Systemic Support Strategies and Individual Factors Facilitating the Transition of Newly Qualified Nurse‑Midwives from Education to Clinical Practice in Northern Malawi: A qualitative Descriptive Study

Systemic Support Strategies and Individual Factors Facilitating the Transition of Newly Qualified Nurse‑Midwives from Education to Clinical Practice in Northern Malawi: A qualitative Descriptive Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Systemic Support Strategies and Individual Factors Facilitating the Transition of Newly Qualified Nurse‑Midwives from Education to Clinical Practice in Northern Malawi: A qualitative Descriptive Study Mathews Brave Mtegha, Maggie Zgambo, Fatch Welcome Kalembo, Tiwonge Mlowoka, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9371366/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: The transition from education to professional practice is a critical phase for newly qualified nurse-midwives (NQNMs), often characterized by challenges in developing clinical competence and professional confidence. However, inconsistencies in clinical support system across health care settings hinder the development of NQNMs into competent and confident practitioners. The aim of the study was to explore the systemic support strategies and individual factors that facilitate the transition of NQNMs from education to clinical practice. Methodology: A qualitative descriptive design was employed. Data were collected through in-depth interviews from a purposive sample of 19 participants with 13 NQNMs and six key informants across the three selected hospitals. Two semi-structured interview guides, one for NQNMs and another for key informants were used to collect data. The qualitative data were analyzed manually using thematic analysis. Results: Two overarching themes emerged: (1) Cultivating confidence through a support system, which encompassed mentorship, peer pairing, continuous professional development (CPD), structured orientation, access to reference materials, and a supportive environment. (2) Purpose-driven growth, which reflected individual factors, self-motivation and passion for the profession. Conclusion: Strengthening structured mentorship, CPD and orientation programs is key for a successful transition to practice. In addition, nurturing passion and self-motivation supports professional growth, strengthens the resilience of NQNMs in demanding work environments and promotes workforce retention. Newly qualified nurse-midwife transition to practice clinical support transition support programs mentorship professional development midwifery Malawi Background The transition experience from education to professional practice is a critical, yet often stressful period for newly qualified nurse-midwives (NQNMs) ( 1 , 2 ). The transition period involves significant learning and adjustment as NQNMs move from a supervised academic environment into autonomous clinical practice ( 3 ). This transition is often faced with challenges, as some NQNMs enter professional practice equipped with theoretical knowledge but may lack the hands on experience and confidence required for independent clinical decision making ( 2 , 4 ). Such challenges underscore the importance of structured support systems that build competence and promote safe, compassionate and quality midwifery care. In Sub-Saharan Africa, the transition experience is compounded by persistent health workforce shortages, high patient workloads, and limited availability of formal support programs. Studies indicate that NQNMs often enter clinical practice with minimal supervision, inconsistent mentorship and inadequate orientation (Murokole et al., 2025; Simane-Netshisaulu et al., 2022). These conditions may hinder skills development, diminish confidence and compromise the quality of maternal and neonatal care. Similar challenges are evident in Malawi, where the transition occurs within a resource-constrained health-care system and maternal and neonatal health outcomes remain a priority ( 5 ). Despite efforts to increase the midwifery workforce, Malawi continues to face a significant shortage of nurse-midwives and the ministry of health reports a 40% vacancy rate among registered nurse-midwives ( 8 ). These nurse-midwives serve as middle managers but are also responsible for provision of care and mentorship of NQNMs during their transition to practice. The shortage and multiple roles places immense pressure on these nurse-midwives through increment of workload and diminishing capacity to mentor and guide less experienced colleagues. This can eventually compromise the quality of maternal and neonatal care delivery ( 5 , 9 ). While the Nurses and Midwives Council of Malawi (NMCM) recognize NQNMs as competent professionals upon licensure, Benner’s (1984) model suggests that most function at the “advanced beginners” level. At this stage, they require guidance to strengthen clinical competence, clinical judgement, and professional confidence. Without structured support, NQNMs may have limited opportunity to consolidate the clinical skills which risks compromising patient care outcomes and workforce retention ( 3 , 4 , 10 ) To address these challenges and work towards achieving Sustainable Development Goal (SDG) 3.1, Malawi introduced the graduate internship program (GIP) in 2018 to strengthening work integrated learning and early professional development. The program is a one year placement for fresh university graduates aged 35 years and below ( 11 ). However, enrolment into the program remains limited relative to the number of NQNMs entering the workforce challenging the overall impact. In addition, formal and informal support strategies such as mentorship and peer support have been reported to be critical facilitators of successful transition although their availability remains inconsistent across midwifery care settings in Malawi ( 5 , 9 ) In the absence of systemic support strategies, the transition of NQNMs to practice relies largely on facility level practices and the informal guidance of senior staff (Rouse et al., 2024). This undermines the skill development of NQNMs and risks compromising patient care outcomes. The study therefore explores the systemic support strategies and individual factors that facilitate the transition of NQNMs from education to professional practice. This may inform development of sustainable and effective supportive structures to improving the transition experience, strengthen midwifery care and improve maternal and newborn health outcomes. Methods Study design This study utilised a qualitative descriptive approach, drawing on a naturalistic paradigm. The descriptive approach was ideal as it involves a systematic, interactive and in-depth approach that yields subjective and rich data used to describe human experiences ( 12 ). This approach was deemed relevant for this study because of the subjective nature of the study topic ( 12 , 13 ). Study setting The study was conducted at three hospitals purposively selected based on the type of maternity services provided, variation in institution type and the resource levels. These institutions are Mzuzu Central Hospital, Mzimba South District Hospital and St John’s Hospital, all in the northern region of Malawi. These hospitals have maternity units that provide antenatal, intrapartum and postnatal services. Mzuzu Central Hospital and Mzimba South District Hospital are public hospitals, while St John’s Hospital is run by the Christian Health Association of Malawi (CHAM). Mzuzu Central Hospital serves as a referral facility for all hospitals in the northern region, managing high patient volumes and a wide range of specialised services. Mzimba South District Hospital is one of the key referral hospitals in Mzimba district offering maternity care within a resource-constrained context, like many other public sector facilities in Malawi. In contrast, St John’s Hospital is among the largest private hospitals in Mzuzu city, providing maternity services within a private non-profit framework, with an organisational culture and management structure distinct from public hospitals. Selection criteria The study included newly qualified and practising nurse-midwives and key informants from the three hospitals. The newly qualified nurse-midwives were recruited in the study if they had completed undergraduate nursing and midwifery education (diploma or degree), and if they had less than two years of transition period in practice. The timeframe reflects the transition period during which support needs are more pronounced. Nurse-midwives who had been in practice for less than 6 months and more than 2 years were excluded. Those less than six months in practice were likely undergoing orientation with limited exposure to the broader transition challenges. Key informants were recruited if they were nursing and midwifery managers (matrons, district nursing officers or chief nursing officers) working in maternity units. Key informants were required to have held management positions for more than a year to ensure adequate familiarity with the transition process and organisational support structure. Key informants were excluded if they were not working in the maternity units, or had less than 1 year leadership experience. This was to ensure that only those with sufficient insight of the maternity unit support structure contributed to the understanding of the transition process. Study population NQNMs were recruited through purposive sampling technique. Purposive sampling helps to recruit participants who are knowledgeable about the phenomena under study ( 14 , 15 ). The principal investigator verbally invited fifteen potential participants assigned to maternity units in these hospitals. The participants were briefed on the study aims and procedures, and voluntarily accepted to participate in the study. During the briefing, the participants were encouraged to ask questions for clarification and were informed of the right to decline or withdraw participation at any stage. Thirteen participants expressed interest and were subsequently provided with written study information, and were asked to give written informed consent to ensure autonomy ( 16 ). We enrolled 13 newly qualified nurse-midwives for interviews, but data saturation was reached at the tenth interview as no new information emerged from subsequent interviews ( 17 ). However, data collection continued for the next three participants to enhance the credibility of the findings. To enrich the data, six key informants were approached in their respective offices and briefed about the study objectives and benefits of participating in the study. They all assented to participate and were recruited for the study Data Collection Procedure The principal investigator, a nursing-midwifery lecturer with no prior relationship with participants, conducted all in-depth interviews from 4th July 2019 to 23rd September 2019. While familiar with the nursing and midwifery context, the researcher maintained reflexive journals and analytical memos throughout data collection and analysis to identify and manage potential biases. The interviews for new graduates were conducted in a quiet room inside the maternity unit to ensure confidentiality and minimize interruptions. Key informants were interviewed in their respective offices. The research team developed two sets of interview guides; one for the new graduates and another one for the key informants (see supplementary material 1). The study objectives and literature review guided the development of the interview guides. All interviews lasted between 20 minutes and 35 minutes and were digitally recorded. Participants consented to have their voices recorded during the recruitment process, and this was confirmed prior to the interviews. Field notes were taken soon after each interview. Ethical Considerations The research was approved by the University of Malawi College of Medicine Research and Ethical Committee (COMREC) reference number P.04/19/2647. Further ethical approval was obtained from the ethical research committees of the three hospitals. Before participation, verbal and written informed consent were sought from the participants. To ensure anonymity, participants were assigned codes and names were not used in the study. After data analysis, the transcripts were kept according to the university’s data management procedures. Data Analysis The raw data from in-depth interviews were transcribed and analysed manually. Each recorded interview was transcribed verbatim by MM and TM. MM verified and corrected errors in the transcription by re-reading the transcribed data while listening to the recorded data. Data analysis followed the six phases of thematic data analysis proposed by Braun & Clarke, (2006, updated in 2021), which are: