gms | German Medical Science

GMS Zeitschrift für Hebammenwissenschaft

Deutsche Gesellschaft für Hebammenwissenschaft e.V. (DGHWi)

ISSN 2366-5076

Integration of internationally qualified midwives in obstetric teams

Research Article

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  • corresponding author Beate Blättner - Fulda University of Applied Sciences, Fulda, Germany
  • Angela Rocholl - Fulda University of Applied Sciences, Fulda, Germany

GMS Z Hebammenwiss 2020;7:Doc04

doi: 10.3205/zhwi000018, urn:nbn:de:0183-zhwi0000186

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/zhwi/2020-7/zhwi000018.shtml

Received: March 1, 2020
Accepted: October 9, 2020
Published: December 10, 2020

© 2020 Blättner et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Abstract

Background: The integration of internationally qualified midwives appears to be one of the strategies implemented to resolve the shortage of midwives in some German federal states. To date, there have been very few studies on the opportunities and limitations of the integration process for midwives.

Objectives: Findings from a project on the integration of internationally qualified nurses were transferred to the work of midwives on an experimental basis, thus highlighting the phenomena which need to be investigated more closely in practice.

Methodology: In total, 19 interviews were conducted with home managers, nurse managers, ward managers, internationally trained nursing staff and their colleagues in four German residential and outpatient health care services for sick people and elderlies. They were evaluated using grounded theory, and memos from discussions with midwifery teams were used to reflect on transferability.

Results: The labour migrants interviewed felt that they were seen more in terms of their shortcomings than their competencies. The existing teams tended to feel overwhelmed by the work integration entailed and to perceive the migrant women as “problematic”. Misunderstandings were perceived as language problems. The added work of integration was poorly recognised by the institutions.

Conclusion: Integration work must be recognised, thoroughly prepared for and rewarded. The competencies of internationally qualified midwives must be seen as such and must be integrated into the everyday working practice of existing teams.

Keywords: midwifery, foreign professional personnel, career mobility, integration, health workforce


Background

A survey of midwives conducted as part of the study “Geburtshilfliche Versorgung durch Hebammen in Nordrhein-Westfalen” (Midwife provision of obstetric care in North Rhine-Westphalia, HebAb) pointed to a shortage of midwives: one in four of the midwives questioned had worked on a maternity ward which had been forced to temporarily close in the past month and 70.6 percent of these closures were due to a shortage of midwives. Only 6.8 percent of the midwives questioned reported that they had not recently worked overtime [8]. In another survey in the German federal state of Hesse, 88 percent of the hospitals that responded stated that they would require additional permanently employed midwives in the next three years; 53 percent had vacant posts at the time of the survey, with an average of 1.9 vacant posts per hospital. Respondents reported that the amount of time required to fill vacant positions was 18.5 weeks, on average [1]. Different options being discussed to tackle the problem of the shortage of midwives include increasing the number of training places, making midwifery a university degree subject and measures to increase the attractiveness of the profession as well as recruitment and recognition of internationally qualified professionals [2].

With regard to the official recognition of the qualifications of midwives who trained abroad, a distinction has to be drawn between EU countries and what are referred to as “third countries”. The procedure for this is regulated by the German Midwifery Law (HebG). Professional qualifications acquired in third countries are either recognised as being equivalent to a corresponding German qualification or are recognised following adaptation measures such as adaptation training, qualifying exams or aptitude tests (Section 54ff HebG). The Skilled Immigration Act, which entered into force in March 2020, made the recruitment of non-EU citizens and the subsequent immigration of their family members easier. Professional qualifications obtained in the member states of the EU and other treaty states or those accorded equivalent status are automatically recognised (Section 46ff HebG).

However, midwives from other EU countries have different skills to those who qualified in Germany. Although the EU Directive (2005/36/EC) sets out the minimum standards that must be met for reciprocal recognition of qualifications, the professional socialisation process during the qualifying phase is geared towards the conditions in the country where the qualification is being acquired.

