Nurse Education in Practice 72 (2023) 103772

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Advocacy, accountability and autonomy; the learning intention of the

midwifery student continuity of care experience
Olivia Tierney a, *, 1, Vidanka Vasilevski a, b, 2, Leigh Kinsman c, 3, Linda Sweet a, b, 4
a
School of Nursing and Midwifery, Deakin University, Victoria, Australia
b
Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, Victoria, Australia
c
Violet Vines Marshman Centre for Rural Health Research, La Trobe University Bendigo, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Problem: The Continuity of Care Experience is a mandated inclusion in midwifery education programs leading to
Midwifery registration as a midwife in Australia. The practice-based learning experience has evolved over time, yet there
Education remains no standardised learning intentions, objectives, or outcomes for the model.
Continuity of Care
Aim: To identify the key learning intentions of the Continuity of Care Experience by an expert panel to support
Student learning
Woman-centred care
the development of learning outcomes.
Learning intentions Methods: A descriptive qualitative study with two focus groups were conducted with an expert panel (n = 15).
Participants were midwifery education subject matter experts on the Continuity of Care Experience with back­
grounds in academia, policy development, curriculum design, accreditation, or clinical education. The discus­
sions were transcribed and thematically analysed.
Findings: Three main themes and six sub-themes describe the learning intentions of the Continuity of Care
Experience. The main themes were: (1) advocacy for women; (2) accountability of care; and (3) autonomy in
practice.
Discussion: The education model of continuity of care enables students to develop midwifery practice that in­
volves advocating for women, being accountable for their care and being autonomous in practice. We have
established that during the experience students practice in partnership with women and are exposed to the full
scope of midwifery care. Importantly students learn holistic woman-centred practice.
Conclusion: The learning intentions of the Continuity of Care Experience reflects woman-centred practice. Having
identified a common understanding of the learning intention, these can now be used to design learning, and
assessment, through the development of measurable learning outcomes.

1. Introduction
In Australia, a qualification leading to registration as a midwife is
achieved by completion of a bachelor, graduate diploma, or masters
degree. Accreditation standards for curriculum content for every
midwifery program is set by the Australian Nursing and Midwifery
Accreditation Council (ANMAC). The Continuity of Care Experience
(CoCE) is a practice-based learning model which enables midwifery
students to follow and care for women through the antenatal, labour and
birth, and the postnatal period. The CoCE has been a mandated inclusion
in the ANMAC standards since 2009 (Tierney et al., 2018). The latest
midwifery education accreditation standards (Australian Nursing And
Midwifery Accreditation Council, 2021) mandates a minimum of ten
CoCE be included in curriculum for all pre-registration midwifery stu­
dents. The CoCE originated to ensure students could gain experiences of
providing continuity of care to women regardless of the health service
delivery model of care the woman was receiving (Tierney et al., 2017).
Despite being a mandated component of curricula there remains no
standardised learning intentions, objectives, or measure of learning
outcomes for the CoCE.

* Correspondence to: 10 Horizons Parkway, Port Macquarie, New South Wales 2444, Australia.
E-mail address: Otierney@deakin.edu.au (O. Tierney).
1
ORCID: 0000–0002-9369–0455
2
ORCID: 0000–0002-2772–811X
3
ORCID: 0000–0002-0790–5887
4
ORCID: 0000–0003-0605–1186

