Exploring transition to practice for newly qualified midwives

doi:10.21203/rs.3.rs-3778546/v1

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Exploring transition to practice for newly qualified midwives

https://doi.org/10.21203/rs.3.rs-3778546/v1

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Background: It can be overwhelming for newly qualified midwives to begin to work independently due to added responsibility and isolation. A support program was introduced in Ontario, Canada in July 2022 to provide educational resources, peer support and opportunities for reflection on clinical decision-making. This study assesses the extent to which the program assists transition through the first year of practice for new midwives.

Methods: We conducted qualitative semi-structured interviews and focus groups with newly qualified midwives and their mentors following a Grounded Theory Methodology for data collection and analysis.

Findings: Data collection from nine participants from July 1, 2022-June 1, 2023, produced four main themes: (1) peer support, (2) building relationships, (3) continuum of autonomous practice, and (4) value of resources which generated a theory explaining how participation in a community of practice (CoP) promotes confidence and enhances transition to autonomous practice for new midwives.

Conclusion: Support is critical for newly qualified midwives to build confidence, reduce isolation and promote adjustment socially and in practice. A CoP is an effective and valued approach to facilitating this process.

Midwifery

transition

support

mentorship

community of practice

The transition from student to qualified midwife is often difficult and overwhelming. Previous research describes this as a process of three discrete phases of Building, Bridging and Being (Sandor, Murray-Davis, Vanstone & Bryant, 2019). The Building phase typically occurs immediately prior to graduation when midwifery students are taking on increasing clinical responsibility and practicing the skills they will need as a qualified midwives. The Building phase lays a foundation for independent practice where students who had more independence in their final clinical placement were better prepared for practice upon graduation (Sandor, Murray-Davis, Vanstone & Bryant, 2019). The Bridging phase is a tumultuous time of adjustment to the weight of clinical responsibilities and the realities of independent practice. The final phase, Being, is characterized by confidence and satisfaction with professional identity and confidence in the role. Progress through these phases is often delayed due to discourse between expectations and requirements of practice contributing to reality shock, insecurity, and potential decisions to leave the profession.

This period of adjustment following qualification is not specific to midwives. Globally, there is literature describing challenges facing new graduates across health professions that are both psychological and emotional as they adjust to new roles with anxiety provoking responsibilities (Ankers, Barton & Parry, 2018; Seah, Mackenzie, Gamble, 2011). A qualitative study by Toal-Sullivan found that new occupational therapists were challenged by inexperience, systems issues, and role uncertainty (Toal-Sullivan, 2006). The impact of inexperience was described by Gardiner and Sheen who found that new graduate nurses experienced a lack of confidence, uncertainty of skill set, heavy workloads, and general feelings of being overwhelmed (Gardiner & Sheen, 2016).

According to Fortune and colleagues, working within complex healthcare environments, with the added burden of autonomy, makes it difficult for new graduates to understand their role in the system (Fortune, Ryan, & Adamson, 2013). Many new physicians, midwives and rehabilitation therapists work on their own, without direct contact with others within their profession. They lack the opportunity for peer support and role modeling necessary to promote role clarity and professional identity. The lack of professional identity may lead to self-doubt or a lack of confidence in clinical competence, demonstrating how these issues intersect (Seah, Mackenzie, & Gamble, 2011). New graduates often have difficulty seeing themselves as qualified health care professionals and have a perceived ‘imposter syndrome.’ Feedback and validation within support settings has been found to assist as new professionals redefine themselves as ‘qualified’ (Seah, Mackenzie, & Gamble, 2011).

Supervision, support, and education are themes identified in the literature as contributing to successful transition (Moores & Fitzgerald, 2017). Experienced supervisors assist new graduates to consolidate skills while helping them to navigate the social, organization and professional roles. Reflective practice has been used in both supervisory and peer relationships as a means of providing feedback and identifying learning needs (Moores & Fitzgerald, 2017; Seah, Mackenzie, & Gamble, 2011). Collaborative approaches to care management that often evolve in supervisory relationships can provide educational opportunities that address skills in critical thinking, while modeling language and practice culture assisting with social integration (Toal-Sullivan, 2006].

