Barriers and enablers in implementing strategies to maintain clinical competence of midwife educators: a scoping review

Abstract

Background

Well-educated and prepared midwife educators are crucial in the provision of high-quality midwifery education, ensuring that midwifery students are equipped with the essential competencies to improve maternal and neonatal health outcomes. The International Confederation of Midwives (ICM) Global Standards for Midwifery Education set out an expectation for midwife educators to remain clinically competent. However, little is known about strategies used by midwives to achieve this, and the factors that influence their ability to maintain clinical competence.

Aim

To identify how midwifery educators maintain clinical competence, and the barriers and enablers that influence this process.

Methods

A scoping review was conducted following Joanna Briggs Institute guidance. Six databases were searched for peer-reviewed articles, published from 2004 to 2024, to explore how midwifery educators maintain clinical competence. Grey literature was also included. Titles and abstracts were reviewed, data was extracted, and key concepts were mapped. Content analysis was used to report findings.

Results

Twenty-one articles were included in the final review. Three main strategies used by midwifery educators to maintain clinical competence were identified: (1) incorporating clinical practice into educator’s roles at education institutes; (2) workshops and training programs; and (3) midwifery educators engaging in hands-on clinical practice at hospitals. Barriers to maintaining clinical competence among educators included high workload and insufficient support from employers. Conversely, enablers included opportunities for regular time in clinical practice, and ongoing workshops and trainings.

Conclusions and significance

Midwifery educators face a range of barriers to maintaining clinical competence, including limited time, insufficient institutional support, and challenges engaging in clinical practice environments. Several studies from low- and middle-income settings described additional barriers related to workforce and resource constraints. Educators who engaged in clinical practice or ongoing professional development reported perceived benefits including improved confidence, updated clinical knowledge, and strengthened links between theory and practice. However, evidence evaluating the direct impact of educator clinical competence on student or clinical outcomes was limited. Further research is needed to identify effective and sustainable approaches to supporting midwifery educators to maintain clinical competence across different settings.

Background

Evidence suggests that when midwives are educated to international standards and provide the full scope of midwifery care, approximately 65 per cent of all stillbirths, maternal deaths, and neonatal deaths could be averted [1]. Despite the evidence for the benefits of midwifery, there remains a global shortage of approximately 900,000 midwives. While many countries are responding to the global shortage of midwives by increasing the number of midwifery students, attention must be paid to the quality and effectiveness of midwifery educators teaching the students, to ensure high-quality midwifery graduates [2]. High quality midwifery education requires experienced and educated midwifery educators who are well-supported to engage in regular clinical practice and are regularly assessed for competency [3]. Clinical competence in midwives is defined as the ability to perform clinical skills to the standard and level of proficiency defined by the International Confederation of Midwives (ICM) Essential Competencies of Midwifery Practice (2024).

There is considerable variation in the quality and content of midwifery education and training programs around the world [2], with many programs not meeting global standards and accreditation processes set out by the ICM [4]. A significant factor impacting quality of midwifery education programs is a lack of support for midwifery educators, and little consensus on how to effectively prepare midwifery educators [3]. Current midwifery educator development programs tend to focus on contemporary methodologies for teaching and learning, and little attention is given to the development and maintenance of other core educator competencies such as clinical skills. Clinical competence is an essential component of safe midwifery care and current clinical skills are necessary for the provision of all care, including effective management of complex emergencies [5].

Several initiatives have been introduced to set international standards for midwifery education, the most significant being the ICM’s Global Standards for Midwifery Education (2021). These standards provide guidance on designing, implementing, and evaluating quality midwifery education programs in line with the ICM definition and scope of practice of a midwife [6]. While clinical preceptors, whose main role is to teach and support students in the clinical setting may be involved in pre-service midwifery education, midwifery educators (also referred to as teachers/faculty), are expected to maintain their clinical competence, even when they only teach theory aspects of a midwifery education program [6]. The expectation of maintenance of clinical competence is to minimise gaps in knowledge and ensure up-to-date, evidence-based and effective education is provided to midwifery students [3].

Midwifery educators have different titles depending on their geographical location of work. In countries where midwifery is not seen as a separate profession to nursing, nurses (or nurse-midwives) are often teachers of pre-service midwifery programs. Even among midwives who are midwifery educators, many do not meet the strict ICM definition of a midwife, as they have not completed a midwifery program based on the ICM Global Standards of Midwifery Education [4]. This is particularly the case in low- and middle-income countries (LMICs). Due to the varied titles and backgrounds of midwifery educators, this review defined midwifery educators as any midwife or nurse-midwife who is directly involved in pre-service education. Pre-service refers to education required before licensure or registration in the profession and entering the workforce. While it is known that a number of countries engage other health professionals, including doctors in the pre-service education of midwives, this review chose to focus on midwives and nurse-midwives given the critical need to strengthen this area of the midwifery workforce.

The ICM Global Standards for Midwifery Education state that a midwifery educator should demonstrate competency in clinical practice, which can usually be accomplished from working across the full midwifery scope for a minimum of two years prior to teaching. The ICM Global Standards for Midwifery Education: Companion Guidelines (2023) recommends documentation of the practice competence of each midwife teacher, including ongoing education, and how a lack of competency in the past has been addressed. A midwifery educator is also expected to engage in ongoing professional development as a practising midwife and should have their clinical competency reviewed on a regular basis, emphasising the importance of maintaining clinical competence throughout their career as an educator. However, these expectations are often not formally assessed.