https://doi.org/10.1016/j.nepr.2023.103772
Received 22 June 2023; Received in revised form 8 August 2023; Accepted 21 August 2023
Available online 23 August 2023
1471-5953/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
O. Tierney et al.
2. Background
Improving access for women to continuity of midwifery care is a key
recommendation of successive national strategic plans for Australian
maternity services (Commonwealth of Australia, 2010; Council of
Australian Government Health Council, 2019) being considered best
practice midwifery. Preparing a midwifery workforce that is skilled
across the full scope of practice, and able to provide continuity of care is
essential to enable system-level changes required to translate evidence
and policy into practice within Australia (Gamble et al., 2020). The
learning model enables students to experience the provision of conti­
nuity of care for women throughout their peripartum period regardless
of the healthcare model the woman accesses. The CoCE requires the
student to engage in a professional relationship with at least ten women
throughout their perinatal period attending a minimum of four ante­
natal and two postnatal episodes of care and the majority of women’s
labour and birth (Australian Nursing And Midwifery Accreditation
Council, 2021). The integration of the CoCE in pre-registration
midwifery programs reflects the essential role it plays in preparing the
midwifery workforce. It is well-accepted that CoCE should be an
embedded learning experience for all midwifery students (Tierney et al.,
2018, 2017; Gamble et al., 2020; Gray et al., 2016; Sidebotham and
Fenwick, 2019). Midwifery education leaders from across Australia and
New Zealand have identified the need to study how best to incorporate
CoCE into clinical experience as a top priority for the future develop­
ment of the profession (Sidebotham et al., 2020). Identifying common
learning intentions is key to informing the purposeful learning objec­
tives and assessment to optimise this practice-based learning experience
(Gamble et al., 2020).
The CoCE is a highly valued learning experience by students, mid­
wives, and education providers in preparation for practice as a regis­
tered midwife. The CoCE is known to be held in high regard by students
for the learning it provides (Gray et al., 2016; Sidebotham and Fenwick,
2019; West et al., 2016; Carter et al., 2015). Students report that the
CoCE is the most valuable learning component of their education
(Tierney et al., 2017). Students have identified that developing close
relationships with women is important learning, and that caring for a
known woman in labour was highly satisfying (Dawson et al., 2015).
The learning enabled during CoCE has been shown to help students to
have a broad understanding of women, including the context of their
family, and psychosocial wellbeing, and allows them to be exposed to
the full potential of midwifery practice (Ebert et al., 2015; Sweet and
Glover, 2011a). The student’s experience of CoCE is largely influenced
by the model of care the woman is receiving (McLachlan et al., 2013;
Sweet and Glover, 2011b; Sweet, 2014). Whilst placing students within
midwifery caseload models of care may provide the ultimate continuity
learning experience for students (Moncrieff et al., 2020), it is recognised
that not all midwifery students are able to undertake a placement in a
midwifery caseload model due to limited availability of these models in
Australia. The opportunity to undertake CoCE with women regardless of
their model of care is the next best alternative.
Women report their satisfaction of involvement in CoCE with stu­
dents (Jefford et al., 2020; Tickle et al., 2016). One study of nearly one
thousand women identified the value women placed on the relationship
they had with their student during CoCE when continuity was lacking in
their models of maternity care (Jefford et al., 2020). A further study of
over two hundred women found a significant positive correlation be­
tween women’s care satisfaction when a student attended their episodes
of care, despite the model of care they were receiving (Tickle et al.,
2016). Continued inclusion of this learning model in midwifery educa­
tion will in turn enable satisfaction of care for women albeit from a
student.
Evidence clearly demonstrates the value of the CoCE learning model,
however, the practicalities of embedding it in education and healthcare
settings can present challenges for students, universities, and clinical
partners (Sweet and Glover, 2011b; Newton et al., 2022). The outcome
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Nurse Education in Practice 72 (2023) 103772
of this learning experience for the student is influenced by the variations
and interactions between the woman, student, university, and the
healthcare model (Tierney et al., 2017). Challenges to the success and
sustainability of the learning model have been identified from the
perspective of the student in regard to financial and workload stress
(Tierney et al., 2017; Sweet and Glover, 2011b; Browne, 2014; Gray
et al., 2013; Foster et al., 2021). Furthermore, midwifery academics
have identified the impact of CoCE on the student workload (Tierney
et al., 2017; McLachlan et al., 2013; Newton et al., 2022) and healthcare
settings arising from the service model and supervision of students
(Tierney et al., 2017; McKellar et al., 2023; Carter et al., 2022). Recent
research has sought to strengthen the CoCE model by exploring how to
best support students overall experience. This includes discovering the
benefit of CoCE for preparation of a workforce and graduates capability
and capacity to work in continuity models (Carter et al., 2022). Atten­
tion has also been directed toward the pedagogy for the model (McKellar
et al., 2023; Hainsworth et al., 2022a), and the clinical context it is
undertaken, including the healthcare setting and support for students
undertaking the CoCE (Foster et al., 2021; Carter et al., 2022). In
addition, there remains a need to define the learning intention for the
CoCE as an important focus of the preparation, learning, and assessment
of this educational model in curricula. Effective pedagogy is funda­
mental to ensure the CoCE learning model achieves the desired outcome.
Learning intentions described as broad concepts give direction to the
learning experience, with learning objectives providing specific mea­
sures of learning, guiding the learning outcomes of skills, competencies
and knowledge the student acquires (Krathwohl, 2002). This research
focuses on identifying the key learning intentions of the CoCE by an
expert panel to support the development of learning objectives and
learning outcomes for CoCE for this mandated learning model.
3. Participants, ethics and methods
A qualitative study was conducted to identify the learning intentions
of the CoCE from the perspective of a midwifery expert panel across
Australia. Focus group discussions were chosen to enable the panel to
explore their perceptions and tap into their collective expertise (Green
and Thorogood, 2018). Midwives involved in CoCE either from an ac­
ademic, research, policy development, curriculum development,
accreditation, or clinical facilitation perspective were identified as the
experts to discuss the learning intentions for the CoCE. Access to this
group of potential participants was identified via 2 sources: (1) pub­
lished authors (post 2009) on the topic of CoCE, and (2) members of the
Trans-Tasman Midwifery Education Consortium (TTMEC). The con­
sortium provides leadership and strategic direction for the advancement
of midwifery education in Australian and New Zealand, by undertaking
research and providing a united voice for future directions. An invitation
to participate was sent via the lead author’s university email address (1)
directly to publicly available contact details of identified published au­
thors of CoCE, and (2) the chair of the TTMEC for distribution to
members. Instruction was provided in the invitation for interested par­
ticipants to register their interest via email directly to the lead author.
All participants who agreed to take part were allocated across two
focus groups with consideration to an even distribution of states and
university providers. The focus groups were conducted in October 2021,
each was hosted online for approximately one hour to enable accessi­
bility and representation of the diverse participant group across
Australia. The discussion was facilitated by the lead author and sup­
ported by a research team member (LS), both with focus group facili­
tation experience. The discussion was prompted by a semi-structured
interview guide (Table 1). Questions were derived from themes identi­
fied in an integrative literature review (Tierney et al., 2017). Ethics
approval was provided by the Deakin University Human Ethics Advisory
Committee (HEAG-H 143_2021). Consent was implied via participation,
with the discussion hosted over Zoom®. The discussions were audio
recorded and transcribed verbatim by the lead researcher. The
O. Tierney et al. Nurse Education in Practice 72 (2023) 103772