familiarising with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report ( 18 ). Firstly, the transcribed data from in-depth interviews were read through multiple times by the first author to familiarise himself with the data and the preliminary analytical ideas useful for organizing the data were noted. Thereafter, a line-by-line analysis of transcribed data was undertaken to drive meaning from the collected data. Sentences in the transcripts were color coded to highlight potential patterns. Codes were derived from the transcripts and grouped into small and meaningful chunks of data. The codes with similar meanings were grouped into subcategories, which were then merged into sub-themes and subsequently organized into overarching themes. Coauthors held several meetings to discuss and review the identified themes for a consensus. Three researchers in nursing and midwifery education with qualitative backgrounds (EC, FK & MZ), who did not participate in data analysis, validated the themes to ensure that they indeed emerged from the transcripts. Rigour To ensure rigour, the researcher used a framework by Lincoln and Guba (1985), who recommended four criteria for promoting the trustworthiness of study findings, which include: credibility, confirmability, dependability and transferability. Credibility was enhanced through member checking to confirm the authenticity of the conclusions made from the participant’s explanations. Three transcripts were selected at random for member checking to confirm the authenticity of the conclusions made from the data. An audit trail which included raw data from 13 newly qualified nurse-midwives and six key informants, thematic categories, process notes and interpretations were kept to establish confirmability of the results. Experienced qualitative researchers reviewed the data analysis procedures and the themes that emerged from the data, which enhanced the dependability of the findings. Further, the research process was comprehensively and clearly reported to ensure the transferability of the results. Study findings Demographic characteristics of participants Data were collected from 19 participants (13 newly qualified nurse-midwives and six key informants). The participants had different educational qualifications and experiences. Eight nurse-midwife technicians had a diploma in nursing and midwifery and five registered nurse-midwives had a degree in nursing and midwifery. The age of the participants ranged from 24 to 34 years. The clinical practice experience of the NQNMs ranged from 6 to 24 months. Three females and three male key informants within the age range of 33 to 43 years participated in this study. Two of the key informants held a master’s degree in reproductive health, while four had a bachelor’s degree in nursing and a university certificate in midwifery. Their clinical experience in managerial positions ranged from 6 to 16 years. Themes Two main themes were developed that describe the clinical support the newly qualified nurse-midwives received upon entry into practice: ( 1 ) Cultivating confidence through a support system and ( 2 ) Purpose-driven growth (see Table 1 ). The themes are expanded below supported by the participants quotes which are presented using codes to ensure participants anonymity. Table 1 Themes and sub-themes Theme Subtheme 1. Cultivating confidence through a support system 1.1. Systemic Support strategies tailored for newly qualified nurse-midwives 1.2. Availability of reference materials 1.3. Supportive environment 2. Purpose-driven growth 2.1. Self-motivation 2.2. Passion for the profession Theme 1: Cultivating confidence through a support system This theme describes participants experiences of how support strategies influenced their confidence and development of competence during transition to practice. The findings highlight the impact of support strategies tailored for NQNMs, availability of reference materials and a supportive work environment. Sub-theme 1.1: Systemic Support strategies tailored for newly qualified nurse-midwives The theme describes the various sources of support that were available to NQNMs during their transition period. Different systemic support strategies such as mentorship, peer pairing, continuous professional development (CPD) and orientation upon entry to practice were available in both government and a CHAM hospital where the study was conducted. The support strategies were valued by the participants even though they were not formally instituted in all the settings the study was conducted. Sub-theme 1.1.1 Mentorship Mentorship was described as a key source of support during the transition period. Participants reported receiving guidance from experienced nurse-midwives facilitated the development of clinical competence and professional confidence as reported in the account below: “ I was lucky that the time I was joining the department, I had a senior nurse-midwife who mentored me on how to perform some skills as well as how to manage the ward…. During the period that we worked together, I used to consult her each time I had a challenge. Like during my early days I had challenges on how to perform manual removal of placenta and she supported me. Whenever consulted, she could demonstrate on how the particular skill was done…. at times she could observe me doing the skill while providing guidance and could give feedback or evaluate my performance. Through this, my skills improved greatly ” (RNM-M-P3). Another newly qualified nurse-midwife described mentorship as working under a shadow and recounted how she was supported by the ward in-charge to attain the right skills: “ I worked under the shadow of unit in-charge for a period of one month. ….. We worked together and she helped me acquire the managerial and leadership skills necessary to lead the ward and the technical skills that I did not acquire from school” (RNM-F-P2). Sub-theme 1.1.2: Peer pairing Most participants commended peers and seniors who steered them in performance of skills, which helped to quickly settle in the ward and gain the expertise. The use of peer pairing has been explicitly expressed in the following extract from one nurse-midwife technician: “Since I was just a novice, each time I was on duty, I was paired with someone senior or a fellow nurse-midwife technician with better skills to support me…. the in-charge had to put me on straight shift for the whole month and I was working with these colleagues until I got used to the ward. Seriously I leant a lot during this period and I had no fears performing procedures as my skills improved” ( NMT-F-P2). Sub-theme 1.1.3: Continuous professional development CPD was another important strategy used to assist the NQNMs during the transition. CPD played a vital role in strengthening clinical competence. Ongoing learning not only enhanced NQNMs skills but also improved the care provided to mothers and newborns. One nurse-midwife highlighted this perspective, acknowledging the benefits of CPD for learning to gain necessary knowledge and skills. “CPD is really helpful because you get updated on knowledge and you also learn best practice on how some skills are performed.... this improves quality of care we provide to mothers (NMT-F- P1) Key informants also emphasised the significance of CPD as an important strategy for professional growth and skill enhancement for NQNMs. The key informant narrated this in support of the CPD: “Much as we appreciate that they attain knowledge from their training institutions, but when it comes to hands-on, they need support…. so, we involve the newly qualified nurse-midwives in CPD sessions by doing presentations in a number of areas we feel they have a knowledge gap. We value CPD because through it they learn a lot in terms of patient care, which improves their skills and reduces stress during their transition period” ( KEY–INFO–F-P6). Similarly, another key informant commented on how they utilize in-service training in supporting the NQNMs as she said; “W e do in-service training within the hospital or outside …. just to help us address some issues in the departments like management of post-partum haemorrhage while supporting the newly qualified nurse midwives attain the right skills and help them gain confidence necessary for the successful transition” ( KEY–INFO–F- P3). Sub-theme 1.1.4: Orientation upon entry to practice The participants also found orientation into the system upon entry to practice important during the transition period. The orientation process was mostly dependent on the entry qualification to practice, whether the graduate had a degree or a diploma. These qualifications defined the scope of practice for newly qualified nurse‑midwives (NQNMs), which managers used to determine the type of orientation appropriate to the role they were expected to assume An excerpt from one registered nurse-midwife exemplifies this: “We were given a schedule to rotate in different wards, 3 days in each ward…. In maternity the ward in-charge oriented us to the ward routines and some reference guidelines to refer to when managing clients” (RNM-F-P4) In line with sentiments from the NQNMs, key informants specified that the orientation was done to help the NQNMs have an idea of what was expected of them and also familiarise themselves with the wards or department they were to work in. This quote from one nurse-midwife explains the orientation that was given: “….. we orient them to our professional documents that we use as nurses and midwives as they act as a guide in the provision of care …... they are given 5 days in each department to know the routines; however, it also depends on the role they are expected to take as per the scope of practice …. but for normal orientation they are supposed to be in a department for at least a month to help them gain confidence and necessary skills in that department” (KEY–INFO–F- P6). The findings indicate that a range of support strategies were available to NQNMs during their transition into professional practice. Although not formally structured across all the study settings, participants described them as helpful in supporting confidence and skills development. Sub-theme 1.2: Availability of reference materials All NQNMs indicated that they found some reference materials and protocols in the midwifery settings they were deployed. They used the materials when they were unsure about the care to provide to patients during their practice. One participant recounted: “….. they were protocols in the ward to which we were always referring to” (NMT-F-P5). Similarly, key informants highlighted some reference materials they had in place that they referred NQNMs to for reference in cases where seniors or qualified staff were not there for support. One informant said: “ We have guidelines, procedure manuals and posters which these new graduates do refer to incase they are stuck…. We also have a folder that has reproductive health standards that these graduates can be referring to from time to time. This builds their confidence and helps them to transition well to practice” ( KEY-INFO-M-P4) Availability of reference materials like management guidelines and protocols was underscored by all the participants as a valuable strategy that helped them to quickly get used to the system. Sub-theme 1.3: Supportive environment Participants described a supportive work environment characterized by reassurance, encouragement and guidance from peers and seniors as instrumental in easing their transition into professional practice. They highlighted that being warmly welcomed by seniors and peers made them feel accepted and supported during their transition as illustrated in the following account: “The environment was so friendly and conducive for us. The team I found was very welcoming, and whenever I had a challenge, they could assist me with solutions, and this helped me to develop confidence and self-esteem” (RNM-M-P3). The presence of experienced midwives and encouragement made them develop the needed confidence for professional growth. Theme 2: Purpose-driven growth The theme describes self-motivation and passion for the profession as critical drivers in shaping a smooth transition to practice. Self-motivation and passion for the profession fostered resilience and proactive learning in NQNMs as described below. Sub-theme 2.1: Self-motivation Participants acknowledged that Self-motivation played a vital role in building confidence and ensuring a seamless transition into practice. Key informants stressed that having knowledge from school only was insufficient to have a better transition; rather NQNMs needed the inner drive to push them, which was self-motivation. One nurse-midwife said: “ I may say that most of them have the knowledge from school but on the ground, it depends