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Correspondence to: LHN 3721, School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada.
Peer support is understudied as a factor that can impact midwifery student retention.
Background
Retention of midwifery students is essential for creating a sustainable maternity care workforce. Research shows that peer support positively influences students’ experiences, but it needs more focus on the role peers play in student retention.
Aim
We aimed to examine how peer support can facilitate midwifery students’ retention by exploring the role peers play in students’ experiences and identifying the types of support students offer each other.
Methods
We conducted 31 semi-structured interviews with students attending Midwifery Education Programmes across Canada. Data were analysed inductively, following the constructivist grounded theory method.
Findings
While motivated and engaged peers improved students’ learning experiences and desire to remain in their program, peers who created an overly competitive academic environment hindered learning. Students also noted that a lack of diversity, particularly of Black and Indigenous peers, limited their ability to learn about culturally safe care. Most students felt a sense of community and relied on one another for emotional, academic, and instrumental support.
Discussion
Peer support has mostly positive effects on student learning and should be formalized by midwifery educators to improve retention. Reducing pressure to succeed, targeting recruitment of students who are Black, Indigenous, and People of Colour, and establishing formal mentorship programmes could enhance the role peers play in student retention.
Conclusion
While retention of students is a complex issue, positive interactions with peers can create a stimulating learning environment and increase students’ desire to stay in their programme.
Peer support can be an important facilitator for student retention, but the link between retention and peer support has not been fully explored.
What is already known
Literature shows that many students withdraw from midwifery education programmes and that peers can positively influence students’ learning experiences.
What this paper adds
This paper shows that midwifery students see peer support as a valuable part of their learning and explores what types of supports students find most beneficial. We also offer recommendations for educators on how to formalise peer interactions and thus improve student retention.
], midwives represent a critical segment of the workforce that needs to grow substantially to address global healthcare needs.
Most of the literature examining the healthcare workforce focuses on retention of professionals who are already in practice, paying substantially less attention to students and trainees [
]. However, retention of students should be an important policy concern, especially in jurisdictions with publicly funded health educational programmes [
]. The literature identifies several factors that can contribute to students’ decision to leave midwifery and nursing programmes, including burnout and emotional strain [
While several retention strategies targeting midwifery education are described in the literature, a focus on the learning environment, and specifically peer support, is somewhat scarce [
Pathway to success: using students’ insights and perspectives to improve retention and success for university students from low socioeconomic (LSE) backgrounds.
In health professions such as midwifery, the role of educational programmes extends beyond the transmission of practical knowledge. During the programme, students undergo the process of professional socialisation, which refers to a combination of formal and informal learning processes that enable students to develop their professional identity [
] provides a useful framework for understanding how interacting with others impacts our behaviours. It suggests that our behaviours are determined by our environment, and that these relationships are reciprocal. That is, a change in one factor (cognition, behaviour or environment) can cause (or be caused by) a change in the other two. This means that individuals are highly impacted by their environment and can adopt new behaviours or emotions by observing others and learning from them.
In the context of midwifery education, preceptors and faculty members are often regarded as role models who offer opportunities for observational learning [
], but considerably less attention is paid to the role of peers. This may be an important oversight, as research that examines midwifery students’ communication with peers shows it is an important positive factor in their academic experiences [
]. In addition to this knowledge gap, there is also some ambiguity in the literature as to what types of social interactions are construed as peer support [
As in many other jurisdictions, the demand for midwives in Canada outpaces the growth in the midwifery workforce, which is why the retention of practising midwives and midwifery students is an important policy and research concern [
]. This trend has also increased globally since the COVID-19 pandemic, with students feeling stressed, anxious, and concerned about finishing their programmes [
]. In this context, it is particularly important to focus on the factors that encourage student retention in midwifery programmes.
Currently, there are six midwifery education programmes (MEPs) across Canada and two community-based programs which combine Western midwifery with traditional Indigenous practices. In this research, we focused on MEPs, which all start with the first 1.5 years spent in the classroom, and then alternate in-class learning with clinical placements. Some placements necessitate relocation, as students must be within driving distance of the clinic’s catchment area. All MEPs offer a baccalaureate degree upon completion of four years of education [
While MEPs are considered direct entry programmes, most students entering their first year already have undergraduate or graduate degrees; they also tend to be older than average undergraduate students and many already have children [
]. The programmes are also relatively small, with some admitting no more than 6 students and the largest capped at 45 students annually. In this context, students often establish strong relationships with their peers, which may impact their learning experiences and their desire to stay in the program.