Table 1
Focus group semi structured interview guide.
Discussion prompt questions

As a midwifery practice experience, what does the CoCE model provide the student?
What would you describe the learning intention of the CoCE model is?
How does the CoCE model enable woman-centred learning?
What professional behaviours does the CoCE model facilitate?

transcriptions were revised and checked for accuracy by the lead author
through review of the recordings. The data was stored and managed in
NVivo 12™. Using Braun and Clarke’s reflexive six phase thematic
analysis process, the lead author coded the data, adopting an inductive
approach to identify concepts and generate themes (Braun and Clarke,
2019) (Braun and Clarke, 2021). The lead author moved through the
data in an iterative approach, to understand and interpret the stories
amongst the data (Braun and Clarke, 2021). Codes were then organised
into themes and sub-themes, identifying patterns of shared meaning
within the data (Braun and Clarke, 2019). Themes were described with
titles that reflected the terminology used by participants. The coding and
themes were reviewed and clarified until agreement was reached by the
Fig. 1. visual interrelationship of themes.
research team.

4. Findings 4.1. Theme 1: Advocacy for women

Seventy-six midwives were invited to participate who met the The theme ‘advocacy for women’ reflected participants’ perspectives
criteria for inclusion. Eighteen agreed to participate, three were unable regarding how CoCE enables midwifery students to understand the
to attend at the scheduled times, producing a final sample of fifteen importance and development of this professional attribute to practice
participants. Participants were actively involved in and brought col­ woman-centred care. This theme has two sub-themes ‘knowing the
lective knowledge and experience regarding midwifery education, woman’ and ‘working in partnership’. These sub-themes describe how
research, policy, curriculum design, accreditation procedures, and/or the CoCE model facilitates the student to understand what is important
published authors on the subject matter. To ensure nationwide per­ to the woman and how to advocate for her choices with this knowledge.
spectives and experience, the panel included representatives with cur­
rent or previous experience from most states and territories across 4.1.1. Knowing the woman
Australia (see Table 2). There were eight participants allocated to the Participants described that CoCE enabled students to get to know a
first focus group and seven in the second focus group. woman in depth over time. The requirements for the CoCE to commence
Three main themes emerged, each with two sub- themes character­ during the antenatal period, continue through labour and birth, and the
ising the learning intentions of the CoCE. The themes and sub-themes postnatal period, facilitates the student to get to know the woman ho­
are not independent of each other, they demonstrate an interrelation­ listically. Through these interactions, the student can better understand
ship with each other to collectively contribute to the learning the what is important to the woman and why, and how decisions regarding
experience (Fig. 1). The themes and sub-themes were: her care will impact her. This knowledge enables the student to be able
to advocate for and support the woman’s needs and choices.
1. Theme 1: Advocacy for women [students] are exposed to so much information about the woman, her
- Working in partnership whole life, understanding her holistically, you know. When they’ve got
- Knowing the woman that relationship and each time they’re getting more information about
2. Theme 2: Accountability of care her just from chatting about the weather or whatever, and you’re finding
- Navigating relationships out she’s got a mum that [is] sick, or you know, she’s got three little kids,
- Learning over time and that her feet are swollen and she can’t get her feet up (FG1)
3. Theme 3: Autonomy in practice
- Finding their voice The participants indicated how the student’s experience of getting to
- Developing a midwifery identity know the woman during CoCE enabled holistic practice. Developing a
holistic view of the woman is optimised during the CoCE and facilitates
the student to learn more deeply about the factors influencing the
woman’s life. One participant said ’[during the CoCE students are] more
nuanced to them [woman], they know their social, emotional, psycho­
logical history, they know if the woman’s experiencing any vulnerabil­
Table 2 ities like DV [domestic violence] or alcohol, substance abuse, they know
Participant location by state within Australia. who her significant others are’ (FG1).
State Number
This depth of understanding facilitates students to advocate for the
New South Wales 3
woman according to her priorities and needs, as the experience positively
Victoria 4
Queensland 3 motivates and drives students to learn to practice this way. As one midwife