In usual models of care, midwives in Canada are independent contractors working in community-based practices, providing comprehensive courses of care including prenatal and postnatal care of parent and baby, and are on call as the most responsible provider for hospital and community births (Association of Ontario Midwives, 2023). The scope of practice is defined according to the College of Midwives of Ontario. At its fullest, it involves midwives providing hospital induction of labour, monitoring and maintaining care after administration of epidural analgesia and first surgical assist for cesarean births. However, some hospital policies or physician preferences may impose restrictions on the scope of practice such that some of these acts are not permitted. Much of the work midwives do is in isolation, attending labouring clients on their own until the time of the birth and completing home visits without other colleagues present. Previous research including new midwives in Canada indicates that adaptation to autonomous work in this model of care causes stress and insecurity (Gray, Malott, Murray-Davis & Sandor, 2016). Stress from professional demands, exhaustion (Wright, Matthai & Warren, 2017) and the impact of on-call schedules on personal life have been cited as contributing to burnout leading to job dissatisfaction (Stoll & Gallagher, 2019). Those who also encountered negative psychosocial or clinical experiences were more vulnerable to burnout and professional attrition (Otiz, 2016). Conversely, supportive relationships with like-minded midwifery colleagues have been shown to be protective against burnout (Stoll & Gallagher, 2019).

In Canada, there is inconsistency in how support is offered within the midwifery practice group environment. New midwives join established practices and most often have one midwife in the practice identified as their ‘mentor’, but the realities of what this looks like can vary greatly. This role may involve formalized expectations for orientation, supervision, chart reviews, and regular check in meetings, or it may be left to the new midwife to seek assistance when and as required. Direct supervision and support from experienced midwives can be challenging within models of care where midwives often work in isolation and are considered autonomous care providers regardless of level of experience (Kool, Freijen-de Jong, Schellevis & Jaarsma, 2019). In some cases, fluctuations within practice group members results in reliance on new midwives to fill positions without effective orientation. This can be particularly challenging when midwives who received the bulk of their clinical pre-qualification education in communities where the midwifery scope of practice is restricted by hospital policies or physician limitations, end up working after qualification in a setting with a fuller scope of practice. This results in significant post-qualification learning needs.

Several factors impact the ability of a practice group to mentor effectively including the number of midwives in the group and their level of experience, the practice location as urban or rural, the practice type as fullest or limited scope practice, and the complexity of the population they serve. inter and intraprofessional relationships and power imbalances and the extent to which the practices are integrated into the local healthcare system also impact how new midwives are welcomed to the community and perceived by others.

Transition to independent midwifery practice requires support and mentorship; however, within the context of Ontario midwifery, little is known about what kind of support is required and how it is best provided. A pilot program was created to address the ad hoc and inconsistent approach to mentorship experienced by some newly qualified midwives in the province. The voluntary program launched in July 2022. All 90 recently registered midwives in Ontario were invited to participate. Invitations to engage in the program were sent through the professional association monthly newsletters. The program consisted of three elements: access to online resource materials, facilitated monthly peer case review meetings for new midwives, and a web-based chat group via ‘Whatsapp’. The online resources included guides for effective orientation and integration to new practices, hospitals and communities, clinical resources for providing care, and personal resources to support self-care and sustainable practice. Monthly meetings were facilitated by an experienced midwife and provided opportunities to discuss care management and decision making in difficult situations. It enabled attendees to give and receive support from peers who were also in their first year of practice. The web-based chat group offered 24/7 access to other newly qualified midwives for immediate peer feedback and guidance. The objective of our study was to assess the impact of this new program with the aim to assess the extent to which the program assists transition through the first year of practice for new midwives.

