical experience. Some thought there should be better timing of assignments to coincide with theory weeks and avoid clustering of deadlines. Apart from midwifery courses, the students said that English instruction was very important and helpful as it was their weakest area. In fact they suggested that the time allotted to this subject should be increased. ‘We feel English content was good and more time should be allotted to this subject.” (Student 9).
Increased confidence was identified as the major personal accomplishment by a majority of students. Previously they were very passive and their role in their practice setting was to follow doctors’ orders. Now they feel empowered to speak up. “Before I joined this programme I would say ‘yes sir… yes sir’ but now I feel confident to question the obsolete practices and examine the situation on the basis of evidencebased knowledge.” (Student 2). Sub-theme: Image of midwife Most of the students said that people in the community refer to a midwife as ‘Dai,” meaning traditional birth attendant. Even in the Urdu language dictionary the meaning of midwife is Dai. After completing this programme they were able to easily distinguish themselves from Dai in the community, based on their knowledge and skills. This programme helped them understand ‘who is a midwife’ and what is their scope of work. All the students felt proud to be a midwife and felt blessed to be in this profession. Some students said they understand now the role of different health care providers in the community, such as Lady Health Visitors, Lady Health Workers and Dais, and this knowledge will help them to work collaboratively with others. As one student said, “My overall role in the community, my knowledge and skills will prove itself that I am a Midwife and not a Dai” (Student 9). Another student proudly said, “Before coming in to this programme I felt very embarrassed when someone called me midwife. I used to report my identity as Nurse. But now when I go back I will proudly say that I am a Midwife.”(Student 18).
Sub-theme: Academic environment and other related activities
Theme 3: Strengths and limitations of the programme
Almost all the students were satisfied with the environment of the school and the hostel where they were housed. The university environment provided all the resources required by the students for their learning. The shared housing provided access to mutual support at all times. Work and study groups could easily form and this also facilitated their learning.
Sub-theme: Clinical sites and supervision The majority of the students felt that exposure to various clinical sites including primary, secondary, tertiary, rural and urban settings was very
2 Gilgit-Baltistan (GB) is highly mountainous region and a remote area with extremely cold weather where people live at great distances in small villages with limited resources (http://www.dostpakistan.pk/brief-history-of-gilgit-baltistan/)
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competence in all aspects of midwifery care as set out by ICM (2013). As described by Carolan-Olah and Kruger (2014), hands-on practice time was essential to gaining both competence and confidence in performing skills independently. The presence of faculty within the clinical site contributed to building confidence, especially when students encountered resistance from obstetricians. To attain clinical competencies a trio clinical model was implemented. In this model, the three key stakeholders were faculty, preceptor and student. The clinical precpetors who were mainly expert midwives and in some cases obstetrician were assigned with the students in 1:1 ratio. The faculty members were ovearall responsible for clinical learning of the student. The preceptors were selected based on their experience of providing midwifery services to women and children, teaching learning and supervision skills, positive role modeling, leadership and interpersonal skills, and evidenced based practice. The role of preceptors was critical to students’ achieving competence. Kaufman et al. (2007), Licqurish et al. (2013), Watkins (2013) and Sidebotham et al. (2015), all noted that healthy relationships between preceptors and students were essential for positive clinical experiences and developing clinical expertise. Moreover, having midwife preceptors who themselves were competent to function as independent practitioners was crucial. Students were more easily able to provide continuity of care (pregnancy to intrapartum to postpartum care) in these primary care settings where there was no continuous medical presence. This reality creates for us a clear agenda to expand and nurture such placements. Building in opportunities to engage in reflective learning through activities such as post-clinical discussion and journaling also contributed to building confidence because students could ‘see” evidence of their own progress. We think the careful attention to building confidence and allotting more than half of the overall curriculum to opportunities for hands-on time led directly to graduates’ perceptions by the end of the programme that they were competent in performing clinical skills. That they found the experience tiring and stressful at times and found it difficult to balance hours of clinical work with assignment demands is not surprising (Jan et al., 2016). Faculty support was crucial in managing student stress, e.g. listening carefully to difficulties, providing encouragement, modifying deadlines and work load as possible. The lessons learned continue to be incorporated into ongoing changes within course expectations. The difficulties that students experienced in working with physicians may result from the low status generally of midwives and the unfamiliarity of physicians with the high level of competence expected of these midwifery degree students. Licqurish et al. (2013) in Australia identified also that medical dominance is a barrier to midwifery practice including inter-professional rivalries and poor understanding of the midwifery care (ten Hoope-Bender et al., 2014). We know that improving inter-professional relationships within clinical settings requires ongoing dialogue and reshaping of attitudes, and we hope that greater exposure to the rigor of the programme and the contributions that skilled midwives can make to women and infants’ health will facilitate improved relationships. Equally important to the graduates’ perceptions of clinical competence was their development of a new professional identity. Seibold (2005) found also that students learned not just theory and skills but developed professional attributes that increased even further their confidence. Students over time developed a clear image of a midwife as an expert in normal birth as was identified also by Sidebotham et al. (2015). Our graduates took pride in identifying themselves as midwives and reported gaining strength to challenge non-evidence based practices. They also better understood the roles of other health care providers. This outcome may facilitate future collaboration in the provision of care to women (Rogers, 2010). The graduates’ feedback was helpful in identifying possible changes to the curriculum. There were strong suggestions to include more content about leadership and management and more theory about the