In order to strengthen the capacity of midwifery educators and accelerate assessment of educator capacity, the World Health Organization (WHO) developed a set of Midwifery Educator Core Competencies [7]. The WHO Core Competencies provide eight domains and 19 competencies for midwife educators to meet, three of which are particularly relevant to the clinical competence of midwifery educators [7]. These include maintaining competence in midwifery practice, practising midwifery in ways that reflect evidence-based and up-to-date knowledge, and facilitating a safe and effective learning environment for students in the clinical setting. One of the four listed requirements to become a midwifery educator includes completing a minimum of two years’ full-time clinical experience across the scope of practice within the last five years [7]. However, despite there being consensus in international guidelines on the importance of clinical competence for midwifery educators, little is known about whether midwifery educators are remaining clinically competent in practice, and what factors affect the ability of midwifery educators to maintain clinical competence.

While improving the quality of midwifery educators has been considered a priority for some time, challenges have made progress slow. Challenges include the high workload of midwifery educators, which can be due to the high student to faculty ratio, found particularly in LMICs [7]. In addition to these challenges, very few midwifery educators in LMICs have had formal preparation or qualifications in teaching, which can make up-skilling and ongoing development more difficult [7].

Our scoping review aimed to identify, synthesise and present the factors that influence midwifery educators’ ability to maintain their clinical competence, including both barriers and enablers, and the different approaches that are used to encourage clinical competency among midwifery educators. Given the extensive clinical training component expected in pre-service midwifery education, and the challenges in the preparation and development of midwifery educators as described above, our review is particularly relevant in the current global context of midwifery education. The question informing our review was: How do midwifery educators maintain their clinical competence and what are the factors that influence this?

Specific objectives included:

1. To identify how midwifery educators maintain clinical competence;

2. To identify and describe the barriers and enablers that influence midwifery educators maintaining clinical competence; and,

3. To provide recommendations for improving professional development of midwife educators in policy and practice.

Methods

This scoping review was conducted per the Joanna Briggs Institute (JBI) guidance for scoping reviews [8] and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [9]. A scoping review protocol was developed prior to undertaking the review but has not been published.

Search strategy

As per JBI guidance, an initial search of PubMed and Medline showed that there are no existing systematic or scoping reviews that gather information regarding the maintenance of clinical competency for midwifery educators.

We developed a three-step approach to the search strategy as per JBI guidelines [8]. We carried out an initial search of two databases, MEDLINE and CINAHL, to identify relevant articles, with key terms from titles and abstracts used to inform and develop our full search strategy. Health research librarians assisted in refining search terms and database selection (Table 1. outlines our full search strategy). We then conducted a systematic search of six health and education databases using our full strategy: MEDLINE, CINAHL, ERIC, Academic Search Complete, Scopus and Web of Science. Reference lists of included articles were hand searched to identify additional sources and grey literature, as well as a Google Scholar search. The full search was undertaken in June 2024.

Table 1.

Search strategy by database

Database and search date	Search	Total
Medline 20/6/24	Midwi* OR midwifery/ OR obstetric nursing/ OR maternal-child nursing/ OR nurse midwives/ OR (Obstetric or maternity or labor or labour) adj4 nurs*) AND educator* OR teacher* OR lecturer* OR faculty OR Faculty, nursing/ OR (preceptor OR preceptors) OR (tutor OR tutors) AND clinical competenc* OR clinical skill* OR clinical experience OR professional competence/ OR Clinical Competence/ OR midwifery competence	339
CINAHL 21/6/24	Midwi* OR (Obstetric OR maternity OR labor OR labour) N4 nurs* OR MH “Midwifery” OR MH “Nurse Midwifery” AND educator* OR teacher* OR lecturer* OR faculty OR MH “Nurse Educators” OR MH “Faculty, Nursing” OR (preceptor OR preceptors) OR (tutor OR tutors) AND “clinical competenc*” OR “clinical skill*” OR “clinical experience” OR MH “Professional Competence” OR MH “Competency Assessment” OR MH “Clinical Competence” OR “midwifery competence”	327
ERIC 21/6/24	Midwi* OR (Obstetric OR maternity OR labor OR labour) NEAR/4 nurs* AND educator* OR teacher* OR lecturer* OR faculty OR (preceptor OR preceptors) OR (tutor OR tutors) OR DE “Teacher Role” or DE “Faculty” AND “clinical competenc*” OR “clinical skill*” OR “clinical experience” OR DE “Clinical Teaching (Health Professions)” OR DE “Clinical Experience” OR DE “Clinical Supervision (of Teachers)” OR “midwifery competence”	4
Academic Search 21/6/24	Midwi* OR (Obstetric OR maternity OR labor OR labour) N4 nurs* OR DE “MIDWIVES” OR DE “MIDWIFERY” AND educator* OR teacher* OR lecturer* OR faculty OR (preceptor OR preceptors) OR (tutor OR tutors) OR DE “NURSING school faculty” OR DE “MIDWIFERY education” OR DE “NURSING preceptorship” OR DE “NURSE educators AND “clinical competenc*” OR “clinical skill*” OR “clinical experience” OR “midwifery competence” OR DE “CLINICAL competence OR DE “PROFESSIONAL competence	703
Scopus 21/6/24	Midwi* OR (Obstetric OR maternity OR labor OR labour) W/4 nurs* AND educator* OR teacher* OR lecturer* OR faculty OR (preceptor OR preceptors) OR (tutor OR tutors) AND “clinical competenc*” OR “clinical skill*” OR “clinical experience” OR “midwifery competence”	380
Web of Science 21/6/24	Midwi* OR Obstetric NEAR/4 nurs* OR Maternity NEAR/4 nurs* OR Labour NEAR/4 nurs* AND educator* OR teacher* OR lecturer* OR faculty OR (preceptor OR preceptors) OR (tutor OR tutors) AND “clinical competenc*” OR “clinical skill*” OR “clinical experience” OR “midwifery competence”	190
Total		1951

Eligibility criteria

We followed JBI’s Population, Concept, Context (PCC) guidance to determine eligibility criteria (outlined in Table 2 below). Midwifery educators were the key population, defined as any midwife or nurse-midwife who is directly involved in pre-service education, including the theoretical teaching of midwives or nurse-midwives. We excluded clinical preceptors or mentors whose primary role is to provide clinical support in a health facility setting, rather than in the education institution setting. As per the review question and objectives, factors that influence midwifery educators maintaining their clinical competence was the concept investigated in this review. Sources of evidence with a focus on competence related to theoretical knowledge or teaching practices were excluded. The context was global.

