What are the benefits and challenges of mentoring in midwifery? An integrative review.

AIM: The aim of this review was to synthesize best available evidence on mentoring programmes for midwives who have worked within the clinical setting for more than 1 year.
BACKGROUND: Lack of job satisfaction, stress, burnout and limited managerial support contributes to midwifery workforce attrition and the ongoing global shortage of midwives. Mentoring may be one way to improve staff retention, leading to positive clinical and organizational outcomes.
DESIGN: A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute for conducting systematic reviews, was used to develop a search strategy, selection criteria, method for quality appraisal and the extraction and synthesis of data.
METHODS: Relevant articles were sought from the following databases: Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, MIDIRS and Scopus. The search and screening process was guided by the Preferred Reporting Items for Systematic Reviews and Meta Analysis 2009 checklist. Narrative analysis was used to develop four main categories derived from the results from the included studies.
RESULTS: Eight studies were included in this review from which four themes were developed that are relevant to mentoring in midwifery; the impact on midwives' direct environment, their immediate relationships with peers and management, and the overarching influence of the organization directly impact the accessibility and support midwives receive in mentoring programmes.
CONCLUSION: To enhance staff retention in the workforce, midwives require support from the wider organization in which they work. RELEVANCE TO CLINICAL PRACTICE: Understanding midwives' perspectives of mentoring programmes will directly influence the development of midwifery-specific mentoring programmes, which may lead to improved staff retention in the midwifery workforce.

Introduction

What does this article contribute to the wider global clinical community?

While there is increasing recognition of the benefits of mentoring students and graduates, little is known on the benefits of mentoring midwives with more than 1 year of clinical experience.

This article highlights the various benefits and challenges of mentoring programmes from midwives’ perspectives. These findings provide a valuable insight when considering the development of future mentoring programmes within the midwifery clinical setting.

A persistent shortage of midwives continues to be a national and global concern in frontline healthcare.[1,2] Lack of job satisfaction, stress, burnout and lack of managerial support has also contributed to midwifery workforce attrition.[1,3,4] However, evidence suggests effective mentoring can improve staff retention, prevention of burnout, increase job satisfaction and contribute to positive clinical and organizational outcomes.[6-8] For the purpose of this review, the authors have agreed that the term ‘mentoring’ will be used as an umbrella term for other terms, such as supervising, coaching, precepting, assessing and guiding throughout this article, which refers to the nature of an educated/ experienced health professional whom is assisting a midwife who has less education or experience.

Midwives have been identified as one of the key professionals needed for the reduction of maternal and neonatal mortality, due to their ability to provide a wide range of maternal and health services. Homer et al. state that investing in training and retention of highly experienced and skilled midwives could prevent more than 60% of maternal and neonatal deaths. Therefore, there is an urgency to invest in the midwifery workforce to retain quality midwives and enhance clinical outcomes for women and the organization.

One strategy suggested by the World Health Organization is to strengthen the midwifery workforce by maximizing the potential for midwives to undertake ongoing professional development and education, and develop collaborative partnerships. Jarosova et al. and Shen et al. echo this and add one of the leading factors contributing to the retention of midwives is accessibility to professional and career development.

The aim of this integrative review was to synthesize best available evidence on mentoring programmes for midwives who have worked within the clinical setting for more than 1 year. A systematic search, review and synthesis of published peer review articles on Registered Midwives’ perspectives of mentoring programmes in clinical based settings were explored.

Methods

A five-step integrative review approach, published by the Joanna Briggs Institute (JBI) for conducting systematic reviews, was used to source, appraise and synthesize new knowledge using the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) checklist.[13,14] The research question used to generate articles for the literature review was ‘what evidence is available on mentoring in midwifery in the clinical setting’. A systematic search was conducted in November 2020, using five databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PubMed, MIDIRS and Scopus using individual key words and Boolean operators ‘AND’ and ‘OR’. Furthermore, the reference list of the studies retrieved was manually searched to identify any additional studies that did not emerge from the databases searches. The final search string used to yield published articles can be seen in Table 1. Email alerts were set up to rerun search strings; however, no new articles were retrieved between November 2020 and the last search July 2021.

Table 1.

Final search strings.

