Interviews in the Recruitment of Student Midwives and Nurses: Safeguard or Artefact of Unconscious Bias? A Brief Commentary

Abstract

Midwives and nurses are integral to the quality and safety of patient care. However, there is a limited amount of critical discussion and debate about the use of interviews to recruit people to study for these professions. There are some reports of people who are marginalised, minoritised, or racialised, being denied the opportunity to study for a degree in these professions, despite meeting the requisite entry requirements. Therefore, this commentary analyses the contemporary narrative and discussion relating to the role of interviews in recruiting student midwives and nurses. This critical analysis uses the UK as a case study and promulgates an alternative approach that could result in a more diverse workforce and enhance patient safety. It is hoped that the critical analytical approach taken in this paper will inspire those involved in recruitment to midwifery and nursing to consider the efficacy, utility, and equity of recruitment interviews and their impact on who is or is not afforded the opportunity to pursue a career in these professions.

1. Introduction

Improving the quality and safety of patient care is a global priority that is contingent on the provision of a well-educated, skilled, and motivated interprofessional healthcare workforce [1,2,3]. Several seminal publications [3,4,5] have highlighted the imperative to embed patient safety in healthcare professional education curricula. However, there is a dearth of evidence and guidance on how best to recruit prospective healthcare professionals onto the associated programmes of study that have the ability, aptitude, temperament, skill, and disposition to enhance patient safety in every aspect of their practice.

The traditional approach in recruiting to midwifery and nursing programmes has been to shortlist and interview applicants before an offer of a place to study is made. However, evidence indicates that such an approach is laden with bias, subconscious or otherwise, as the people who do the interview tend to recruit those who look, think, and feel like them [6,7]. The rationale given by many midwifery and nursing colleagues for having face-to-face to interviews is so that they can ensure/verify that people with the ‘right’ values—that is, those deemed to have what it takes to successfully complete the programme of study and who also have realistic insight into the profession—are offered a place to study for these safety critical disciplines.

There have long been reports by people from marginalised, minoritised, and racialised groups of meeting all the entry requirements to study midwifery or nursing but not been offered a place after their interview [6,7]. Indeed, there are anecdotal reports of people not being offered places to pursue these professions either due to their looks or because they had a lived experience or perspective that differed from key decision-makers on the interview panel. There is some dated evidence [8], which suggests that interviews are of limited efficacy in screening out potential dropouts and reducing the attrition rates on nurse education programmes. It has also long been established [9] that the utility of interviews in student nurse recruitment can be subverted, as applicants quickly establish what the appropriate responses are to the questions that they are asked. The evidence from these dated studies [8,9] is bolstered by more recent research [10,11,12,13], which highlights the lack of evidence about the utility and efficacy of interviews in recruiting student midwives and nurses. There is also an increasing amount of evidence from different studies [10,11,13,14,15,16,17,18], which supports the use of alternative approaches to student midwife and nurse recruitment, such as multiple mini-interviews and emotional intelligence tests.

Catastrophic failures in healthcare often arise in organisations and systems where there is a dominant culture or mindset that overlooks alternatives that are inconsistent with the dominant group narrative [19,20]. The culture in any facet of healthcare invariably has people that are consigned or ascribed to in-groups, out-groups, or a subculture [21]. Therefore, it is important to critically analyse the often-articulated narrative among some midwives and nurses that they can identify people with the ‘right’ values and those have what it takes as students to thrive, flourish, and progress into a career in these professions through recruitment interviews.

In line with foundational scientific principles, it is always best to subject all views, regardless of how they are expressed, to careful examination and deliberation. Overlooking views that are unpalatable or uncomfortable impoverishes professional practice and, ultimately, humanity. Humility is always prudent given humans’ susceptibility to inattentional blindness or the inability to see and recognise something that is one’s field of vision, unless someone else draws attention to it, because it is unexpected in that context [22,23]. Inattentional blindness can cause harm, especially in the context of healthcare [22]; therefore, it is important to adopt a phronetic approach to consider what role interviews could and should play in recruitment to midwifery and nursing programmes.