Table 2.

Inclusion and exclusion criteria

	Inclusion Criteria	Exclusion Criteria
Participants	Midwifery, Nurse-midwife Educator, Teacher, Tutor, Lecturer, Faculty in pre-service midwifery education	Educators outside preservice education (e.g. working with qualified midwives), Clinical Mentors or Clinical Preceptors with no involvement in theoretical teaching Community Health workers, Traditional birth attendants, Midwifery students, Other health professionals e.g. doctors, nurses outside midwifery
Concept	Clinical competence of Midwifery Educators Barriers to maintaining clinical competence Enablers to maintaining clinical competence	Objective Structured Clinical Exam (OSCE) competence Theoretical competence Clinical credibility
Context	All countries	-
Types of Sources	Primary research including qualitative, quantitative and mixed method studies Case studies Relevant grey literature including reports and conference proceedings Published between 2004–2024 Full text in English language	Commentary and editorials Scoping, systematic and literature reviews Published prior to 2004 Full text not available in English language

Sources meeting the following criteria were considered eligible for inclusion in the review: peer-reviewed, primary qualitative, quantitative, and mixed methods research studies, published in English language, full text available through library access, and published between June 2004-June 2024. In addition to peer-reviewed publications, grey literature, including reports, were eligible for inclusion.

Search outcome

Evidence selection

Citations identified through the database searches were uploaded to Endnote referencing software [10] where initial duplicates were identified and removed. The remaining citations were then uploaded to Covidence systematic review software [11] where further duplicates were identified and removed. Two authors (AF and BC) independently screened the titles and abstracts of all sources against the eligibility criteria. Any conflicts were discussed by AF and BC and resolved by a third reviewer (SBZ) as necessary. Full-text screening and screening of grey literature was conducted by AF and SBZ. Findings from evidence selection process is reported in the PRISMA flow diagram (Fig. 1).

Fig. 1.

PRISMA flow diagram

Data charting

A data charting tool was developed by AF in consultation with SBZ. The tool was pilot tested on three studies and further refined to ensure all relevant information was extracted. Data were charted by AF and any uncertainty about data extraction and relevance to the review was discussed with SBZ. Data extracted included study methodology, key information relating to clinical competence, and barriers and enablers to maintaining clinical competence. (Table 3).

Table 3.

