Supporting Midwifery Students During Clinical Practice: Results of a Systematic Scoping Review

Background: Midwifery educators are highly concerned about the quality of clinical support offered to midwifery students during clinical placement. The unpreparedness of midwifery practitioners in mentorship roles and responsibilities affects the competence levels of the next-generation midwives being produced. Objective: The aim of this paper is to highlight various clinical support interventions to support midwifery students globally and propose a framework to guide mentorship training in South Africa. Methods: This paper adopts a mixed methodology approach guided by the Arksey and O’Malley framework. Keywords such as midwifery students, clinical support, mentorship, preceptorship, and midwifery clinical practice were used during the literature search. The review included primary quantitative, qualitative, and mixed methods design papers published between 2010 and 2020, and studies on clinical support interventions available to midwifery students during clinical placement. The search strategy followed a 3-stage system of title, abstract, and full-text screening using inclusion and exclusion criteria. All included papers were quality appraised with a mixed methods appraisal tool. Extracted data were analyzed and presented in themes following a thematic content analysis approach. Results: The screening results attained 10 papers for data extraction. In total, 7 of the 10 (70%) studies implemented a mentorship training program, 2 (20%) used a training workshop, and 1 (10%) used an intervention guide to support midwifery students in clinical practice. Of these 10 papers, 5 were qualitative, 4 mixed methods, and 1 quantitative in approach. In total, 9 of the 10 (90%) studies were conducted in high-income countries with only 1 study done in Uganda but supported by the United Kingdom.


Introduction
Supporting students placed at various clinical facilities is an essential component of learning during clinical practice.In clinical education programs, such as midwifery, clinical placement is a perfect opportunity to achieve the skills necessary to become a safe and competent practitioner.The quality of midwifery students graduating is the responsibility of both midwifery practitioners and educators [1].The midwifery module in the undergraduate nursing program is a hands-on module that expects midwifery students to spend most of their module time in clinical practice [2].Therefore, midwifery educators rely on midwifery practitioners to clinically prepare students for role-taking, hoping that new graduates become competent, safe, and independent practitioners.
Recent challenges in the health care system and its effects on the quality of clinical support offered to midwifery students have become a significant concern for midwifery educators globally [3][4][5].High student enrollment rates have subsequently increased the teaching workloads of midwifery educators [6].Additionally, challenges related to developments in nursing programs and the unexpected disruptions experienced during the COVID-19 pandemic have increased midwifery educators' academic and clinical responsibilities.The corresponding increase in the number of students placed at clinical sites has also become a challenge for midwifery practitioners.Uncertainties about mentoring roles, negative feelings about teaching, time constraints, and dire staff shortages and resources have negatively affected the clinical support of midwifery students [3,6,7].
However, global efforts using various clinical support models, such as mentorship, preceptorship, and clinical supervision, have shown positive outcomes on midwifery students' clinical learning and support [8][9][10][11].Mentorship is a highly recommended means to provide the support that students require [9,11,12], and mentorship training programs to support midwifery practitioners in mentoring roles have shown numerous benefits globally [11,13].Mentorship in maternity units is a direct relationship between the mentor (midwifery practitioner) and the mentee (midwifery student).Midwifery practitioners who are either not trained or inadequately supported in mentorship roles experience difficulties in supervising students [12,14,15] and, as a result, feel unprepared to share the responsibility of mentoring students [2,16,17].Lack of support for mentors in maternity departments is a global challenge [18].Clear guidance on how to conduct mentorship training and a need to identify interventions to support midwifery practitioners in mentorship is likely to improve the clinical support of midwifery students in clinical practice.Disregarding mentorship improvements poses the risk of employing unprepared and unsafe practitioners who are detrimental to health care outcomes.This review aims to identify clinical support interventions for midwifery students globally and develop a framework to guide mentorship training in South Africa.

Study Design
This systematic scoping review followed a protocol developed to analyze the evidence on interventions to strengthen the clinical support of midwifery students during clinical placements [4].The review followed a population, concept, and context framework [19].The review focused on the concept of the clinical support available to midwifery students (population) in clinical placements in a global context.