The existing research on Canadian MEPs identifies some factors that can shape student retention, including the structure of the programme, experiences in clinical placements, communication with preceptors, and the challenges of maintaining a work/life balance [
]. However, the role of peers, both as a source of support and a factor impacting retention, has yet to be explored. In this paper, we address this gap by exploring what role peers play in shaping students’ experiences in the programme, and what type of supports midwifery students offer to each other and find valuable. Therefore, our aim is to understand the peer-to-peer interactions in Canadian midwifery programmes, and how these interactions may impact student retention.
2. Methods and participants
This paper is based on the analysis of a subset of qualitative data collected between 2016 and 2021 for a mixed-method pan-Canadian study on retention of midwives. The data collection included the administration of cross-sectional and longitudinal surveys and interviews conducted with midwives and midwifery students. Our quantitative analysis and insights about retention of practising midwives are reported elsewhere [
]. In this paper, we report on the findings derived from the analysis of qualitative, semi-structured interviews with midwifery students.
Upon receiving ethics clearance from all academic institutions involved in the study, we reached out to all MEPs across Canada (n = 6), asking programme coordinators to distribute information about our study to potential participants. Seeking to understand how experiences in the programme may impact students’ decision to stay, we purposively recruited senior and more novice students, as well as recent graduates and those who withdrew from the programme. Because of the small number of students attending MEPs, we refrained from asking participants’ sex/gender, race/ethnicity, sexual orientation and other demographic characteristics to ensure confidentiality.
After obtaining participants’ consent, the interviews were conducted over the phone, in English or French, by a trained research assistant and lasted between 1 and 3 h. The interview guide utilised open-ended questions and explored students’ experiences in the program, including challenges they faced and facilitators for retention. Interview transcripts were deidentified and uploaded to NVivo-12 for qualitative data analysis. The data analysis was done inductively and was informed by Charmaz’s [
] guidelines, moving from line-by-line to focused coding and the development of analytical categories. Our decision to utilise Charmaz’s constructivist grounded theory method was driven by the desire to stay close to the data in order to capture the participants’ experiences, but also to acknowledge the fact that our own positionalities as researchers and students’ accounts were co-constructed during interviewing and analysis. The coding process, therefore, involved multiple readings of the data by four separate members of the research team, and was iteratively developed in discussing the interpretations that the research team rendered from the data. The topic of peer support was one of the many themes developed during this iterative process and prompted going back to the data to re-examine how it appeared in participants’ accounts and aligned with other analytical categories, including retention.
In what follows, we present our analysis. To protect the confidentiality of participants, we intentionally omit or obscure some of the demographic data that was shared by the participants, including programme location. Pseudonyms are utilised when quoting participants.
3. Findings
In total, 31 students took part in the study. The profile of participants resembled the demographic characteristics of midwifery students [
]. That is, study participants were older than typical undergraduate students, with 49 % reporting the ages of 30–39. Among the participants, 68 % had children and 89 % were born in Canada. We had students from all six MEPs enrolled in year 1 (n = 5), year 2 (n = 8), year 3 (n = 5), and year 4 (n = 9). We also interviewed one recent graduate and three students who left their programme.
Reflecting on their experiences in the programme, most students felt that their peers provided a lot of support. Below we summarise students’ accounts, first describing how midwifery students perceived their peers and the role peers played in their learning experience, and then exploring what type of supports peers offered to cope with challenges faced in the programme. We use illustrative quotes to substantiate our interpretation of the data.
3.1 Noticing the (lack of) diversity of midwifery students
Unlike large undergraduate programmes, which most of our participants attended before joining the MEP, midwifery classes were small. This contributed to a feeling of intimacy among students who got to know each other by attending the same courses and learning in a small group. Kelly, a second-year student, said:“I feel like my cohort in my MEP was more diverse in different ways, there was a wider range of people’s ages than there had been in my previous degree, there were different educational and vocational backgrounds, too.”