Even the duration of the (academic) training is heterogeneous in Europe, ranging from three to five years. In France, for instance, midwives need a master’s degree before they can practice [5]. In Italy, a three-year university degree resulting in a BA-equivalent qualification (Laurea) is sufficient, although there are some pilot projects aiming for a five-year degree [6]. Similarly, in Poland, a bachelor’s degree also qualifies a graduate to work as a midwife, although, in 2016, a total of 17 percent of all practicing midwives had a master’s qualification and there are other opportunities to specialise [12].

To some extent, midwives’ scope of responsibility also differs between countries: In the Netherlands, for instance, together with general practitioners, midwives are responsible for the primary care of pregnant women since gynaecologists only work in hospitals [7]. In France, midwives are even permitted to prescribe certain medication and carry out immunisations [5].


State of research

To date, there has been no research on the extent to which internationally qualified midwives are integrated in German care structures, the opportunities and obstacles associated with integration into an existing team and the impact of differences in training and professional practice. International studies on the situation are equally scarce.

A British study on the international recruitment of qualified professionals for the NHS included the recruitment of midwives but only a small number of issues were analysed separately for the different professions. The study showed that staff shortages can be addressed but that this was associated with significant financial expense and organisational effort. Among other things, the study also determined how many years a labour migrant had to work before the investment paid off: The study showed that for midwives and nurses, the investment paid off more quickly (within an average of 3.1 years) than for doctors (3.8 years for medical consultants and 4.6 years for general practitioners). The study highlighted that the integration of internationally qualified midwives resulted in innovative ideas, infrastructural benefits and positive effects on training [16].

In Australia, 18 midwives who had migrated from the United Kingdom were asked about their experiences. The author of the study came to the conclusion that it was essential for midwives to be well informed prior to migration in order that they may start work with realistic expectations. It was also found that management staff should endeavour to match the midwives to roles where their skills will be maximised [11].

In a more recent Australian study, interviews were conducted with 11 internationally qualified midwives. The study found that the different culture of the work environment, differences in midwifery practice, lack of autonomy and perceived discrimination impacted integration. The success of integration depended on the migrant midwives’ ability to develop a sense of belonging and to adopt strategies that assist in dealing with new workplaces and an unfamiliar workforce. The authors come to the conclusion that a structured integration programme as well as a mentorship programme focusing on Australian midwifery care and culture may be effective strategies to facilitate integration [9].


Objectives

The aim of this research was to ascertain how relevant the topic of integrating internationally educated midwives is in Germany, as well as the challenges this presents in everyday practice.

To this end, data on the recognition procedures for internationally qualified midwives was prepared and the findings from a project on the integration of foreign nurses was transferred to the work of midwives on an experimental basis. This highlighted the phenomena which need to be examined more closely in practice.

Our initial assumption was that the type of work and areas of responsibility of midwives and nurses would be fundamentally different but that the integration of qualified professionals would be associated with similar difficulties. The project concentrated less on questions of recruitment, the quality of recruitment agencies, the language skills required for the recognition of a professional qualification or the form and duration of the recognition procedure. Instead, the research was focused on generating information on the specific achievements of existing teams regarding integration in everyday working practice.


Methodology

Based on the “grounded theory” research methodology [15], which allows us to link heterogenous data collected in different contexts, we approached the questions of interest in a three-step process: the investigation of integration processes in the care sector, an analysis of the relevance of the topic for obstetric care using statistical data and the transference of knowledge on the integration of nurses to the midwifery profession based on a comparison with additional data.

This is one of ten implementation projects (Integration Internationaler Pflegekräfte in regionale Einrichtungen, InTIP; Integration of Foreign Nurses in Regional Institutions) that are part of the transfer project funded by the Joint Federal Government-Länder Programme Innovative Hochschule (Innovative Further Education) [3], [4] with two hospitals and two providers of residential and outpatient nursing homes. The ongoing project studies the integration of internationally qualified professionals based on the example of nurses with the aim of transferring the acquired insights to other health care professions. Both of the hospitals participating in the project have obstetric departments (top level perinatal centre, maternity hospital), but do not have any substantial experience of integrating foreign midwives, only foreign nurses.