Search Strategy
The retrieval of records was through database searching conducted between September 2019 and March 2020.Hence, this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart [20].The search strategy included keywords midwifery students, clinical support, mentorship, and midwifery clinical practice.The search was refined to English and confined to the last 10 years (January 2010 to August 2020) to ensure only current and updated clinical support interventions for this review.The review included a hand search through the main published papers and citations from the "related literature" list.Electronic databases used for this review included (1) EBSCOHost (CINAHL, MEDLINE, Health Source: Nursing/Academic Edition) using boolean terms such as midwifery and clinical support, midwifery and mentorship, midwifery and clinical supervision, and midwifery and preceptorship; (2) PubMed and Science Direct included MeSH (Medical Subject Headings) terms such as midwifery students and clinical support, or midwifery students and mentorship, or midwifery students and clinical supervision; and (3) Google and Google Scholar used keywords such as midwifery students in undergraduate nursing programs, midwifery students and clinical support, mentorship in midwifery, and midwifery clinical practice and clinical supervision.
The librarian assisted with retrieving full-text papers not found on the website.All researchers kept an electronic record of retrieved papers.

Study Selection Process
The search strategy followed a 3-stage system of title screening, abstract screening, and full-text screening.The selection

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RenderX included qualitative, quantitative, and mixed methods papers published in peer-review journals.All selected papers were exported to an EndNote (Clarivate, 2020) library.Duplications were removed from the list.The primary investigator and an independent collaborator screened all saved abstracts using a standardized Google Form as a tool.Both the primary investigator and the independent collaborator applied the inclusion and exclusion criteria developed for this search.
Inclusion criteria include (1) only primary studies conducted between 2010 and 2020; (2)  All papers selected from the abstract-screening stage were eligible for a full-text paper screening process using another standardized Google Form.Both the primary investigator and the research collaborator worked independently to screen all retrieved papers and compiled a report of both the abstract and full-text screening.A third reviewer (the research supervisor) was available to resolve any discrepancies; however, there were none at the time.The involvement of 3 reviewers prevented bias in the selection of papers.All selected papers from the screening process were saved in an EndNote software folder.

Quality Appraisal
All included studies were quality appraised using a mixed methods appraisal tool [21].The intention was to retrieve high-quality papers related to the topic, avoid reading flawed literature, and prevent bias or untrustworthy information, which is the essence of conducting a systematic scoping review.

Data Charting and Analysis
This review identified papers, which included clinical support interventions.The data charting variables, included (1) the author's name, (2) the year of publication, (3) the aims of the study, (4) intervention outcomes, and (5) the most significant findings.
A desktop review of included papers was followed by a thematic content analysis approach [21].Data were organized into meaning units, coded, and presented as themes and subthemes.

Ethics Approval
Ethical approval was obtained from the Human and Social Science Research Ethics Committee of the University of KwaZulu-Natal (HSS/1509/018M).

Results
The results are presented as the screening results and the data extraction results.

Screening Results
The researcher selected only papers from primary studies for this review and adopted the PRISMA flowchart [20].The result of the screening process is shown in Figure 1.Screening results include the study characteristics (the research approaches and the study settings) and the quality of included papers.

Quality Assessment
Ten papers remained for data extraction, and the quality assessment of these papers was according to the research approaches selected in these primary studies.Hence, the mixed methods appraisal tool was selected to audit these papers.In total, 5 of the 10 papers (50%) were qualitative, of which 3 scored 100% and 2 scored 75%, showing high-quality values.The quality of 4 mixed method designs showed scores between 50% and 100%, and the remaining quantitative design paper scored 100%.These results indicated that all 10 papers were of high quality and complemented the purpose of conducting a systematic scoping review.

Data Extraction Results
Ten papers published between 2010 and 2020 remained for data extraction.The objective of this review was to identify interventions to support midwifery students during clinical practice.Data charting variables were applied to extract data during this stage.Table 1 shows the data extraction results.

Significant findings Intervention used Aims of the study Authors and year A transition model of preceptorship
To support preregistration midwifery students during clinical placement Broad et al [22], 2011 • The intervention facilitated midwifery students learning in practice through the guidance of a preceptor.

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Increased confidence and competence of newly qualified midwives.

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Contributed to staff retention, increase co-operation, and quality of care given.