Data extraction table

Reference and country/s	Title	Study Design	Sample Size	Intervention	Profession	Results	Barriers	Enablers
JHPIEGO, (2008) [20] Africa & Asia	Access to Clinical and Community Maternal, Neonatal and Women’s Health Services Program: Year 3 Annual Report.	Report	70	6-day regional Clinical Training Skills /Curriculum Design course 2-week technical update and clinical skills standardization course on BEmONC	Midwifery Educators	Midwifery educators in Ghana trained by ACCESS continue to demonstrate competence as verified through the follow-up visits with local midwifery tutors who participated in an ACCESS-supported clinical skills standardization and technical update course. This was assessed through knowledge surveys and clinical observations using anatomical models.	Funding limits and lack of time – 2 weeks was not enough	Advocacy to improve linkages between the schools and the clinical practical sites. Tanzania Nurses and Midwives Council (TNMC) developing standards to support learning and practice assessments for midwifery educators.
WHO, 2020 [21] Botswana, Cameroon, Lesotho, Malawi	Project on Scaling up Midwifery Education in Four African Countries	Report		Identification of gaps in the competencies of the educators and introduction of competency-based education	Midwifery Educators	Competency-based educational strategies were adopted by educators and used effectively. Clinical competencies were often achieved by using available national, regional and global guidelines for midwifery practice. One evaluation method used was self-reporting.	No consistent continuous professional development available, any development is done at own cost, and no functioning laptops and wifi issues	OSCE training available with adequate mannequins and equipment, updates offered more than once a year. Educators participating in audits and committees. Minimum 4 months spent in clinical Educators being proactive, engaged in research and updating guidelines
Fowler et al., 2008 [16] United Kingdom	Joint appointees’ experiences within a school of nursing and midwifery	Qualitative	12	Joint Appointees role	Nursing and Midwifery Educators in Joint Appointees role	Joint appointees were more actively involved in clinical services than they were normally able to access. Joint appointments increased the clinical credibility of lecturers and reduced the theory–practice divide.	A poor understanding of role and resistance from clinical staff - seen as a hindrance, no clear expectations. Adjusting to 2 different cultures and workplaces, as well as feeling isolated and unsupported was reported. Some practical issues such as carparking, office space, computer access, and travel time.	Flexibility of employment and trying different roles.
Akiode et al., 2010 [22] Nigeria	An evaluation of a national intervention to improve the postabortion care content of midwifery education in Nigeria	Quantitative	169	Training of Trainers courses involving 24 h of classroom teaching and 16 h of clinical practice	Midwifery Educators	After attending courses, midwifery educators had significantly more experience and exposure to Post Abortion Care. The intervention ensured that midwifery instructors were better prepared and equipped to deliver the content to the students.	Training alone cannot change clinical practice – teachers were not allowed to use aspects of training due to stigma
Attenborough & Abbott, 2019 [31] United Kingdom	The impact of Nursing and Midwifery Council revalidation on the professional identity of academic staff in a higher education institution: A qualitative study	Qualitative	10	NA	Nursing and Midwifery Educators	Those who engaged with clinical practice reported increased connectedness with colleagues in practice, and increased connections with the profession in general.	Barriers include not being able to practice the full scope (specialism in practice), dishonesty of midwives with revalidation process, employers not providing time, space support for education, and educators not wanting to do clinical practice.	Enablers include good communication with clinical staff and students to understand current issues, the desire for clinical credibility, and collaboration with clinical colleagues through projects, committees, or meetings.
Ashrafinia et al., 2022 [33] Iran	Explanation of the Midwifery Lecturers’ Experiences of the Challenges in an Undergraduate Midwifery Program: A Phenomenological Study	Qualitative	8	NA	Midwifery Educators	There was a lack of clinically experienced teachers. This needed to be improved so the clinical skills of students could align with international standards.	Some educators have completed consecutive undergraduate and doctoral courses so don’t have any clinical experience.
Shikuku et al., 2024 [23] Kenya & Nigeria	Evaluation of the feasibility of a midwifery educator continuous professional development (CPD) programme in Kenya and Nigeria: a mixed methods study	Mixed	108	20 h of free, self-directed online modules and 3-days of face-to-face practical sessions including selected EmONC skills	Nursing and Midwifery Educators	The intervention updated and improved educator’s knowledge, skills and confidence in teaching.	Barriers included maintaining the quality and academic integrity of education programs, bias in the selection of educators to attend workshops, and courses being too short and therefore inadequate time to learn. Also not having adequate in-country trainers to deliver the practical component of CPD, and a lack of funding.	Enablers included flexibility of employment, the personal commitment by educators, policy framework for mandatory midwifery educator specific CPD programme, regular, ongoing CPD programs available, peer-support learning, and one-to-one support from facilitators during trainings.
Shikuku et al., 2022 [24] Kenya	Improving midwifery educators’ capacity to teach emergency obstetrics and newborn care in Kenya universities: a pre-post study	Quantitative	30	Four-day training to strengthen the capacity of educators to deliver EmONC	Midwifery Educators	The intervention improved the educators’ knowledge, skills and confidence to deliver the updated EmONC-enhanced curriculum		To ensure that midwifery educators maintain their competence, there is need for structured regular mentoring and continuous professional development.
Doherty, 2017 [27] United States of America (USA)	The Experience of Nurse-Midwives in Teaching Roles	Qualitative		NA	Nurse-Midwife Educators	Some educators tried to juggle full-time teaching with their own clinical hours which was very difficult.	Barriers included high workload and not having enough time to engage in clinical practice, and the expectation from the university to produce scholarly work. Also, a poor understanding of teaching role by clinical colleagues.	Significant previous experience
Collington et al., 2012 [12] United Kingdom	Supporting the midwifery practice-based curriculum: the role of the link lecturer	Mixed	228	Link Lecturer role	Midwifery Educators	Midwife educators’ engagement with practice is variable and is determined by the particular organisation model used. 51% of respondents were unable to complete the expected 20% of time in clinical practice.	Barriers included travelling long distances, not enough time, preference for research activities, and lack of support from the university	Many educators wanted to have clinical credibility and be up to date in practice.
Vuso & James, 2017 [17] South Africa	Effects of limited midwifery clinical education and practice standardisation of student preparedness	Qualitative	17	NA	Midwifery Nurse Educators	The inconsistent clinical practice and assessments of midwifery educators led to students not learning the necessary skills required.	Educators believing the clinical staff are not clinically competent	Suggested enablers included working hand-in-hand with clinical supervisors, scheduled teachings and good communication between educators and clinical department.
Sebach, 2024 [42] USA	Psychometric Testing of a Tool to Assess Midwifery Clinical Educator Skill Acquisition	Quantitative	143	Academic Clinical Nurse Educator Skill Acquisition Tool	Midwifery Educators	Educators reported lowest confidence with applying theory to clinical practice during clinical nursing education experiences. Reported high level of confidence with demonstrating clinical expertise.
Mills, 2007 [13] United Kingdom	Midwifery lecturer-practitioners’ (MLPs) views and experiences of their role and responsibilities	Qualitative	Not stated	NA	Midwifery Educators with MLP role	The role of the MLP is complex, and fraught with aspects of role conflict and ambiguity.	Inter-role conflict, high workload, role overload, lack of support from clinical colleagues.	Desire for clinical credibility
Lakhani et al., 2017 [26] Pakistan	Implementation of a Bachelor’s in midwifery programme in Pakistan: Reflections of Midwifery Faculty	Qualitative	6	A series of professional development activities preceding enrolment of the first batch of midwifery students	Midwifery Educators	Twenty per cent of each teacher’s time was allocated to clinical practice to build and maintain midwifery competencies.	Midwifery care was not possible at the university hospital, so educators had to go elsewhere for clinical	Dedicated time in clinical practice, and individualised plans for each faculty member to guide and monitor their progress. International experts were utilised.
Goodman et al., 2006 [18] United Kingdom	A South-West regional survey to identify education staff development needs in clinical skills and practice	Mixed Methods	426	NA	Nursing and Midwifery Educators	Educators teach a limited range of clinical skills, have less confidence in teaching skills in practice, minimal experience in working in practice settings and difficulties in engagement in practice. They experience role diversity and a wide variation in meeting clinical demands for clinical competence. 43% stated they have worked between 0 and 14 days in the last year in practice settings, and 22% stated between 15 and 28 days.	Incorporation of midwifery into Higher Education settings, lack of clinical practice and limited access to it. Forced to choose between practice and education, high workloads. Feeling of already being de-skilled	Importance of practice being recognised and greater support from education institutes and clinical practice sites.
Fraser, Avis, & Mallik, 2013 [28] United Kingdom	The MINT project—An evaluation of the impact of midwife teachers on the outcomes of pre-registration midwifery education in the UK	Mixed Methods		NA	Midwifery Educators	Midwifery educators immersed in practice had an impact on student learning in both the university and practice settings. These teachers brought reality to the classroom, and ensured through tripartite discussions that teaching and assessment for students in practice were appropriate and fair.	Teaching role always took priority, juggling teaching, research and clinical practice, not having allotted time for practice	Fear of being out of touch, different roles within teams so could prioritise activities accordingly
Fowler, Baker, & Geraghty, 2017 [14] Australia	Is faculty practice valuable? The experience of Western Australian nursing and midwifery academics undertaking faculty clinical practice - A discussion paper	Qualitative	3	Faculty clinical practice model	Nursing and Midwifery Educators	Uptake of this model among academic staff has been minimal. Remaining clinically competent benefits student learning, progression in academic promotion, credibility and the strengthening of relationships in industry and the community, and personal satisfaction.	Minimal support from the university and clinical staff, one day a month is not sufficient, not having enough time, resistance from clinical staff, anxiety and apprehension prior to clinical practice, lack of understanding of role from clinical staff	Collaboration and collegial relationships with clinical staff, regular clinical practice, clearly defined learning objectives, strong sense of needing to direct one’s own learning experience
Cook, 2006 [19] United Kingdom	The value of clinical practice to senior lecturers in higher education	Qualitative	7	NA	Senior Midwifery Educators	Those midwifery educators involved in clinical practice perceived it to be valuable in terms of informing teaching activities and increasing confidence as opposed to those not directly involved. Four of the educators had involvement in clinical practice whilst 3 did not		Liaison with clinical practitioners, involvement in midwifery committees, miss the contact with women, fear of losing clinical skills
Bogren et al., 2019 [25] Bangladesh	Build professional competence and equip with strategies to empower midwifery students – An interview study evaluating a simulation-based learning course for midwifery educators in Bangladesh	Qualitative	17	Four-day simulation-based learning course	Midwifery Educators	Participation in the simulation-based learning course equipped the midwifery educators with practical skills and how to teach these manoeuvres. The course had also inspired self-reflection and the desire to learn more.	Four days was not enough time to learn new ways of doing things.	Using simulation when clinical practice was not available, self-reflection and inquisitiveness of educators, training prior to teaching and repetitive in-service training, utilising international experts
Bogren, Kaboru, & Berg, 2021 [35] Democratic Republic of Congo	Barriers to delivering quality midwifery education programmes in the Democratic Republic of Congo — An interview study with educators and clinical preceptors	Qualitative	85		Midwifery Educators and Clinical Preceptors	There was no continuing professional development offered to educators. Some had taken a one-off course in simulation-based learning pedagogy, but it was reported as not good, and difficult to maintain knowledge without continuous practice.	Not having access to clinical equipment or simulation-based learning equipment, hospital being partially destroyed during political conflict, shortage of midwifery educators, one-off courses	Continuing professional clinical development
Thomas et al., 2010 [34] Global – 49 countries	Sharing best practices through online communities of practice: a case study	Qualitative	273		Midwifery Educators	Midwifery educators lack the competencies required to assess student competencies. Many educators are not providing clinical services.		Consider job-based training and e-learning, resources to be relevant to context.

