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The content of midwifery courses is very similar across universities. The teaching approach is not, with universities adopting a variety of pedagogical methods.
Aim
To explore views of midwifery students, midwifery academics and senior academic managers comparing a continuity approach where one main academic provides the majority of midwifery content plus pastoral care compared with a team-teaching approach of midwifery education where lecturers change throughout the course.
Methods
Semi-structured interviews and focus groups were used to discover thoughts, benefits and disadvantages of two teaching approaches. Data were analysed using thematic analysis.
Findings
Midwifery students and academics valued relationship building, consistency of advice and assessment expectations of the continuity approach but also appreciated a variety of teaching styles and content found in the team-teaching approach. Senior academic managers favoured a team-teaching approach due to workload concerns.
Discussion
Continuity and team-teaching pedagogical approaches offer different advantages. Continuity in midwifery education may provide students with a meaningful trusting relationship with their teacher and consistency of information, which could aid learning. A team-teaching approach provides students with diversity of teaching styles and midwifery ‘stories’. A combination of both pedagogies offering both a mix of teachers and a named ‘go-to’ mentor might help meet student requirements for both continuity and variety.
Conclusion
Relationship building, consistency and trust, were all evident in the continuity approach whereas the team-teaching approach was considered to be a more sustainable workload model.
Midwifery courses are demanding. It is useful to evaluate teaching approaches to aim for continual ongoing improvement of the student experience.
What is already known
Continuity of midwifery care is known to advantage women and midwives, in part due to relationship building. No such model has been described between student midwives and their teachers.
What this paper adds
Evidence that midwifery students appreciate building a trusting relationship with midwifery academics but also value a variety of midwifery academic experiences (‘stories’). Midwifery academics can see the advantage of teaching over the whole curriculum but understand the stress of remaining knowledgeable over all subjects. Senior academic manager concerns focus on achieving manageable staff workloads. A combination of both approaches is proposed to offer students variety in teaching but with a named mentor to provide support throughout the whole course.
Introduction
Women have demonstrated a preference for continuity of care by a midwife for the duration of their pregnancy, birth and postnatal period [
]. The continuity of care model results in enhanced maternal and neonatal outcomes and also improved maternal satisfaction, partly due to the relationship between mother and midwife, developed over the childbirth journey [
]. Similar recognition of the importance of continuity models is held by midwives, who describe this way of practice as philosophically aligned, contributing to sustainability and work-satisfaction [
The emotional and professional wellbeing of Australian midwives: a comparison between those providing continuity of midwifery care and those not providing continuity.
]. Australian student midwives understand the special relationship as they are required to recruit and follow at least ten women during their entry to registration midwifery course, as specified by the accrediting body, the Australian Nursing and Midwifery Accreditation Council [
]. In contrast, students enroled in Australian midwifery courses do not usually have continuity of lecturer or cohort leader but instead are taught by a team-teaching approach, where students are exposed to many lecturers, tutors and clinical facilitators across the course.
A continuity approach to education is most commonly seen in primary schools, with one class teacher taking responsibility for the education of children within one class over the most of the curriculum for one year [
]. The continuity approach changes when children enter secondary school, where they are taught by subject specialists and this changed model continues into tertiary education, with different unit (subject) coordinators, lecturers and tutors all contributing to student learning.
], but there is no overarching cohort leader. This multi-lecturer approach was used for the ‘team-teaching’ arm of our study. The cohort leader is defined as being similar to the concept of the ‘class teacher’ where one lecturer becomes the ‘go to’ person for students for pastoral issues. The cohort leader follows a cohort of students from the first to last day of the course, providing the majority of the midwifery content across the entire course (programme) for a cohort of students, with additional interprofessional and multidisciplinary lecturers for specialist subjects. The continuity approach has not been defined in the literature; for this research project participants were provided with the description of ‘cohort leader’ as defining the continuity model.
When our university was developing a new midwifery course, senior academic managers, midwifery academics and students were invited to give their views on a preference for the continuity approach or team-teaching approach. Although there is little evidence comparing the team-teaching approach with a continuity approach in midwifery education, other areas of education have compared team-teaching with individual teaching and reported mixed results [
The aim of the study was to explore the views of midwifery students, midwifery academics and senior academic managers regarding continuity approach compared with one using a team-teaching approach.
