The Construction of Midwifery Professional Identity through Integration Situations: Daily Experience and Expectations of Midwifery Trainee Learners ()
1. Introduction
Every profession is defined by knowledge and a field of expertise, but also by belonging to a social group associated with certain privileges, a status and a specific organization, which allows the group to self-regulate. Thus, midwives are given a professional identity on the one hand by the institutions that train and employ them but also by the professional and lay people with whom they interact [1].
The development of both prenatal and postnatal care services and nursing techniques during and after childbirth has resulted in expanding the scope of midwifery activity. Like all health professionals, midwives receive solid medical-technical training, which they put into practice on a daily basis. This allows them to work in a multidisciplinary team in which they must maintain their autonomy and identify with their field of practice [2] [3]. It should nevertheless be noted that the loss of professional identity is dependent on the midwife’s lack of commitment to the exercise of her practice, which generates frustration and stress that can negatively influence the quality of sexual and reproductive health care [4].
However, for the midwife learner in training, integration situations can contribute to the acquisition of this identity. For the purposes of integrating learners’ acquired knowledge, or for assessment purposes, integration situations are developed in the initial training of midwives. This teaching method allows training as close as possible to reality, while respecting the rule “Never the first time on the patient”. Learners can thus test their knowledge, practice technical gestures, integrate decision-making and be active in an emergency situation, and in complete safety [4]. For the learner, this identity is built through contact with peers and colleagues during integration situations organized by the school. However, the observation that during the internship, these learners find themselves in front of their peers and other health professionals from various disciplines who work for the well-being of women. However, they remain perplexed and confronted with a reality other than that learned during the simulation workshops at school [5].
Unfortunately, field trainers do not understand what we really are, some acts of other professionals are attributed to us and the midwifery practice care model is limited to care administered in the maternity ward; no support or follow-up once the woman returns home.
During exploratory interviews with some perinatal professionals in health training, some of these specialists believe that midwifery trainees do not understand the boundaries of their profession, they are assimilated to nurses who are for the most part their field supervisors. This position often leaves them perplexed when providing midwifery care. Some midwifery learners we met think that the integration situations that prepare them for the profession are designed in a biomedical model and do not meet the holistic model of midwifery care.
Indeed, the “Never the first time on the patient” approach underlies a questioning of the acquisition of the midwife’s identity during integration situations. This motivates us to conduct a study in order to understand the experience and expectations of midwifery trainee learners on integration situations for the process of building their professional identity, with a view to contributing to the development of the midwifery profession, one of the pillars in reducing maternal and infant mortality.
The construction of the professional identity of midwifery learners through integration situations is a little-developed subject in midwifery research and projects in the Democratic Republic of Congo. Therefore, understanding the experience of learners on their construction of professional identity through integration situations requires our attention and deserves to be undertaken, with a view to establishing autonomy and leadership in the development of midwifery practice.
In this approach, we intend to identify the daily experiences and expectations of midwifery trainee learners in the final year of high school on the process of construction of professional identity through integration situations, in order to propose strategies to properly construct their professional identity without identity tensions.
2. Material and Method
2.1. Presentation of the Study Environment
This study is carried out at the midwifery section of the higher institute of medical techniques of Kinshasa (ISTM Kinshasa). Located in the commune of Mont Ngafula, city of Kinshasa in the Democratic Republic of Congo.
2.2. Target Population, Sampling and Sample
The target population of this study is made up of midwifery students at ISTM-Kinshasa. To carry out the study, it used the theoretical non-probabilistic sampling technique gradually constituted by saturation or redundancy. The participants were selected according to the following criteria: being a midwifery learner in the final classes who had experienced integration situations before the internship; being on internship during the period of our study and voluntarily and voluntarily agreeing to participate in the study.
2.3. Data Collection Method, Technique and Instrument
To collect data relating to the objectives of our study, the study used the grounded theory survey method and the respondents were contacted individually using the semi-structured interview technique. In addition, the triangulation of data collection techniques, namely: face-to-face interviews and documentary research, was used to minimize the lack of validity of the results in qualitative research.
In a major concern to support the interview and avoid the scattering of data that could result, a semi-structured face-to-face interview guide was constructed and implemented. This instrument guided our interview given to midwife trainee students in the final class who had experienced integration activities before the internship.