on the graduate’s self-motivation. Those who are motivated to work, they don’t take long to get back on track …. and are confident in discharging their duties as they are mostly not afraid of taking challenging tasks” ( KEY-INFO-M-P4). In line with key informants’ sentiments, some NQNMs highlighted how keen they were to learn from experienced midwives. One participant said; “ I was very keen to know, to learn, and to acquire new information and skills from the midwives that I knew were experienced and had the right skill to equip me…. I took up the role very seriously and I was free to ask wherever stuck…. I easily consulted, for I felt I should not live within the mask because whenever I asked, they guided me and with that knowledge I found that I was moving towards the right channel” ( RNM-M-P5). Both NQNMs and key-informants acknowledged that most of the self-motivated NQNMs had theoretical knowledge from college which empowered them to face clinical challenges with confidence and a positive mind. One participant said: “I was not much stressed up the time I was joining the profession because I knew I had knowledge. We were taught on how to conduct deliveries and how to manage most of the conditions in labour ward…. this gave me confidence that I could perform and I had no fear taking challenging tasks” ( RNM-F-P4). Likewise, a key informants said: “….. So those who feel that they have enough knowledge in terms of patient management, they transition well compared to those who have knowledge deficit as they lack confidence” ( KEY-INFO-M-P4). Sub-theme 2.2: Passion for the profession Beyond self-motivation, a deep passion for the profession acts as a strong foundation for successful transition. The subtheme describes the passion the NQNMs had for the profession and their ability to room in. Many participants stated that they stayed in the profession with less stress because they loved it. This acted as a motivation hence facilitated their transition into practice. Those that had a passion for the profession, enjoyed the transition experience as one graduate said: “ For me, being a midwife is not by mistake; it is by choice. I made a decision and, in every decision, you make, you should be ready to meet obstacles and the moment you overcome those obstacles, thus when you say you have achieved” ( RNM-F-P2). Participants who demonstrated openness to learning described more positive transition experience, emphasizing the importance of engaging with experienced colleagues: “I wanted to learn that means I had to affiliate myself to them. I gave myself a room to learn from the system or everyone else on the ground because I felt they were good on hands on practice …. and I never gave a room to their negative responses, rather I kept on pressing and this made me grow professionally” (RNM-M-P5). Passion for the profession not only sustained their motivation but also allowed them to embrace learning opportunities and remain resilient in the face of obstacles. Further, their decision to remain in the profession was mostly influenced by their passion and self-motivation. Discussion The findings of this study highlight the crucial role of both system and personal factors in facilitating the transition of NQNMs from education to professional practice. The findings revealed that access to support systems and a purpose‑driven approach to growth are essential for cultivating confidence and facilitating the transition of NQNMs. Strategies and other factors that facilitated the transition process for the NQNMs are discussed in the sections below. Systemic Supportive strategies Various systemic support strategies such as peer pairing, mentorship, CPD, and structured orientation, were identified as critical in facilitating the transition process. The study results reveal that participants benefited more from peer support. NQNMs often relied more on their colleagues for support, which helped them learn to collaborate and build a supportive network. The findings are consistent with study results by Kool et al. (2023) who documented that NQNMs spend time collaborating with fellow midwives as role models and for the purpose of consultations during the transition period. Fenwick et al. (2012) described peer support as a “life raft” during the transition period, emphasising the importance of peers during the period. Additionally, NQNMs acknowledged informal mentorship they received from senior staff. Although not institutionally formalised, it played a vital role in guiding them through hands-on clinical practice as they were provided with technical support, feedback and skills demonstration. The fundamental role of mentorship in enhancing clinical competence and fostering confidence among NQNMs is well established in the literature ( 1 , 7 , 19 , 20 ). In Malawi, informal mentorship occurs naturally as it is flexible, relational and integrated into everyday clinical practices. This creates an environment where NQNMs can comfortably seek help without fear or hierarchical limitations that may accompany structured programs. It emerges from existing interpersonal rapport, making the support more accessible. Despite the contextual strength, literature recommend structured mentorship as a more effective strategy of fostering competence and professional socialisation among NQNMs ( 19 – 21 ). Therefore, acknowledgement of informal mentorship in these settings does not contradict the literature, rather, underscores the need to complement the informal mentorship with a formalised mentorship program. The government, through the Ministry of Health should establish a structured mentorship program to ensure all NQNMs receive equitable support during the transition regardless of the practice setting. Such a program would help NQNMs develop the essential skills and confidence required for effective practice. CPD was another essential strategy that supported the professional growth of NQNMs. Participants engaged in CPD activities that enabled them to acquire new knowledge and skills that boosted their confidence and clinical performance. These findings are in line with a cross-sectional study conducted in 3 European countries that highlighted that CPD provides an opportunity to NQNMs stay up-to-date with latest evidence, acquire new skills and enhance professional growth ( 22 ). The findings underscore the need for institutions to emphasise CPD’s role in professional and skills development, ultimately contributing to improved care for mothers and newborn. Furthermore, participants identified orientation programs as beneficial in helping NQNMs adapt quickly to their new role during the transition period. The general orientation introduced them to professional documents, institutional policies, ward routines, and the physical setting. This process allowed them to familiarise themselves with workplace expectations and enhanced role clarity. Rush et al. (2015) described such orientation as an essential organizational strategy to integrate NQNMs into the hospital environment. In this study, however, the scope and structure of orientation varied based on the institution and the nurse-midwife’s qualification. Participants had an orientation period of between 2 days and 4 weeks often shorter than the duration suggested in international literature. Participants with a degree had a longer period of orientation than those with diplomas. Unanimously they reported that the period though not enough, had a positive impact on their transition. In contrast, studies suggest that an extended formal orientation of over 4 weeks provides more significant benefits like reduced stress, improved competence and professional satisfaction ( 10 , 20 ). Extending orientation, adopting formalised orientation frameworks and incorporating competency assessments can optimize the effectiveness of these programs, ensuring that NQNMs are adequately supported during the transition period. Availability of reference materials NQNMs reported that access to clinical guidelines, manuals and standard operating procedures significantly contributed to their confidence in decision making. When faced with a complex or unfamiliar situation, reference materials served as safety nets reinforcing their theoretical knowledge and informing their practice mainly in the absence of senior colleagues. This increased their confidence and enable them to deliver appropriate care. The findings are in line with the previous studies that observed that midwifery care in Malawi is guided by national standards ( 23 ) and access to evidence-based resources enhance clinical competence and promote independent decision making among NQNMs ( 24 ). Ensuring that all maternity settings are equipped with up-to-date reference materials and encouraging their routine use could strengthen clinical decision for NQNMs during the transition period. Supportive environment A positive and welcoming work environment was identified as a key factor in easing the transition from training to practice. The NQNMs valued emotional support they received from colleagues and midwifery leaders through reassurance, encouragement and guidance. The receptive and inclusive environment helped alleviate stress and instilled a sense of belonging. Similar findings have been reported in literature, emphasizing that a supportive work environment fosters job satisfaction, confidence and retention among NQNMs ( 1 ). Emotional encouragement also fosters internal motivation a key factor in professional growth ( 1 , 21 , 25 , 26 ). These insights emphasise the importance of creating and sustaining a culture of support through regular team building activities to enhance professional growth among NQNMs. Purpose driven growth While the systemic support played a crucial role in the transition of NQNMs, the study also identified personal attributes such as self-motivation and passion for the profession as key factors to a successful transition. Self-motivation was found to be a critical enabler in ensuring a seamless transition of NQNMs. Participants acknowledged that while formal education provided foundational knowledge, personal drive and eagerness to learn played a significant role in their professional development. Key informants also emphasised that self-motivated individuals adapted more quickly to clinical practice. This finding is consistent with findings from previous research that revealed that intrinsic motivation enhances learning, resilient, and job satisfaction in nursing and midwifery regardless of challenges encountered ( 27 – 30 ). Beyond self-motivation, a passion for midwifery emerged as another enabler to a successful transition. NQNMs who had a deep commitment to the profession found greater fulfilment and were more likely to embrace challenges as learning opportunities. These findings are supported by previous findings that linked, passion to increased job satisfaction, commitment and resilience, all of which contribute to professional growth and retention of nurse-midwives in the profession ( 28 – 30 ). Nurturing passion among undergraduates and graduate nurse-midwives is therefore essential to facilitate smooth transition into practice and strengthen retention within the midwifery workforce. The role of theoretical knowledge Findings indicate that theoretical knowledge acquired during training provided a foundational support for the NQNMs. Participants who believed they had grasped the midwifery concepts clearly were less stressed when discharging their duties compared to their counterparts who had knowledge deficit. The findings are in line with results of a study in China found that basic knowledge and skills learned in school are helpful in facilitating the transition of NQNMs, but insufficient to help them develop required confidence to handle complex and emergency situations in midwifery setting ( 4 ). Despite graduates having theoretical knowledge, they need support during the transition period to develop confidence and necessary skills. Strength and limitations of the study Data were collected from degree nurse-midwives, diploma nurse-midwives and key informants. This helped to enrich the study findings as ideas presented were from a wide perspective, which helped to reduce biases. The study illuminates both systemic support and individual factors that facilitate the transition of NQNMs from education to practice within the Malawian context. Despite these strengths, the study has some limitations. First, data were collected from three selected midwifery settings as such the findings may not fully represent the experiences of other nurse-midwives in other settings. However, detailed description of the research process and the study context allow readers to assess the transferability of the findings to a similar setting. Secondly, as a qualitative