“Registered midwi*” OR “Obstetric nurs*” OR Midwi* OR “Nurse Midwi* AND Mentor* OR “Peer support*” OR “Buddy midwife program*” OR “Buddy nurse program*” OR “Foster program*” OR “Peer guidance program*” AND Hospital OR “Clinical setting” OR “healthcare”“healthcare” AND (((MH “Midwives +”) OR “Midwife” OR (MH “Nurse Midwifery”) OR (MH “Midwifery”) OR (MH “Lay Midwifery”)) OR (obstetric nurse) OR ((MH “Obstetric Nursing”) OR (MH “Perinatal Nursing”) OR “obstetric nurse”)) AND ((“peer support” OR (MH “Emotional Support (Saba CCC)”)) OR ((MH “Mentorship”) OR “mentorship”))

Study selection

Guided by the ‘Population’, ‘Phenomenon of Interest’ and ‘Context’ (PICo) criteria, a search was designed and undertaken (see Table 2). Inclusion and exclusion criteria were defined and agreed on by all members of the research team. This included primary research published in English language, peer-reviewed journals and articles available in full text. Date criteria were not included to ensure all articles on the topic were screened. Research that focused on mentoring programmes for nurses, students and newly graduated midwives (with less than 1 year experience) was excluded from the study, which resulted in 140 studies (n = 140). A further four (n = 4) articles were found following manually searching of referencing lists. Four (n = 4) duplicates were removed, resulting in 140 studies (n = 140) which were screened by journal, title and abstract. A further 122 studies (n = 122) were excluded due to their inability to answer the research question. In total, 18 studies (n = 18) were retained for full-text screening. After full-text review, 10 (n = 10) studies were excluded due to inability to answer the research question.

Table 2.

Logic grid: ‘What evidence is available on mentoring in the midwifery clinical setting?’.

Population (P)	Phenomenon on Interest (I)	Context (Co)	Inclusion criteria
Registered midwife	Mentor	Hospital	Primary research
Obstetric nurse	Peer support	Clinical setting	English language
Midwife	Buddy midwife programme	Healthcare	Academic journals
Nurse midwife	Buddy nurse programme		Full text
Lay midwife	Foster programme
Perinatal midwife	Peer guidance programme
Obstetric nursing	Emotional support

Quality appraisal outcomes

A total of eight articles (n = 8) were deemed suitable for quality appraisal. Qualitative articles (n = 3) were appraised using the JBI Critical Appraisal Checklist for Qualitative research. Mixed method articles were assessed using the Mixed Methods Appraisal Tool (MMAT) version 2018. All studies were reviewed by K.W. and A.D.L.; if consensus was not reached – a third author, D.B. or S.B., reviewed for article inclusion or rejection. No articles were excluded (n = 0). The search and screening process is presented in Figure 1, adopted from the PRISMA flowchart review process.

Figure 1.

Prisma flow diagram: study selection process for research question: ‘What evidence is available on mentoring in midwifery in the clinical setting?’.

Data abstraction and synthesis

Data abstraction from the literature was guided by Munn et al. approach, which described a method for extracting and categorizing common themes into categories. These were then merged to form four major categories agreed on by all authors, which were used to synthesize what evidence is available on mentoring in midwifery clinical practice.

All of the articles except for McNamara et al. focused on either the effects or midwives’ perspective of being mentored. However, McNamara et al. investigated both the experiences of mentoring from the mentors and mentees perspective. The data abstracted from the eight articles are summarized in Tables 3 and 4.

Table 3.

Summary of included studies – data extraction quantitative studies.