The questions that constitute our semi-structured interview guide were developed based on our objectives, our initial questions and the prior study of the literature.
This instrument made it possible to collect information on the daily experience and expectations of final-year student trainees on the contribution of integration situations to the construction of midwifery identity. This instrument contains open-ended questions to avoid yes or no answers.
2.4. Processing Plan and Data Analysis
The data is analyzed according to a systematic approach, called phenomenological reduction, which aims to bring out the hidden meanings inherent in the descriptions that the subjects of the investigation made of the phenomenon studied which is the process of constructing the professional identity of the trainee learners. In midwifery of final classes during integration activities. The following procedure was followed: Listen to the entire audio cassette; Attempt to describe the highlights of the interview; List the keywords or key expressions; Define general expression; Transcribe the interviews in verbatim form to develop a “feel”; Identify the data under the statements and expressions that relate to it; Eliminate repetitions of statements and formulate themes and sub-themes; Delineate all meanings into a central theme; Analyze the central theme according to the specific objectives of the research; Configure the results of the literature review into the theoretical elements.
2.5. Ethical Considerations
The first step when contacting the subjects was to request their free and informed consent while respecting their right to refuse or participate in our investigation. To ensure the confidentiality of their comments collected during the transcription of the interviews, the identity of each subject was not revealed, to guarantee anonymity. We further reassured them that the recording dictaphone is only necessary for the study and that it will be destroyed shortly after the transcription of the interviews and the analysis of the data.
3. Results
3.1. Sociodemographic Characteristics
Sociodemographic data of our sample are presented as follows: One respondent is male. The majority of them had no previous profession, i.e. 5/9. Age varies between 23 and 51 years, with an average of 30 years. Concerning their previous studies, the biochemistry and commercial management sectors were each attended by 3 of our respondents. Only two studied medical humanities and one of them general education. All our respondents are assigned to level one to three maternity wards. (See Table 1)
Table 1. Distribution of study subjects according to their profile.
| Student |
Sex |
Age
(year) |
Previous study |
Previous occupation |
Stage site |
| And1 |
Feminine |
24 |
Commercial |
None |
LISUNGI Maternity |
| And2 |
Feminine |
24 |
Pedagogical |
None |
LISUNGI Maternity |
| Et3 |
Feminine |
23 |
Commercial |
None |
ETONGA Maternity |
| And4 |
Feminine |
23 |
Biochemistry |
None |
Saint CRISTELLE Maternity |
| Et5 |
Feminine |
42 |
Commercial |
Shopkeeper |
Saint CRISTELLE Maternity |
| Et6 |
Feminine |
29 |
Medical |
Nurse A2 |
Maternity ETONGA |
| Et7 |
Feminine |
26 |
Biochemistry |
Saleswoman |
BONDEKO Maternity |
| Et8 |
Feminine |
30 |
Biochemistry |
None |
Maternity REVOLUTION |
| Et9 |
Male |
51 |
Medical |
Nurse A2 |
Saint Joseph Maternity |
3.2. Results on Study Themes
By analyzing the data from our study, a central theme emerged, namely: Daily experience and expectations on integration situations for the construction of midwife identity. From this central theme, five essential themes emerged with their subthemes, including:
Theme 1: Motivation for the profession
The choice of profession;
The image of the midwifery profession before entering the first degree;
The meaning of practice on mannequin;
The meaning of presentation file in training.
Theme 2: Differentiation from other health professionals
Woman-centered care while respecting human rights;
Respect for midwifery scope of practice;
Active participation in the work team.
Theme 3: The perception and representation of midwife identity
Theme 4: The formation of midwife identity
The experience professional;
The feeling of performing midwifery actions;
The desire to remain a midwife;
Appreciation of integration situations.
Theme 5: The expectations of midwifery trainee learners
These themes and sub-themes identified several categories which we summarize in the following lines:
Interest in the profession;
Financial constraints;
Midwifery profession;
Discipline for women’s health;
Acquisition of midwifery skills;
Preparation for practicing the profession;
Positive self-image;
Responsibility;
Woman-centered care while respecting human rights;
Respect for midwifery scope of practice;
Active participation in the work team;
Midwifery simulation;
Reflective feedback session on field practices;
Positive self-image;
Remain a professional midwife;
Positive experience in integration situations regarding the midwifery profession;
Negative experience of integration situations regarding the midwifery profession;
Addition of credits to integration situations;
Protection of the profession.