study, the potential for subjectivity in data interpretation cannot be entirely eliminated. However, the process of data analysis involved a group of researchers with expertise in qualitative research who examined the transcripts and the coding process and the themes to validate the study findings. Additionally, we asked the participants to review the transcripts after data collection to validate and improve the credibility of the findings. Lastly, the data submitted were collected in 2019. Despite the delay in reporting, the data findings remain relevant given the ongoing Malawi health system challenges that affect maternal and neonatal health outcomes. Conclusion Transition support strategies such as structured mentorship, CPD, orientation, and access to reference materials play a critical role in strengthening the confidence and competence of NQNMs. Combined with personal attributes such as self-motivation and passion for the profession, these strategies foster resilience, professional growth, and retention in the workforce. Formalising and scaling transition-to-practice programmes across Malawian health-care settings may therefore contribute to improved quality of maternal and newborn care. Declarations Ethical approval and consent to participate The study was conducted in accordance with the declaration of Helsinki 1964 and local ethical guidelines set by the Kamuzu University of Health Science. The ethics approval to conduct the study was granted from the College of Medicine Research and Ethics Committee of the Kamuzu University of Health Science (KUHeS) reference number P.04/19/2647. In addition, permission was sought from all the three hospitals where the study was conducted. Verbal and written consent were obtained from all participants. To ensure anonymity, participants were assigned codes and names were not used in the study Consent for publication Participants provided written informed consent prior to participation, including consent for the use of their data and publication of the study findings. Availability of data Data is available with the corresponding author and may be made available upon request Disclosure of conflict of interest We declare that there is no conflict of interest Funding The study received no funding Author’s contributions The research design and data collection was done by MM. Data analysis was conducted by MM, TM, EC, EC, FWK and MZ. The original manuscript was drafted by MM and EC. MM, FWK, EC, EC and MZ reviewed the manuscript. All the authors contributed towards the completion of this manuscript and have read and approved it. Acknowledgements We sincerely thank all the midwives who accepted to participate in this study. We also acknowledge the hospital management teams for granting permission to conduct the study. References Kool E, Schellevis FG, Jaarsma DADC, Feijen-de Jong EI. How to improve newly qualified midwives’ transition-into-practice. A Delphi study. Sex Reprod Healthc. 2023 Dec;38:100921. doi:10.1016/j.srhc.2023.100921 Shi J, Li X, Li Y, Liu Y, Li J, Zhang R, et al. Experiences of newly qualified midwives during their transition to practice: a systematic review of qualitative research. Front Med. 2023 Aug 16;10:1242490. doi:10.3389/fmed.2023.1242490 Gray M, Malott A, Davis BM, Sandor C. A scoping review of how new midwifery practitioners transition to practice in Australia, New Zealand, Canada, United Kingdom and The Netherlands. Midwifery. 2016 Nov;42:74–9. doi:10.1016/j.midw.2016.09.018 PubMed PMID: 27769012. Wong SWJ, Che WSW, Cheng MTC, Cheung CK, Cheung TYJ, Lee KY, et al. Challenges of fresh nursing graduates during their transition period. 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Adm Policy Ment Health. 2015 Sep;42(5):533–44. doi:10.1007/s10488-013-0528-y PubMed PMID: 24193818; PubMed Central PMCID: PMC4012002. Bolderston A. Conducting a Research Interview. J Med Imaging Radiat Sci. 2012 Mar;43(1):66–76. doi:10.1016/j.jmir.2011.12.002 PubMed PMID: 31052024. Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. 2022 Jan;292:114523. doi:10.1016/j.socscimed.2021.114523 Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021 Jul 3;18(3):328–52. doi:10.1080/14780887.2020.1769238 Nolan S, Baird K, McInnes RJ. What strategies facilitate & support the successful transition of newly qualified midwives into practice: An integrative literature review. Nurse Educ Today. 2022 Nov;118:105497. doi:10.1016/j.nedt.2022.105497 PubMed PMID: 35952415. Sandor C, Murray-Davis B, Vanstone M, Bryant C. The Transition to Clinical Practice for New Registrant Midwives in Ontario, Canada. In: Gray M, Kitson-Reynolds E, Cummins A, editors. Starting Life as a Midwife: An International Review of Transition from Student to Practitioner [Internet]. Cham: Springer International Publishing; 2019 [cited 2022 Feb 13]. p. 73–94. Available from: https://doi.org/10.1007/978-3-319-93852-3_4 doi:10.1007/978-3-319-93852-3_4 Regan S, Wong C, Laschinger HK, Cummings G, Leiter M, MacPhee M, et al. Starting Out: qualitative perspectives of new graduate nurses and nurse leaders on transition to practice. J Nurs Manag. 2017 May;25(4):246–55. doi:10.1111/jonm.12456 PubMed PMID: 28244181. Napolitano F, Pagnucci N, Aleo G, Walsh N, Kearns T, Wray J, et al. Newly qualified nurses’ and midwives’ experience with continuing professional development during transition: A cross-sectional study. Nurse Educ Pract. 2024 Oct 1;80:104123. doi:10.1016/j.nepr.2024.104123 Chodzaza EC. Midwifery decision making during the first stage of labour within the Malawian context [Internet]. 2016 Jul 1 [cited 2020 Aug 29]. Available from: https://era.ed.ac.uk/handle/1842/31019 Pertiwi RI, Hariyati RrTS. Effective orientation programs for new graduate nurses: A systematic review. Enferm Clínica. 2019 Sep;29:612–8. doi:10.1016/j.enfcli.2019.04.094 Ebrahimi H, Hassankhani H, Negarandeh R, Gillespie M, Azizi A. Emotional Support for New Graduated Nurses in Clinical Setting: a Qualitative Study. J Caring Sci. 2016 Mar 1;5(1):11–21. doi:10.15171/jcs.2016.002 PubMed PMID: 26989662; PubMed Central PMCID: PMC4794541. Fenwick J, Hammond A, Raymond J, Smith R, Gray J, Foureur M, et al. Surviving, not thriving: a qualitative study of newly qualified midwives’ experience of their transition to practice. J Clin Nurs. 2012;21(13–14):2054–63. doi:10.1111/j.1365-2702.2012.04090.x Bloxsome D, Bayes S, Ireson D. “I love being a midwife; it’s who I am”: A Glaserian Grounded Theory Study of why midwives stay in midwifery. J Clin Nurs. 2020;29(1–2):208–20. doi:10.1111/jocn.15078 Bogren M, Grahn M, Kaboru BB, Berg M. Midwives’ challenges and factors that motivate them to remain in their workplace in the Democratic Republic of Congo-an interview study. Hum Resour Health. 2020 Sep 17;18(1):65. doi:10.1186/s12960-020-00510-x PubMed PMID: 32943067; PubMed Central PMCID: PMC7499901. Matlala MS, Lumadi TG. Perceptions of midwives on shortage and retention of staff at a public hospital in Tshwane District. Curationis. 2019 Jul 22;42(1):e1–10. doi:10.4102/curationis.v42i1.1952 PubMed PMID: 31368315; PubMed Central PMCID: PMC6676782. Mbalinda SN, Livingstone K, Najjuma JN, Gonzaga AM, Lusota D, Musoke D, et al. Fostering Professional Identity Formation and Motivation for Joining Nursing and Midwifery Programmes among Undergraduate Nursing/Midwifery Students and Recent Graduates in Uganda. Ann Glob Health. 2024 Oct 10;90(1). doi:10.5334/aogh.4435 Additional Declarations No competing interests reported. Supplementary Files SUPPLEMENTARYMATERIAL.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 27 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 16 Apr, 2026 Editor invited by journal 13 Apr, 2026 Editor assigned by journal 10 Apr, 2026 Submission checks completed at journal 10 Apr, 2026 First submitted to journal 09 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9371366","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625722754,"identity":"e07287e8-e8ec-44de-85ac-05de3a82ead5","order_by":0,"name":"Mathews Brave Mtegha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYLACxgYGOQkGHqLVM4O1GJOuJXEG0Vp0p50/+PDrDrv0mTNyDz78wWAnzyB2xgCvFrPbyczGsmeSc2dL5CUb8zAkGzZI5xDUwiYt2cacO08ix0wa6MwEBuncDYS0sP+WbKtPl5PIMf/5g6GeKC1sjB/bDidIA20BhsBhorQYSzO2HTec2fPGWJrH4Lhhm3T+BwJaEh9+/NlWLS9xPMfw44+Kanl+6bQEvFpAgBkRI8CwYiOoHggYfxCjahSMglEwCkYuAABUvz/70648KgAAAABJRU5ErkJggg==","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mathews","middleName":"Brave","lastName":"Mtegha","suffix":""},{"id":625722755,"identity":"b5dd726f-df23-44fd-b2fc-56dcbeb9004b","order_by":1,"name":"Maggie Zgambo","email":"","orcid":"","institution":"Edith Cowan University","correspondingAuthor":false,"prefix":"","firstName":"Maggie","middleName":"","lastName":"Zgambo","suffix":""},{"id":625722756,"identity":"6fc329c5-ed7b-4546-8f94-6fd446ecd5ce","order_by":2,"name":"Fatch Welcome Kalembo","email":"","orcid":"","institution":"Curtin University","correspondingAuthor":false,"prefix":"","firstName":"Fatch","middleName":"Welcome","lastName":"Kalembo","suffix":""},{"id":625722757,"identity":"f447a4a9-fb79-4750-a53e-76967bd04c57","order_by":3,"name":"Tiwonge Mlowoka","email":"","orcid":"","institution":"Mzuzu University","correspondingAuthor":false,"prefix":"","firstName":"Tiwonge","middleName":"","lastName":"Mlowoka","suffix":""},{"id":625722758,"identity":"7319dcbc-ee20-4102-a8e9-1b4ce36ac1a6","order_by":4,"name":"Ellen Chirwa","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ellen","middleName":"","lastName":"Chirwa","suffix":""},{"id":625722759,"identity":"d0eadfa1-4ab3-490d-98ff-d0ee400202b3","order_by":5,"name":"Elizabeth Chodzaza","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Chodzaza","suffix":""}],"badges":[],"createdAt":"2026-04-09 17:24:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9371366/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9371366/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108180961,"identity":"5d20494c-7272-4adb-a287-92698e9d5c0d","added_by":"auto","created_at":"2026-04-30 08:55:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":262086,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9371366/v1/d6ccca11-64ae-4b29-aa99-8aa0f3c9ce58.pdf"},{"id":107727208,"identity":"c578867f-d30d-4a54-975f-b478ec13c422","added_by":"auto","created_at":"2026-04-24 12:14:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18963,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYMATERIAL.docx","url":"https://assets-eu.researchsquare.com/files/rs-9371366/v1/9f8e2983e942d51d4884c26d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Systemic Support Strategies and Individual Factors Facilitating the Transition of Newly Qualified Nurse‑Midwives from Education to Clinical Practice in Northern Malawi: A qualitative Descriptive Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe transition experience from education to professional practice is a critical, yet often stressful period for newly qualified nurse-midwives (NQNMs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The transition period involves significant learning and adjustment as NQNMs move from a supervised academic environment into autonomous clinical practice (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This transition is often faced with challenges, as some NQNMs enter professional practice equipped with theoretical knowledge but may lack the hands on experience and confidence required for independent clinical decision making (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Such challenges underscore the importance of structured support systems that build competence and promote safe, compassionate and quality midwifery care.