South Australia 1 explained, ‘[the student is] the one who will be able to step forward and
Western Australia 3 advocate for her because she knows the woman better than anyone else
Northern Territory 0 does’ (FG1).
Australian Capital Territory 1
Total 15 Another commented, ‘This is how they learn to stand up and

3
O. Tierney et al. Nurse Education in Practice 72 (2023) 103772

advocate, because they truly understand what the woman needs’ (FG2). anything else for that matter, they see the whole thing, so it’ll give them a
much better understanding of how that works (FG1)
4.1.2. Working in partnership
The CoCE also affords a great depth of learning as students have a
Participants explained that CoCE facilitated exposure to the core of
more complete account of a woman’s progression through pregnancy
woman-centred midwifery care, forging a true partnership between the
and how various issues develop, what impact this has on her care, and
midwifery student and the woman. The participants described that this
the influence it has on her personal life.
partnership aided the student to learn about the woman’s perspective.
continuity of care actually enables them to look at that progression of
the students seem to have that ability to see the experience from the
pregnancy, how that occurs, if for example, the woman has a complica­
woman’s perspective and I think they kind of get a lens on the care that’s
tion of pregnancy, they actually get to learn at such a deep level through
provided from the woman’s perspective and not from the clinician’s
the continuity of care experience because they can see that it’s not just a
perspective. I think that’s something that is unique to those continuity of
case, it’s actually, I think as [name] said, it’s attached to a woman, it’s
care experiences (FG1).
attached to your life, it’s attached to their community (FG2)
It was described that through this partnership, the woman develops a
sense of trust and becomes invested in the students’ learning. There is
4.2.2. Navigating relationships
joint ownership of both the woman’s outcomes and the student’s
The participants described the importance of the development of a
learning. This investment provides the student with further opportu­
relationship between the student and woman over the duration of time
nities to learn, as the woman trusts the student’s advice and decisions,
of the CoCE. An effective relationship provides the student with the
and usually consents to them providing clinical care.
understanding and opportunity to learn more about the woman and
I might ask that student to explain a concept to the woman, … the student what is important to her, build rapport, and develop a true therapeutic
will feel really safe in doing that, because she knows … there’s no way that relationship over time.
that woman is going to worry if she gets something wrong, I’m going to be
One of the main intentions [of the CoCE] would be the ability to develop a
supporting her, and that the woman is actually rejoicing in her learning
trusting therapeutic relationship. A trusting professional therapeutic
(FG2).
relationship, which is really difficult in a snatched 15 min with somebody
The partnership was described by participants to also provide a you don’t know (FG1).
learning environment where the student can understand and learn how
The relationships formed during CoCE are of great depth between the
to advocate for the woman’s choice. One participant said, ‘it’s really
woman and student and enables the student an opportunity to learn to
about advocacy as well, that’s a really good lesson in facilitating decision
balance responsibility and professional boundaries. The student is
making’ (FG1).
exposed to navigating a developing relationship simultaneously with the
women, her support networks, and care providers, while needing to
4.2. Theme 2: Accountability of care
maintain professional boundaries, and ensure safety for themselves and
the women. This is suggested to facilitate the development of a sense of
The theme ‘accountability of care’ was identified, describing how the
responsibility to be accountable for the care they provide to women.
student develops an understanding of being accountable for the care
they provide to women. Participants expressed how the multiple en­ So, this is also a way for them not only to learn about the journey and
gagements and extended time spent with a woman during the CoCE about what it means to actually really understand the woman’s wants and
creates an experience where the student links their clinical decision needs but also how to start creating and separating the professional
making to a woman with the knowledge that they would see the woman relationship from that personal one as well, and trying to balance the role
again. Two sub-themes ‘learning over time’ and ‘navigating relation­ of what a midwife really needs to be, to be effective (FG2)
ships’ were identified that facilitate the student to learn how they are
responsible and accountable for their midwifery practice.