Methods
A qualitative exploratory design was used to offer in-depth insight into participant interpretation of particular views, including thoughts, benefits and disadvantages [
]. Ethical approval was obtained by Curtin University (HRE2019–0531) and there were no conflicts of interest.
Between December 2017 and March 2021, a purposive sample of midwifery students and midwifery academics and senior academic managers were invited via email and learning management system postings to participate in separate focus groups. Senior academic managers were invited by email to individual interviews. The midwifery academic and student focus groups and interviews were held face to face at the university. Open ended questions were asked to provoke discussion and description. All participants were provided with an information letter, including a description of the researchers’ motivations for undertaking the study, and verbal consent was provided by them prior to their agreement to participate in an audio recorded interview/focus group.
Three student focus groups (total 26 students), 2 midwifery academic focus groups (total 4 participants) and two separate senior academic manager interviews took place. As the participants were midwifery students and the investigation team included midwifery teaching staff an academic not involved in their teaching conducted the focus groups with the students. A non-midwife member of the research team conducted the midwifery academic focus groups, while a midwifery academic conducted the interviews with senior academic managers. All members of the research team are female and are experienced researchers (PhD qualified). Focus group/interview guides with 2 main open-ended questions were used: firstly, explain your views regarding a continuity approach and secondly explain your views regarding the team-teaching approach. Additional prompts were used if required. Focus group/ interview times ranged from 20 to 50 min, with only the participants and the interviewer present.
Participants
The student focus groups comprised one beginning semester group and two final semester groups of a post-graduate 18-month midwifery course, in which all the students were previously nurses. All end of course students had received the team-teaching approach for their midwifery education. The members of the academic focus groups varied in midwifery education experience from between 3 and 15 years and all taught midwifery; one senior lecturer and 3 lecturers. The senior academic managers included one midwife and one nurse, both of whom were in senior management positions in the school, a professor and associate professor. All participants (students and academic combined) apart from one were female, with ages ranging from 21 to 62 years.
Data analysis
Thematic analysis of the content of the open-ended questions from transcribed focus groups and interviews was carried out by three members of the research team using the Braun and Clarke six stage process [
V. Braun, V. Clarke, G. Terry, Thematic analysis, in: P. Rohleder AL (Ed.), Qualitative Research in Clinical and Health Psychology. Palgrave MacMillan, Basingstoke, 2014
]. The six steps, which were followed independently by the researchers, included familiarisation with the data, initial coding and searching for themes within the initial coding. Investigators chose to use manual coding, either open or line-by-line, or via NVivo v12 software. A subsequent meeting resulted in defining the themes through discussion, clarification and agreement [
in: Jirojwong S. Johnson M. Welch A. Research Methods in Nursing and Midwifery: Pathways to Evidence-based Practice. Oxford University Press,
Melbourne2014: 261-284
]. As the data were transcribed verbatim, and direct quotes are used in the description of themes, it was not considered necessary to ask participants to provide feedback on the findings.
Trustworthiness
The results are reported in accordance with the COREQ Checklist for Interviews and Focus Groups [
]. Further, the team employed strategies such as immersion in the raw data to ensure credibility, and agreement among researchers regarding the emergent codes and themes via triangulation. Confirmability is addressed through the use of direct quotes from participants, which are presented to maximise transferability, cognisant that generalisability is not a feature of qualitative research [
Due to the variety of indistinguishable voices in the focus group recordings, the student focus groups have been referenced as Student Focus Group 1 SFG1 (end of course students); SFG2 (beginning of course students) and SFG3 (a second group of end of course students). The academic focus group have been referenced as Academic Focus Group 1 and 2 (AFG1, AFG2). Senior academic managers are named S1 and S2.
Qualitative analysis of the three discrete groups, students, midwifery academics and senior academic managers, provided distinct views of preferences for the two pedagogical approaches, however there was also intersections of views. Each group provided what they saw as the advantages and disadvantages of each teaching approach, illustrated in Fig. 1, Fig. 2, Fig. 3, Fig. 4.
Fig. 1The Advantages of a Continuity Approach; Overlapping themes of students, academics and managers.
Fig. 1 Themes within two pedagogical approaches: The Continuity Approach and Team-Teaching Approach.