We conducted semi-structured interviews and one focus group underpinned by a Grounded Theory methodology for data collection and analysis. Our research questions and data collection tools were informed by Benner’s stages of clinical competence (Benner, 1982) where development from novice to expert occurs with experience over time and addressed the following questions:

How does participation in a support program in the Canadian context impact readiness for independent practice for new Ontario midwives?

How does a support program contribute to feelings of satisfaction and support for new midwives?

All newly qualified midwives who enrolled in the program were eligible to participate in the evaluation. Data was collected through interviews and one focus group and occurred over 2 phases (Table 1). All interview questions used in the study were created by the research team and informed by a provincial needs assessment completed by the Association of Ontario Midwives in collaboration with the first author in 2022. Phase 1 of the study (July-December 2022) included semi-structured interviews and one focus group with new midwives and their mentors. Phase 2 data collection included semi-structured interviews with new registrants at the end of their first year of practice (June 2023). All interviews and the focus group were conducted, with consent, by the first author. They took place via zoom with audio recording and immediate transcript creation. Field notes with reflective thought were created immediately following interviews to build understanding of concepts and patterns within the data. The qualitative data were analyzed using thematic content analysis. This was conducted by the research team in a concurrent and iterative manner, using open coding (Thorogood, Green 2018) according to Charmaz (Charmaz, 2003). Differences in coding were discussed until consensus was reached. Axial coding continued until patterns were identified, and agreement of their meaning was reached. Organization of the data and creation of a conceptual framework developed with ongoing discussion. The study was approved by the Hamilton Integrated Research Ethics Board Project Number: 14705

Forty-four midwives enrolled in the program and 10 new midwives, and 5 mentors participated in the evaluation. One participant was lost to follow up (n = 14). Mentors’ experiences are reported elsewhere. Demographic characteristics of the new registrant participants and their practices are summarized in Table 1. The new registrant participants were between 20 and 30 years of age and identified as mostly white European or White North American with only 22% being people of colour. This reflected the ethnic composition of graduates at that time. There was essentially an equal number of those who were married or single and those with or without dependents. Seventy-eight percent had some experience working with the practice with 67% having been senior students at the same practice where they were as new registrants. Midwives in all but one group had oxytocin induction of labour in their scope of practice, and the practice that did not, was actively working to have it included, and all practices included epidural management as part of their scope. Eighty-nine percent of practices were either urban, or mixed urban/rural. The majority were large practice groups with 8 or more midwives.

Table 1

Characteristics of new registrants and their practices
Characteristic	N	%
Age </=29 years > 30 years	5 4	56 44
Ethnicity White European/North American BIPOC	7 2	78 22
Marital Status Single Married	4 5	44 56
Dependants Yes No	4 5	44 56
Previous relevant work experience Yes No	7 4	78 44
Experience with practice as senior student Yes No	6 5	67 56
Placement of any kind with practice Yes No	7 2	78 22
Includes management of oxytocin and epidural Yes No	8 1	89 11
Type of practice Urban/rural Rural	8 1	89 11
Number of midwives in group 4–7 8+	3 6	33 67

The data from participants was organized into four main themes (Table 2). The themes and quotations from participants using pseudonyms will be reviewed next to shed light on the data.