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Increased investment in health care and education.
Mentor support by PEFs a To train and support the role of mentors in assessing clinical Barker et al [23], 2011 • Support for mentors is critical to improve student facilitation and support in clinical practice.competence of midwifery students

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Protected time was necessary for SOMs b to attend workshops.

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The intervention showed that better patient care outcomes increased collaboration between mentors, PEFs, and university and improved mentor assessment skills.

A developmental program to support mentors
To develop skills in mentorship using a developmental program Durham et al [27], 2012 The program promoted high standards of mentoring knowledge and skills and improved understanding and accountability of the mentorship roles.

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A tripartite role benefitted the institution and the SOM.

A transition support program for midwives
To evaluate the core elements of a transition support program for newly qualified midwives Clements et al [24], 2012 • A structured support during this transitional phase is necessary to ensure quality and safe practice of midwives.from undergraduate and postgraduate nursing program

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Supernumerary time was highly valued but not always available.

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Midwives appreciated study days, which allowed them to share their clinical experiences and debrief.

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The program promoted peer midwife to midwife support.

A planned clinical practice approach
To gain a better understanding of midwifery students' first encounter in the maternity wards Thunes and Sekse [25], 2015 • Student-mentor relationships are crucial for students' achievements and learning outcomes.

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Midwifery students need to feel valued and included in the team, learning was based on students' expec-and what was essential to them in the learning environment tations, understanding, and previous experience.
Mutual engagement with mentors is necessary.
An MFYP program To explore the retention of new graduates in midwifery practice Dixon et al [29], 2015 • The program provided mentor support to new midwifery graduate and increased their confidence in the first year of practice as a registered midwife.following participation in the MFYP c program

SOMs and the value they hold to this role
To explore the experiences and the value of "SOMs" Moran and Banks [26], 2016

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Mentors valued their role and found it to be essential for the supervision of midwifery students during clinical practice.

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Students value mentors for continuity, feedback, and planning.

A peer mentoring program in midwifery clinical placement
To explore the benefits of a peer mentoring program for midwifery students Hogan et al [28], 2017

Answering the Research Question
The objective of this review was to identify interventions available to strengthen the current clinical support for midwifery students globally.Interventions identified in this review included training programs, workshops, and one intervention guideline.
Meta-analysis of the significant findings was conducted to identify how interventions can be combined, adapted, and integrated to produce a more robust conclusion on strengthening midwifery students' clinical support during practice.Six codes emanated from the significant findings, as seen in Textbox 1.
The third reviewer verified the findings and the constructed codes.These codes included academic-service partnerships, collaboration and consultation, clinical support methods, clinical support guidelines, clinical support materials, and course content.
These constructed codes were further analyzed to identify a more intense understanding of how to strengthen mentorship in midwifery.The review adopted a thematic content analysis approach [21].Overall, 2 themes, with 2 subthemes each, emerged from the analysis.These themes are essential to guide mentorship program development and sustainability.

Academic-service partnership
• Partnership between the clinical placement facility and the higher education institution is essential when designing an intervention for clinical support of midwifery students

Overview
The included papers revealed that improved partnerships and consultations were vital in supporting students during clinical placement.This theme developed from 2 subthemes: establishing stronger partnerships between NEIs and clinical facilities and improving consultation between midwifery educators, practitioners, and students.

Subtheme 1.1: Establishing Stronger Partnerships Between Nursing Education Institutions and Clinical Facilities
In 2011, the transition model of preceptorship began through regular meetings between the nurse managers and heads of departments at NEIs [22].This strategy aimed to link the education and practice setting through a preceptorship model, which assisted midwifery students in achieving the required clinical practice standards.This highlighted that collaboration between the health facility, the facilitator, and the NEI is the cornerstone for success in mentorship [13], especially when negotiating protected time for mentors to attend workshops [23] or conduct mentor skills training [27].Support from liaison facilitators employed at hospital facilities and educators of higher education facilities helped mentors to gain confidence in teaching and supervising students in practice.Hence, strengthening partnerships between NEIs and clinical facilities will facilitate continued collaborations and thus improve the clinical support of midwifery students.The idea was well-supported in other studies included in this review [11,26,28].