\u003c/p\u003e \u003cp\u003eIn Sub-Saharan Africa, the transition experience is compounded by persistent health workforce shortages, high patient workloads, and limited availability of formal support programs. Studies indicate that NQNMs often enter clinical practice with minimal supervision, inconsistent mentorship and inadequate orientation (Murokole et al., 2025; Simane-Netshisaulu et al., 2022). These conditions may hinder skills development, diminish confidence and compromise the quality of maternal and neonatal care. Similar challenges are evident in Malawi, where the transition occurs within a resource-constrained health-care system and maternal and neonatal health outcomes remain a priority (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite efforts to increase the midwifery workforce, Malawi continues to face a significant shortage of nurse-midwives and the ministry of health reports a 40% vacancy rate among registered nurse-midwives (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These nurse-midwives serve as middle managers but are also responsible for provision of care and mentorship of NQNMs during their transition to practice. The shortage and multiple roles places immense pressure on these nurse-midwives through increment of workload and diminishing capacity to mentor and guide less experienced colleagues. This can eventually compromise the quality of maternal and neonatal care delivery (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the Nurses and Midwives Council of Malawi (NMCM) recognize NQNMs as competent professionals upon licensure, Benner\u0026rsquo;s (1984) model suggests that most function at the \u0026ldquo;advanced beginners\u0026rdquo; level. At this stage, they require guidance to strengthen clinical competence, clinical judgement, and professional confidence. Without structured support, NQNMs may have limited opportunity to consolidate the clinical skills which risks compromising patient care outcomes and workforce retention (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTo address these challenges and work towards achieving Sustainable Development Goal (SDG) 3.1, Malawi introduced the graduate internship program (GIP) in 2018 to strengthening work integrated learning and early professional development. The program is a one year placement for fresh university graduates aged 35 years and below (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, enrolment into the program remains limited relative to the number of NQNMs entering the workforce challenging the overall impact. In addition, formal and informal support strategies such as mentorship and peer support have been reported to be critical facilitators of successful transition although their availability remains inconsistent across midwifery care settings in Malawi (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn the absence of systemic support strategies, the transition of NQNMs to practice relies largely on facility level practices and the informal guidance of senior staff (Rouse et al., 2024). This undermines the skill development of NQNMs and risks compromising patient care outcomes. The study therefore explores the systemic support strategies and individual factors that facilitate the transition of NQNMs from education to professional practice. This may inform development of sustainable and effective supportive structures to improving the transition experience, strengthen midwifery care and improve maternal and newborn health outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study utilised a qualitative descriptive approach, drawing on a naturalistic paradigm. The descriptive approach was ideal as it involves a systematic, interactive and in-depth approach that yields subjective and rich data used to describe human experiences (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This approach was deemed relevant for this study because of the subjective nature of the study topic (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003e The study was conducted at three hospitals purposively selected based on the type of maternity services provided, variation in institution type and the resource levels. These institutions are Mzuzu Central Hospital, Mzimba South District Hospital and St John\u0026rsquo;s Hospital, all in the northern region of Malawi. These hospitals have maternity units that provide antenatal, intrapartum and postnatal services. Mzuzu Central Hospital and Mzimba South District Hospital are public hospitals, while St John\u0026rsquo;s Hospital is run by the Christian Health Association of Malawi (CHAM).\u003c/p\u003e \u003cp\u003eMzuzu Central Hospital serves as a referral facility for all hospitals in the northern region, managing high patient volumes and a wide range of specialised services. Mzimba South District Hospital is one of the key referral hospitals in Mzimba district offering maternity care within a resource-constrained context, like many other public sector facilities in Malawi. In contrast, St John\u0026rsquo;s Hospital is among the largest private hospitals in Mzuzu city, providing maternity services within a private non-profit framework, with an organisational culture and management structure distinct from public hospitals.\u003c/p\u003e\n\u003ch3\u003eSelection criteria\u003c/h3\u003e\n\u003cp\u003eThe study included newly qualified and practising nurse-midwives and key informants from the three hospitals. The newly qualified nurse-midwives were recruited in the study if they had completed undergraduate nursing and midwifery education (diploma or degree), and if they had less than two years of transition period in practice. The timeframe reflects the transition period during which support needs are more pronounced. Nurse-midwives who had been in practice for less than 6 months and more than 2 years were excluded. Those less than six months in practice were likely undergoing orientation with limited exposure to the broader transition challenges.\u003c/p\u003e \u003cp\u003eKey informants were recruited if they were nursing and midwifery managers (matrons, district nursing officers or chief nursing officers) working in maternity units. Key informants were required to have held management positions for more than a year to ensure adequate familiarity with the transition process and organisational support structure. Key informants were excluded if they were not working in the maternity units, or had less than 1 year leadership experience. This was to ensure that only those with sufficient insight of the maternity unit support structure contributed to the understanding of the transition process.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eNQNMs were recruited through purposive sampling technique. Purposive sampling helps to recruit participants who are knowledgeable about the phenomena under study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The principal investigator verbally invited fifteen potential participants assigned to maternity units in these hospitals. The participants were briefed on the study aims and procedures, and voluntarily accepted to participate in the study. During the briefing, the participants were encouraged to ask questions for clarification and were informed of the right to decline or withdraw participation at any stage. Thirteen participants expressed interest and were subsequently provided with written study information, and were asked to give written informed consent to ensure autonomy (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). We enrolled 13 newly qualified nurse-midwives for interviews, but data saturation was reached at the tenth interview as no new information emerged from subsequent interviews (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, data collection continued for the next three participants to enhance the credibility of the findings. To enrich the data, six key informants were approached in their respective offices and briefed about the study objectives and benefits of participating in the study. They all assented to participate and were recruited for the study\u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eThe principal investigator, a nursing-midwifery lecturer with no prior relationship with participants, conducted all in-depth interviews from 4th July 2019 to 23rd September 2019. While familiar with the nursing and midwifery context, the researcher maintained reflexive journals and analytical memos throughout data collection and analysis to identify and manage potential biases. The interviews for new graduates were conducted in a quiet room inside the maternity unit to ensure confidentiality and minimize interruptions. Key informants were interviewed in their respective offices. The research team developed two sets of interview guides; one for the new graduates and another one for the key informants (see supplementary material 1). The study objectives and literature review guided the development of the interview guides. All interviews lasted between 20 minutes and 35 minutes and were digitally recorded. Participants consented to have their voices recorded during the recruitment process, and this was confirmed prior to the interviews. Field notes were taken soon after each interview.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e The research was approved by the University of Malawi College of Medicine Research and Ethical Committee (COMREC) reference number P.04/19/2647. Further ethical approval was obtained from the ethical research committees of the three hospitals. Before participation, verbal and written informed consent were sought from the participants. To ensure anonymity, participants were assigned codes and names were not used in the study. After data analysis, the transcripts were kept according to the university\u0026rsquo;s data management procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe raw data from in-depth interviews were transcribed and analysed manually. Each recorded interview was transcribed verbatim by MM and TM. MM verified and corrected errors in the transcription by re-reading the transcribed data while listening to the recorded data. Data analysis followed the six phases of thematic data analysis proposed by Braun \u0026amp; Clarke, (2006, updated in 2021), which are: familiarising with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFirstly, the transcribed data from in-depth interviews were read through multiple times by the first author to familiarise himself with the data and the preliminary analytical ideas useful for organizing the data were noted. Thereafter, a line-by-line analysis of transcribed data was undertaken to drive meaning from the collected data. Sentences in the transcripts were color coded to highlight potential patterns. Codes were derived from the transcripts and grouped into small and meaningful chunks of data. The codes with similar meanings were grouped into subcategories, which were then merged into sub-themes and subsequently organized into overarching themes. Coauthors held several meetings to discuss and review the identified themes for a consensus. Three researchers in nursing and midwifery education with qualitative backgrounds (EC, FK \u0026amp; MZ), who did not participate in data analysis, validated the themes to ensure that they indeed emerged from the transcripts.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRigour\u003c/h3\u003e\n\u003cp\u003eTo ensure rigour, the researcher used a framework by Lincoln and Guba (1985), who recommended four criteria for promoting the trustworthiness of study findings, which include: credibility, confirmability, dependability and transferability. Credibility was enhanced through member checking to confirm the authenticity of the conclusions made from the participant\u0026rsquo;s explanations. Three transcripts were selected at random for member checking to confirm the authenticity of the conclusions made from the data. An audit trail which included raw data from 13 newly qualified nurse-midwives and six key informants, thematic categories, process notes and interpretations were kept to establish confirmability of the results. Experienced qualitative researchers reviewed the data analysis procedures and the themes that emerged from the data, which enhanced the dependability of the findings. Further, the research process was comprehensively and clearly reported to ensure the transferability of the results.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy findings\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eDemographic characteristics of participants\u003c/h2\u003e \u003cp\u003eData were collected from 19 participants (13 newly qualified nurse-midwives and six key informants). The participants had different educational qualifications and experiences. Eight nurse-midwife technicians had a diploma in nursing and midwifery and five registered nurse-midwives had a degree in nursing and midwifery. The age of the participants ranged from 24 to 34 years. The clinical practice experience of the NQNMs ranged from 6 to 24 months. Three females and three male key informants within the age range of 33 to 43 years participated in this study. Two of the key informants held a master\u0026rsquo;s degree in reproductive health, while four had a bachelor\u0026rsquo;s degree in nursing and a university certificate in midwifery. Their clinical experience in managerial positions ranged from 6 to 16 years.