Reviewers	AuthorDateJournalGeographical location	TitleStudy design	Theoretical model	Methods/sampling methods/setting	Measures/instruments	Scoring	Reliability (Cronbach’s alpha)	Validity	Analysis	Key findings
S.B.K.W.	Musabwasoni, M.Kerr, M.Babenko-Mould, Y.Nzayirambaho, M.Ngabonzima, A.2020International Journal of Nursing Education ScholarshipRwanda	Assessing the impact of mentorship on nurses’ and midwives’ knowledge and self-efficacy in managing postpartum haemorrhage (PPH)Pre- and post-quasi-experimental study design	Not reported	Quantitative data123 midwives/nurses surveyed from 68 health centres from Northern Province of Rwanda	1. Study sample characteristics2. Pre-knowledge in managing PPH3. Pre-self-efficiency of management of PPH4. Post-mentorship knowledge in managing PPH5. Post-mentorship self-efficiency6. Number of mentoring visits on knowledge and self-efficiency7. Correlation between pre-mentorship knowledge if associated with pre-self-efficacy and post-mentorship knowledge associated with post-mentorship self-efficacy.	1. 4 items2. 5 items3. 4 items4. 5 items5. 4 items6. 3 items7. 1 item	Not reported	Valid instrument used	Statistical software package for Social Sciences version 25Paired t-testANOVA test.	1. Post-mentorship results revealed midwives knowledge and self-efficiency increased in managing PPH.2. Knowledge and SE correlated moderately positive at pre-mentorship and strongly positive at post-mentorship.3. The number of mentorship visits was positively associated with increase in knowledge and self-efficacy.
D.B.K.W.	Shikuku, D.Mukosa, R.Peru, T.Yaite, A.Ambuchi, J.Sisimwo, K.2019BMC Pregnancy and ChildbirthRural Western Kenya	Reducing intrapartum foetal deaths through low-dose, high-frequency clinical mentorship in a rural hospital in Western Kenya: a quasi-experimental study.Nonequivalent control group pretest–posttest design, quasi-experimental design	Not reported	Quantitative data.13 nurses and midwives survey in experimental hospital compared to control hospital between the periods (pre) Oct 2015–July 2016 and (post) Aug 2016–May 2017	1. Mode of delivery between pre-intervention, during and post-intervention at both intervention and control hospital2. Perinatal outcomes between pre-intervention, during and post-intervention and intervention and control hospital	1. 3 items2. 5 items	Not reported	Not reported	STATA 12	This study demonstrated that through onsite mentoring, nurses/midwives improved their performance of identifying labouring risk factors, =increased in assisted vacuum extractions and management of neonates at risk of birth asphyxia. Therefore, reduction in fresh stillbirths (0.5%–0.1%).1. Assisted vacuum births increased from 0.2%–2.5% during the implementation period at the intervention hospital in comparison to control hospital.2. Breech deliveries halved (1.5%–0.7%) with no change at control hospital.3. Decrease in normal deliveries across both hospitals.4. Increase in referral emergency obstetric and newborn care facility (3.0%–6.5%).5. Increase in live births between both periods (98.9% versus 99.3%).6. Neonates with low APGAR levels requiring resus increased from 1.7% to 3.7%.7. Neonatal deaths halved from 0.5% to 0.3% at the intervention hospital.8. No change in the proportion of macerated stillbirths at the intervention hospital (0.6%–0.6%).9. Increase in macerated stillbirths (0.4%–1.4%) with no change in babies born with low APGAR scores, fresh stillbirths, neonatal deaths at the control hospital.10. No maternal mortalities reported during the two study periods at both facilities.
A.D.L.K.W.	Barnes, M.White, E.Winstanley, J.Reed, R.2013Focus on Health Professional Education: A Multi-Disciplinary JournalQueensland	Clinical supervision and continuing professional development for midwives in Queensland, Australia: Findings from an online survey.Online survey	Not reported	Mixed methods questionnaire. Sample of 316 midwives registered with the Queensland Nursing Council	1. Demographic details including employment and clinical practice status2. Access to professional development and clinical supervision experience and the perceived influence on practice and patient care3. Asked if they were familiar with the concept of clinical supervisor (CS) and if they had received CS, their experience with CSThe participants who had experience with CS were asked to complete the Manchester Clinical Supervision Scale4. Perceived barriers to professional development and clinical supervision	4 items8 items2 items5 items	Not reported	Valid instrument used	Thematic content analysis	1. 87% of midwives reported they had offered CPD opportunities, 69% of those offered financial support.2. 73.9% of midwives indicated that, in practice, there was little or no support for CPD.3. 68% reported familiarity with CS, 43% had never given/received CS during career.4. 56% – CS offered, 17% indicated did not know.5. 65% would be interested in receiving CS if offered, only 8.5% of midwives currently receiving CS.(Further details on results in qualitative table).
A.D.L.K.W.	Roseghini M.Olson, S.2015British Journal of MidwiferyLondon	What do midwives think about midwifery supervision?Online survey	Not reported	Mixed methods questionnaire.188 midwives responded to the survey	1. Qualities of a Supervisor of midwives (SoM)2. Accessing an SoM3. Changing supervisor4. Is supervision a positive process?5. Becoming an SoM	1 item4 items1 item2 items – 1 quantitative and 1 free text1 item	Not reported	Not reported	Thematic analysis	1. Qualities wanted in SoM’s – supportive, accessible, knowledgeable and clinical competent.2. Four midwives have not accessed their SoM, 5.9% of midwives reported it was not easy to access their SoM. 5.9% of midwives also reported they did not consider supervision at the Trust to be a positive process.3. 29.3% of midwives accessed their SoM for reflection and debriefing.4. 62.7% never accessed SoM on call.5. 39% were unaware of how and whether they were able to change SoM.4. 73.4% felt supervision was a positive experience (see qualitative table for more results).
S.B.K.W.	Ojemeni, M.Niles, P.Mfaume, S.Kapologwe, N.Deng, L.Stafford, R.Voeten, M.Theonestina, K.Budin, W.Chhun, N.Squires, A.2017BioMed CentralTanzania	A case study on building capacity to improve clinical mentoring and maternal child health in rural Tanzania: the path to implementationCase study	None	Mixed methods 19 nurse-midwives across two hospitals located in rural Tanzania participated in training. 74% response to post-training survey	1. Demographics of participants2. Self-assessment of clinical competence and barriers to practice within their setting3. Post-training evaluation	2 items2 items11 items	Not reported	Valid instrument used	Not reported	From 74% response rate, 57% of participants were able to demonstrate proficiency on the concepts of mentorship and supervision, provide action plans on how to address challenges on their wards and mentor students and novice nurses.7/14 – reported language as barrier but did not provide specifics.