Synthesis

We employed content analysis to synthesise and report the findings in relation to our review objectives. Of the 21 sources of evidence included in our review, twelve used qualitative methodologies, three used quantitative, and six used a mixed-methods approach. Quantitative data in the sources predominantly focused on educator skills scores and confidence levels.

Results

Seven out of the 21 sources were from the United Kingdom (UK). The remaining sources had broad geographic spread and included Nigeria [3], Kenya [3], United States of America (USA) [3], and one each from Iran, South Africa, Pakistan, Australia, Bangladesh, and Democratic Republic of Congo (DRC). One report included multiple countries in both Africa and Asia, and one regional report from Africa. We have presented our findings against our review objectives of identifying the ways in which midwifery educators maintain clinical competence, and the barriers and enablers that influence midwifery educators maintaining clinical competence.

Ways of maintaining clinical competence

Various strategies were discussed when it came to midwifery educators maintaining clinical competence. These strategies fit into three broad categories: [1] incorporating regular opportunities for clinical practice into educator’s roles at education institutes; [3] workshops and training programs for midwifery educators; and [2] midwifery educators engaging in hands-on clinical practice at hospitals.

Four sources identified specialised roles used by educational institutes to support midwife educators to maintain their clinical competence [12–15]. One study from the UK discussed the role of a Link Lecturer which encouraged educators to spend 20 per cent of time in the practice setting supporting students [12]. Two other studies from the UK described roles that were joint hospital-university appointments, using the titles Midwifery-Lecturer Practitioners and Joint Appointees [13, 16]. While these three studies focused on supporting students in the clinical environment, the Faculty Clinical Practice Model, discussed in an Australian study, provided dedicated time for educators to work alongside clinical staff in the clinical environment where the students were placed to support their own learning and development [14]. No other included studies mentioned how much, or if any, of the midwifery educators’ teaching role required them to spend time in clinical settings. However, whilst not defined, several studies reported maintaining clinical practice was often up to the individual and how much they personally prioritised it [12, 17–19].