Themes were identified as advantages and disadvantages of each educational approach, with subthemes identifying certain aspects of each. Each theme with subthemes will now be described, supported by direct italicised quotations. Square brackets have been used for additional clarification as necessary.
Continuity approach - advantages
Matches continuity of care philosophy
There was overwhelming agreement that the continuity approach of teaching reflected the model of care students provided to the women they cared for through the CCE component of the course: You get to know the lecturer and they get to know you, like continuity of care experience with women…We know the outcomes are better because they build up a rapport and get to know each other and trust each other (SFG1). The benefit of consistency was corroborated: There would be benefits from being more relaxed in the classroom, not trying to find a new way again, not getting to know the new lecturer’s ways, knowing that what they said was it, no changes (SFG2). Midwifery academics agreed with the CCE analogy: Maybe the student group get more sense of … belonging when they have one person that is on the journey with them, and that fits well, given the philosophy that we’re teaching (AFG2).
Trust and understanding
The development of trust and understanding between the cohort leader and student meant there was no time wasting in getting up to date with aspects of the students’ lives: They understand what you're going through outside of the course (SFG3), also reiterated by an academic: You know them… for the whole course. There is no re-learning names or trying to work out their personalities. You don't waste time worrying about that (AFG1).
Maintaining knowledge
One beneficial aspect of following a cohort through the entire course was described by academics as providing them with the incentive to remain up-to-date with their own midwifery knowledge. They were aware that in order to teach all midwifery subjects to a high standard they had to be aware of the latest evidence and practice: The main benefit as an academic is your currency, your recency in all aspects of the course (AFG1). Having a reason to remain knowledgeable over all aspects of midwifery was seen as an advantage: Actually, you've got to get out of your comfort zone. You’ve got to prepare yourself, get up to date, stand in front of them and know what you're talking about. So it's stimulating. It actually makes you learn stuff and you know midwifery inside out, and It’s significantly more stimulating and fulfilling because you have fresh content to work with (AFG1).
The advantage of being across the whole of midwifery knowledge was acknowledged as beneficial in the context of classroom CCE discussion: And that is particularly true of the continuity of care experience because they will bring up any subject anytime. So you’ve got to be over the whole lot. So yeah, it does prepare you to be on top of that (AFG2).
Relationship building
Both students and academics felt the benefit of relationship building with the continuity approach. Students focused on developing familiarity: (They) would know our learning styles and everything as well and our lifestyle (SFG3). One student reiterated the value of the relationship with their reflection on the team-teaching approach they had received during their course: It would have been better just to have had that same person rather than having to re-explain it all the time (SFG3). The academic focus group AFG2 talked about having richer relationships with students and an academic from AFG1 spoke of … that really special relationship when you know them all really well.
Consistency
The common subtheme amongst all three groups of participants was the value of consistency for both students and academics. Academics acknowledged that midwifery courses are notoriously challenging for students, who have to be very committed: The midwifery curriculum for all students in Australia is so demanding that the students are seeking stability… they just want that level of consistency in a very dynamic, challenging course (AFG2). Students echoed this with their wish for consistency with assessment marking: To have the same person who sees your learning journey improve. And so you're not getting the opposite feedback that you're actually doing worse. That would be nice. (SFG1). Senior academic managers acknowledged that a continuity approach would afford greater awareness of student progression but with a caveat: I can see some possible advantages because you would have a better perspective of student progression. However [with] good team-teaching you should have that anyway (S1).
Continuity approach - disadvantages
Poor experience follows you
Students pointed out that if your continuity cohort leader was lacking in educational skills, it could mean a poor course rather than just a poor unit or lecture: I wouldn’t want the same person all the way through if they weren’t interesting or didn’t teach very well or were confusing. If that was the case I would want to try another lecturer the next semester (SFG2). One of the senior academic managers also suggested that poor performance of a continuity cohort leader could be worrying: I get concerned where it becomes heavily reliant on the performance of one individual. that the individual's just not up to performing (S2).
One student suggested that two continuity cohort leaders could work: I think two's a really good amount of people to switch between, because if you don't necessarily gel with one person, you might have a really good rapport with another (SFG1).
