 Anakota everyone and now I'm on the other side of the fence. It feels very, very, very nervous. Thank you for the opportunity to present to the VIDM conference today. It's a real honour to be talking to my colleagues and friends from around the world and it's just amazing to see where everybody has come from and some people who are staying up quite late so thank you very much for joining us today. I'm presenting on behalf of our team who have all made a contribution to this particular study and the list of them are there on the front page. This was very much a collaborative project. Our aim was designed to close the loop on a suite of student focus projects where we sought feedback from students on their experiences in the blended midwifery program at Otago Polytechnic. In the study we sought feedback from midwives who had graduated from our program. We wanted particularly to ask them about how well prepared they felt for beginning midwifery practice and what they believed would have improved their experience. An invitation to complete an online survey was sent to their last known email addresses and these were the midwives who had graduated between 2011 and 2014. No personal details were asked for in the survey and to preserve confidentiality a research fellow was employed to administer the survey and to download and de-identify the data or data rather. The survey was opened on the 20th of September 2016 and was made available for eight weeks. Reminder emails were sent at four and six-week intervals. From a possible 174, and I appreciate you won't be able to read this, 174 alumni, 163 emails were delivered. After two reminders we had 42 alumni complete the survey and this resulted in a 25.8% response rate. The questions included the midwives year of graduation, the current area of practice and the services that they offered to women. We wanted to know how prepared they had felt themselves to be when they began practice and what aspects of their midwifery program they believe had prepared them well and what additional content would have been useful. We also asked how well the program had prepared them to work with women from different cultures. Finally we asked if they had enrolled or were considering enrolling in postgraduate study and what topics would appeal to them. There was a higher response rate from midwives who had graduated in the recent years. Now it's possible that email addresses for earlier graduates had changed given the time frames. More were in lead maternity care or LMC practice than in hospital work and none were currently in education or research and just one midwife was not currently practicing. The midwives were working in a range of areas in urban, in rural and remote rural practice settings and they offered birth care in an equally wide range of areas such as community and the hospital. In response to how prepared they felt remembered feeling for practice only 16 had felt really well prepared with 20 unsure and six not feeling well prepared. These reflections contrast with those that we found in data from the three graduate cohort surveys in 2011, 12 and 13 which showed that at the end of their programs all but a few graduates felt well prepared for beginning practice. So there was a difference once they got into practice in terms of how well prepared they felt. The aspects of the program that have prepared them well included unsurprisingly the practice placements with the face-to-face tutorials and the intensive classes also popular. The comments however were mixed and clearly show that the overall combination of program elements appears to have covered the range of student learning styles. So they learned from their face-to-face and practice which were their preferred learning places but they also learned from the online and the tutorial sessions as well. Midwives were asked to comment on how well they believed they'd been prepared to work with women from other cultures and it was encouraging to see that the courses focusing on cultural diversity, the Māori health paper and the Nohul Marae where they stay on a Marae overnight and engage with activities on the Marae and a Treaty of Waitangi Workshop helped shape their thinking not just for working with Māori but also with women from other cultural backgrounds. Further comments provided insights into the graduate to medwife experience and four broad-themed areas were distinguished from the survey responses. These were the importance of a sound knowledge and practice skills base, the ability to manage both the self and their practice and the need to develop confidence and the importance of a supportive environment in which to grow as midwives. These are represented in the VIN diagram as a series of intersecting circles. Each factor needed to be present for optimal transition to practice that appeared and these transition elements are further illustrated with quotes in these following slides. The theme of knowledge and practice skills included those skills associated with working in secondary and tertiary settings, supporting women to breastfeed, managing miscarriage and competence in challenging social situations. This included also the skills to work with other health professionals. The students recognised however that it would be hard to prepare completely for the range of experiences they were likely to encounter. Examples offered included working with women from communities with high levels of drug abuse and violence which some felt unprepared for. Managing time and their business was commented on by eleven of the alumni and included aspects such as tax and GST and a district health board negotiating the district health board contracts and the protocols that were present in each of these settings. And while the challenge of managing time and stress is not unique to midwives, the 24-hour nature of midwifery practice and the on-call demand for LMCs in particular made this an important issue and this was clearly demonstrated by Karen in