Referring to her peers as “my cohort”, Kelly applauded the age and vocational diversity among students as beneficial for her learning. The sense of belonging and strong affiliation with her educational cohort was echoed by Irina, a student in her first year, who described her class in the following way:“I think we have a really special cohort. I really, really appreciate the other students in the programme. I do think they’re special and different than the other students I’ve encountered… They are highly motivated, they also tend to be more mature in terms of age.”
The link between maturity and life-long learning, made by Irina, was also confirmed by Abigail, a first-year student who felt that midwifery, as a profession, attracts students of various ages, which creates a unique learning environment because the students in the programme “have such different life experiences”.
While “diversity” can refer to different intersections of personal and professional identities, in students’ accounts this term was mostly used to describe the age differences and professional or educational experiences. References to marginalised intersectional identities were rarely mentioned by students as contributing to the exchange of ideas. Among a few exceptions was Emily, who said that her classmates had a variety of religious identities which she felt students were “able to respect”, although she did not explain how diverse religious worldviews offered students opportunities to learn from each other. Jennie, a second-year student, was more direct when she said:“It was a great learning time because we had a great mixture of urban-based women and rural based women, and women who are from the North, and we learned a lot from each other.”
Broadly referring to the “North”, where the majority of the population is rural and Indigenous, Jennie suggested that student diversity might have contributed to the exchange of ideas between students.
Despite not being as prevalent in students’ accounts, some participant voices focused on students’ racial/ethnic identities as potential sources of rich knowledge. For instance, Katrina, a student in her second year of the programme, shared a story about an Indigenous peer who had to leave the programme because they experienced systemic barriers. Describing this case, Katrina felt it is “mandatory” to do more to recruit Indigenous students into the MEP and to learn more about Indigenous ways of knowing. Her words were echoed by Iris, a student who self-identified as a Black woman, who noted:“There’s not enough of the marginalised, racialised, disenfranchised representation within midwives and within the faculty, and the teaching and admin faculty that is reflective of who we are taking care of [as clients].”
In Iris’ view, lack of Black, Indigenous, and People of Colour (BIPOC) representation in the midwifery community is also problematic because it reduces students’ ability to learn how to offer culturally safe care to clients, many of whom are BIPOC and marginalised. Therefore, while most student participants described a welcoming and diverse community of MEP students, some students did raise concerns about cultural and racial inclusivity as a platform for sharing diverse ways of knowledge.
3.2 Co-creating learning environment
Talking about their fellow students, the participants believed that their peers created a unique context for their learning. For instance, Irena detailed how her peers facilitated a culture of learning in the classroom in the following way:“[Midwifery students are] very motivated and very engaged in the classroom, willing to discuss things, willing to question and challenge professors, willing to ask interesting questions… I’m always really glad to have midwifery students in other courses… because… they’re also bringing interesting topics in the classroom and asking important questions.”
In Irena’s description, midwifery students were portrayed as active learners, fostering the exchange of ideas and creating a stimulating learning environment. The sense of “otherness” from other students, which further crystallised when midwifery students attended courses outside of their departments, contributed to the sense of a shared identity.
While most participants saw the motivation and drive of their peers as beneficial for learning, some interviewees also described them as inhibiting their learning environment. For instance, Anna, a third-year student said:“Maybe it [the MEP] does attract a certain person that is a little bit of a type A personality, that’s an achiever, and a striver, and can be particularly hard on themselves and each other.”
Anna was one of the several participants who referred to their peers as possessing a “type A personality”, which is characterised by a strong drive to achieve, competitiveness, impatience, and sometimes aggressiveness [
]. In Anna’s account, these personality traits, while stimulating for some, could also be counterproductive, leading students to be too competitive with each other. Isabelle offered a similar description of her peers, describing them as “definitely motivated”, but also “all over-achievers”. Although some students thrived in this learning environment, others found it challenging to cope with the indirect pressure placed on them by their highly successful and competitive peers, seeing it as a “nice little recipe for overwork” (Ingrid). Sharing her experience in the programme, Aurora, a student in her second year, said:“There is no room to be unsuccessful in this programme. That’s how I’m feeling, at least. There is a pressure to be successful in this programme. There is a level of competitiveness that is carried on by the programme…. There is an expectation of not failing in this programme by your preceptors, by your tutors, by everyone around you, by your student friends, so it’s a tough thing.”