4.3. Theme 3: Autonomy in practice

4.2.1. Learning over time
The length of time that the student engages with a woman during
The theme ’autonomy in practice’ identified how the CoCE enables
CoCE, from pregnancy through to postpartum care, enables a unique
the development of the student’s knowledge and exposure to the full
opportunity for them to learn over the duration of the woman’s transi­
scope of midwifery practice. During the continuity experience students
tion from pregnancy to motherhood. The extended time that care is
learn to speak up, practice more independently, and learn to make
provided during CoCE supports learning a strong sense of accountability
autonomous decisions in consultation with a midwife for the care of a
for the student’s midwifery practice and how this affects the woman.
woman. This theme has two sub-themes of ‘finding their voice’ and
when you’re [the student] palpating [and deciding] whether this baby’s a ‘developing a midwifery identity’.
bit small, you don’t subconsciously think, I’m not sure, the next person
will pick it up, you follow it up. So, I think that they [student] definitely 4.3.1. Finding their voice
develop a much stronger sense of accountability (FG1) Participants described how the CoCE enables students to become
more confident in their midwifery knowledge and skill, and in turn their
Participants described that the CoCE enables a greater capacity for
ability to speak up develops over the time spent getting to know a
the student to take theory into practice with a holistic approach to care.
woman and her care providers. As the student becomes more familiar
The ongoing engagement with individual women supported students to
with a woman and develops a relationship with her, their confidence
link their learning to the woman and see physiology and the outcomes
grows and they can find their voice, to interact with the woman and
from their care unfold. .
other care providers, and be more self-assured in their midwifery
… also the students will see if there is a pathology, if there is any problem practice.
they will see it develop, they will see it right from the very beginning, and
I agree with [name] … who talked about finding their voice. I think that’s
how it … either deteriorates or it’s managed, but they will actually be able
absolutely probably the number one thing that I can see that happens with
to follow that journey right from the very start of any pathology, or
that progression of learning over the period of time with a continuity
experience (FG2)