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThemes\u003c/h2\u003e \u003cp\u003eTwo main themes were developed that describe the clinical support the newly qualified nurse-midwives received upon entry into practice: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Cultivating confidence through a support system and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Purpose-driven growth (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The themes are expanded below supported by the participants quotes which are presented using codes to ensure participants anonymity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Cultivating confidence through a support system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1. Systemic Support strategies tailored for newly qualified nurse-midwives\u003c/p\u003e \u003cp\u003e1.2. Availability of reference materials\u003c/p\u003e \u003cp\u003e1.3. Supportive environment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Purpose-driven growth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1. Self-motivation\u003c/p\u003e \u003cp\u003e2.2. Passion for the profession\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Cultivating confidence through a support system\u003c/h2\u003e \u003cp\u003eThis theme describes participants experiences of how support strategies influenced their confidence and development of competence during transition to practice. The findings highlight the impact of support strategies tailored for NQNMs, availability of reference materials and a supportive work environment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.1: Systemic Support strategies tailored for newly qualified nurse-midwives\u003c/h2\u003e \u003cp\u003eThe theme describes the various sources of support that were available to NQNMs during their transition period. Different systemic support strategies such as mentorship, peer pairing, continuous professional development (CPD) and orientation upon entry to practice were available in both government and a CHAM hospital where the study was conducted. The support strategies were valued by the participants even though they were not formally instituted in all the settings the study was conducted.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.1.1 Mentorship\u003c/h2\u003e \u003cp\u003eMentorship was described as a key source of support during the transition period. Participants reported receiving guidance from experienced nurse-midwives facilitated the development of clinical competence and professional confidence as reported in the account below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI was lucky that the time I was joining the department, I had a senior nurse-midwife who mentored me on how to perform some skills as well as how to manage the ward\u0026hellip;. During the period that we worked together, I used to consult her each time I had a challenge. Like during my early days I had challenges on how to perform manual removal of placenta and she supported me. Whenever consulted, she could demonstrate on how the particular skill was done\u0026hellip;. at times she could observe me doing the skill while providing guidance and could give feedback or evaluate my performance. Through this, my skills improved greatly\u003c/em\u003e\u0026rdquo; (RNM-M-P3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother newly qualified nurse-midwife described mentorship as working under a shadow and recounted how she was supported by the ward in-charge to attain the right skills:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI worked under the shadow of unit in-charge for a period of one month. \u0026hellip;.. We worked together and she helped me acquire the managerial and leadership skills necessary to lead the ward and the technical skills that I did not acquire from school\u0026rdquo;\u003c/em\u003e (RNM-F-P2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.1.2: Peer pairing\u003c/h2\u003e \u003cp\u003eMost participants commended peers and seniors who steered them in performance of skills, which helped to quickly settle in the ward and gain the expertise. The use of peer pairing has been explicitly expressed in the following extract from one nurse-midwife technician:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Since I was just a novice, each time I was on duty, I was paired with someone senior or a fellow nurse-midwife technician with better skills to support me\u0026hellip;. the in-charge had to put me on straight shift for the whole month and I was working with these colleagues until I got used to the ward. Seriously I leant a lot during this period and I had no fears performing procedures as my skills improved\u0026rdquo; (\u003c/em\u003eNMT-F-P2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.1.3: Continuous professional development\u003c/h2\u003e \u003cp\u003eCPD was another important strategy used to assist the NQNMs during the transition. CPD played a vital role in strengthening clinical competence. Ongoing learning not only enhanced NQNMs skills but also improved the care provided to mothers and newborns. One nurse-midwife highlighted this perspective, acknowledging the benefits of CPD for learning to gain necessary knowledge and skills.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;CPD is really helpful because you get updated on knowledge and you also learn best practice on how some skills are performed.... this improves quality of care we provide to mothers\u003c/em\u003e (NMT-F- P1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eKey informants also emphasised the significance of CPD as an important strategy for professional growth and skill enhancement for NQNMs. The key informant narrated this in support of the CPD:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Much as we appreciate that they attain knowledge from their training institutions, but when it comes to hands-on, they need support\u0026hellip;. so, we involve the newly qualified nurse-midwives in CPD sessions by doing presentations in a number of areas we feel they have a knowledge gap. We value CPD because through it they learn a lot in terms of patient care, which improves their skills and reduces stress during their transition period\u0026rdquo;\u003c/em\u003e \u003cb\u003e(\u003c/b\u003eKEY\u0026ndash;INFO\u0026ndash;F-P6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, another key informant commented on how they utilize in-service training in supporting the NQNMs as she said;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;W\u003cem\u003ee do in-service training within the hospital or outside \u0026hellip;. just to help us address some issues in the departments like management of post-partum haemorrhage while supporting the newly qualified nurse midwives attain the right skills and help them gain confidence necessary for the successful transition\u0026rdquo; (\u003c/em\u003eKEY\u0026ndash;INFO\u0026ndash;F- P3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.1.4: Orientation upon entry to practice\u003c/h2\u003e \u003cp\u003eThe participants also found orientation into the system upon entry to practice important during the transition period. The orientation process was mostly dependent on the entry qualification to practice, whether the graduate had a degree or a diploma. These qualifications defined the scope of practice for newly qualified nurse‑midwives (NQNMs), which managers used to determine the type of orientation appropriate to the role they were expected to assume\u003c/p\u003e \u003cp\u003eAn excerpt from one registered nurse-midwife exemplifies this:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We were given a schedule to rotate in different wards, 3 days in each ward\u0026hellip;. In maternity the ward in-charge oriented us to the ward routines and some reference guidelines to refer to when managing clients\u0026rdquo;\u003c/em\u003e (RNM-F-P4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn line with sentiments from the NQNMs, key informants specified that the orientation was done to help the NQNMs have an idea of what was expected of them and also familiarise themselves with the wards or department they were to work in. This quote from one nurse-midwife explains the orientation that was given:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;.. we orient them to our professional documents that we use as nurses and midwives as they act as a guide in the provision of care \u0026hellip;... they are given 5 days in each department to know the routines; however, it also depends on the role they are expected to take as per the scope of practice \u0026hellip;. but for normal orientation they are supposed to be in a department for at least a month to help them gain confidence and necessary skills in that department\u0026rdquo;\u003c/em\u003e (KEY\u0026ndash;INFO\u0026ndash;F- P6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe findings indicate that a range of support strategies were available to NQNMs during their transition into professional practice. Although not formally structured across all the study settings, participants described them as helpful in supporting confidence and skills development.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.2: Availability of reference materials\u003c/h2\u003e \u003cp\u003eAll NQNMs indicated that they found some reference materials and protocols in the midwifery settings they were deployed. They used the materials when they were unsure about the care to provide to patients during their practice. One participant recounted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u0026hellip;.. \u003cem\u003ethey were protocols in the ward to which we were always referring to\u0026rdquo;\u003c/em\u003e (NMT-F-P5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, key informants highlighted some reference materials they had in place that they referred NQNMs to for reference in cases where seniors or qualified staff were not there for support. One informant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe have guidelines, procedure manuals and posters which these new graduates do refer to incase they are stuck\u0026hellip;. We also have a folder that has reproductive health standards that these graduates can be referring to from time to time. This builds their confidence and helps them to transition well to practice\u0026rdquo;\u003c/em\u003e\u003cb\u003e(\u003c/b\u003eKEY-INFO-M-P4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Availability of reference materials like management guidelines and protocols was underscored by all the participants as a valuable strategy that helped them to quickly get used to the system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.3: Supportive environment\u003c/h2\u003e \u003cp\u003e Participants described a supportive work environment characterized by reassurance, encouragement and guidance from peers and seniors as instrumental in easing their transition into professional practice. They highlighted that being warmly welcomed by seniors and peers made them feel accepted and supported during their transition as illustrated in the following account:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The environment was so friendly and conducive for us. The team I found was very welcoming, and whenever I had a challenge, they could assist me with solutions, and this helped me to develop confidence and self-esteem\u0026rdquo;\u003c/em\u003e (RNM-M-P3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe presence of experienced midwives and encouragement made them develop the needed confidence for professional growth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Purpose-driven growth\u003c/h2\u003e \u003cp\u003eThe theme describes self-motivation and passion for the profession as critical drivers in shaping a smooth transition to practice. Self-motivation and passion for the profession fostered resilience and proactive learning in NQNMs as described below.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSub-theme 2.1: Self-motivation\u003c/h2\u003e \u003cp\u003e Participants acknowledged that Self-motivation played a vital role in building confidence and ensuring a seamless transition into practice. Key informants stressed that having knowledge from school only was insufficient to have a better transition; rather NQNMs needed the inner drive to push them, which was self-motivation. One nurse-midwife said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI may say that most of them have the knowledge from school but on the ground, it depends on the graduate\u0026rsquo;s self-motivation. Those who are motivated to work, they don\u0026rsquo;t take long to get back on track\u003c/em\u003e\u003cb\u003e\u0026hellip;.\u003c/b\u003e\u003cem\u003eand are confident in discharging their duties as they are mostly not afraid of taking challenging tasks\u0026rdquo;\u003c/em\u003e\u003cb\u003e(\u003c/b\u003eKEY-INFO-M-P4).