Describing how she felt, Aurora identified multiple sources of pressure, but saw her peers as contributing to the programme’s competitiveness. Christina, a student in her fourth year, echoed Aurora’s perception of midwifery students as competitive, but she attributed it to gender dynamics, suggesting that “women tend to see other women as competition”. Iris, on the other hand, saw some midwifery students as projecting a sense of entitlement:“There is an underlying form of entitlement within a good number of MEP students… and it’s definitely not everyone, and it’s not specific to an economic or racial background or sexual orientation, but it is very prevalent.”
According to Iris, this sense of entitlement was exemplified in students’ “arrogance, know it all, it should be my way, why isn’t it working out for me kind of attitude”. While Iris did not see this characteristic as uniting all midwifery students, she did point out that this attitude was common enough to be recognised by her as a featured trait of a midwifery student. As such, the learning environment of midwifery students emerged as a highly competitive setting co-created with peers, which was stimulating for some students but caused anxiety in others.
3.3 Relying on peers for support
Midwifery education has been described in the literature as a rollercoaster [
]. The competitive learning environment, academic workload, and rotation in clinical placements, some of which necessitate relocation, posed a multitude of challenges for midwifery students in this study. In this context, peer support emerged as a critical factor for participants’ success and their ability to stay in the programme.
The most common type of support that students offered to each other was a sense of community along with a strong emotional bond that some students developed with their peers. Jasmine, a fourth-year student, described her cohort as a “sisterhood that we found in the classes”, with Ariel echoing this by stating that “it’s just a fantastic group of women that I’m privileged to be part of”. This sense of community was likely created by the physical proximity in small classes and was a prevalent topic among first-year students. For instance, Abigail, who was a first-year student, said:“I think there is no separation between academics and personal life at all… We’re all in this together sort of mentality, and we’re there to support each other”
Abigail’s words were echoed by Irena, also a first-year student, who shared the following reflection:“You know, in some ways, the relationship is very focused on the programme and that commonality we have, so we support each other, we study together, spend time in between classes chatting and, you know, checking in with each other and what we’re at.”
For both Abigail and Irena, the physical proximity of their peers and the intimate nature of the small programme provided a strong foundation for developing a sense of community. While many participants agreed with Abigail and Irena, some felt less immersed in the student life. For example, Elizabeth, who balanced family responsibilities with studying, said:“There are some drastic and different personalities, there is a wide range, but we’ve all kind of you know, found our groove and not all of us hang out everyday. I certainly don’t as much, because I have to come home to my family and my kids, but we get along and are supportive of each other, it’s nice.”
Students attending a part-time programme were also not as connected to their peers, balancing work and personal commitments with midwifery education. Many of them had considerably less interactions with their peers.
The initial strong bond formed between students was sometimes put to the test by transitions to clinical placements, which created a physical separation. Recalling her experience, Aurora, stated:“To have peer support is very hard, because we’re all in the same boat, and we don’t even get to see each other [other] than [during] our tutorial hours, because everyone is placed somewhere else, in another clinic, so it’s a tough situation in terms of being supported, feeling supported emotionally.”
While Aurora felt that clinical placement posed a challenge for staying connected to her peers and receiving or offering emotional support, Shelly, a fourth-year student, described how she was able overcome this challenge when she recalled:“[I was] just making sure I was keeping in touch with people by phone and texting and Facebook, and using the tutorial time to check in. It’s really easy to forget, when you’re isolated, that there is that group of people out there that get what you’re going through. I tried to talk to friends that were not midwifery people, and they would obviously listen and try to be supportive, but you get completely different support when you are talking to somebody that is going through exactly what you’re going through.”
Shelly emphasised the importance of shared experience as a key source of emotional support. By proactively and intentionally staying connected to her peers, she tried to overcome the loneliness she felt while being in placement.
Academic support was another pathway through which students offered assistance to each other. Study groups, for instance, were mentioned by the participants as a strategy to manage their course work. While some students preferred to study on their own, “a lot of folks bonded well over studying and formed relationships and groups because of that” (Shelly). Therefore, study groups were both a driver and an outcome of students’ close relationships with each other, and generated a stronger sense of community.