Table 4.

Summary of included studies – data extraction of qualitative studies.

Reviewer	AuthorGeographical location	Date	Journal	Title	MethodologyMethod	Phenomena of interest setting	ParticipantsData analysis	Summary	Findings/themes
A.D.L.K.W.	Roseghini, M.Olson, S.London	2015	British Journal of Midwifery	What do midwives think about midwifery supervision	Mixed methodsDescriptive studySurvey	Midwives’ evaluation of midwifery supervision	188 midwivesThematic analysis	Most midwives felt supervision was a positive experience.The potential for supervision to enhance practice varies according to the nature of the relationship between midwife and supervisor.Barriers to becoming an SoM are relevant	Majority of midwives felt supervision was a positive process, themes of those who found it a positive experience reported SoMs were supportive, accessible, helpful in providing feedback.‘Sometimes positive experience’ – supervision is variable-dependent on individual SoM.Poor personal experience of supervision included:‘I needed to remind my SoM to meet for my annual review’.‘Often the SoM on-call is the midwife in charge of the shift, I feel like this is a conflict of interest’.‘I don’t believe SoM is useful/necessary as a system to support midwives. I do it because I have to’.Themes associated with becoming an SoM:Experience (not enough/enough)Work/life balance including other commitmentsInsufficient timeApprehension regarding being on-call.
A.D.L.K.W.	Barnes, M.White, E.Winstanley, J.Reed, R.Queensland, Australia	2013	Focus on Health Professional Education: A Multi-Disciplinary Journal	Clinical supervision and continuing professional development for midwives in Queensland, Australia: Findings from an online survey	Mixed methodsDescriptive studySurvey	Identify the extent in which midwives in Queensland were involved with CS and continuing professional development (CPD) as a part of their professional practice	316 midwives registered with the Queensland Nursing CouncilThematic analysis.	Midwives whom received CS reported their experience of CS to be of a non-efficacious quality.Barriers to PD and CS share similar characteristics, lack of support, time, staff backfill and geography, appropriate supervisors and workplace culture	Barriers to CPD included:Lack of time, staff and backfill, lack of support in workplace.Work statusImpact on family commitmentsCost – travel and using annual leave for CPDCasual and junior staff overlooked for CPDGeography issues.Barriers to CS included:Structural impediments (operational workload and staffing issues)CS-specific factors (lack of appropriate supervisors)Institutional context of CS (workplace culture, fear of judgement, management concerns).‘The current health care system; poor interpersonal skills . . . not a conducive learning environment’ (p.7).‘Current work levels so high, it would be impossible with current work and time restraints’ (p.7).‘People may find it (clinical supervision) threatening, as if you are questioning their abilities’ (p.7).
D.B.K.W.	McNamara, M.Fealy, G.Casey, M.O’Connor, T.Patton, D.Doyle, L.Quinlan, C.Ireland	2013	Journal of Clinical Nursing	Mentoring, coaching and action learning: interventions in a national clinical leadership development programme	Qualitative designFocus groupsIndividual interviewsNonparticipant observation	Evaluate mentoring, coaching, action learning interventions used to develop nurses’ and midwives’ clinical leadership competencies and participants experiences of interventions	120 participantsThematic content analysis and Nvivo version 9	Mentoring, coaching and action learning were positively experienced by participants and contributed to the development of clinical leadership competencies.The use of interventions that are action-oriented and focused on service development, such as coaching, mentoring and action learning, should be supported in action learning programmes.	Positive aspects of experiencing mentoring: Viewed mentoring as an intervention suitable for enabling individuals to clarify and examine their clinical leadership development needs in the context of their role.Positive aspects of mentoring; mentor was motivator, ‘she hasn’t given me the answers, [but] she has really made me think and she has dangled the carrot for me to bite, but yet guided and supported me all the way’ p. 2536‘My mentor has been. . .very much focusing on the need to develop myself and the service being developed as a by-product of that’ (p.2536).Valued one-to-one arrangements, having the right person as a mentor.Negative aspects of mentoring:-One participant saw greater merit in having a mentor as a colleague than an assigned mentor.-‘Being a puppet on a string. . .it reined me in a little bit’ (p.2536)- Open-ended time commitment-Mentoring was chiefly concerned with ‘personal development rather than actually looking at service needs’.Mentors experience:-Assisted the mentee to develop-importance of the mentee leading the process-Good mentor qualities; clarity, self-aware and effective listener, balance levels of support and challenge, ongoing communication with mentee, mentor and line manager.-suggestions included need for tripartite meetings with mentor, mentee and line managers and flexibility selecting competencies to reflect individual and service needs.Experience coaching-respective roles of coach and coachee – up to the coachee to find answers-coaching arrangements are more structured than mentoring-choosing the coaching intervention based on needing someone outside of personal workplace.-Having a scared space to discuss real issues-assisted with communication-linking coachee’s current position in terms of competency and developing a plan to achieve competency
									‘The nature of the personal awareness work achieved in developing the competency involves shifts in personal beliefs and attitudes that enable information to be put into action. This learning can be applied in all aspects of the coachee’s (mentee’s) professional and personal life. . .’(p.2538)-cancelled appointments, geographical distance, lack of time to conduct coaching.-a threat to effective coach was when personal and emotional issues emergedExperiencing action learning-Participants saw action learning as valuable for emphasis on action, a way of finding ‘some way forward towards [problem] resolutions and be able to work on that’ (p.2538)-Action learning sets required good group facilitation to develop group dynamics and promote participant engagement in learning and problem-solving.