Working in a diverse group gave us rich experience. Living in a hostel was very helpful and problems were solved in no time and we supported each other. We got lots of support from the registrar's office (Student 19). Students said they shared social celebrations and went for outings as well. The limitation, however, was that extracurricular activities were within their own group and students were less involved in other activities within the university due to their heavy clinical workload in diverse settings. One of the students verbalized, ‘We did several daytrips but we were rarely introduced to other student life activities and we felt isolated from other academic programmes.” (Student 14). Sub-theme: Feedback and evaluation For the theoretical work, most of the students felt that they needed more feedback on their assignments. They preferred to get detailed and individualized feedback. Students were satisfied with the evaluation criteria but suggested that guidelines for assignments should be more comprehensive. Students also mentioned inconsistent marking across different instructors. The students suggested that the faculty member who provides direction about an assignment should evaluate that assignment to promote consistent marking. Teacher (A) and Teacher (B) had different expectations so we faced problems when one teacher briefed us about the assignment guidelines but the assignment was checked and marked by another teacher. Constant faculty for a group of student in terms of guidance and grading is suggested (Students 7). One of the students stated that including various subjects and using a variety of teaching-learning and evaluation strategies is a strength of the programme. It facilitated student learning and helped develop their weakest areas like computer skills, English language, writing skills, and reflective learning. Discussion Evaluating a new academic programme is a multifaceted activity of which the views of students/graduates are one component. The feedback elicited from the first graduates is helpful and can be used to make continuous quality improvements in the BScM programme for midwives. It was not surprising to us that these mature students needed and valued a high level of support to assist them in meeting programme objectives. The transition from working as a health care provider to being a student who is learning new knowledge, skills and a new identity is not easily accomplished. The students were undertaking studies in an academic environment they had not previously experienced and most were away from home and family, living in communal residence. The students’ need for support and a favorable learning environment is consistent with Carolan-Olah and Kruger (2014) who identified that the support of educators made a significant impact and assisted students through their course of study. Peers were also an essential support system that provided strength to each other to meet programme expectations. Rogers (2010) similarly identified socialization and support as an important aspect of the learning experience. A participant in Sidebotham et al. (2015) study described peer support as a ‘sense of being rescued when struggling’. We had designed our teaching approach to incorporate many principles of adult learning (Knowles, 1973). Because the students could include their previous experience and knowledge in learning new concepts, they engaged more readily in interactive activities and discussions. Reports of evaluations of other midwifery programmes also note the importance of participatory teaching approaches (Kaufman et al., 2007; Rogers, 2010; Carolan-Olah and Kruger, 2014). A major emphasis of the programme was the acquisition of clinical 98
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Clinical trial registry and registration number (if applicable)
teaching-learning process. Many of the graduates will be moving to employment positions that will demand knowledge of these areas. This feedback differs from findings of Carolan-Olahand and Kruger (2014) where students suggested more practical experience rather than theory. We think the gaps in theory in diploma level programmes in Pakistan leads to this need to strengthen the theoretical base in bachelor's degree programmes (Sarfraz and Hamid, 2014).
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Conclusions and recommendations We conclude that, while much support was needed, the graduates completed the programme successfully and perceived themselves to be clinically competent and to have developed a much more positive personal professional identity. They were able to overcome the challenges of becoming a university student and of facing resistance to their new roles. They learned to take pride in identifying themselves as midwives and thought they were equipped to bring positive change to their future places of work. We gained added insight into aspects of the programme that will benefit from modification, such as expanding the enrichment programme prior to the outset of actual enrollment, introducing more theory relevant to leadership and teaching, articulating more clearly assignment grading criteria, and adjusting deadlines to take account of conflicting responsibilities. Very importantly, we learned about the central place of preceptors in a programme such as ours. We need to invest more time and effort in developing preceptor training, mentoring new preceptors and providing access to resources tailored to their needs. Our faculty members will continue to reach out to clinical leaders in departments that provide maternal and infant care to promote collaboration, inform others of the educational goals of the programme and demonstrate our own commitment to being competent practitioners. Systems for quality improvement must be integrated into programme development and implementation activities through detailed curriculum review, assessment of our teachers and teaching methods, and our use of resources to ensure we meet evolving international and national standards as recommended by ICM for midwifery programmes. The views of our graduates are a valuable contribution to our ongoing assessment of this new programme. Future follow-up of graduates will also be a source of added information about programme quality. We hope what we have learned from our graduates will be useful to other universities within Pakistan or other countries who are contemplating offering similar programmes. Acknowledgements The authors would like to thank Ms. Laila Lalji and Ms. Rozina Sewani for their assistance in the data collection process. We also thank all the graduates for their voluntary participation in the study. Conflict of interest The authors declared no conflicts of interest with respect to the research, authorship, or publication of this article. Ethical approval Ethical review committee of Aga Khan University Karachi, Pakistan. ERC# 3321-SON-ERC-14, approval received on 26th November 2014. Funding sources Not applicable.
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