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn line with key informants\u0026rsquo; sentiments, some NQNMs highlighted how keen they were to learn from experienced midwives. One participant said;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI was very keen to know, to learn, and to acquire new information and skills from the midwives that I knew were experienced and had the right skill to equip me\u0026hellip;. I took up the role very seriously and I was free to ask wherever stuck\u0026hellip;. I easily consulted, for I felt I should not live within the mask because whenever I asked, they guided me and with that knowledge I found that I was moving towards the right channel\u0026rdquo; (\u003c/em\u003eRNM-M-P5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBoth NQNMs and key-informants acknowledged that most of the self-motivated NQNMs had theoretical knowledge from college which empowered them to face clinical challenges with confidence and a positive mind. One participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was not much stressed up the time I was joining the profession because I knew I had knowledge. We were taught on how to conduct deliveries and how to manage most of the conditions in labour ward\u0026hellip;. this gave me confidence that I could perform and I had no fear taking challenging tasks\u0026rdquo; (\u003c/em\u003eRNM-F-P4).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLikewise, a key informants said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;.. So those who feel that they have enough knowledge in terms of patient management, they transition well compared to those who have knowledge deficit as they lack confidence\u0026rdquo;\u003c/em\u003e \u003cb\u003e(\u003c/b\u003eKEY-INFO-M-P4).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 2.2: Passion for the profession\u003c/h2\u003e \u003cp\u003eBeyond self-motivation, a deep passion for the profession acts as a strong foundation for successful transition. The subtheme describes the passion the NQNMs had for the profession and their ability to room in. Many participants stated that they stayed in the profession with less stress because they loved it. This acted as a motivation hence facilitated their transition into practice. Those that had a passion for the profession, enjoyed the transition experience as one graduate said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eFor me, being a midwife is not by mistake; it is by choice. I made a decision and, in every decision, you make, you should be ready to meet obstacles and the moment you overcome those obstacles, thus when you say you have achieved\u0026rdquo; (\u003c/em\u003eRNM-F-P2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants who demonstrated openness to learning described more positive transition experience, emphasizing the importance of engaging with experienced colleagues:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I wanted to learn that means I had to affiliate myself to them. I gave myself a room to learn from the system or everyone else on the ground because I felt they were good on hands on practice \u0026hellip;. and I never gave a room to their negative responses, rather I kept on pressing and this made me grow professionally\u0026rdquo;\u003c/em\u003e (RNM-M-P5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePassion for the profession not only sustained their motivation but also allowed them to embrace learning opportunities and remain resilient in the face of obstacles. Further, their decision to remain in the profession was mostly influenced by their passion and self-motivation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study highlight the crucial role of both system and personal factors in facilitating the transition of NQNMs from education to professional practice. The findings revealed that access to support systems and a purpose‑driven approach to growth are essential for cultivating confidence and facilitating the transition of NQNMs. Strategies and other factors that facilitated the transition process for the NQNMs are discussed in the sections below.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eSystemic Supportive strategies\u003c/h2\u003e \u003cp\u003eVarious systemic support strategies such as peer pairing, mentorship, CPD, and structured orientation, were identified as critical in facilitating the transition process. The study results reveal that participants benefited more from peer support. NQNMs often relied more on their colleagues for support, which helped them learn to collaborate and build a supportive network. The findings are consistent with study results by Kool et al. (2023) who documented that NQNMs spend time collaborating with fellow midwives as role models and for the purpose of consultations during the transition period. Fenwick et al. (2012) described peer support as a \u0026ldquo;life raft\u0026rdquo; during the transition period, emphasising the importance of peers during the period.\u003c/p\u003e \u003cp\u003eAdditionally, NQNMs acknowledged informal mentorship they received from senior staff. Although not institutionally formalised, it played a vital role in guiding them through hands-on clinical practice as they were provided with technical support, feedback and skills demonstration. The fundamental role of mentorship in enhancing clinical competence and fostering confidence among NQNMs is well established in the literature (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In Malawi, informal mentorship occurs naturally as it is flexible, relational and integrated into everyday clinical practices. This creates an environment where NQNMs can comfortably seek help without fear or hierarchical limitations that may accompany structured programs. It emerges from existing interpersonal rapport, making the support more accessible.\u003c/p\u003e \u003cp\u003eDespite the contextual strength, literature recommend structured mentorship as a more effective strategy of fostering competence and professional socialisation among NQNMs (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Therefore, acknowledgement of informal mentorship in these settings does not contradict the literature, rather, underscores the need to complement the informal mentorship with a formalised mentorship program. The government, through the Ministry of Health should establish a structured mentorship program to ensure all NQNMs receive equitable support during the transition regardless of the practice setting. Such a program would help NQNMs develop the essential skills and confidence required for effective practice.\u003c/p\u003e \u003cp\u003eCPD was another essential strategy that supported the professional growth of NQNMs. Participants engaged in CPD activities that enabled them to acquire new knowledge and skills that boosted their confidence and clinical performance. These findings are in line with a cross-sectional study conducted in 3 European countries that highlighted that CPD provides an opportunity to NQNMs stay up-to-date with latest evidence, acquire new skills and enhance professional growth (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The findings underscore the need for institutions to emphasise CPD\u0026rsquo;s role in professional and skills development, ultimately contributing to improved care for mothers and newborn.\u003c/p\u003e \u003cp\u003eFurthermore, participants identified orientation programs as beneficial in helping NQNMs adapt quickly to their new role during the transition period. The general orientation introduced them to professional documents, institutional policies, ward routines, and the physical setting. This process allowed them to familiarise themselves with workplace expectations and enhanced role clarity. Rush et al. (2015) described such orientation as an essential organizational strategy to integrate NQNMs into the hospital environment. In this study, however, the scope and structure of orientation varied based on the institution and the nurse-midwife\u0026rsquo;s qualification. Participants had an orientation period of between 2 days and 4 weeks often shorter than the duration suggested in international literature. Participants with a degree had a longer period of orientation than those with diplomas. Unanimously they reported that the period though not enough, had a positive impact on their transition. In contrast, studies suggest that an extended formal orientation of over 4 weeks provides more significant benefits like reduced stress, improved competence and professional satisfaction (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Extending orientation, adopting formalised orientation frameworks and incorporating competency assessments can optimize the effectiveness of these programs, ensuring that NQNMs are adequately supported during the transition period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eAvailability of reference materials\u003c/h2\u003e \u003cp\u003e NQNMs reported that access to clinical guidelines, manuals and standard operating procedures significantly contributed to their confidence in decision making. When faced with a complex or unfamiliar situation, reference materials served as safety nets reinforcing their theoretical knowledge and informing their practice mainly in the absence of senior colleagues. This increased their confidence and enable them to deliver appropriate care. The findings are in line with the previous studies that observed that midwifery care in Malawi is guided by national standards (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and access to evidence-based resources enhance clinical competence and promote independent decision making among NQNMs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Ensuring that all maternity settings are equipped with up-to-date reference materials and encouraging their routine use could strengthen clinical decision for NQNMs during the transition period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eSupportive environment\u003c/h2\u003e \u003cp\u003eA positive and welcoming work environment was identified as a key factor in easing the transition from training to practice. The NQNMs valued emotional support they received from colleagues and midwifery leaders through reassurance, encouragement and guidance. The receptive and inclusive environment helped alleviate stress and instilled a sense of belonging. Similar findings have been reported in literature, emphasizing that a supportive work environment fosters job satisfaction, confidence and retention among NQNMs (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Emotional encouragement also fosters internal motivation a key factor in professional growth (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). These insights emphasise the importance of creating and sustaining a culture of support through regular team building activities to enhance professional growth among NQNMs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003ePurpose driven growth\u003c/h2\u003e \u003cp\u003eWhile the systemic support played a crucial role in the transition of NQNMs, the study also identified personal attributes such as self-motivation and passion for the profession as key factors to a successful transition.\u003c/p\u003e \u003cp\u003eSelf-motivation was found to be a critical enabler in ensuring a seamless transition of NQNMs. Participants acknowledged that while formal education provided foundational knowledge, personal drive and eagerness to learn played a significant role in their professional development. Key informants also emphasised that self-motivated individuals adapted more quickly to clinical practice. This finding is consistent with findings from previous research that revealed that intrinsic motivation enhances learning, resilient, and job satisfaction in nursing and midwifery regardless of challenges encountered (\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeyond self-motivation, a passion for midwifery emerged as another enabler to a successful transition. NQNMs who had a deep commitment to the profession found greater fulfilment and were more likely to embrace challenges as learning opportunities. These findings are supported by previous findings that linked, passion to increased job satisfaction, commitment and resilience, all of which contribute to professional growth and retention of nurse-midwives in the profession (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Nurturing passion among undergraduates and graduate nurse-midwives is therefore essential to facilitate smooth transition into practice and strengthen retention within the midwifery workforce.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe role of theoretical knowledge\u003c/h3\u003e\n\u003cp\u003eFindings indicate that theoretical knowledge acquired during training provided a foundational support for the NQNMs. Participants who believed they had grasped the midwifery concepts clearly were less stressed when discharging their duties compared to their counterparts who had knowledge deficit. The findings are in line with results of a study in China found that basic knowledge and skills learned in school are helpful in facilitating the transition of NQNMs, but insufficient to help them develop required confidence to handle complex and emergency situations in midwifery setting (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Despite graduates having theoretical knowledge, they need support during the transition period to develop confidence and necessary skills.