S.B.K.W.	Ryan, A.Goldberg, L.Evans, J.Canada	2010	Journal of Clinical Nursing	Wise woman: mentoring as relational learning in perinatal nursing practice	Qualitative feminist phenomenological studyOne-to-one interview, practice observations and reflective journal	Exploring how perinatal nurses engage with each other and engage with birthing women on a journey of learning in perinatal nursing practice. Exploring the contextual, lived experiences of informal mentoring relationships within perinatal nursing	Five midwives from labour and birth (midwives)Thematic analysis, feminist phenomenological analysis	Four themes emerged: the meaning of nurse-to-nurse mentoring, mentoring as embodied learning, contextual understanding of nurse-to-nurse mentoring, mentoring as relational learning. Expert perinatal nursing knowledge develop within positive mentoring relationships between perinatal nurses practicing with birthing women. Learning extends beyond tasks to holistic understanding of clinical situations within specific health and social context. The mentor models positive perinatal nursing practices and creases a sense of enthusiasm that harness the raw passion new nurses often have for the profession.	‘Becoming’ developing the skills to engage with the birthing woman. Midwife–woman relationshipRelational learning transpires between and among midwives’ and birthing women.Relational learning transpires among midwives themselves, between mentors and mentees in complex health, social and gendered contexts.-learning occurs when other midwives observe each other interacting with a birthing woman.-Learning occurs without the presence of the birthing woman – mentees/mentors share their experiences of birth women to seek advice/validation from colleagues.-Obtaining counsel from nursing colleagues when caring for birthing woman.-The birthing woman is central text in which the mentees and mentors share their relational learning space.-Collegiality, respect, openness to ideas and believing in others key to supporting nurses in practice.-Mentees emphasized the focus on how the mentors enabled the mentees to build relationships with labouring women.-Connection to the heart that provides meaning and purpose to perinatal nursing practice – sense of intrinsic value and self-affirmation.-All the midwives cited a mentee and a mentor’s passion for and commitment to perinatal nursing practice as integral to supporting a positive mentoring relation and for supporting positive relations with birthing women.-The notion of reverence enacted in perinatal practice when a nurse elicits deep respect for the birthing woman and her family creates a sense of excitement, enthusiasm and passion new nurses often have for the practice.
S.B.K.W.	Ojemeni, M.Niles, P.Mfaume, S.Kapologwe, N.Deng, L.Stafford, R.Voeten, M.Theonestina, K.Budin, W.Chhun, N.Squires, A.Tanzania	2017	BioMed Central Journal	A case study on building capacity to improve clinical mentoring and maternal child health in rural Tanzania: the path to implementation	Mixed methodsCase studySurvey	Describe the development and implementation and evaluation of a mentoring and supervision training programme aimed at midwives to improve maternal child health across two hospitals in Tanzania	19 nurse-midwives completed the training14 midwives completed evaluation survey	57% of participants were able to demonstrate and provide examples of the concepts of mentoring and supervision at 4 and 11 months post-training. Participants indicated with confidence in skills was not lacking, barriers to providing quality care lay mostly in understaffing.	Pre-programme self-assessment forms of clinical competence and barriers to practice in their hospital.Midwives from both hospitals self-reported they were confident in their skills to provide competent care to both pregnant women and their newborns.Barriers to practice within their full scope:-lack of staffing-lack of resourcesPost-training evaluations comments on new knowledge acquired on:-Mentoring-Clinical case management-Newborn resuscitationComments on the climate was conductive to learning and students felt comfortable to engage and ask questions57% able to demonstrate proficiency on the concepts of mentorship and supervision, provide examples of action plans to address challenges on their wards and mentor students and novice nurses.-Highlighted workforce shortages, lack of professional development for themselves and co-workers as impediments to their professional practice.
A.D.L.K.W.	Deery, R.England, United Kingdom	2005	Midwifery	An action-research study exploring midwives’ support needs and the affect of group clinical supervision	QualitativeAction-research studyIn-depth interviews, focus groups and workshop sessions	Explore community midwives’ views and experiences of their support needs in clinical practice.	Eight National Health Service community midwives working within the same teamVoiced centred relational data analysis/feminist approach	Ongoing organizational change and increase in demands on midwives by managers are found to be determinantal to the process of clinical supervision and working relationships with peers and clients. As well as inhibiting the process of change.	Emotion work associated with the job is not acknowledged or understood by midwives, managers or wider organization.Team midwifery – increasing workload and stressProfessional power is detrimental to working relationships with clients and peersPseudo-cohesion and resistance to change were key defence mechanisms used by participating midwivesMidwives are overwhelmed by the increasing workloadsMidwives feel unsupported, isolatedClinical supervision was perceived as beneficial; however, midwives stated they had no time to undertake the process, viewing it as more commitment and hassle alongside the increasing demands from the organization.