Finally, the participants also offered each other instrumental support, by sharing relevant information or helping with programme logistics. For instance, when faced with relocation, students sometimes had to find living accommodations, often only for a few months, as well as childcare arrangements if they had children. In this context, support from other students was welcomed and included sharing of information and other practical advice. Ellie, a second-year student who had to relocate for clinical placement and needed to find a place to live, said she used the assistance of her fellow midwifery students to secure accommodations:“It [fellow midwifery students] is a very supportive group in terms of helping one another find appropriate living. I was also fortunate in the fact that I don’t have children or a partner that had to relocate with me for the placement and have ended up with a really wonderful living situation with roommates that have been great supports to me in the programme.”
While not all participants formed strong relationships with their peers, those that did found them to be very beneficial for their learning experiences and their ability to cope with challenges. Sometimes these relationships extended beyond the programme, which was noted by Macy, a fourth-year student, who stated:“What’s really good is that through some of the friends I made in first year, we had this on-line running, text running conversation where we would text each other all the time to check in and make sure they’re ok, and now that my friends have graduated and started working as midwives, we still do that with each other.”
Macy’s account pointed to the possibility of continuing to rely on peer support after finishing the programme, when students transition into their first jobs. It also demonstrated the benefits of establishing connections with more senior students. This was also Abigail’s position, who said:“I think it would’ve been helpful to have a [more senior student] student that I could ask questions to… it would’ve been a better thing, a better experience to have a student that I could’ve talked to, but they didn’t get it up and running [mentorship programme] for whatever reason. The problem with this programme, too is that senior students are in placement, and they don’t necessarily have time to be meeting with first years, having coffee and chit chatting.”
Abigail’s account suggested that learning from senior students offered additional benefits to developing a sense of community. Having had such mentoring could have offered Abigail more opportunities to foster meaningful relationships with her peers. Communicating with peers could have enabled her to rely on the knowledge of more experienced peers and perhaps learn more about how to succeed in the programme.
4. Discussion
This paper examined how students enrolled in Canadian Midwifery Education Programmes saw their peers and what type of peer supports they found most beneficial for their learning. Our findings suggest that most students saw their peers as a unique group of students, whose diverse voices created a stimulating learning environment. The Social Cognitive Theory proposes that through observational learning, the environment can positively impact behaviours and shape individuals’ perceptions [
]. The findings from this study show that midwifery students can co-create such an environment, reinforcing a strong sense of community and shared professional identity, which can positively impact students’ decision to stay in the programme. Indeed, most students found their peers to be highly motivated, which they believed fostered their own desire to succeed. However, while most participants found this learning environment to be academically stimulating, others were concerned about not keeping up with their peers, sometimes feeling stressed and overworked and considered leaving the program.
The promotion of competition as a driver for academic success is not a unique feature of midwifery studies, but, rather, a hallmark of higher education [
]. In health professions, some researchers openly challenge the promotion of competition, suggesting to replace numerical or letter-grade assessment systems of coursework with pass/fail grades to reduce students’ anxiety and stress [
] and improve their desire to remain in the programme. The findings from this study suggest that decreasing the emphasis on competition might also be beneficial in the context of midwifery education, where students are already self-driven and highly motivated to succeed.
Consistent with the findings from previous research [
], our analysis revealed that peers play a central role in students’ educational experiences and offer each other various types of supports, which can improve retention. However, following the call from the literature to better understand what is meant by “support”, we also examined which types of peer support students found most beneficial. Our findings suggest that the support offered by peers could be broadly categorised into emotional, academic, and instrumental (see Fig. 1).
In enrolling in the MEP, many students found themselves in a small classroom for the first time, which enabled them to foster a strong sense of community. These relationships formed a basis for emotional support, which was particularly important for retention during clinical placements, when students were away from their peers. Peer support was regarded by some participants as unique because it created a shared experience of facing similar challenges.
Many students also benefitted from academic support formed through joining study groups, which were both the result of and the driver for creating a sense of community. Some participants suggested that these groups became a foundation for continuous connection with other students, sometimes past graduation.
Finally, students also suggested that they benefitted from instrumental support offered by their peers who could share information and other resources that would help them to rent an apartment or find suitable childcare arrangements. This type of support was particularly important to students during the transition to clinical placements, which often forced students to move to unfamiliar communities.