Table 2

Organization of data
Themes	Categories	Subcategories
1.Peer support	Meaning of support	Connecting with peers Asking without judgement 24/7 Availability of peers Regular volunteer check-in points Peers as resource for emotional and work/life balance
	Peer review	Learning through peer’s experiences Increasing confidence through peer discussions Comfortable environment with peers Safe space for sharing Appreciating informality Space for structure Bridge the gap Valued timing & frequency Formal education Dry run for presentations
	Online platform	Selective access Enhancing access and promoting inclusivity Appreciating prompt responses Confirming plans Real time encouragement It’s not just me Safety Net for decision-making Lonely and uncertain Experiencing a sense of community
2.Building relationships	Selecting a mentor	Assigned or organic From within practice External to practice
	The effective mentor	Desired characteristics Like me Experienced with special populations
	Benefits to the practice	Bringing information to protocol development Supporting fullest scope practice
	Power inequities	Avoiding being needy Avoiding being weak Avoiding being a burden Needing to please The year-long interview Wanting to be independent
3.Continuum of Autonomous Practice	Settling in	Celebrating joy in profession Feeling capable Developing midwifery identity Finding balance Ability to shut off
	Gaining confidence	Building familiarity Knowing systems Developing relationships of trust Knowing inter and intra professional team culture Demonstrating competence and gaining respect Seeing self as integral part of the practice
	Continuity of experience	Feeling known Refining skills Shifting from student to registered midwife Experiencing the feedback loop
4.Value of Resources	Degree of use	Reviewed initially and not again Not a priority but wished it was
	Format	Too many clicks Too much like school Value of prompting question One document Mobile access Increased clinical focus Timing of release of materials
	Content	Addresses inconsistencies in orientation Checklist provides direction Living document Ordering and use of equipment Don’t know what I don’t know How things work Value of quick references
	Human resources	Benefit of facilitator Voice of experience

Peer support

The participants shared many examples of how new registrants encouraged, validated, or inspired each other. Participants described the type of and availability of support they needed. They articulated the value of a safe space to discuss demanding situations that were both clinical and social in nature including advice on how to create work life balance. The monthly peer case review sessions were highlighted as an effective strategy for peer support. Attendees spoke about how they were adjusting to independent practice and balancing their lives. Participants also articulated that the web-based chat groups were valuable and offered 24 hour/day contact with other new midwives for peer consultations. Having the ability to check in with others was appreciated by several participants who recognized that without it, the profession was isolating. This was described when one person said: Throughout senior year we were sharing [in our tutorial groups] at check in, and talking about how we felt, so we realized that we were all doing the same thing and now it's been months since we've had that, and we lose sight of the fact that everyone is feeling the same way (Sasha)

Including an informal check-in time within the peer review sessions was valued by several participants as a means of validating the challenges they were experiencing. Knowing that they were not alone with their feelings of insecurity, uncertainty and self-doubt was articulated as feeling grounding. It provided affirmation in ways that only others having the same experiences could offer. Being able to share thoughts before presenting a clinical situation formally to their practice group was reassuring to many participants: There’s a sense of validation, talking about experiences and management that you may not want to share in a formal practice peer review… Just being able to get feedback from people who are also at your stage of practice, you feel like you have more people in your corner (Alex)

These group discussions were seen by participants as being helpful for building capacity to cope with stress and to navigate the demands of clinical practice. Peer support contributed to building confidence that participants had the capacity to be midwives and had the coping skills to continue in the career in the future: I think [the program] will help a lot of people prevent future burnout. That was my goal for joining. I have come too far, and have too much invested to quit but honestly, I was having my doubts whether I could do this long term or not (Cyrus)

The peer support participants experienced through the program provided real time encouragement, reassurance and validation of care management plans that was believed by participants to have the potential to reduce burnout by building confidence.

Building Relationships

Building relationships with midwives within the practice group was an important concept that came through in the data. There was a clear need to be as independent as possible and to be perceived as being clinically competent, confident, and not a burden to the group. The need to maintain the appearance of independence was linked to the precarious nature of the new registrant contract. Participants were aware that they were required to work within an established practice on an employment contract typically funded for one year, until such a time that they would be eligible to become a general registrant without restrictions. Participants highlighted that following the first year of practice, they may be able to renew their contract with their practice group or they may need or want to seek a position at another midwifery practice. As such, the first year of practice was described as feeling like one long job interview. One participant went on to describe: It’s hard to be vulnerable to your practice mentors because you don't want to appear weak or that you can't be independent (Jiang)