Results

Authors would like to acknowledge that three of the eight articles included in this study; Barnes et al. used clinical supervision as a term for professional and personal development to support midwives within the clinical setting. These articles were included in this review, as the authors felt that any support, either professional, personal, or emotional could be considered as mentoring within this particular context. Furthermore, the term nurses and midwives were used interchangeably across four studies, three of which did not distinguish whether the participants were nurses or midwives but referred to them as a group; Musabwasoni et al., Ojemeni et al., and Shikuku et al. In addition, Ryan et al. referred to midwives with the term as ‘perinatal nurses’; therefore, these studies were included in this literature review as they all referred to midwives as health professional responsible for caring for women during the childbearing period and their newborns. Furthermore, it would like to known the location that the studies were taken place was noted; three studies were conducted in Africa,[6-8] two were conducted in the United Kingdom,[21,22] one conducted in Ireland, one in Canada and one in Australia.

Four categories were identified through the process of data extraction and synthesis. These represent what is known to date on mentorship for midwives in clinical practice.

Category 1: Mentoring in midwifery facilitates effective learning and development

Findings in three of the eight articles reviewed clearly suggest that mentoring is multifaceted and assists mentees’ to translate the learning they encounter from practice into personal and professional growth.[18,20,21] These learning moments occur through relational and action processes and through feedback gleaned through reflection and debriefing. Relational learning can be defined as the relationship between midwives’, birthing women, women’s families and midwife colleagues as a journey of learning and midwifery professional development. Learning can occur through observation (such as midwives observing each other interacting with a birthing woman), sharing past experiences or seeking advice from other midwifery colleagues. This is then complemented by action learning, in which individuals focus on developing skills, their relationship to real-world practice problems and by employing actionable solutions to improve their competence. McNamara et al. highlighted that midwives’ felt action learning was a valuable tool as its emphasis is an action and ‘finding a way forwards towards [problem] resolutions’ (p.2538), and group discussion is helpful to facilitate this learning.

According to McNamara et al., mentoring can help midwives determine where to ‘find’ relational learning opportunities and how to action its application in practice. Mentoring is also considered a comprehensive tool for evaluating midwives’ current position in terms of competencies and for developing a plan to reach the mentees goals. McNamara et al. suggest this can be achieved by the mentor providing the mentee with the necessary tools, guidance and support to find solutions to achieving those goals themselves.

Category 2: Mentoring positively impacts clinical and organizational outcomes

Three of the eight articles reviewed, reported that mentoring positively impacts the organization and the clinical outcomes of healthcare consumers.[6-8] Musabwasoni et al. administered a post-mentorship questionnaire with midwives who participated in a mentoring programme that aimed to improve the knowledge and self-efficacy around the management of postpartum haemorrhage (PPH). Results revealed a statistically significant increase in midwives’ overall knowledge and self-efficacy in the management of PPH. Furthermore, the number of mentorship visits attended was also associated with midwives’ scoring higher levels of post-mentorship knowledge and self-efficacy scores. These findings resonate also with the participants in Shikuku et al.’s study regarding mentoring within the workplace, suggesting mentoring programmes not only improved the ability to identify risk factors in labouring women but also reduced the proportion of stillbirths fivefold, from 0.5% to 0.1%, during the intervention period. Similarly, midwife participants in Ojemeni et al. study reported acquiring new knowledge in clinical case management, neonatal resus and mentoring other novice midwives’; this led Ojemeni et al. to conclude that mentoring provided a conductive climate to engage and ask questions that led to the improvements in clinical practice.