Theme 1: Motivation for the profession
1) Reason for undertaking midwifery studies:
As a personal interest in the profession, midwifery students explain that the reason which pushes them to study midwifery is to Save human lives. Some of them can be explained: Et1 (…) it’s to save the lives of women and then the lives of children Et4 (…) To save the lives of mothers who come to give birth and their babies Et9 (…) so I came to save human lives
The students explain that the midwives’ sense of professionalism pushes students to feel the desire to become a midwife. This is what they say: Et8 Since I was too little I loved being a midwife or midwife. And2 It was always my ambition when I saw midwives in hospitals saving women and children, (…) And6 I only like midwives (…). The relationship that midwives build with women encourages students to study midwifery. A student says: Et5 (…) when I gave birth to my first daughter, I was touched by what the midwives had done to me. They took me as I was their sister, they did a lot of good things to me (…). In addition to other motivations such as lack of financial means, interest in gyneco-obstetrics and the short duration of studies push students to study midwifery. This student declares: Et7: “ (…) Since I did not have enough means for medicine, I chose midwife which also refers to obstetrics and gynecology and the studies are for three years (…)”
2) Image of the midwifery profession before entering the first license
The students interviewed explain that for them, the midwife is a presentable and courteous person, charitable, a hard worker, a person who has learned and has knowledge about women’s illnesses. They say them in these stories: Et2 (…) I liked their outfit. (…) Et6 (…) the way of being a midwife… Et8 Their way of being, very kind and welcoming… Et2 (…) then the love that midwives show towards women (…) Et4 A person who helps mothers, who accompanies them during pregnancy, during childbirth and after delivery Et5 When I saw the profession of midwives, (…) you have to have pity to take charge of someone, it you have to have a big heart… And3 For me, midwives work well (…) And1 It’s only childbirth, (…) And7 (…) I came to learn how to become a midwife. (…) to have knowledge about women and their problems. Et9 (…) to come and really learn how to save the human lives that come into the world and those that give life.
3) Place of practice on a mannequin in training
Practice on a mannequin is preparation for clinical situations, it provides manual skills to students. Explain three students: Et7 (…) the fact of manipulating also allows you to stay with something. It allows us to be put in the clinic, you feel that you are in the hospital (…). Et8 Before going to the training site you had already learned how to manage childbirth (…) so in the field you would not have any problems… Et9 We learn how to manage childbirth.
4) Place of presentation file in training
Reflective feedback sessions on practices experienced in the field provide students with communication skills, a foretaste of defending research work and improve skills. Two students speak: Et1- Et8 (…) it helped us practice the profession of midwife.
And7 (…) it helped us resolve difficult cases in the maternity ward. (…)
Theme 2: Differentiation from other health professionals
Midwifery practice through integration situations prepares learners for woman-centered care while respecting human rights: The midwife gives the woman the opportunity to develop her power and make decisions; The midwife provides humanized care to the woman; respect for the midwife’s field of practice: The midwife does what is within her scope of practice (the midwifery learner learns to distinguish herself from other perinatal health professionals).
The midwife collaborates with other health professionals for professional recognition in the care of women. The midwife makes her contribution to the interdisciplinary team.
Theme 3: The perception and representation of midwife identity
Midwifery learners see midwifery as a great responsibility that requires skills to care for women and their children. Some express themselves: And1 (…) when we talk about midwives we can think of how there is a little thing like that. Being a midwife means being a great person, not in relation to the means (…) Et2 (…) taking action (…) Et3 I see myself capable of helping women give birth and take care of their baby Et4 I am thinking of a person who saves lives (…) And7 (…) to be competent with the profession… And8 (…) to take care of a woman… And6 For the best care of the parturient… And5 (…) it is to firstly the desire to first love what you want to do (…) And9 it’s my job that I want to do until the end.