While the participants spoke about various types of support they received from (or offered to) their peers, most of these supports were shared informally. Given the importance of peer support for student retention [
], it would be prudent to consider how MEPs could facilitate a formal structure for student-to-student interactions. Hogan et al. (2017), for instance, outlined the benefits of a mentorship programme for both midwifery students and their peer mentors [
]. Some of our participants mentioned their desire to have a similar programme offered in their academic institution. Students also talked about the benefits of forming study groups, which could be further promoted by establishing more formal opportunities for collaboration through curricular requirements. Organising formal and informal events for students could further facilitate student interactions with their peers and improve their learning experiences. As our education systems are recovering from the lockdowns caused by COVID-19, it is important to consider how educators can facilitate student interactions to encourage positive relationships between members of their learning communities. These bonds could help students to succeed in their academic programmes and improve retention, both within midwifery programmes and beyond, when new registrants enter the workforce. Table 1 summarises our recommendations for educators on how to promote peer support in their educational programmes.
Table 1Recommendations to facilitate peer support in midwifery education programmes.
Recommendation
Agent of Implementation
Providing formal opportunities for developing peer-to-peer relationship via group work and group projects
Instructors and tutors
Promoting the establishment of study groups among students
Instructors and tutors
Developing learning communities in the classroom
Instructors and tutors
Utilising universal design in course development
Instructors and tutors
Establishing mentorship programs between novice and mature students
MEP staff and administration
Creating social events for students
MEP staff and administration
Making connections between alumni and current student via formal and informal social events
MEP staff and administration
Promoting recruitment of diverse individuals into MEP
Educational institutions
Offering financial support, scholarship, and mentorship to BIPOC students
Educational institutions
Showing explicit commitment to the Equity, Diversity and Inclusion (EDI) values
Educational institution
Decreasing emphasis on competition by establishing a letter-based grading system
Although the aforementioned strategies can facilitate peer interactions, it is important to note that these suggestions will do little to address systemic problems that negatively influence student retention. For instance, some of our participants talked about the lack of BIPOC representation within the midwifery educational community, which prevented a meaningful and intentional exchange of culturally diverse ways of knowing among students. Since peer mentorship was identified as a particularly important factor for retaining BIPOC students [
], a recruitment strategy that explicitly targets this demographic could offer a more sustainable path for student retention. However, this practice can only be successful if educational institutions provide supports to BIPOC and other students experiencing marginalisation, including financial assistance, the adoption of universal design in course development, and a strong commitment to the principles and values of Equity, Diversity and Inclusion (EDI).
This study has some limitations. By prioritising the confidentiality of our participants, we did not offer insights on how the size of the programme can shape peer support. We also did not explore how the intersection of marginalised identities (such as race/ethnicity, gender/sexual orientation, or immigration status) may have impacted peer interactions. Our analysis did not reveal how peer support changes throughout the programme and is impacted by students’ unique personal circumstances. Notwithstanding these limitations, we believe that our relatively large sample and iterative coding, firmly grounded in the data and examined from the multiple positionalities of the authors of this paper, offer meaningful insights about the role peers play in student retention.
5. Conclusion
While retention of students is a complex issue, positive interactions with peers can create a stimulating learning environment and increase students’ desire to stay in the programme. In this study, we showed that most midwifery students saw their peers as fostering a stimulating learning environment, which could positively impact retention. However, some participants voiced their concerns about their peers and felt that they created a competitive learning environment, which added more stress to their experiences in the programme. Students who relied on their peers were able to receive academic, emotional and instrumental support which helped them to cope with the challenges and stay in the programme. Students indicated that formal mentorship opportunities, especially with more senior students, could further enhance their learning and facilitate positive student interactions. Given the central role peers play in midwifery education programmes, especially in smaller-sized MEPs such as those offered in Canada, it is important for educators to consider how to promote peer interactions in order to enhance learning experiences and improve student retention.
Conflict of interest
All authors would like to confirm that they have no financial or other interest and no conflict of interest of any kind relevant to the publication of this study.
Acknowledgements
We would like to thank Irina Oltean for her assistance with data collection and analysis. We would also like to thank our Research Advisory Committee for their assistance with this project. Finally, we would like to thank the participants who took part in our study and shared their experiences with us.
References
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Pathway to success: using students’ insights and perspectives to improve retention and success for university students from low socioeconomic (LSE) backgrounds.
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