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O. Tierney et al.
Finding their voice supported the development of confident
communication for the student, both with the woman and her care
providers. A participant described this as ‘I would expect in the CoCE
context that they are more confident in their communication with the woman
[which] grows as they develop the relationship’ (FG1).
4.3.2. Developing a midwifery identity
Participants described that during the CoCE, students have an op­
portunity to learn and understand the full scope of midwifery practice,
and by doing so develop their own midwifery identity. Through the
continuity experience the student becomes the person who knows the
woman the best, is trusted by and has a therapeutic relationship with the
woman, which supports the student to feel safe and to practice more
independently. This enables them to understand what a midwife is when
working across the full continuum of care. One participant stated, ‘within
the continuity of care relationship, they get much more of an understanding of
who a midwife is, and what a midwife does, and what a midwife’s role is, and
how that role interacts with other roles’ (FG1). The experience affords the
midwifery student the learning space to develop their woman-centred
care approach and truly understand the full scope of autonomous
midwifery practice.
so over the course of the time when they’re seeing these different women
and they are gaining that insight into what it truly means to be with
woman, they mature in their outlook, and so they identify different things
that they’re getting from the experience (FG2).
4.4. Interdependence
Through the participant discussion there was a strong sense of inter-
relationship between one learning intention and another. The themes
identified in this study demonstrate a clear interaction, and cyclical
dependence, rather than linear flow to ensure the most effective learning
is achieved during the CoCE. It was identified that ‘learning over time’
aids the student to get to ‘know the woman’ which in turn enables the
student to ‘find a voice’, enhancing their learning. In addition, the
exposure to ‘working in partnership’ enables the student exposure to
‘navigating relationships’ which supports the development of their
‘midwifery identity’, that in turn enhances the partnership between the
student and woman.
5. Discussion
This study aimed to identify the common understanding of the
learning intentions for the midwifery student practice-based experience
of continuity of care. The major themes that emerged through the focus
group discussions with fifteen Australian midwifery experts were: i)
Advocacy for women; ii) Accountability of care; and iii) Autonomy in
practice. This describes the intended midwifery practice students
develop through learning in the CoCE model. Participants expressed that
CoCE afforded midwifery students learning opportunities to develop
woman-centred care across the full continuum of midwifery practice.
The duration of time spent between a student and woman during the
CoCE enables the development of a relationship between them, the
student’s confidence develops, facilitating an effective learning experi­
ence for the student to develop skills and knowledge. From working in
partnership with the woman, the student is exposed to the full scope of
midwifery care, supporting the development of their own woman-
centred midwifery philosophy underpinned by practice that advocates
for women, is accountable to care, and autonomous.
The CoCE provides an opportunity for students to develop a deep
connection and relationship with a woman throughout her childbearing
journey. The findings further support the idea that students undertaking
CoCE engage in a symbiotic relationship, learning about the woman and
what is important to her (Sweet and Glover, 2011b). It was identified
that students are observed to seemingly build on the relationship as they
5
Nurse Education in Practice 72 (2023) 103772
interact with and get to know the woman over numerous episodes of
care, which is unique to the CoCE model. These findings are in line with
other studies exploring the students perspective where the time afforded
in the CoCE enhanced their ability to develop relationships with women
(Hainsworth et al., 2022b; Gray et al., 2012). Development of this close
relationship is instrumental to the students’ learning experience and
enables a sense of accountability and investment in their care provision
and midwifery practice. This study further validates the notion that
when a relationship develops between the woman and student, this fa­
cilitates an effective learning environment (Sidebotham and Fenwick,
2019; Dawson et al., 2015).
This study identified that the student’s confidence appears to grow
over the period of time the student spends together with the woman. Due
to the nature of the CoCE relationship and the ability for the student and
woman to get to know each other, this familiarity empowers the student
to be more confident. This finding is consistent with the students re­
ported experience of being in the CoCE (Sidebotham and Fenwick, 2019;
Carter et al., 2015; Sweet and Glover, 2011b; Hainsworth et al., 2022b).
The growth of confidence for the student results in their improved
ability to speak up and interact with the woman and the multidisci­
plinary team, learning how to advocate for the woman alongside mid­
wives, and thus developing their own sense of autonomous midwifery
practice. This interaction translates into the student truly engaging in
the learning experience, forming their own midwifery identity (Browne,
2014; Seibold, 2005). The findings suggest the CoCE relationship is
observed to impact the student’s level of confidence and their devel­
opment, understanding and knowledge of midwifery philosophy.
The learning environment that is created through CoCE is an op­
portunity for students to integrate theory into practice. The findings
from this study confirm that when a student is learning in the CoCE they
can apply their theoretical knowledge specifically to a known woman
they are caring for from pregnancy through to postnatal. One participant