One frequently discussed means of maintaining clinical competence, particularly evident in sources from in low- and middle-income countries (LMICs), was attending workshops and courses that focused on learning and developing clinical skills [20–25]. One such course described was the Access to Clinical and Community Maternal, Neonatal and Women’s Health Services Program which included courses for midwifery educators in Ethiopia, Ghana, Malawi and Tanzania [20]. This program included a six-day Clinical Training Skills course, Basic Emergency Obstetric and Newborn Care (BEmONC) clinical skills updates, and a two-week technical update and clinical skills standardisation course [20]. Prior to attending the in-person component, some of the courses introduced midwifery educators to clinical training skills through interactive computer-based preparatory sessions. This study was one of the few which described provision of follow-up skills updates for the educators. In other studies, workshops and training courses were mostly one-off and short in duration, with no supportive clinical supervision or mentoring available post training [20, 23, 25].

Other training included Training of Trainers (TOT) courses for educators on topics such as post-abortion care which included 24 h of classroom teaching and 16 h of clinical practice [22]. One study included a four-day midwifery simulation-based learning course conducted by international midwifery educators [25], and two other studies conducted training on BEmONC skills using online and face-to-face methods [23, 24]. One study described a one-off program provided by a pre-service training institute whereby educators were provided with a series of professional development activities, including time in clinical practice, to improve their clinical skills prior to starting to teach the first batch of midwifery students [26].

The third strategy identified for midwifery educators to maintain clinical competence was by educators engaging in hands-on clinical practice at hospitals. Apart from the university that offered the opt-in Faculty Clinical Practice Model, this was predominately done in the educator’s own time and required a personal commitment by educators [12, 19, 23], with two studies describing educators undertaking casual shifts at local hospitals [12, 19].

Barriers to maintaining clinical competence

The most frequently identified barrier to midwifery educators maintaining clinical competence was a lack of time allocated to clinical practice [12, 13, 27], 18, 28, 14]. This was due to workload as a full-time educator, role overload, shortage of midwifery educators [29, 30], and employers not supporting time for clinical practice [31]. Educators reported feeling isolated and unsupported by the education institutes to maintain clinical competence [12, 14, 32], and felt that employers valued scholarly work and research more than clinical practice [27, 28]. One study discussed not having access to clinical equipment or simulation labs at their education institute, so they relied on theory when teaching and subsequently lost their clinical skills [29].

Access to professional development opportunities through workshops and training programs was often difficult, or not available, in a number of countries [21, 29]. One study reported the lack of adequate in-country trainers to deliver the practical components of professional development, bias in the selection of educators to attend workshops, and difficulty maintaining the quality and academic integrity of the education programs [23]. For countries where workshops or training were available, many reported these as insufficient in length and therefore providing inadequate time to learn [20, 23, 25].

A lack of resources was frequently discussed as a barrier to maintaining clinical competence, particularly regarding ongoing education and attending workshops. Financing was mentioned in three studies, referring either to a lack of funding to run courses, or participants not being able to afford the costs of attending courses [20, 21, 24]. Lack of technology such as not having functioning laptops or adequate Wi-Fi was also mentioned as a barrier when online learning was offered [21].

Several studies found that when educators undertook clinical upskilling in a hospital as a way of maintaining their clinical competence, there was poor understanding by the clinical midwives about their role as a midwifery educator in the clinical environment, and resistance to their presence by clinical staff [13, 16, 27]. One study reported educators in practice settings being viewed as a hindrance by clinical staff, and concluded that having a supportive clinical environment was much more conducive to encouraging educators to engage in clinical practice [14].

Inter-role conflict experienced when working as a midwifery educator and also working in clinical practice was also identified as a barrier, with educators feeling forced to choose one role, as maintaining both was seen as too difficult [13, 18]. Three studies also addressed the difficulties in adjusting to two different workplaces and cultures [14, 16, 18]. The reality for some educators was that there were no clinical practice facilities that offered midwifery services nearby for them to access [26]. In the Democratic Republic of Congo, political conflict had meant that the local hospital had been destroyed and hadn’t been rebuilt [29]. This meant that both students and midwifery educators did not have access to an appropriate clinical site.

The attitude of educators influenced how much value was given to maintaining clinical competence. Educators who had been in the role for some time had the attitude that it was too late to maintain clinical competence as they were already deskilled [18]. Other barriers included initial anxiety and apprehension about clinical practice, although this usually subsided with time [14]. There were also educators who viewed the clinical staff as incompetent in clinical practice so did not see any benefit to working alongside them [20].

Enablers to maintaining clinical competence

Enablers to navigating work as a midwifery educator and maintaining clinical competence included both workplaces recognising the importance and the requirement for educators to maintain clinical knowledge and skills [18, 21], and having flexibility with employment and being able to try different roles [16, 23]. One study reported that the educators had various roles at the education institute so they had the ability to prioritise their own work activities accordingly, including clinical practice [28]. Other enablers included advocacy with stakeholders to increase commitment to improving links between education institutes and practical sites [20], and having good communication between both workplaces [17]. In addition, good communication between educators, clinical staff and students supported educators to understand current clinical issues and therefore maintain clinical competence [19, 31]. Midwifery educators identified collaborations and partnerships as an enabler to maintaining clinical competence, through involvement in various joint projects, committees, and meetings [12, 19, 21, 31].