The peer support described earlier played an important role in managing this appearance of independence. For example, to be less of a burden to their mentors, the new midwives accessed their peers as a first line of contact for feedback and validation. Participants articulated that this contributed to feelings of confidence in their relationships with their mentors and a sense that they were on the right track. An example of this was provided by one participant who said: I did run care plans by the peer group first, so I was more organized...I was able to work through plans with more time in the group and I think that reduced the strain on [mentor] or at least the amount of support I needed from her (Ali)]

The newly qualified midwives in the program felt that building relationships with other new midwives as well as with mentoring midwives within the practice groups was essential during their transition. Peers provided consultation and guidance which helped new midwives to be more prepared and appear more independent, and competent in their interactions with practice members; all of which contributed to feelings of acceptance and belonging.

Continuum of Autonomous Practice

Several participants commented on how the program helped them consolidate decision-making skills and begin to develop confidence. They articulated that refining clinical skills, increasing confidence, and developing decision-making skills over time was beneficial to their growth as a midwife. They saw themselves moving along a continuum from unsure and anxious toward capable and secure. These feelings were described by midwives and were felt to be influenced by the all-consuming and overwhelming sense of responsibility that often accompanies on-call primary healthcare. One newly qualified midwife stated: Setting the foundation through this group might make all the difference for me: consolidating my skills, learning to maintain work/life balance, and building that sense of community (Seiko)

For one participant, confidence was compromised by having to relocate after senior year and learn new systems, protocols, and processes: I feel like I left them [skills] in a bag in[town]. They were there in that community, and they were strong. I feel like they haven’t gotten here yet…When the skills aren’t so great, the confidence goes down. The confidence goes down and you don’t feel strong (Sasha). Unfamiliarity with the system required extensive orientation for this participant who added: I really had to start at the beginning and get to know the hospital, the systems, the community, and the practice. It was like, there’s no manual, just figure it out. I had no idea how I fit in (Sasha).

Several participants described how the familiarity of remaining in the same practice through their last year of pre-qualification training and in the first year of practice contributed positively to their transition. Not having to relocate meant that there was already an understanding of practice policies, community standards and expectations of their midwifery and interprofessional colleagues. They had established themselves as competent clinicians who were trustworthy. One participant spoke about how this enabled progression toward more autonomous practice and professional development: Now I’m starting to feel like okay, I'm a midwife. I feel like I don't need to sweat like crazy every time I get a page...or justify my care. So now, I’m kind of feeling I would like to keep learning … rather than just surviving…I feel like this was easier for me since I continued here after my senior year (Sade)

The point at which new midwives enter and advance through the continuum of autonomous practice varies with clinical experiences and interpersonal interactions that either build or break down confidence. Progression for our participants was influenced by perceived capacity to create work-life balance rather than survive it, and the ability to manage the responsibilities of primary care.

Value of Resources

The new midwives valued the online resources within the program as a means for supporting their transition, but they articulated that they were often too busy to engage with them fully. One participant described how their ability to engage with the resources changed once they began on-call work when they stated: I would have used [online materials] before I moved and maybe that could have helped me settle in- If I wasn’t on call yet. Once I started, I was just totally overwhelmed (Ali) In particular, several participants identified that information related to orientation was essential and expressed that having this information available early and in an accessible, online format would promote its utility.

Information in the program about hiring and employment and arm’s length facilitators of the peer case reviews were also seen as important to new practitioners. Since many assigned ‘mentors’ from the practice group were perceived to hold positions of power within the midwifery practice and would be contributing to decision-making related to whether a new graduate’s contract would be renewed beyond the first year of practice, the mentor did not always feel like an impartial, or safe source of support. Participants valued the presence of an experienced midwife who the facilitated the peer review sessions, but who was not involved in their practice group. It was highlighted as a vital component of the program: It’s good to provide experience to clarify sometimes because we’re all lost sometimes, right? The blind leading the blind [laughter]… [Facilitator] pushes us to move beyond chatting and catching up, which is also important but it’s good to do both (Seiko)

The online resources and the facilitator for peer case review provided guidance to new midwives and complemented the social support included in the program.