Periodically, mentoring is solely focused on personal development rather the needs of service providers. In addition, McNamara et al. proposed this also benefits the organization, as tripartite meetings between mentor, mentee and the line managers may assist in developing and selecting clinical leadership competencies to reflect both individual and service needs.

Category 3: Positive mentoring experiences are dependent on the relationships built between the mentee, mentor and the organization

This category highlights that positive experiences of mentoring were closely dependent on the individual mentor.[18,20-22] This was exemplified in four of the articles reviewed, which reported on the challenging aspects of mentoring from a mentee midwife perspective. The inability to choose their own mentor, conflicts of interest when the mentor was the midwife in charge, and lack of accessibility were all challenges reported by midwives. ,19,[21,22] The importance of having the right person as a mentor and the importance of a good mentor–mentee relationship was pivotal to the success of the mentoring programme.

Midwives experienced positive mentoring when the mentor was motivational, supportive, accessible, knowledgeable, clinically competent and helpful with providing them with feedback. Personal attributes of a mentor were also important to the midwife and included clarity, self-awareness, effective listening skills, providing support for the mentee and ongoing communication between mentee, mentor and line manager. The study by Ryan et al. echoes this, adding that midwives benefit from their mentor possessing heartfelt passion, a commitment to mentoring and the midwifery profession as a whole.

Additionally, midwives’ highlighted that having the ability to choose their own mentor, either outside their place of work or within the organization contributed to midwives’ motivation to access their mentor for support. Midwives’ ability to choose their own mentor outside the workplace also reduced the issue of conflict of interest, highlighting that professional power can be detrimental to the mentor–mentee relationship.[18,22]

Category 4: Mentoring is not prioritized by midwives or their workplaces

The findings in this category identified the barriers midwives experience towards accessing, mentoring or continuing professional development programmes (CPD).[8,18],19, The operational barriers identified as inhibiting midwives’ ability to participate in mentoring and CPD programmes included lack of managerial support, lack of appropriate mentors, toxic workplace culture, fear of judgement, workplace shortages and increasing workloads. ,19, Difficulties accessing mentors and limited awareness of the option to change mentor were also the factors that contributed negatively to the mentoring experience. As one participant in Barnes et al. study stated, ‘the current health care system [is] . . . not a conducive learning environment’.

Even though mentoring was perceived by participants in three of the studies reviewed as beneficial, midwives stated they had no time to undertake the process, viewing it as another commitment alongside increasing demands from the workplace. ,19, Also noted were issues that some midwives did not consider it useful: midwives expressed they did not believe mentoring was useful or necessary as a strategy for supporting them.[18,21] McNamara et al. reports one midwife remarked on the experience of feeling like a ‘puppet on a string’ in the mentoring relationship, further commenting, ‘I felt it reined me in a little bit’ (p.2536). Roseghini and Olsen concurs with these findings, reporting one midwife stated, ‘I don’t believe a SoM (Supervisor of Midwives) is useful/necessary as a system to support midwives. I do it because I have to’ (p.663).

Discussion

The findings reported in this review represent the immediate and overarching factors that influence the uptake of mentoring programmes by midwives working in clinical areas. Bronfenbrenner’s Ecological System Theory, which focuses on the interrelatedness of microsystem, mesosystem, exosystem and macrosystem influences on humans,[24,25] provides the underpinning framework to explain our findings. The midwife is placed in the centre and is influenced by the microsystem (which consists of midwives’ immediate environment), the mesosystem encapsulates the microsystem (which comprises the interrelations and relationships of the microsystem, midwives’ colleagues and immediate management) and the overarching exosystem (which is the health organization or commonly known as the sphere of influence, in which the midwife works). The macrosystem (which can include the socioeconomic status, geographical location and the ideologies of the culture) that can influence the midwife, however for the purpose of this review, will be excluded.