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations of the study\u003c/h2\u003e \u003cp\u003eData were collected from degree nurse-midwives, diploma nurse-midwives and key informants. This helped to enrich the study findings as ideas presented were from a wide perspective, which helped to reduce biases. The study illuminates both systemic support and individual factors that facilitate the transition of NQNMs from education to practice within the Malawian context.\u003c/p\u003e \u003cp\u003eDespite these strengths, the study has some limitations. First, data were collected from three selected midwifery settings as such the findings may not fully represent the experiences of other nurse-midwives in other settings. However, detailed description of the research process and the study context allow readers to assess the transferability of the findings to a similar setting.\u003c/p\u003e \u003cp\u003eSecondly, as a qualitative study, the potential for subjectivity in data interpretation cannot be entirely eliminated. However, the process of data analysis involved a group of researchers with expertise in qualitative research who examined the transcripts and the coding process and the themes to validate the study findings. Additionally, we asked the participants to review the transcripts after data collection to validate and improve the credibility of the findings.\u003c/p\u003e \u003cp\u003eLastly, the data submitted were collected in 2019. Despite the delay in reporting, the data findings remain relevant given the ongoing Malawi health system challenges that affect maternal and neonatal health outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTransition support strategies such as structured mentorship, CPD, orientation, and access to reference materials play a critical role in strengthening the confidence and competence of NQNMs. Combined with personal attributes such as self-motivation and passion for the profession, these strategies foster resilience, professional growth, and retention in the workforce. Formalising and scaling transition-to-practice programmes across Malawian health-care settings may therefore contribute to improved quality of maternal and newborn care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the declaration of Helsinki 1964 and local ethical guidelines set by the Kamuzu University of Health Science. The ethics approval to conduct the study was granted from the College of Medicine Research and Ethics Committee of the Kamuzu University of Health Science (KUHeS) reference number P.04/19/2647. In addition, permission was sought from all the three hospitals where the study was conducted. Verbal and written consent were obtained from all participants. To ensure anonymity, participants were assigned codes and names were not used in the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants provided written informed consent prior to participation, including consent for the use of their data and publication of the study findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available with the corresponding author and may be made available upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of conflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare that there is no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received no funding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research design and data collection was done by MM. Data analysis was conducted by MM, TM, EC, EC, FWK and MZ. The original manuscript was drafted by MM and EC. MM, FWK, EC, EC and MZ reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAll the authors contributed towards the completion of this manuscript and have read and approved it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all the midwives who accepted to participate in this study. We also acknowledge the hospital management teams for granting permission to conduct the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKool E, Schellevis FG, Jaarsma DADC, Feijen-de Jong EI. How to improve newly qualified midwives\u0026rsquo; transition-into-practice. A Delphi study. Sex Reprod Healthc. 2023 Dec;38:100921. doi:10.1016/j.srhc.2023.100921\u003c/li\u003e\n \u003cli\u003eShi J, Li X, Li Y, Liu Y, Li J, Zhang R, et al. 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Available from: https://www.scribd.com/document/919113986/Call-for-Applications-for-a-2025-26-Graduate-Internship-12-Cohort-V2\u003c/li\u003e\n \u003cli\u003eRenjith V, Yesodharan R, Noronha JA, Ladd E, George A. Qualitative Methods in Health Care Research. Int J Prev Med. 2021;12:20. doi:10.4103/ijpvm.IJPVM_321_19 PubMed PMID: 34084317; PubMed Central PMCID: PMC8106287.\u003c/li\u003e\n \u003cli\u003eColorafi KJ, Evans B. Qualitative Descriptive Methods in Health Science Research. HERD Health Environ Res Des J. 2016 Jul;9(4):16\u0026ndash;25. doi:10.1177/1937586715614171\u003c/li\u003e\n \u003cli\u003eCampbell S, Greenwood M, Prior S, Shearer T, Walkem K, Young S, et al. Purposive sampling: complex or simple? Research case examples. J Res Nurs JRN. 2020 Dec;25(8):652\u0026ndash;61. doi:10.1177/1744987120927206 PubMed PMID: 34394687; PubMed Central PMCID: PMC7932468.\u003c/li\u003e\n \u003cli\u003ePalinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015 Sep;42(5):533\u0026ndash;44. doi:10.1007/s10488-013-0528-y PubMed PMID: 24193818; PubMed Central PMCID: PMC4012002.\u003c/li\u003e\n \u003cli\u003eBolderston A. Conducting a Research Interview. J Med Imaging Radiat Sci. 2012 Mar;43(1):66\u0026ndash;76. doi:10.1016/j.jmir.2011.12.002 PubMed PMID: 31052024.\u003c/li\u003e\n \u003cli\u003eHennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. 2022 Jan;292:114523. doi:10.1016/j.socscimed.2021.114523\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021 Jul 3;18(3):328\u0026ndash;52. doi:10.1080/14780887.2020.1769238\u003c/li\u003e\n \u003cli\u003eNolan S, Baird K, McInnes RJ. What strategies facilitate \u0026amp; support the successful transition of newly qualified midwives into practice: An integrative literature review. Nurse Educ Today. 2022 Nov;118:105497. doi:10.1016/j.nedt.2022.105497 PubMed PMID: 35952415.\u003c/li\u003e\n \u003cli\u003eSandor C, Murray-Davis B, Vanstone M, Bryant C. The Transition to Clinical Practice for New Registrant Midwives in Ontario, Canada. In: Gray M, Kitson-Reynolds E, Cummins A, editors. Starting Life as a Midwife: An International Review of Transition from Student to Practitioner [Internet]. Cham: Springer International Publishing; 2019 [cited 2022 Feb 13]. p. 73\u0026ndash;94. Available from: https://doi.org/10.1007/978-3-319-93852-3_4 doi:10.1007/978-3-319-93852-3_4\u003c/li\u003e\n \u003cli\u003eRegan S, Wong C, Laschinger HK, Cummings G, Leiter M, MacPhee M, et al. Starting Out: qualitative perspectives of new graduate nurses and nurse leaders on transition to practice. 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Emotional Support for New Graduated Nurses in Clinical Setting: a Qualitative Study. J Caring Sci. 2016 Mar 1;5(1):11\u0026ndash;21. doi:10.15171/jcs.2016.002 PubMed PMID: 26989662; PubMed Central PMCID: PMC4794541.\u003c/li\u003e\n \u003cli\u003eFenwick J, Hammond A, Raymond J, Smith R, Gray J, Foureur M, et al. Surviving, not thriving: a qualitative study of newly qualified midwives\u0026rsquo; experience of their transition to practice. J Clin Nurs. 2012;21(13\u0026ndash;14):2054\u0026ndash;63. doi:10.1111/j.1365-2702.2012.04090.x\u003c/li\u003e\n \u003cli\u003eBloxsome D, Bayes S, Ireson D. \u0026ldquo;I love being a midwife; it\u0026rsquo;s who I am\u0026rdquo;: A Glaserian Grounded Theory Study of why midwives stay in midwifery. J Clin Nurs. 2020;29(1\u0026ndash;2):208\u0026ndash;20. doi:10.1111/jocn.15078\u003c/li\u003e\n \u003cli\u003eBogren M, Grahn M, Kaboru BB, Berg M. Midwives\u0026rsquo; challenges and factors that motivate them to remain in their workplace in the Democratic Republic of Congo-an interview study. Hum Resour Health. 2020 Sep 17;18(1):65. doi:10.1186/s12960-020-00510-x PubMed PMID: 32943067; PubMed Central PMCID: PMC7499901.\u003c/li\u003e\n \u003cli\u003eMatlala MS, Lumadi TG. Perceptions of midwives on shortage and retention of staff at a public hospital in Tshwane District. Curationis. 2019 Jul 22;42(1):e1\u0026ndash;10. doi:10.4102/curationis.v42i1.1952 PubMed PMID: 31368315; PubMed Central PMCID: PMC6676782.\u003c/li\u003e\n \u003cli\u003eMbalinda SN, Livingstone K, Najjuma JN, Gonzaga AM, Lusota D, Musoke D, et al. Fostering Professional Identity Formation and Motivation for Joining Nursing and Midwifery Programmes among Undergraduate Nursing/Midwifery Students and Recent Graduates in Uganda. Ann Glob Health. 2024 Oct 10;90(1). doi:10.5334/aogh.4435\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Newly qualified nurse-midwife, transition to practice, clinical support, transition support programs, mentorship, professional development, midwifery, Malawi","lastPublishedDoi":"10.21203/rs.3.rs-9371366/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9371366/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The transition from education to professional practice is a critical phase for newly qualified nurse-midwives (NQNMs), often characterized by challenges in developing clinical competence and professional confidence. However, inconsistencies in clinical support system across health care settings hinder the development of NQNMs into competent and confident practitioners. The aim of the study was to explore the systemic support strategies and individual factors that facilitate the transition of NQNMs from education to clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e A qualitative descriptive design was employed. Data were collected through in-depth interviews from a purposive sample of 19 participants with 13 NQNMs and six key informants across the three selected hospitals. Two semi-structured interview guides, one for NQNMs and another for key informants were used to collect data. The qualitative data were analyzed manually using thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Two overarching themes emerged: (1) Cultivating confidence through a support system, which encompassed mentorship, peer pairing, continuous professional development (CPD), structured orientation, access to reference materials, and a supportive environment. (2) Purpose-driven growth, which reflected individual factors, self-motivation and passion for the profession.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Strengthening structured mentorship, CPD and orientation programs is key for a successful transition to practice. In addition, nurturing passion and self-motivation supports professional growth, strengthens the resilience of NQNMs in demanding work environments and promotes workforce retention.\u003c/p\u003e","manuscriptTitle":"Systemic Support Strategies and Individual Factors Facilitating the Transition of Newly Qualified Nurse‑Midwives from Education to Clinical Practice in Northern Malawi: A qualitative Descriptive Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 12:14:50","doi":"10.21203/rs.3.rs-9371366/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-12T23:51:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282443878074109299811950953020880509442","date":"2026-05-08T22:28:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T06:58:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54280127190388056146856534883986749195","date":"2026-04-16T14:54:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T14:09:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-13T08:43:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-10T05:51:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-10T05:50:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-04-09T17:20:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab4c71bf-bdb8-435e-955e-cb9fc8b2261e","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-12T23:51:02+00:00","index":44,"fulltext":""},{"type":"reviewerAgreed","content":"282443878074109299811950953020880509442","date":"2026-05-08T22:28:51+00:00","index":41,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T12:14:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 12:14:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9371366","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9371366","identity":"rs-9371366","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}