Our research explored how a program of online resources, peer support and facilitated peer case reviews supported newly qualified midwives during their first year of practice. The resources provided to participants along with the peer support, relationship and confidence building that occurred as part of the shift toward autonomous practice were seen as core elements for supporting new midwives. These themes formed the foundation of a theoretical model that positions ‘Community of Practice’ (CoP) as central to the experience of transition through the first year of practice. (Fig. 1). A Community of Practice is a group of people with a shared interest and common goal of learning that serves the entire group (Wenger-Traynor & Wegner-Traynor, 2015). Our findings illuminate how newly qualified midwives who participated in a CoP with other new graduates received validation and reassurance through peer support that encouraged critical thinking and built confidence. Critical thinking is key to effective care management and this research shows that peer support facilitates critical thinking by enabling safe space discussions that include how and why decisions were made and provides insight into the importance of reassurance for new clinicians.

Our study also provides evidence of the value of shared experience and specifically, how peer support contributes to confidence building through direct experience, as well as through the indirect experiences of others at the same stage in professional development. Our data elucidates the relationship between increased confidence and progression toward autonomy and provides insight into the timing and type of resources most helpful to new midwives. Furthermore, the insights participants expressed about mentorship highlight some of the limitations of the current model of mentorship and raise questions as to what type of mentorship model may be most effective.

Social support theory, widely studied in psychology and healthcare, has demonstrated that social support can enhance the ability to cope with stress and uncertainty, therefore having a positive impact on health and well-being. (Leahy-Warren, 2014). Our findings align with this by demonstrating that new midwives benefit from engagement in a community of practice with others with similar needs and adds to the understanding that there is value in unbiased mentorship that comes from outside specific midwifery practices and provides judgment free guidance and support. Peer support is a form of social support provided by people in similar circumstances. The literature is clear that peer support that occurs in a CoP fosters genuine acceptance, given the mutual understanding of shared experiences (Gottlieb, 1988; Helgeson & Cohen, 1996). This acceptance promotes identity and a sense of belonging which is critical to reducing professional attrition. Our findings suggest that early career midwives are a group, experiencing similar circumstances, who would benefit from this form of social support.

The peer support in CoPs for new midwives may represent an important element in reducing feelings of isolation within the profession. This has been demonstrated in medicine where new physicians often work in isolation and mask their insecurities in attempts to maintain a competent image (Eley, 2010; Sturman, Tan, & Turner, 2017). Additional research has shown that new physicians often practice in unfamiliar hospital structures while having added responsibilities (Westerman, Teunissen, van der Vleuten, Scherpbier, Siegert, van der Lee, & Scheel, 2010) emphasizing the importance of orientation and understanding organizational structures to practice effectively. This was echoed in our findings where effective new midwives stressed the importance of an effective orientation to promote understanding of their role.

The benefits of reflective practice in the CoP in our study are consistent with those described in the literature (Wain, 2017) and included in the professional standards for midwives in Ontario (College of Midwives of Ontario, 2021) and national core competencies for midwives (Canadian Midwifery Regulators Council, 2020). As such, they are essential skills that must be encouraged. The value of reflection and learning from the experiences of colleagues demonstrated in our study concurs with previous work (Kool, Schellevis, Bax, Jaarsma, Feijen-de Jong, 2023), building a body of midwifery literature. Our outcomes add to current understanding by demonstrating specifically how social support can be effectively enacted within midwifery practice in the Canadian context, through a community of practice of new midwives, grounded in principles of psychological safety. Psychological safety has been shown to contribute to wellness (Hylton, Karjane, Santen, Rigby & Appelbaum, 2019) and retention in the workplace (Keitz, Aron, Brannen, et al., 2019; O’Donovan & Mcauliffe, 2020) and is enhanced in situations of peer support and trust (Newman, Donohue & Eva, 2017). Findings from our study illuminate the importance of creating safe space for learning through reflective practice.