Not “owning” units; always personalising previous lecturer’s units
Academics voiced concerns regarding the workload involved to learn and improve new materials each semester: I think the workload allocation and the cognitive load of developing and refreshing new material every semester in the context of… driving a body of research… is too demanding and competitive and so one of those would suffer (AFG2). Similarly, another academic in AFG2 suggested that trying to stay on top of the whole curriculum would hamper new ideas: I think what you're doing is condensing that innovative approach to one unit rather than trying to forecast across the whole course. Senior academic manager 1 felt that if there was no ongoing ownership of the unit, the quality of the unit could diminish: And what is the quality of that unit because is it constantly in caretaker mode? (S1).
Possible staffing issues due to reliance on one academic
Senior academic managers, who were responsible for budgets and staffing had the helicopter view of management issues that could be affected by the continuity approach and demonstrated awareness of academic workload expectations: Can they [academics], with the workload expectations realistically give it [the unit] the attention that it needs? (S1). Similarly concerns were raised regarding reliance on one sole person: The programme becomes very heavily reliant on that individual and should anything happen to them, that can create a significant problem, not just in terms of the organisational aspects, but around the students and the expectations they've grown accustomed to (S2).
Bias
All three groups independently suggested that there could be favouritism if one academic followed the cohort through the whole course, with one academic suggesting that remaining impartial could be problematic: The bias of the person who's teaching them all of the time (AFG1). Senior academic manager 1 stated that quality and equity could be affected: Is there a potential for things to become over-inflated when you've got one person following those students throughout? I think that's another issue with the checks and balances when you're the only person. (S1). The student concern was regarding assessment, that there may be a certain predisposition in marking that affected the course weighted average: Yeah, what if you got one that marked really hard.
Team-teaching approach - advantages
Different midwifery stories
An advantage to the Team-teaching approach was that students were able to enjoy a variety of lecturers’ experiences: An academic from AFG1 stated: I can definitely see an advantage of different views and different experiences coming into the classroom, corroborated by a senior academic manager S1: So, students have that experience, they learn from a broader range of people. Students were unanimous in their preference for a variety of stories and teaching styles: They all have different things that they bring to the course so far and we’ve had lots of different styles (SFG3); I quite like getting tips and tricks from different people so that I can choose what I think works for me and the women I'm caring for (SFG1).
Ongoing improvement of teaching materials
The advantages of ongoing unit improvement semester by semester with the team-teaching approach was voiced: You have much better quality control over your unit. You are able to invest the energy that it needs to improve it because you have the recurrent engagement with it (AFG1). An academic in AFG2 agreed: Because I've [now] had to repeat it [the unit] three semesters consecutively. I've been able to mould it into something that I think is valuable and useful. Another academic in AFG2 added: I don't feel like I'm any less passionate a teacher or any less enthusiastic because I only teach that unit. I still bring a lot of energy and innovation to that unit.
Management of academic workload
The workload involved in being a continuity cohort leader was identified by an AFG2 academic as being untenable: Being able to sustain and maintain a teaching and research position [whilst] being a continuity cohort leader wouldn't work right? (AFG2). One of the senior academic managers agreed: With the expectations [from university], the new academic capability framework and whatever, there's an expectation of more than just teaching from us (S1). The second senior academic manager corroborated: I do see the [continuity of] cohort model is a more risky approach from a managerial perspective (S2).
Increased student resilience
Senior academic managers felt that a team-teaching approach provided better preparation for students entering the workforce by enforcing an ability to be subject to change: [Team-teaching would] mimic the reality of the work environment… they will not be looked after by one person throughout. Their wards and work situations will chop and change. Are they resilient enough to deal with all the different personalities that are in the liquorice allsorts box? (S1).
Variety of teaching styles
Students learn in a variety of ways; Senior academic manager 1 suggested that a larger group of lecturers would provide students with a greater diversity of teaching styles: Having more players at the table… you've got different people looking after different units, students learn from a broader range of people (S1). Some students agreed: I quite like having different mentors and different people, especially in midwifery, there's no one right way to do things I feel (SFG3).