2. Institutions, Recruitment, and Values

Many institutions have adopted a values-based approach to recruitment for midwifery and nursing programmes [14,24], which involves interviews. The extent to which these values-based approaches to interview-based recruitment are underpinned by robust evidence is open to question. Indisputably, values matter to the midwifery and nursing professions as enshrined in their standards for education, proficiency, and clinical practice, both in the UK [25,26,27] and globally [28,29,30]. The professional values that underpin midwifery and nursing—such as those articulated in key codes and practice drivers [28,29,30]—are often used to inform and underpin recruitment and retention initiatives [31]. A key feature of the values discourse in midwifery and nursing is on recruiting and retaining staff with the attributes to consistently deliver safe, high-quality, evidence-based, and person-centred care [30,31]. The congruence between the values of an individual healthcare professional—the values that are manifest in the context that they are working in with the values of their employer—have been shown to be associated with staff wellbeing, burnout, and patient safety [31,32]. Specifically, when there is a misalignment between the values of the individual midwife or nurse and the wider values that are at play as they carry out their duties, their work, their wellbeing, as well as patients safety are likely to diminish [31,32,33]. Given the variety of ways in which values relate to different facets of midwifery and nursing, it is understandable that a values-based approach to recruiting with interviews for pre-registration programmes is attractive to many.

Values are also at play in higher education institutions, such as universities, throughout the world. These institutions all have mission statements or guiding principles that articulate the values that they hold dear. In most countries, universities are characterised as bastions of free speech, in which people are given a platform to discuss and debate ideas in a quest to advance knowledge and wisdom for the benefit of humanity. Universities are often at the vanguard of thinking and innovation, so they often consider themselves to be the conscience of society and/or global drivers of change. The wider value laden societal context coupled with the requirements of professional regulatory and statutory bodies mean that universities have the mandate to make decisions about who is afforded the opportunity to pursue a programme of study leading to qualification as a midwife and/or nurse. Consequently, it is important to examine the issues that often arise in attempting to ensure congruence between institutional, professional, and societal values in interview-based recruitment through a case study.

In the UK, universities that provide pre-registration midwifery and nursing courses profess to espouse a wide range of values. These universities claim that these values are the basis on which they can make pronouncements about who will make a good nurse and who will not through recruitment processes such as interviews, written statements, and demonstration of experience. However, there is a lack of critique, and perhaps candour, about how the values that universities espouse are operationalised in interview-based recruitment processes. The values that universities claim to espouse do not arise in a vacuum, but they are temporo-spatially located and socio-culturally mediated. Simply put, the values that universities seek to embody tend to reflect the values of wider society and the culture within a given time and space. In addition, the values that universities seek to embody often mirror, and evolve in keeping with changes to, socio-cultural norms and mores. At one point in time, those involved in recruiting applicants onto midwifery and nurse programmes through interviews in the UK often declined men that met the entry requirements because of the prevailing societal views about gender and roles, on the basis that these were ‘unsuitable’ professions for a man. In the prevailing socio-cultural mores at the time of writing in the UK, such views and behaviours are completely unacceptable, as gender discrimination of this nature is illegal.

3. Enacting Values in Recruitment Interviews

One view of university pre-registration midwifery and nursing interview-based recruitment processes is that there is a misalignment between what universities describe as their purpose and mission and the way in which they conduct their business. In effect, the contention is that universities have ‘laminated values’ [33] that are proclaimed, documented, and often prominently displayed to the public, but have little practical consequence or relevance. A less charitable view held by some in society is that universities have become ‘woke’, so they promulgate laminated values as a means of performative virtue signalling instead of using them as cardinal principles that inform and underpin every facet of their work. Whatever view one holds or adopts, any gap(s) between the values professed and those manifested in the actions taken by universities and their employees can have far reaching consequences.

Values provide a sense of purpose, mission, and vision, but are largely inconsequential if they are not enacted or embodied appropriately [32,33]. Misalignment between values and action in recruitment can disenfranchise, marginalise, and exclude some members of wider society. Anecdotal reports suggest that paradoxically, those who are the most susceptible to being excluded or overlooked by universities through interview-based recruitment are often the very same groups of people who are under-represented and would benefit the most from higher education. The consequence of clumsy, interview-based recruitment processes devoid of robust underpinning evidence is experienced as the cruel crushing of dreams for those that are excluded, who feel that, for whatever reason, their faces did not fit. Furthermore, interview-based recruitment approaches such as these mean that the opportunities for true diversity beyond the nine protected characteristics enshrined in legislation is extinguished.