Our study demonstrates that the transition to clinical practice for new midwives occurs with experience over time, along a continuum of autonomy. This is consistent with the literature highlighting the needs of new graduates of midwifery and other healthcare programs and the value of longitudinal mentorship support programs (Kitson-Reynolds, Ferns, & Trenerry, 2015; Murphy & Janisse, 2017; Pairman, Dixon, Tumilty, Gray, Campbell, Calvert, Lennox & Kensington, 2016; Rayment-Jones & Williams, 2019; Reynolds, Cluett, & Le-May, 2014). Our research suggests that early career support has the potential to impact clinical outcomes, job satisfaction and ultimately, sustainability of the profession by promoting advancement across a continuum of autonomy. The implications of these findings are significant. Attrition within the midwifery profession in Canada has been identified as a problem (Stoll & Gallagher, 2019) requiring immediate attention. Effective ways to enhance confidence are needed to promote retention; a primary concern of parties invested in the profession of midwifery across Canada.

While this study has shown that there are benefits to a program grounded in psychological safety the challenge is making participation an expectation both with new clinicians, and the practices they join. Participating in this program was voluntary and may not necessarily have been priority in busy clinical practice. Also, we recognize the potential selection bias of those who chose to participate and that further research with a larger cohort is necessary. This study focused on the experiences of new midwives for one year. This is a brief period considering findings related to other professions. Hayward, et al. (2013) studied novice physical therapists in the United States and found that graduates continued to develop professional identity, consolidate skills, and develop clinical reasoning during the first two years of practice. This supports the notion that a longer study period is warranted to better understand the experience of new midwives. It has also been shown that newly graduated nurses require at least one full year to feel confident practicing in the acute care settings due to limited exposure to care management and application of critical thinking skills (Casey, Fink, Krugman et al., 2004; Chen, Duh, Feng, Huang, 2011; Sandauand & Halm, 2010). Given the increased level of responsibility and autonomy in midwifery, it is reasonable to see advantages to evaluating transition over a longer period.

It is critical for both the sustainability of the profession and public protection to find ways to promote effective mentorship and set clear expectations of new midwives for accessing the emotional and informational support needed to promote excellent care. There is a role for regulatory bodies to ensure this occurs. Ongoing development of this program in collaboration with regulators and policy makers is important to continue to provide effective support for new graduates.

Midwives in Ontario who were beginning their first year of practice valued being part of a supportive, structured program. Requirements by policy makers for engagement in structured support programs is recommended to ensure new midwives have access to appropriate mentorship, and support. Approaches need to be informal, social, and grounded in principles of psychological safety. Didactic resources should be easily available and shared before beginning the first year of practice. Further research recommendations include conducting a longitudinal study with a larger sample size to determine the impact of the support program over time, and to complete an in-depth analysis of preferred approaches to mentorship.

All authors verify that the data support published claims. All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Anne M. Malott, Beth Murray-Davis, and Christine Sandor. The first draft of the manuscript was written by Anne M. Malott and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Conceptualization was a collective effort of all authors to further work initiated by Christine Sandor. Methodology, data collection and formal analysis were led by Anne M. Malott, supported by Beth Murray-Davis and Christine Sandor. No funding was received for this study.

Competing interests

No funding was received for this study or the preparation of this manuscript. None of the authors have potential conflicts of interest to disclose. All authors have been faculty at McMaster University while engaged in this research project. No authors stand to gain financially in any way through the publication of this manuscript. No authors have non-financial interests that could impart bias on the work such as professional interests or personal relationships.

Funding: No funding was received for conducting this study or to assist with the preparation of this manuscript. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Ethics approval: The questionnaire, methodology, information, and consents for this study were approved by the Hamilton Integrated Research Ethics Board (McMaster University). Ethics approval Project Number: 14705

Consent to participate: Informed consent was obtained from all individual participants included in the study. No identifying information or images have been included in this submission.

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No competing interests reported.

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Exploring transition to practice for newly qualified midwives

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