Subtheme 1.2: Improving Consultation Between Midwifery Educators, Practitioners, and Students
The review revealed that main stakeholders such as the nurse managers, regional or placement coordinators, clinical preceptors or mentors, midwifery practitioners, practice educators, or link lecturers have their roles in supporting midwifery students in clinical placements.Six papers showed that knowing the role of the mentor or preceptor, a named preceptor, contact details, clinical rotation, study days, and supernumerary time were factors that influenced the degree of clinical support offered to students by midwifery practitioners [22][23][24][26][27][28].In addition, the continuity in students' support by the same preceptor with a planned or structured clinical plan influenced students' learning outcomes [13,25].These authors further recommended that mutual engagement, shared knowledge, and shared goals are imperative to improving students' learning outcomes.Continuous relations between midwifery educators and practitioners should be encouraged because both share the responsibility of mentoring midwifery students during clinical practice.
Mentor relationships affect the students' perceptions of clinical practice.Students felt they depended on mentors to teach, show, and help them [25], and mentors, too, became optimistic.They showed interest in students' expectations and engaged with students through good teamwork and communication [26].Furthermore, the mentor roles were valued because they played an essential role.Therefore, describing the mentors' role and expectations is critical in the training program, and this should be clear at the training program's onset [27].[22].Therefore, mentorship training programs should include the policies and guidelines that govern midwifery education, practice, and training.In this review, 9 of the 10 studies (90%) were in first-world countries and guided by the Nursing and Midwifery Council (NMC).One peer mentoring study used the "Australian and New Zealand Support Services Association Incorporated guidelines" for peer mentoring.The training included the program's aims and objectives, the available resources, and a program evaluation [28].According to Thunes and Sekse [25], mentorship training programs should have a planned clinical practice approach that emphasizes students' knowledge, skills, and learning needs to provide an overview of the mentors' expectations.Therefore, training courses for mentors should include information regarding student expectations of the midwifery curriculum, clinical practice requirements, and competencies to be achieved during clinical practice.Midwifery practitioners should be familiar with student requirements outlined in midwifery clinical workbooks and portfolios [27] or clinical booklets [28] to assist students to meet these requirements timeously.The content of training programs becomes critical to the success of mentorship.

Theme 2: Providing Mentor Support Through Training
The information offered should ensure that training attendees become knowledgeable and skilled in their expected roles and responsibilities.

Subtheme 2.2: The Training Duration and Structure
This review identified clinical support interventions that range from a 3-hour face-to-face training session to a 10-day study program and extended to a 12-month program.Training sessions were either informal or unplanned or formal and planned and took place in the clinical placement site.Findings showed that mentors involved in informal, shorter, or fragmented training sessions could not attend all the sessions as they experienced challenges with leaving the wards and received poor support from senior colleagues and managers [23,24].A well-planned and structured mentorship training program contributed to better clinical support outcomes [25,28].Hence, the timing of mentorship training programs is vital to consider in line with ensuring that the program is well-planned, formalized, and nonfragmented.

Developing a Framework
Themes identified in this systematic scoping review are the significant results emanating from tried and tested interventions of previous studies.Therefore, the results that were recurrently seen in the included studies guided the researchers to identify core considerations when planning and developing mentorship training programs.These 4 subthemes are foundational for supporting any mentorship training program, and hence, the researchers propose these subthemes as a framework (see Figure 2) to guide mentorship training.

Comparison of Prior Work
The quality of clinical support for midwifery students is a concern despite efforts toward improvements.This review showed that mentorship is the blueprint for supporting midwifery students to achieve the expected competence needed to become safe and independent practitioners.Mentorship benefits are seen globally, especially in many developed countries, and are effective in clinically preparing students for role-taking [12].Similarly, this review presented that the benefits of mentorship extend from midwifery students to practitioners, academics, and patients or clients.Therefore, nurse managers and heads of NEIs should support midwifery practitioners and educators, respectively, in this shared mentorship responsibility.Hence, partnerships and collaborations between NEIs and clinical placements are necessary.
Continued consultation opportunities contribute to a better understanding of students' clinical expectations [22,23].In 2011, trained sign-off mentors assisted midwifery students in achieving the requirements for clinical practice.However, these mentors experienced numerous challenges and felt inadequately prepared and supported in the role [23].Subsequently, practice education facilitators were employed to support sign-off mentors in their roles [23].
In South Africa, midwifery educators and practitioners share the responsibilities of mentoring midwifery students during clinical placement.Improving consultation between midwifery educators (from NEIs) and midwifery practitioners (from clinical facilities) is needed to improve students' support.Student-centered learning approach in higher education institutions promotes student responsibility and accountability for own learning outcomes.As a result, midwifery students understand that establishing good mentorship relationships with midwifery educators and practitioners is crucial in achieving clinical learning outcomes.In an attempt to review the current midwifery preregistration programs, the NMC supports and empowers students to become active or self-directed learners [32] as does the South African Nursing Council (SANC) [2,32].2) is an investment to midwifery education and practice.