Theme 4: The formation of midwife identity
In their professional experiences during the training, the learners note the contribution of the SONU workshop to adaptation during the internship: The SONU workshop is a reference during the internship, a complement to theoretical training, and it allowed students to acquire midwifery skills. Here are some testimonials: Et3 Something was added to the training, we added what we didn’t see in the course... Et5 In any case it strengthened me a lot, giving intelligence, encouraging in the work of the midwife… And7 (…) It was at that moment that I felt like a midwife. (…) Et9 From what we have seen, we are capable.
In their assessment of integration situations, they note the positive experience of integration situations regarding the midwifery profession: The learner is supported by field supervisors on what she learned at school and Integration situations allow students to identify and resolve problem situations in the field of midwifery practice.
Learners also find in integration situations preparation for practicing the profession of midwife. And9 Moreover when you are there in the field there will not be enough problems because you know directly from the study bench (…) What we have already done in the workshops what we practice in hospital level. But also, they raised a negative experience regarding integration situations regarding the midwifery profession. Integration situations still do not meet learners’ expectations.
Theme 5: The expectations of midwifery trainee learners
Faced with integration situations, learners suggest that midwifery practice should only be reserved for professional midwives; they plead for the addition of credits to integration situations.
4. Discussion
4.1. Socio-Demographic Characteristics of Respondents
It appears from Table 1 that the majority of respondents are around twenty years old and four of them worked before undertaking midwifery studies; three of the respondents studied business humanities and three others studied biology-chemistry humanities; two respondents studied medical humanities; one respondent followed the general pedagogy. According to a survey carried out in France by Schweyer (1996), before entering school, the level of training of three-quarters (75.7%) of future midwives is that of the baccalaureate (minimum level required since 1983). The most represented baccalaureates belong to the scientific series (62%), then the literary series (17.4%) [1]. For (Toulet, 2016), when a student begins their training, they already have a personal identity that they have built throughout their life and which will continue to evolve over time. This unique person changes status to become a student, he builds his professional identity through professionalization, the acquisition of skills and through a reflective attitude with the help of his peers [6].
4.2. Motivation for the Profession
The reason learners choose to study midwifery relates to their personal interest in the profession and financial constraints. Learners choose midwifery studies for their personal interest in reducing maternal and neonatal mortality, midwives’ sense of professionalism. Some choose because of the few means they have to finance medical studies and the short duration of training.
For Lateyrie (2013), upon entering midwifery school, each student has the feeling of having oriented themselves either by default or by choice, with regard to the values that drive them. But these values, which were a source of motivation when entering midwifery school, evolve during the studies and as the state diploma approaches [7].
Thus, midwifery learners build their professional identity in stages, thanks to the knowledge and experience they acquire in classes and internships, and thanks to their growing maturity. The midwife’s know-how, expressed through good relationships with her clients, pushes certain learners to study midwifery. Et5 states: “(…) when I gave birth to my first daughter, I was touched by what the midwives had done to me. They took me as I was their sister, they did a lot of things to me (…)”
Knowledge of the midwifery profession before entering the first license is one of the elements of the process of building professional identity.
Before beginning their studies, midwifery learners have an image of the profession. For some, the midwife is in their eyes a presentable person, courteous, charitable and a hard worker. While for others, she is a knowledge holder (a person who has learned and has knowledge) about women’s illnesses.
In a study on the motivation of midwifery students, Claire ROUX, cited by Tiffany Vallet, 2018) specifies that: “few students knew the profession of midwife before entering the sector”. In addition, students choose this path mainly for the relational side and the medical nature of the profession. The professional autonomy and responsibilities assigned to midwives also attract students [4].
Practice on a mannequin and the presentation file are part of the integration situations developed in midwifery training. One comes before the internship and the other after. Several meanings are attributed to practice on a mannequin and to the presentation file. The practice on a mannequin is according to the midwifery trainee learners: the simulation material for learning, the practical application of theoretical courses, preparation for clinical situations, gives manual skills to the students.
For Okuda et al. (2009), “Health simulation is an educational method which brings together a reproduction of the characteristics of the reality of a situation or a healthcare environment” [8]. This reconstruction allows contextualized learning: it allows students (…) the integrated learning of technical skills (gestures, decision-making algorithms), but also non-technical skills (organizational, human and material resource management).