A total of 19 structured interviews were conducted with home managers, nurse managers, ward managers, internationally trained nursing staff and their colleagues. The subject of the interviews was the experience to date of the process of integrating internationally qualified nurses. The interviews were conducted by trained interviewers already working on the subject of labour migration in the health care sector and from a migration background themselves.

In addition, we carried out three guest observation visits in elderly care and nursing care, one guest visit to observe one of three training courses for foreign nursing staff in the process of having their qualifications recognised at one of the hospitals, as well as an interview with the training supervisor. We also had regular one-to-one and group meetings with the respective project partners. To document our findings, field notes, observational logs and memos and interview transcripts were prepared. The project is ongoing and new data is continuously being added.

All interviewees provided written consent.

To evaluate the data, we conducted open, axial and selective coding and the results of the analysis were recorded in theory-generating memos, the findings of which, in turn, inspired the collection of new material.

To address the question of the transferability of findings to the midwifery profession, a special evaluation, requested specifically for this purpose, was conducted by the Federal Statistical Office of Germany (Statistisches Bundesamt) [13]. The evaluation focused on the question of the current relevance of internationally trained midwives in German obstetric care.

The final step was to compare and contrast the knowledge on the integration of internationally qualified nurses with memos documenting observations on the work of foreign midwives. These memos were written during discussions with partner hospitals, as far as any comments on internationally qualified midwives were made, and discussions on the university’s experiences with adaptation measures for foreign midwives. In the comparison, as with the selective coding [15], we searched for similarities and differences in the material which enabled us to answer the question by way of creating hypotheses.


Results

Relevance for care provision

During the discussions with the hospitals, the impression was that, in some hospitals in Hesse, both the midwife shortage and the integration of midwives who had qualified abroad represented a genuine problem being faced in midwifery practice, while other hospitals in the region (Hesse, West Thuringia, North Bavaria) had not yet been confronted with this problem. The observations suggested regional differences.

The special evaluation by the Federal Statistical Office showed that, in 2018, a total of 324 applications were received across Germany for recognition of equivalence of a midwifery qualification obtained abroad [13]. Between 2013 and 2015, the corresponding figure was just 155 applications per year, on average [13]. A different source positions midwifery in 11th place in a ranking of professions regulated under federal law for which applications for recognition of qualifications are most frequently received, quoting 381 cases [14].

As expected, the majority of the 324 applications (108) came from the most populous federal state North Rhine-Westphalia, with Hesse (66 applications) in second place. Looking at the period from 2016 to 2018, it is clear that the majority of cases (71.9 percent) are concentrated in the federal states of North Rhine-Westphalia, Bavaria, Hesse and Baden-Württemberg [13] (see Figure 1 [Fig. 1]).

Based on size of population, however, Hesse was in fact in first position in terms of the annual average number of applications, followed by Rhineland-Palatinate and Bavaria.

Of the 324 applications received in 2018, a total of 53.7 percent (n=174) were made by midwives from another EU member state and a further 25 percent came from other European countries. Accounting for a 17.5 percent share, Asia, particularly Iran, also played a relatively significant role while applications from Africa, North and South America and Australia tended to be isolated cases (see Figure 2 [Fig. 2]). Among the applications from EU member states in 2018, the largest number came from Italy (56.9 percent), followed by Poland (12.1 percent). The situation in 2016 and 2017 was similar, while in the period from 2013 to 2015 when a smaller number of applications were received overall, Poland dominated among the EU member states [13].

In 2018, after a review of the applications in the federal states, of the 222 completed procedures, 156 cases (70.3 percent) were recognised as having full equivalence, and in 63 cases (28.4 percent), a compensation measure was stipulated. Full equivalence was established almost exclusively for applications from EU countries, while compensation measures were generally stipulated for applications from all other countries [13].

If we compare these figures with the number of training places for midwives in Hesse, the following picture emerges: A verbal ministerial decision determined that 120 training places were necessary to meet future demand for midwifery care in the federal state, compared to the annual average from 2016 to 2018 of almost half that number of applications for recognition of equivalency of a qualification (58). In an average of 31 cases, the procedure resulted in full recognition [13]. Thus, in recent years, when it comes to meeting the demand for qualified professionals, the ratio of foreign midwives awarded full recognition of their qualifications in Germany to midwives qualifying in the federal state each year was 1:4. Internationally qualified midwives therefore play a significant role in meeting the demand for midwives.