Limitations
The limitations of the study are as follows.First, this review was restricted to clinical support interventions available to midwifery students only and may have limited the clinical support interventions available across nursing disciplines.However, the selected population of this review was midwifery students only and hence did not affect the study results.Second, a restricted timeframe over the last decade (2010 to 2020) may have excluded older but more applicable models of interventions.In view of this limitation, the results may have been short-played.Third, the review excluded the implications of mentorship to other categories of nurses, and hence, this should be explored further in future studies.

Future Directions
The results of this review are likely to assist program developers and midwifery educators to participate in mentorship training and support programs.Strengthening mentorship through training opportunities for midwifery practitioners creates a platform to network and collaborates for the betterment of midwifery clinical practice and education.Given the limited papers retrieved from African countries in this review, there is a need for more research studies and publications on midwifery clinical education in African countries.

Conclusions
Across the globe, mentorship training programs were the most common clinical support available to midwifery students.Mentorship in maternity departments is crucial, and mentors require the support of their colleagues, senior managers, and midwifery educators to ensure mentorship success.The ultimate success of mentorship lies in improved patient care outcomes.Therefore, mentorship training and support for midwifery students should not be side-lined because the safety of our patients is in the hands of these students currently in training.
Mentorship training and support programs alone are insufficient to meet role players' needs.It is important to strengthen partnerships between NEIs and clinical facilities as it allows midwifery educators to become involved in the training and support of midwifery practitioners ceasing consultation and collaboration opportunities.By expanding and promoting engagements between midwifery students, practitioners, and educators, mentorship in midwifery becomes an equally important 3-fold shared responsibility, and this is the goal mentorship program developers want to achieve.
So, mentorship program developers want to advance the scope of mentorship.Attempts to revive mentorship training opportunities are necessary.Despite global attempts to strengthen mentorship, the competence of midwifery students produced remains a significant concern.The framework to guide mentorship training proposed in this review is likely to encourage midwifery educators to pursue more mentorship training opportunities with ease and hence, improve the quality of midwifery clinical education.
A structured mentorship training program to support midwifery practitioners in their mentorship roles and responsibilities is necessary to make improvements in the quality of clinical support.Midwifery students who are well-supported during clinical placement assures that the next generation of midwives are safe and competent practitioners who are likely to contribute to positive maternal health outcomes globally and in South Africa.

Figure 1 .
Figure 1.The screening results presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram [20].

Figure 2 .
Figure 2. A framework to guide mentorship.
This review answers the research question what interventions are available to strengthen the current clinical support for midwifery students globally?By identifying and analyzing the clinical support interventions available on a global platform, the researchers desired to integrate these interventions to develop a new framework to guide mentorship training in South Africa.

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Partnership includes liaison between various stakeholders such as university educators, nurse managers, government personnel (if necessary), Mentors or preceptors or clinical facilitators, and expert advisory groups • NMC Standards framework for nursing and midwifery education (2018) [31] • Australian and New Zealand Support Services Association Incorporated guidelines Materials used in clinical support training sessions • Workbooks, portfolios, booklets, information pack, and a toolkit Course content • Role of the clinical mentor and mentee-named preceptors • Outline of the program-practical component or areas of practice or placement schedules or clinical rotations, study days or skills education days, relationship building, communication skills, feedback, and debriefing opportunities • Professional issues-NMC guidelines or standards for mentors • Responsibilities or role expectations of clinical mentors-include boundary restrictions • Self-care or support services available and referrals