The presentation file means for final year midwifery trainee learners: a foretaste of a defense of research work, facilitates communication skills, and constitutes reflective practice for the improvement of skills.
For Toulet (2016), work-study training therefore allows the tutor to put the trainee in a reflective position by using their theoretical knowledge and the reality on the ground. These two processes allow the nursing student to become professional. This stage will also allow him to become responsible, autonomous and to achieve the construction of his professional identity [9].
Finally, if no reflection is carried out on action, the development of skills can remain on the side of doing and know-how (execution of professional gestures) without ever becoming know-how to act (reflective practice), without ever borrowing the paths to professionalization [8].
4.3. Differentiation from Other Health Professionals
Differentiation from other health professionals is the central element in the construction of the professional identity of midwifery trainee learners in final year classes. This is established through care centered on the woman while respecting her rights, respect for the field of midwifery practice as well as active participation in the work team.
Midwifery trainee trainees in final year classes distinguish themselves from other perinatal professionals through their support, a period during which they give the woman the opportunity to develop her power and make informed decisions. During this support, the midwife provides humanized care to the woman.
For Lateyrie (2013), support is one of the strong values of the profession. It is the center of midwifery activity and practice [6]. So, the midwife allows women to be actors in their pregnancy. They are there to help them, to comfort them in their choices and not to decide for them.
Midwifery trainees in final-year classes only do what is within their scope of practice. This skill is acquired during initial training. For Lateyrie [6]. Apprenticeship in midwifery school helps future midwives to develop clinical awareness, to become responsible for the medical monitoring of their patients, while developing appropriate procedures. However, Coralie Fregonese (2016) finds that midwife autonomy is relative, because the necessary transfer of patients to doctors from the moment the situation encountered exceeds their skills in the field of physiology [10].
Let us note with Schweyer that the code of ethics of midwives does not allow the activities of midwives to be defined, but only the limits within which they can be found. During integration situations, in particular the Clinical internship, some learners find themselves overflowing with actions.
Schweyer states that: “the weakening of the profession could also come from the blurring of its public image and from a competence of midwives not clearly established, limited rather than specific” [1].
The professional integration of midwives into a healthcare team causes conflicts because of the emergence of the midwifery profession. The midwife, by distinguishing herself from other professionals, sees her field of practice restricted. For Coralie Fregonese (2016), the increasingly important place of technical and medical work and the non-recognition of the relational aspect claimed as specific to the profession restricts the field of midwifery practice [10].
Interactions between final-year midwifery trainees and their field supervisors are based on their professional recognition in decision-making in the multidisciplinary team. This could be explained by the fact that professional identity is not a simple attribution but also a confrontation between demands and offers of possible identities. Dubar (2010) speaks of identity negotiation, redefinition of criteria but also of the conditions of identities and skills associated with identities [11].
For Lyanna Després (2016), the presence of recognition stimulates and promotes professional identity while the lack of recognition threatens it [12]. Goffman (1975, cited by Natalie Beaudry, 2011), highlights that work relationships are the place where the need for recognition is expressed, where the act of belonging is affirmed [10].
4.4. The Perception and Representation of Midwife Identity
The professional identity of final year midwifery trainee learners is constructed by the perception these learners have of the midwifery profession and the representation they have of midwifery identity during integration situations. Midwifery learners perceive integration situations as preparation for the practice of their future profession and they see professional identity as being a heavy responsibility for midwives.
This combines with the purpose of integration situations to prepare the learner to face the practical/professional field. Furthermore, for Tiffany [4], the profession of midwife is not limited to the simple representation of the “midwife”. In reality, it is all the aspects that make up the profession, the extent of responsibilities as well as the skills that allow students to identify with the profession.
4.5. Formation of Midwife Identity
Midwifery trainee learners in final year classes form their professional identity based on their professional experience, the feeling they have about performing midwifery acts, their desire to remain a midwife and their assessment of situations. integration which helps them in this process.
During the course, learners mobilize resources by referring to the EmONC workshop which constitutes their assortment. For Okuda et al. (2009), Simulation complements knowledge and skills through performance. This transfer of learning corresponds to the ability of learners to apply knowledge, know-how and attitudes in situations different from those in which they were learned [8]. An awareness of the construction of experience appears necessary to understand the professional knowledge invested in the action and allow its conscious use. It is therefore in this process that the individual becomes professional and develops his experience beyond developing skills [10].