The importance of regular, ongoing professional development programs being available to educators was regularly discussed and an enabler [21, 23–25, 29]. International partnerships were also reported to be helpful, particularly in countries that did not always have the expertise or resources to conduct training [25, 26]. Clinical training that incorporated peer-support learning and one-to-one support from facilitators, was seen as positive [23]. Individualised Continuous Professional Development (CPD) plans were seen as enabling when educators could choose the particular clinical area they wanted to develop [14, 26]. One study suggested various ways of incentivising the completion of CPD programs as a way to encourage educators to engage more [23].

Policy-level enablers included countries having regulated CPD standards and providing learning opportunities to help with skill development [20]. If CPD standards were in place, one study mentioned the importance of regulating the standards as this ensured compliance [31]. The need for a period of sustained clinical practice was highlighted, as some reported educators having no clinical experience, as policies allowed them to go directly from under-graduate to post-graduate courses, to teaching positions in education institutes [33]. The importance of having access to both local and international guidelines (including from WHO) as a way to encourage clinical competence was also considered an enabler [21].

Many included studies suggested that regular engagement in clinical practice may support maintenance of clinical competence [12, 14, 26, 29]. Regarding the timetabling of this, two studies suggested that consecutive days as opposed to intermittent shifts were better for educators [21], with one study stating that one day a month was not enough and, in fact, reduced confidence and increased anxiety around clinical practice in educators [14]. Educators who were able to undertake casual employment at a hospital enabled them to engage with clinical practice in their own time [12, 19].

When it came to supporting educators who were engaging in clinical practice for their own development, it was important to have clearly defined learning objectives for educators prior to clinical placement to avoid unclear expectations by clinical staff [14]. Suggested ways included educators working together with a clinical supervisor [17], providing opportunities for observation [26] and job-based training [34]. Structured regular mentoring for educators in practice was also mentioned [24].

The attitude of midwifery educators was mentioned several times as an enabler to maintaining clinical competence. The presence of a personal commitment to maintaining clinical practice by the educators was a notable enabler, with many doing it in their own time and of their own accord [12, 14, 15, 19, 21, 23]. The desire for clinical credibility from both students and colleagues was often sought after, and [31].

Discussion

This review highlights many barriers for midwifery educators in maintaining clinical competence, and the variability in their engagement with clinical practice. While the ICM’s Global Standards for Midwifery Education (2021) recommend that midwifery educators have current clinical practice experience, there is a lack of consensus about the best way for educators to maintain clinical competence. Some midwifery educators suggested that staying updated through research and theoretical knowledge of current clinical issues is sufficient [12, 14, 19, 31] while other educators emphasised the necessity of hands-on clinical practice [12, 14, 26, 35]. In several studies, prior clinical experience was considered sufficient, irrespective of how much time had lapsed, with the belief that you never lose the basics [12, 19, 27, 31]. Education facilities often ignored the need for educators to engage in ongoing clinical practice, instead placing importance on educators engaging in scholarly work and research [27, 28], creating silos between academia and clinical practice. Similar trends are noted in nursing, where academic activities are highly valued, reinforcing a hierarchy that sidelines clinical engagement [36].

Prior to 1990, in many countries both midwifery and nursing training was undertaken on the job, akin to an apprenticeship model [37]. With the aim to increase professionalism, training moved into Higher Education institutions [12, 37], however this separation of clinical practice and education has contributed to role confusion for educators [18, 36]. Over the past 30 years, many Nursing and Midwifery Councils have required educators to dedicate time to clinical practice, however implementation and monitoring has been difficult [38]. Challenges include a lack of direction or consensus on time required for maintenance of competence [38].

When clinical competence is not valued by employers, responsibility for maintaining clinical competence falls on the midwifery educators themselves. Studies suggested that those who did engage in clinical practice usually had a strong personal commitment, were self-supporting, and did so in their own time [12, 14, 16, 19, 21, 23]. This is concerning given the high workload of midwifery educators, compounded by the identified workforce shortage [29, 30]. Research published after the date of inclusion for this review also highlights the struggle midwifery educators face with having multiple roles, high teaching workloads, and a lack of support from education institutions regarding maintaining clinical competence [39]. Relying on educators to take responsibility for maintaining their own clinical competence, without employer support or dedicated time within their workload is unsustainable. In contrast, the medical profession integrates teaching, clinical practice, and research, with career progression often involving clinical practice. This integration is supported by professional regulation, as well as joint appointments and shared facilities between medical schools and teaching hospitals [13].

While many studies indicate that maintaining clinical competence requires regular dedicated time in clinical practice [12, 14, 26, 29], there is a lack of consensus around the amount of time required to do this, and the content of this clinical practice. In one study, educators felt that one day a month in clinical practice was not enough, and in fact increased anxiety and reduced their confidence [14]. It is also unclear whether maintaining clinical competence can be achieved by spending time in clinical settings supporting students, or whether it needs to be working as a clinical midwife [12]. These are areas that could benefit from further research and consensus.

Whilst most studies highlighted the barriers faced by educators in maintaining clinical competencies, enablers were also presented. Enablers for encouraging midwifery educators to engage in clinical practice included casual shifts being available at the local hospital, clinical facilities providing structured regular mentoring [24], as well as the opportunity for educators to choose how they engage, whether this was by observation or practice [26]. Clinical mentoring for educators has been discussed in nursing literature [40, 41], however within this review, while clinical mentoring was often discussed as important for students [12, 18, 28], only one study mentioned it as a possible way to support clinical competence amongst midwifery educators [24].