Perhaps then, the gap between the values professed and manifested in interview-based recruitment processes can be understood as a form of intellectual ‘group think’ that perhaps unwittingly beguiles the intended audience into suspending their disbelief and overlooking the reality that they are facing. The use of the phrase ‘group think’ in this context should not be misconstrued as a jibe or dig at those who proclaim values but find it challenging to enact them. It is also important that a failure to live up to the values that one cherishes or treasures is human and not a reason for derision, ridicule, or criticism. Neither is the use of this phrase an attempt to impute any malign or deceptive intent to universities or their employees. Instead, the phrase ‘group think’ is used light-heartedly to, frankly, encapsulate the human proclivity to seek a narrative that justifies what we do or do not do. This propensity, in turn, obviates the need for critical scrutiny, self-awareness, and reflection about the impact of our actions, even when unintended, on others. Perhaps then, ‘group think’ is an apt way of describing the human propensity to suspend disbelief by acting on a narrative that aligns with our world view and conscious/unconscious biases.

The rationale for interview-based recruitment to pre-registration midwifery and nurse education is understandable, regardless of whether one considers it to be group think or not. In the UK, a course is unlikely to be approved by a Higher Education Institution, such as a university, and a professional regulatory body like the Nursing and Midwifery Council (NMC), without a convincing explanation of the recruitment measures that are in place to select people with an appropriate set of values. Indeed, UK-based universities that offer pre-registration midwifery and nursing are required by the NMC [27,34] to demonstrate that applicants who are offered a place have values that are consistent with the code of practice [35] for these professions. This is consistent with the requirement that all midwives and nurses adhere to a shared set of professional values set out in the international codes of ethics [28,29]. The extent to which interview-based recruitment measures are meaningful and duly reflect the appropriate values is contestable, so it can be argued that they are illusory and of limited merit. Any institutions that recruit people onto a programme of study who do not have an appropriate set of values and/or are unable to convincingly explain how they will do so are liable to face sanction. This is the case even when these institutions are forward-thinking and their approach is in keeping with the expectations of the public whom the professional regulators seek to protect.

The complex, contingent, and emergent nature of healthcare is such that a business-as-usual approach with interview-based recruitment approaches in the absence of robust evidence about their utility and efficacy is intellectually untenable. Recruitment should be data-informed and evidence-based to the same extent as any aspect of medical treatment. Indeed, recruitment is not an inert gatekeeping process: while it has the potential to do good, it can also privilege, exclude, and harm. The latter two—specifically, exclusion and harm—often pertain to those who are overlooked or rejected. It could well be that the prevailing norms, customs, and practice(s) mean that only those able to convince the recruitment panel at interview that their values are suitably aligned with those of the profession are permitted to enrol on pre-registration midwifery and nursing programmes. Conversely, those who are less able to convey a suitably compelling values narrative at interview find that the opportunity to pursue the career of their choice dissipates in front of them. Every facet of midwifery and nursing practice must be based on evidence [35,36,37], so there is a strong case for an evidence-based approach to recruitment in both professions.

Student midwife and nurse recruitment matters because these disciplines are integral to patient safety and to protect the public from people who might seek to enter these professions with malicious intent or dubious motives. Midwives and nurses play a central role in ensuring patient safety, as they are often the first to encounter patients and those who access healthcare [38,39]. In light of their safety critical roles, it is imperative that midwives and nurses have the knowledge, skills, and attitude to assess, treat, and look after people in an evidence-based, culturally appropriate, person-centred way [2,38,39]. In midwifery and nursing, all these expectations and requirements are underpinned and informed by values in the academic setting of a university and the praxis of healthcare.

4. Values Ventriloquy and Mimesis in Recruitment Interviews

The interview-based recruitment process in midwifery and nurse education functions as a screening process devoid of scientifically robust tools that have been tested and proven to have sufficient sensitivity and specificity. Such an approach is out of step with the best practice in relation to screening in the context of public health where the use of such evidence-based tools is de rigueur. The absence of such tools in pre-registration, interview-based recruitment processes is a cause for concern and may give rise to ceremonial compliance to best practice, which contradicts and undermines the dictum and ethos of evidence-based practice in midwifery as well as nursing. This raises the disconcerting paradox that midwifery and nursing profess values of equity, justice, and inclusivity. However, their use of interviews in recruitment may inadvertently perpetuate practices that countermand the essence, means, and end of the values that they seek to achieve of a healthcare workforce that reflects the diversity of wider society which in turn enables all to thrive, flourish, and prosper.