Team-teaching approach - disadvantages
Lack of consistency of advice and expectation
Academics gave examples of student discontent regarding changing goalposts: When I have taken over from someone else [students make comments like]… “Last semester this was considered OK and now you're saying that it's not”. You know, that sort of “We can't keep up with what's expected. Why can't you all just do the same thing?” (AFG2). One student gave their perspective of how a lack of consistency affected assignments: Grading, because you do semester one grading and we had our assessments graded, and then … next semester with like totally opposite grades… And you're like, wow, I got this feedback from this post-grad lecturer and now I'm getting this feedback (SFG1). One student reflected on the inconsistency of lecturers in her previous nursing degree: They would actually tell you different things which made it all quite confusing. They had their own opinions, fair enough, but when it comes to what’s expected in an assignment or what we need to know for an exam there needs to be consistency (SFG2).
Building relationships with new students each semester
The final sub-theme was the academic perspective of repeated teaching of their same unit to a new group of students each semester. They felt there were difficulties surrounding building new relationships each semester, with one admitting that learning student names only once per cohort would be helpful: I mean with me now my age, the students’ names each semester is really tricky. With continuity of cohort, you know them for the whole course. There is no relearning names or trying to work out their personalities. You don't waste time worrying about that (AFG1).
From another perspective, one academic felt that if she were able to meet the students at the beginning of the course and build the relationship when they were fresh and enthusiastic the strength of that relationship would help through the difficult times: I think establishing the relationship when they're super excited and amped and ready to go, it would help smooth them through that period of time where they feel overwhelmed and exhausted (AFG1).
Discussion
In higher education the student learning experience is affected by many factors, including the method of teaching. Team-teaching is one such style and is known to take many forms, from co-teaching, with two or more teachers in the classroom at the same time, to many individual teachers over the length of a unit or course [
] found student learning was improved with team-teaching, reportedly due to a more reflective and collaborative means of content delivery. Participants in this Western Australian (WA) study reported similar advantages, with students describing greater breadth of understanding, due to the varied clinical midwifery experiences of the teaching academics, which students felt enhanced their learning. Equally, learning styles of students vary as much as teaching styles of academics. Letterman and Dugan [
] suggest that students benefit from this variety, also corroborated by our WA study.
The style of team-teaching practiced in the WA study university is by unit ‘ownership’, where one academic coordinates and teaches the content of one unit repeatedly, as each new cohort comes through. The teaching academics in our study were positive about this style of team-teaching approach, as the individual unit ‘ownership’ provides opportunity to continually refine and improve teaching materials. In today’s climate of academic workload issues [
], such strategies are important to help academics optimise the workload burden. The senior managers interviewed in our study, being responsible for workload allocation, were able to see this advantage clearly in terms of staff efficiency.
The concept of resilience-building in students was raised by the senior academic managers in this WA study, who believed that the team-teaching approach helps build student resilience, increasing their versatility by adapting to a variety of lecturers. It has been documented that resilience is a high priority current issue in the health care sphere [
]. Our study raised the possibility that imposing adaptability could help improve student resilience, providing transferable resilience skills to the sometimes-confronting clinical area.
Despite positive findings of team-teaching, students found some aspects of this approach detracted from the learning experience. Students were less able to form a personal relationship with individual unit lecturers and found a lack of consistency of course and assessment materials and information between the team teachers. These issues were also raised by Dugan & Letterman, [
] whose study participants voiced concerns that communication issues and inconsistent standards often translated to poor assessment grades. The students in our WA study reported a similar lack of uniformity causing variation of assessment information and marking levels. Fair and just assessment is an ongoing process for many universities, with increased vigilance around moderation aiming to reduce inequalities [
The other pedagogical approach investigated in our WA study was the continuity of cohort approach where one individual provides the majority of teaching through the entire course. Although few courses take this approach and little is evident in the literature, advantages of a continuity model include consistency of content delivery and advice, familiarity with the lecturer’s teaching style and continuity of subject matter [
]. Students in our WA study favoured the consistency and familiarity but above all they valued a relationship of trust, which has been identified as enhancing student performance outcomes, also known as transformational teaching [
How transformational lecturers promote students' engagement, creativity, and task performance: the mediating role of trust in lecturer and self-efficacy.