Integration in care provision

The level of experience when it came to integrating internationally qualified health professionals in the institutions studied was very heterogenous, but there were nevertheless similarities in terms of the difficulties of integration in the institutions as well as between nurses and midwives. Colleagues in the field reported that, after successful recruitment, internationally qualified professionals needed to work for one to two years to familiarise themselves with the job before they could fully perform all the duties that were part of their role.

The internationally qualified nurses we interviewed reported not always feeling adequately prepared when it came to job content and processes in the German health system, and their understanding of what their job entailed deviated from German practice. They said that they felt as though their German-speaking colleagues tended to view them in terms of their weaknesses, rather than valuing their skills. Language barriers exacerbated this phenomenon because they were not always able to convey their skills and were not able to express themselves in a professional context as well as they could in their mother tongue. They did not feel as though they had an opportunity to contribute their unique professional expertise to the established job structures.

The existing teams tended to feel overwhelmed by the work involved in integrating foreign employees: induction, compensating for the new member of staff, acting as an intermediary, as well as dealing with communication difficulties resulted in an increased burden at a time of staff shortages. To a certain extent, therefore, internationally qualified staff were perceived as a “problem” and their skills viewed as inadequate. Misunderstandings were put down to language difficulties, even if different expectations due to different professional socialisation could be an equally plausible cause. Language skills and cultural competencies were named as the resources that internationally trained staff had to offer in treating patients from other cultures.

Even among the staff who were actually responsible for the integration and adaptation process or the training required for this, a negative view of the foreign employees prevailed. For instance, respondents described Italian midwives as being overly ready to “medicate” and reported not seeing midwives from third countries “as being capable of practicing midwifery”. When explicitly asked about skills that could enrich midwifery care in Germany, respondents were unable to give examples. The expectation was that foreign staff would fully adapt to the rules of conduct that were legally and organisationally stipulated or had become working practice. This even applied when the standards of hygiene in German nursing care did not meet the international standards and recommendations of the Robert Koch Institute.

Rather than bringing relief, the integration of internationally qualified midwives was initially associated with more work for the existing staff teams; an additional burden that was rarely acknowledged or rewarded by the institutions. The individual tasks associated with social integration were attractive, as long as they were restricted to one-off events, but once they became routine duties, they stopped being as attractive.

The analysis of the data showed that integration work as a task that needed to be performed was a key category. Here integration work means any form of organisational and interactive work the purpose of which is to integrate new members of staff into the organisation, its structures and the existing team as well as everyday working life. Integration work is a goal-oriented form of action which follows an action plan and aspires to a specific result. It requires the cooperation of others. It is a process in which various actors are involved and calls for those doing the integrating and those being integrated to adjust to one another. Integration work places additional demands on both sides.

Integration work is necessary irrespective of where the new member of staff comes from. However, when it comes to integrating qualified professionals from other countries, this type of work takes on additional dimensions. These primarily pertain to the potentially heterogenous perceptions of the role of the relevant health professional, which have to be aligned, as well as the solution of linguistic and particularly specialised terminology problems, which can be exacerbated by regional dialects and technical jargon.

Integration work is a complex process that has to be systematically planned and implemented. For members of the existing teams, this requires, for instance, being relieved of other duties, a clear definition and allocation of tasks as well as clarification of responsibilities, staff being appropriately qualified for the job and being rewarded in one way or another for the additional work. Preparing for integration work also includes an institutionalised readiness from all those working in the German health care system to want to benefit from skills acquired in other countries.

An analysis of the data suggests that, if there is no preparation for, reflection on or reward for integration work, the result is a negative attitude focused on shortcomings when it comes to the skills of internationally qualified professionals. As a result, collaborative work on equal terms is then no longer possible.


Discussion

In Germany, the integration of internationally qualified midwives in obstetric care with the aim of tackling midwife shortages is currently a challenge that the various regions across the country are facing to differing degrees.