The ICM Global Standards for Midwifery Education: Companion Guidelines (2023) state that midwifery educators should engage in ongoing professional development as a practising midwife. Several studies recognised the importance of keeping up to date with the latest knowledge and research, whether this was in conjunction with clinical practice or not [12, 14, 19, 31]. Our review identified few professional development programs that focused on clinical competence, and those that existed were often limited to one-off workshops on specific skills, such as emergency techniques, typically using simulation equipment rather than real clinical settings. There was broad agreement amongst the included studies that one-off trainings were rarely sufficient in maintenance of competence, but rather the ongoing, continuous aspect of clinical practice was essential [20, 21, 23–25, 29]. Studies assessing clinical competence after training relied on self-reported levels of expertise or confidence [18, 22, 42]. However, there is often a significant difference between self-perception and external evaluation of competence [28]. If clinical competence is a requirement for midwifery educators, further research is needed to establish accurate and reliable assessment methods, as well as on the effectiveness of workshops and simulation versus time in actual clinical practice. It is essential that LMICs are well-represented in future research, as these countries face additional resource challenges and inequities.

Many studies indicated that midwifery educators maintaining clinical competence benefited both themselves and their students [22–24], 28, 14, 19, 25]. This is important as the primary goal of midwifery educators maintaining clinical competence is to enhance teaching effectiveness, and therefore improve the quality of graduating midwives [4]. Educators who engaged in clinical practice reported they felt better prepared and equipped to teach midwifery skills to students [22, 25], had updated knowledge [23, 24], and were more confidence in teaching [19]. Other studies suggested that increased confidence in teaching improved student learning through the educator bringing real-world experience into the classroom, and fostering better communication between students, educators, and clinical staff, making assessments fairer [14, 28]. Further research is needed to assess the impact of clinically competent educators on teaching quality and student outcomes.

Strengths and limitations

This is the first scoping review, to our knowledge, to explore the barriers and enablers influencing midwifery educators’ ability to maintain clinical competence across different settings. The review draws together evidence from a range of countries and study designs, including qualitative, quantitative, mixed methods, and grey literature, providing a broad overview of current approaches and challenges. However, several limitations should be considered when interpreting the findings. As a scoping review, the purpose was to map and synthesise the available literature rather than assess the quality of evidence or determine the effectiveness of specific strategies. The findings therefore reflect reported experiences, perceptions, and approaches described in the literature, rather than evidence of causality or intervention effectiveness.

The included studies were highly heterogeneous in terms of setting, study design, terminology, and how clinical competence was defined and measured. Much of the evidence was qualitative or based on self-reported perceptions of confidence, preparedness, or competence, with relatively few studies including objective assessment of clinical competence or longer-term outcomes. In addition, few studies directly examined the impact of educator clinical competence on student learning outcomes, clinical practice, or maternal and newborn health outcomes.

Terminology used to describe midwifery educators and related teaching roles varied considerably across countries and professions. Despite using broad search terms, some relevant studies may not have been identified. The review was also limited to English-language publications, which may have excluded relevant evidence from non-English speaking settings, particularly LMICs. Although the review aimed to capture global evidence, most included studies were from high-income countries, particularly the United Kingdom. Evidence from LMICs was more limited, despite these settings often facing additional challenges related to workforce shortages, limited resources, and restricted access to continuing professional development opportunities. This limits the transferability of some findings across different contexts.

Finally, grey literature was included to capture a broader range of evidence and policy perspectives; however, the level of methodological detail and reporting quality varied across these sources. In some studies, findings from nursing and midwifery educators were reported together, making it difficult to distinguish experiences specific to midwifery educators alone.

Conclusion

Our scoping review identified three key strategies midwifery educators commonly used to maintain clinical competence: incorporating clinical practice into their roles at education institutes; workshops and training programs; and engaging in hands-on clinical practice at hospitals. Integrating clinical practice into educators’ roles requires the support of both the educational institute and clinical sites to ensure prioritisation and feasibility. Although dual teaching-clinical roles exist in midwifery and nursing, they are often opt-in roles and are not universally available. These roles also vary in purpose, focusing on either supporting students in clinical practice, or educator professional development. Ways to include clinical practice for all midwifery educators with clear learning objectives is an area that requires further research.

Future research should also explore effective strategies to support midwifery educators in maintaining clinical competence and accurate methods for assessing this. While workshops and training programs are valuable for continuous professional development, they are often insufficient for maintaining clinical skills. Research on the effectiveness of ongoing clinical skills updates and creating high-quality programs across countries could provide significant benefits.

Midwifery educators often engage in hospital clinical practice on their own initiative, balancing this with heavy teaching workloads. Finding ways to support regular clinical practice that complements their teaching role is an area requiring attention. As midwifery is rooted in clinical practice, it is important for educators to remain clinically competent to train competent graduates capable of meeting global sexual and reproductive health needs. Our review primarily includes data from high-income settings, highlighting the need for research and implementation of these strategies in low-income settings, where the demand for midwives and educators is greatest.

Authors’ contributions

AF – Conceptualization, Investigation, Data curation, Validation, Formal analysis, Visualization, Writing – original draft BC – Data curation, Validation, Writing – review & editing CSEH – Conceptualization, Supervision, Validation, Writing – review & editing RS – Data curation, Writing – review & editing SBZ – Conceptualization, Supervision, Validation, Formal analysis, Visualization, Writing – review & editing.

Funding

This review was supported by the University of Melbourne and Burnet Institute as part of the Master of Public Health program.

The study was partially funded by the UNFPA HQ as part of the Bill and Melinda Gates Catalytic Leadership Initiative (CLI) grant. UNFPA were not involved in the research – study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

SBZ, RS and CH’s salaries are partially funded by a NHMRC Investigator Grant #2016379.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.