]. Several factors have been identified which enhance learning in a higher education environment, including consideration of student emotional engagement, particularly trusting relationships enhanced by experience-sharing [
An additional consideration related to continuity teaching, identified by midwifery academics in this WA study, is the requirement for teaching academics to be knowledgeable over the entire curriculum. Whilst teaching academics found the opposite method, the team-teaching approach helped them continually improve a narrow realm of learning materials, they voiced concerns about becoming specialist experts, instead of maintaining currency over the whole midwifery curriculum. An alternative way to help lecturers maintain recency was reported in a study which demonstrated the value of university commitment to maintaining lecturers’ clinical skills, by providing them with designated hours to practice in the clinical area [
Is faculty practice valuable? The experience of Western Australian nursing and midwifery academics undertaking faculty clinical practice - a discussion paper.
]. The study conclusions were that additional university supported hours resulted in increased student: lecturer credibility and lecturer confidence and improved teaching abilities [
Is faculty practice valuable? The experience of Western Australian nursing and midwifery academics undertaking faculty clinical practice - a discussion paper.
Reliance on one person to deliver the whole content of a course was also raised as a potential problem by senior manager participants in our study, corroborated by Lester and Evans [
], who advise that the merits of isolated practice must be questioned. As well as the danger of heavy reliance on one person, an additional issue raised by students in our WA study was the problem of a continuity cohort leader who failed to meet their expectations. The healthy functional partnership between student and lecturer is built on trust and respect, as it is for midwife and woman in the clinical area [
]. If the relationship breaks down, or there is concern about quality of teaching, the student in a continuity programme is left with no alternative. A possible solution may consist of a combination of both pedagogical approaches of continuity and team-teaching, offering both a mix of teachers and a named ‘go-to’ mentor, so meeting student requirements for both continuity and variety.
] the team-teaching and continuity approaches to teaching a midwifery curriculum were described to have both advantages and disadvantages by students, midwifery academics and senior managers. Factors described by students and midwifery academics included relationship building, consistency and trust, all evident in the continuity approach. Senior managers and midwifery academics voiced concerns regarding midwifery academics large commitment of remaining current over a whole midwifery curriculum compared with becoming proficient in the content of a smaller slice of the course. All participant groups agreed that variety of lecturers provides breadth and depth to student learning.
Limitations
Although our interviews yielded rich data during analysis, there were several limitations that restrict the conclusions we can draw. Our investigation was limited to two teaching approaches, specific to one university; however, aspects of the findings could provide basis for consideration for approaching pedagogical methods within midwifery education. Although adequate numbers of students and midwifery academics formed the focus groups, only two senior academic managers were interviewed and despite many similarities in the issues raised in both interviews, the study would have provided richer data if more interviews at that level had taken place. Despite these limitations, we gained detailed insight that can help establish a baseline for future research and to provide consideration for midwifery education.
Ethical approval
Ethical approval was obtained from Curtin University human research ethics committee ((HRE2019-0531).
Funding
None declared.
Contribution of the paper
The idea was conceived by Lesley Kuliukas, interviews were carried out by Lesley Kuliukas, Janie Brown and Anna Bosco, transcription and coding was carried out by Zoe Bradfield, Lesley Kuliukas, Janie Brown and Anna Bosco, themes were decided by all authors, manuscript was written by Lesley Kuliukas and reviewed by all authors.
Clinical Trial Registry and Registration number
Not applicable.
CRediT authorship contribution statement
Lesley Kuliukas: Conceptualization, Data curation, Methodology, Formal analysis, Investigation, Project administration, Validation, Visualisation, Writing – original draft. Janie Brown: Data curation, Methodology, Formal analysis, Investigation, Validation, Visualisation, Writing – review & editing. Anna Bosco: Methodology, Data curation, Formal analysis, Investigation, Writing – review & editing. Zoe Bradfield: Methodology, Data curation, Formal analysis, Investigation, Writing – review & editing.
Conflict of Interest
None declared.
References
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‘It's a good thing…’: women's views on their continuity experiences with midwifery students from one Australian region.
The emotional and professional wellbeing of Australian midwives: a comparison between those providing continuity of midwifery care and those not providing continuity.
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How transformational lecturers promote students' engagement, creativity, and task performance: the mediating role of trust in lecturer and self-efficacy.
Is faculty practice valuable? The experience of Western Australian nursing and midwifery academics undertaking faculty clinical practice - a discussion paper.
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