The data presented here were collected as part of a transfer project focused on foreign nursing staff but addressing the issue of the transferability of the findings to other professions as a secondary topic. The examination of the results based on data from obstetric teams was more sporadic than systematic. The study design is therefore strongly exploratory with the primary aim of posing new research questions. The findings should be seen as hypotheses to be tested in further research studies for their relevance to midwifery.

The similarity of the difficulties faced by the institutions when it came to integrating labour migrants, despite their different experiences, as well as the parallels between the differences in training and perceptions of the role between nurses on the one hand and midwives on the other suggests that the findings are likely to be transferable to midwifery. The data material used for reflection does not give any indication of a lack of transferability of findings to the other profession. A comparison with the existing literature also substantiates the similarities between the experiences [9], [11], [16].

The intention of the maternity hospitals attempting to integrate internationally qualified midwives is to help solving the problem of midwife shortages. We can assume that midwife-led institutions such as midwifery practices or birthing centres would be keen to work with internationally trained midwives but the effort and costs of recruiting staff from abroad is not something they can afford. Currently adaptation measures require a link to a midwifery school, and in future this will be to a university offering a cooperative study programme. However, one condition for recognition could also be participation in practical placements in outpatient care.

The recruitment of internationally qualified midwives could, in principle, bring potential relief to the existing midwife teams in hospitals. However, such measures should not be seen as a replacement for initiatives to make the midwifery profession more attractive. In fact, in the long term, Germany will only attract midwives from other countries if, at the same time, midwifery is made more attractive to everyone by improving the general conditions within the profession.

After an individual’s professional qualification has been formally recognised, their integration in a staff team and in working processes and how their language skills are dealt with are of crucial importance to ensure that internationally qualified professionals develop a connection with Germany. This brings challenges for both sides: the employer and the internationally trained employees. However, professional integration is often only enforced through the re-skilling of labour migrants, instead of by creating spaces for an exchange of views and perspectives. In the best case scenario, recently immigrated qualified professionals can take on the role of a trainee or apprentice who is supported by members of staff from the institution in which they are working while they realign their professional identity [10]. When migrants are essentially seen only through the prism of their shortcomings rather than their skills, frustration can increase the chances of them returning to their countries of origin.

Alleviating the workload of the existing midwife team is initially hindered by the additional task of the integration work the team needs to perform. If we suppose that the training and induction of internationally qualified midwives is similar to that of nurses and draw parallels with the new arrangements for the cooperative degree programme for midwives, then we can assume that, during their first year of work, internationally qualified midwives would have to be accompanied for 25 percent of their working time by a dedicated practice instructor trained in intercultural relations. However, according to the available data material, in practice, the induction of labour migrants is carried out alongside the other duties without the relevant training or additional remuneration. A situation like this is bound to lead to tensions.

Beyond alleviating staff shortages, the integration of internationally qualified midwives could also bring the following benefits: In general, they can make a contribution to overcoming linguistic and cultural barriers in obstetrics where clients themselves increasingly come from other countries. However, this assumes, of course, that the linguistic and cultural background of the qualified professionals matches that of the clients. Moreover, an international exchange of experience and information also provides the opportunity to learn how obstetrics differs in other countries and in doing so to develop and improve the discipline both in terms of theory and practice by critically questioning habits and traditions and comparing them with actual evidence. However, this requires a certain level of willingness from the side of the institution.


Conclusions

The integration of internationally qualified midwives in existing teams is becoming increasingly relevant in Germany but is not a subject that has been adequately researched. Insights from research in similar professions demonstrate that integration can only be successful if the work it entails is recognised, prepared for and rewarded. Integration work can only be successful if the skills of internationally trained midwives are recognised as such and must be integrated into the everyday working practice of the existing teams.


Notes

Ethics statement

The study received a positive evaluation from the Research Ethics Commission of the Fulda University of Applied Sciences. All interviewees provided written consent.

Acknowledgements

The authors would like to thank Agnieszka Satola, Nadja Noll and Heinrich Bollinger for the data they made available and for the findings of the joint analysis, as well as Lukas Slotala for procuring the special evaluation conducted by the Federal Statistical Office on the recognition procedure for midwives.

Competing interests

The authors declare that they have no competing interests.


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