The final year midwifery trainee only recognizes himself as a professional when he feels capable or competent to perform midwifery acts or gestures in his future profession. This position allows him to build a positive self-image during integration situations. Which ties in with the definition of professional identity as a personal satisfaction which is not nourished by the gaze of others but by the pride of belonging to a unit, the pride of participating in the realization of a project, the pride in advancing one’s skills and therefore one’s status and pride in asserting oneself [13].
The quote from Marchal and Psiuk (2010) illustrates this feeling: “In trust, the nurse will find the basic elements for constructing their professional identity […] an already structured personal identity gives self-confidence which is a path takeoff for the development of professional identity” [14]. Finally, for Tiffany Villet (2018): “Having an identity or acquiring it is being able to be recognized for your competence and therefore to hold your place in an organization”.
Remaining a professional midwife is a desire expressed by all of our respondents. The midwife’s skill set is also reasons that motivate students to become midwives.
Integration situations allow students to identify and resolve problem situations in the field of midwifery while being supported by field supervisors on what they learned at school. However, some learners think that the organization of integration situations does not allow them to acquire relational skills. The activities have more of an exam character and the teachers are running behind time. Dubois et al. (2017), confirm that the simulation device is mainly used as an evaluation tool, in the logic of training in technical gestures [15].
4.6. Expectations of Midwifery Trainee Learners
Midwifery trainee learners in final year classes want midwifery practice to be reserved for professional midwives only. In the Democratic Republic of Congo, the midwife is under the responsibility of director of nursing in all hospitals and the Ministry of Public Health, Hygiene and Sanitation assimilates them into the category of paramedics.
The time load reserved for integration situations does not allow the learner to master certain sequences of the workshop. Which pushes him to request the addition of credits to integration situations. This goes against Okuda et al., who say that the simulation is aimed at novices, it is centered on a theme with simple and unique clinical cases to develop [8].
4.7. Limitation of the Study
Apart from the main criticisms expressed with regard to the qualitative approach including: (small size and non-representativeness of the sample, lack of reliability and validity of the methods), the present study has a certain number of limitations with regard to the results found as can be seen above.
In addition, the research instrument developed for data collection has some limitations; the responses provided by the interviewees using the instrument may be influenced by subjective factors on the part of either the respondent or the interviewer that we were.
The interview with the respondents took place at the time when the learners came to the section either to submit internship ratings or for complaints. No appointment has been made with them. Some looked in a hurry. The interviews had to be done by appointment and at the internship location where they would feel relaxed.
Furthermore, the saturation of data, the opposite of what has already been recorded, stress, fear, emotion, complex and many elusive things based on what is left unsaid are exposed as limitations to the present study.
5. Conclusions
For the purposes of integrating learners’ acquired knowledge, or for assessment purposes, integration situations are developed in the initial training of midwives. However, some authors believe that in addition to reproducing reality, simulation involves a professional identity. Whereas during integration situations, the status of midwifery learners oscillates between technician and birth attendant. Which served as the basis for this study on the construction of midwifery professional identity through integration situations: Daily experience and expectations of midwifery trainee learners.
After the analyzes carried out as part of this study, integration situations are part of the philosophy of “Never the first time on the patient” which is a pedagogy aimed at protecting patients from trial and error by novices. During the simulation scenarios, the learner acquires technical and non-technical skills, which must be mobilized once in the exercise of the profession.
However, for the practice of sages, workshops are organized either to assess the skills of learners or to learn technical gestures promoting professionalization. During integration situations, the learner is called upon to construct his professional identity. Because these activities prepare him for his future profession.
The construction of the professional identity of midwifery trainee learners through integration situations is done through motivation for the profession, differentiation with other health professionals, the perception and representation of the midwife identity, the formation of the midwife identity and their expectation of integration situations.
The final year midwifery trainee learners express their expectations regarding integration situations which allow them to build their professional identity. They would like credits to be added to the hourly charge reserved for integration situations in order to allow them to master certain sequences of the workshop and to practice on their own.
This wish proves how much interest learners place in integration situations in training.
Conflicts of Interest
The authors declare no conflicts of interest.