It is worth considering the unpalatable notion that interview-based recruitment processes for midwifery and nursing students, as currently constituted, could well be promoting ‘values ventriloquy’. In other words, applicants who express the values that midwives or nurses prize in their written statements and demonstrate or convey them convincingly in an interview are chosen. This means that those who are less adept at effecting ‘values mimesis’ in key aspects of the interview-based recruitment process will be afforded the chance to pursue a midwifery or nursing career. In this context, the metaphor ‘values ventriloquy’ refers to the ability of applicant to express the values that the think recruiters are seeking while concealing their actual values. Plainly put, values ventriloquy is the ability of an applicant to produce socially desirable value statements and behaviours. Applicants are motivated to act in this way because they understand that they need to say and do the right things to obtain a place on the midwifery or nursing programme. This accords with the wider literary and societal discourse that associates ventriloquy with exclusionary practices as a means of consciously or unconsciously justifying the privilege of some people or perspectives to the detriment of others who are silenced [40,41,42]. Values mimesis is a neologism that describes the ability of a person to imitate what they perceive as the values that are sought or cherished by others, in their writing, speech, and how they present themselves. Mimesis is the way in which people construct their schema of similarity or difference, which are integral to shared experiences [43]. Therefore, values mimesis is also a fitting metaphor to describe the ability of some people to affect the language, speech, and behaviours of those that they are imitating. This enables them to disguise who they really are as well as what they think, believe, and feel.

The notion of values ventriloquy is challenging to countenance, as it conjures the image of the ventriloquist manipulating an inanimate and disembodied dummy/puppet to deceive the audience. The ventriloquist’s art lies in their ability to convince those watching that the dummy being manipulated is capable of independent thought and conscious speech. Nonetheless, it highlights the need to be better informed in our approach to recruitment to avoid rewarding those who can best convey the value narratives of those involved in interview-based recruitment want to hear. It is also apposite to consider that, in the case of midwifery and nursing, those involved in recruitment may unwittingly propagate practices that privilege the ability of applicants that are proficient at saying the right things about values verbally and in writing. Such an approach simultaneously disadvantages those who do not know and/or are unable to sufficiently express themselves using the appropriate values lexicon that is congruent with professional expectations.

5. The Case for an Extended Assessment of Values in Recruitment

It is prudent to evaluate the view that a one-off interview-based recruitment process, as currently constituted, does little more than assuage the beliefs of recruiters that they have selected applicants with the right values. There is a burgeoning consensus and evidence [44,45,46,47,48,49,50] that inclusion, diversity, equity, and accessibility are integral to the just provision of safe, high-quality, and person-centred healthcare for all. It is imperative, therefore, that safety and care quality improvement efforts are predicated on insights and knowledge from robust studies that give due consideration to the lived experience and voice of those who are marginalised, minoritised, othered, overlooked, or silenced [45,46,47,48,49,51]. Robust theory-based and theory-informing studies on the recruitment education, training, and formation of healthcare professionals are key to any effort to improve care quality and safety, especially with regard to inclusion, diversity, equity, and accessibility [52,53,54]. However, huge gaps exist in the evidence relating to the efficacy and utility of different aspects of midwifery and nursing recruitment that must be addressed urgently. There is a lack of robust research on what makes for an appropriate and successful recruitment process or otherwise. This is especially the case when it comes to predicting who will finish the programme of study and eventually qualify as a registered midwife or nurse. What little evidence there is focuses on the successful completion of a course of study. There is no panacea, that is, ready-made or incontrovertible solution, to the challenges at hand in student midwife and student nurse recruitment. Therefore, every suggestion and idea must be considered.