her talk this morning. And this included preparing their families for the realities of midwifery practice. Quite a lot of midwifery literature in the recent years has addressed these challenges some by Donald and Wakeland and Skinner and there has been quite a few coming out of New Zealand and from other areas around that demand for that 24-hour coverage and the stress that is for midwives. Similarly, getting familiar with local protocols and the art of consulting and referring to obstetricians and other health professionals was a recurring theme throughout the findings. While feeling competent to practice, confidence was more elusive for the newly graduated midwives. There was a sense of nervousness and of having to prove themselves. Others commented on the awareness and overwhelming reality of the responsibility and this included not just experiencing the positives but also the negative aspects of the job. For these skills to come together required a supportive environment, a place where they could consolidate their midwifery knowledge and skills and grow their confidence. The literature tells us that supportive and approachable midwives have a facilitating effect on the confidence of new practitioners and the perception of their competence. So how well they've been supported in the time that they've been coming through their program in their placements and in those early experiences in practice are from midwives as important as anything else. So while the newly qualified midwives are frequently challenged by the transition from student to beginning practitioner, the support of others, especially mentors and fellow midwives, can ease this transition. And this is summed up by Barry et al. whose study showed that a supportive environment enables midwives to work through stages of personal development to an appreciation of the bigger picture. And this support is as Kensington in 2015 observes the responsibility of the whole profession. Eight of the 42 midwives had enrolled in postgraduate study, which is not very many, possibly reflective though of their relatively recent venture into practice. Reasons for enrolling included opportunities to advance their knowledge, their career options and access to the latest research. And the topics of interest included a range of practice issues such as lifestyle change, business management, family planning and fertility and mental health issues for women, possibly reflecting situations they had met in practice and felt challenged by or feeling they needed more information on. Current study has some limitations of course. Firstly the response rate was 25%. And therefore may not be representative of the alumni population for all five years. The response rates to online surveys do tend to be low overall, so we were happy enough with 25% given some of the low expectations from online surveys. However the midwives who did respond comprise a diverse sample of both lead maternity carers and hospital medwives working in both urban and rural areas and covering the broad range of birthing environments from home birth to tertiary facilities. And these percentages align approximately with the 2016 workforce report from the Medwifery Council of New Zealand. Secondly the method combined with the broad sweep of questions may have mitigated against an in-depth analysis of the phenomena associated with the transition to medwifery practice. And we see that there is still plenty of room for exploring this in some more depth. Further three of the four themes resonate with the extant literature relating to the support and development of medwives and studies around the transition to practice. So what's already out there is still resonates with that literature. So what can we take from the student feedback to continue to enhance our program? Firstly that the mix of modes in the Blender program does provide benefits for studying locally while providing opportunities for shared learning and face-to-face interaction. And the model from the study provides a rudimentary map of the elements that need to be blended into each aspect of the program. Specifically the results provide opportunities to focus on some of the challenges of personal and practice management within the teaching and assessment. And importantly the inclusion of simulated situations where students can safely explore and negotiation referral skills and so on to prepare them for working in multidisciplinary teams and for negotiating at the interface between medwives and other health professionals. And this is supported by Murray Davis who states that the newly qualified medwives appeared better able to integrate interprofessional training into practice when this had occurred previously in a favourable learning environment. So our key conclusions were that becoming both a competent and a confident midwife is a complex process involving not just them having had the knowledge and practice skills honed during their time in the midwifery education program but also needing the opportunities to develop skills around managing their time and also their business particularly if they're going into lead maternity care positions. Further practice confidence also requires a supportive environment and in summary a comprehensive program of knowledge, sound practice, development of interpersonal skills within a supportive environment will best equip our alumni to grow in confidence as medwives who become lifelong leaders and learners. And finally we wish to thank our alumni medwives whose candid responses helped us understand their journey into practice. That's not the people who are in our survey of course, that's just an opportunist photograph from a recent group of our new intake. We also acknowledge the work of Alex and Amanda for their help with the survey process and with the data analysis and the Otago Polytechnic Research and Postgraduate Directorate for the Financial Assistance to enable the research to proceed. Kia ora and thank you for listening.