described this concept as observing the student learning to be ‘pinned to
a woman’. These findings are consistent with the student perspective of
their enhanced application of knowledge when learning in the context of
the CoCE (Foster et al., 2021; Hainsworth et al., 2022b). The continued
inclusion of the CoCE in midwifery curricula ensures optimizing the
learning experience, bringing the theory to life alongside a woman for
students during practice-based learning component of their program.
The findings from this study demonstrate that the learning intentions
for the CoCE can be defined. This is a crucial step toward ensuring any
learning experience is pedagogically sound (Krathwohl, 2002). The
identified learning intentions of the CoCE show that the model should
enable students to develop woman-centred care by development of
practice that reflects accountability, advocacy for women and under­
standing of autonomy of practice across the full scope of midwifery
practice. Made possible due to the time immersed in the experience for
the student and the relationship that forms, enabling the student to gain
exposure to learning alongside the woman’s pregnancy, birth, and
postnatal period. Caring for and learning occurs alongside and in part­
nership with the woman. This exposure to the full role and capability of
midwifery care enables the student to better understand and develop
their own identity as a woman-centred midwife. A recent scoping review
of contemporary midwifery practice, (Watkins et al., 2023) identified
the role of the midwife was to be in partnership with the woman, to be
autonomous, and an advocate in the provision of woman-centred care.
To ensure a future midwifery workforce that is well prepared it is
imperative that the pedagogy of the CoCE be enhanced with the addition
of standardised learning outcomes that are informed by learning in­
tentions. Strengthening how this model can be embedded in curricula
may address the variations and challenges that exist with the mandated
model and afford students the opportunity to fully engage and immerse
in this learning. Importantly, by doing so students can develop practice
that aligns with the Midwifery Practice Standards (Nursing and
Midwifery Board of Australia, 2018). Ensuring strategies that support
the CoCE to be central to student’s learning is necessary to ensure the
O. Tierney et al.
continued success of the model (Moncrieff et al., 2022). This will pro­
vide grounding for embedding the CoCE in tertiary programs to guide
curriculum design, support in practice and student learning. Further
research is recommended to discover how the themes identified in this
study can be reflected in learning outcomes and incorporated into cur­
riculum design and student assessment. Once this is achieved, the
learning intention of the CoCE can be evaluated to ensure the mandated
experience is pedagogically sound.
6. Strengths and limitations
This study identifies the common understandings of the learning
intentions of the CoCE from the perspective of an expert panel of
midwifery professionals. The panel size was small, however the diversity
of the 15 participants contributed combined knowledge, expertise, and
experience providing an in-depth insight regarding the pedagogical
intent and observed learning that occurs with the CoCE. The study does
not include the perspective of students, however, some of the findings
reaffirm the reported students’ experience of learning in other studies.
The findings align with identified strengths of the CoCE and brings
together a collation of the learning intentions for the development of a
model. Whilst the study explored the CoCE learning model specifically,
it is acknowledged that the learning intentions may also be reflected in
other clinical placement models.
7. Conclusion
Previous research shows that CoCE is a positive experience for both
women and students and is highly valued for the unique learning it
provides. The learning intentions of the CoCE had not previously been
well articulated. This study identified the learning intentions of the
CoCE, defining the goal of the practice-based model to guide the future
development of learning outcomes. Learning outcome statements will
provide students, education providers, and midwives guidance for how
the CoCE can be designed, imbedded in curricula, and assessed. The
purpose of this study was to provide evidence that will contribute to
improving standardization of the pedagogy of the CoCE. A step toward
ensuring all students achieve and optimise their learning with CoCE,
irrespective of which university they attend, or the healthcare setting or
model their midwifery practice experience is undertaken. With the
future development of learning outcomes aligned with the learning in­
tentions, the CoCE can contribute to preparation for practice of
midwifery students. In turn develop a future midwifery workforce who’s
practice reflects the themes in this study that advocate, are accountable
and autonomous in their practice to provide woman centred care and
optimise outcomes for women and their babies.
Funding Sources
No external funding sources.
Ethical statement
Please accept this as confirmation that this study obtained ethical
approval from Deakin University human ethics advisory group- health
[HEAG-H 143_2021], approved 13/08/2021.
CRediT authorship contribution statement
Olivia Tierney: Conceptulization, Methodology, Investigation,
Writing – original draft, Writing – review & editing, Visualisation.
Vidanka Vasilevski: Methodology, Writing – review & editing, Super­
vision. Leigh Kinsman: Methodology, Writing – review & editing, Su­
pervision. Linda Sweet: Methodology, Investigation, Writing – review &
editing, Supervision.
6
Nurse Education in Practice 72 (2023) 103772
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
We thank the participants for their time and contribution to this
study.
Author agreement
The article is the authors original work and had not received prior
publication or under consideration for publication elsewhere. All the
authors have seen and approved the submitted manuscript. The authors
abide by the copyright terms and conditions of Elsevier.
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