A radical alternative approach, which is arguably more apt, would be to shift to a default position in which prospective students are subject to ongoing assessment and evaluation of the extent to which they consistently embody and enact the values of midwifery or nursing throughout the course of study. This would be coupled with the option of being withdrawn from the programme if issues arise regarding behaviour, attitude, and value alignment. Simply put, applicants that meet all the other entry criteria are accepted onto midwifery and nursing programmes, where there will be subject to the longitudinal assessment of their values alignment with those of their chosen profession. Such a change may bear fruit if the challenges relating to interview-based recruitment and are understood through the metaphors of ‘values ventriloquy’ and ‘values mimesis’. No ventriloquist or actor can remain in character interminably, because invariably, the fourth wall is broken and the essence of the persona behind the performative mask falls away as time progresses. It is also apposite to remember that people who have had a challenging upbringing, have experienced trauma, or are disenfranchised from the education system are less likely to have the qualifications, experience, or be able to appropriately express the values needed to secure a place to study midwifery or nursing. While these two professions are not and should not be a means to remediate wider societal ills and failings, it raises questions about the extent to which the values of equity, justice, and inclusivity are operationalised in interview-based recruitment processes. Bearing in mind these wider considerations adds credence to the extended assessment of values alignment through the duration of the trajectory of a pre-registration midwifery or nurse education programme.

The prospect of an extended recruitment process with ongoing assessment of values alignment in pre-registration midwifery and nursing may also enhance patient safety in a different way. Quality improvement and safety research has shown the benefits of having in-built ‘affordances’, which are processes, mechanisms, or nudges based on the principles of choice architecture that make it almost impossible to do the wrong thing like starting a car without first ensuring that the gear is in neutral [3,55,56,57]. In some respects, such an approach might be an appropriate affordance in the recruitment of students onto pre-registration midwifery and nursing programmes in universities. Furthermore, an extended recruitment process would afford the opportunity to gather evidence from a variety of sources in academia and clinical practice of each student’s ability to enact and embody the values which they profess at the point of admission onto a course of study.

Like any other approach, an extended approach to recruitment that entails the longitudinal assessment of values alignment with those of the profession has its strengths and limitations. For example, there are aspects of this approach that merit further clarification relating to the resource burden, reliability, as well as equity if the longitudinal values data are unevenly or atypically distributed. A detailed critical examination of the exposition of the pros and cons of an extended approach to assessing values alignment in relation to these and other potential barriers will be set out in a subsequent paper. This follow-up paper will also contain a visual schema for the extended recruitment approach that concisely sets out the timeline, data sources, and safeguards, so it can be utilised/implemented to best effect. So, this paper concludes with an invitation to reconsider what can, is, and should be possible to ensure that every new midwifery and nursing registrant possesses values that align with those of the profession at the point of registration. In sum, this paper puts forward the kernel of a new approach to values-based recruitment that offers rich promise, but it invariably requires further development and testing to underpin its effective implementation.

6. Conclusions

In exploring different aspects of the evidence and discourse relating to the use of interviews to recruit students to pre-registration midwifery and nurse programmes, it is hoped that those involved in recruitment will consider their utility and efficacy in a value-based recruitment approach. This paper posits that there may be an element of self-deception or suspension of disbelief, as in the audience watching the ventriloquist’s dummy/puppet, in the view that interviews are the best way of recruiting student midwives and nurses. The notion of self-deception or suspension of disbelief is implicit in the notion that those involved in recruitment interviews are somehow uniquely positioned and adept at intuitively ascertaining who people with the ‘right’ values are that deserve the opportunity to access these professions. Critical self-reflection is disconcerting, painful, and difficult. However, this does not recuse midwives, nurses, academics, and professional regulators from an earnest appraisal of who they are, what values they privilege, and who benefits in relation to recruitment. There is a certain irony in the idea that those in positions of power within interview-based recruitment processes may subconsciously recruit those in their image, which goes against the values of diversity, inclusion, and equality they profess. This is because the recruitment gatekeepers, as it were, are arguably more likely to find themselves, or someone that they love, in the ward of those they selected to be midwives or nurses, as they are typically older and tend to access healthcare more frequently than younger people. There is a wide range of evidence that diversity enhances the quality and safety of healthcare, but also that the opposite is true. At the very least, there is pressing need to ponder, posit, probe, research, and theorise about midwifery and nursing’s approaches to recruitment. This is a pressing imperative, lest educators be hoist by their own metaphorical petard when they themselves require safe, high-quality care from midwives and nurses who embody the values, behaviours, and demeanours that are prized by all.