Microsystem

Within this inner-most system, the findings labelled ‘Mentoring is not prioritised by midwives or their workplace’ represent the micro considerations that impact midwives’ participation and uptake of mentoring programmes within the clinical midwifery profession. In comparison to the literature, the findings of our study concur with Geraghty et al., Mollart et al. and Sidebotham et al., which report on the increasing demands and workplace shortages that are felt by midwives within the profession. Findings from our study highlighted that under the current working conditions, midwives are struggling with workloads due to these shortages, often, leading to burnout and stress. It is reasonable to assume that their motivation and capacity to participate in mentoring programmes is compromised as a result. This also resonates with work from Catling and Rossiter, who report that current staffing levels negatively impact the provision of standard of care to women and their families. Sterry suggests that for midwives to participate in restorative clinical supervision (RCS) programmes (i.e. mentoring programmes), ‘systems need to be in place to allow staff release from clinical duties and a professional midwifery advocate (mentor) needs to be available at an appropriate venue or ‘safe place’ to . . . conduct the RCS session’ (p163).

Furthermore, the impact of mentoring on midwives’ environment also falls into the microsystem. The findings from our study highlighted that mentoring has the ability to improve individual, clinical and organizational outcomes.[6-8] These findings are consistent with Zannini et al., who confirm that mentoring programmes create a sense of professional growth and development. More recently, Ajorpaz et al. suggest there is a direct correlation between mentoring and improvement of clinical competence in the areas of foundational skills and knowledge, leadership, collegiality, professional development and overall perceived competence in perioperative student nurses. Zhang et al. and Davey et al. concur with these findings, concluding that mentoring enhances nursing competency, career development opportunities and establishing a supportive workforce environment, resulting in positive outcomes for the individual, clinical and the organization.

Mesosystem

Within midwives’ mesosystem, interrelations and relationships within the microsystem were found to either inhibit or assist midwives’ motivation and ability to participate in mentoring programmes. A toxic workplace culture and lack of support from management were perceived to be barriers for midwives to participate in mentoring programmes. ,19, These findings are inconsistent with the evidence found by Horgan et al. who report that even though senior management perceived clinical leadership of high importance in relation to other staff, in the study conducted by Barnes et al., midwifery participants identified a lack of support to participate in mentoring/clinical leadership opportunities from direct management.

Furthermore, the finding of the review reported in this article found that the relationship between mentor and mentee heavily influenced the midwives’ perception of mentoring programmes. Midwives reported mentoring as a positive experience when the mentor possessed personal attributes, such as and not limited to, effective listening skills, supportive, motivational and clinical competence.[18,21] This findings from our study concur with Ward et al., who suggest that the mentors role ‘consists of providing . . . expertise, support and encouragement, and open and honest feedback’ (p3). This also resonates with other work from Zhang et al. who confirm that a satisfactory mentor and mentee relationship is a pivotal factor to an effective mentoring programme. It is evident that midwives’ direct and indirect relationships heavily influence the effectiveness of mentoring programmes.

Exosytem

The exosystem sphere of influence is concerned with the formal and informal overarching structures that indirectly influence the midwife. The findings from our review suggest organizational buy-in was one of the pivotal factors that influenced the success of mentoring programmes, which were also reflected in work published by Davey et al., Elliot et al. and Zhang et al. Jackson et al. and Zhang et al. also highlighted the lack of institutional support as one of the main barriers to effective mentorship programmes. Furthermore, Elliott et al. suggest that without organizational support, service development through mentoring programmes, resulting in development of the midwifery profession, will not be realized. Zhang et al.’s systematic review on the effectiveness of mentoring programmes for newly graduate nurses reported that, when the organization supported mentoring programmes, registered nurses (RN) turnover costs and staff retention rates translated into significant financial savings for the organization and hospital.

Limitations

This integrative review explored what evidence was available on mentoring for midwives in the clinical setting. While an exhaustive database search was undertaken, there is a possibility that articles in journals not indexed in the search databases were missed. Studies published in other languages other than English were excluded, potentially resulting in missed studies from different contexts. It is acknowledged that due to the date parameters used for the database search, some articles may have been missed. Furthermore, the underpinning framework used to describe the categories from the data abstracted from studies may underrepresent the results from each study.

Conclusion

The aim of this research was to synthesize best available evidence on mentoring programmes for midwives who have worked within the clinical setting for more than 1 year. The findings of this review highlight the need for organizational buy-in of mentoring programmes, which involves recognition of the role and formal protection of time for mentors and midwives to participate in mentoring programmes. Recommendations for further research include investigating and identifying the specific support mechanisms that midwives believe are essential for the development and implementation of a successful mentoring programme for clinical midwives. Furthermore, identifying how maternity healthcare organizations can assist with providing midwives with the necessary support to participate and implement mentoring programmes within the clinical setting.

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Supplemental material, sj-docx-1-whe-10.1177_17455057221110141 for What are the benefits and challenges of mentoring in midwifery? An integrative review by Krystyl Wissemann, Dianne Bloxsome, Annemarie De Leo and Sara Bayes in Women’s Health