Modern teaching strategies in midwifery education and their impact on evidence-based practice competencies: A qualitative study in German universities
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GraceKomuhangi¹1
FlorianNeuhann¹1,2
JürgenWacker²1,2
BrianMikka3
CharlotteBach4
ValerieRLouis¹1,2
GraceKomuhangi1✉Email
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¹Heidelberg Institute of Global Health, University Hospital and Medical FacultyHeidelberg UniversityIm Neuenheimer Feld 130.369120HeidelbergGermany
2²Department of Obstetrics and Gynecology, Faculty of MedicineHeidelberg UniversityIm Neuenheimer Feld 130.369120HeidelbergGermany
3Department of Clinical Epidemiology, College of Health Sciences, School of MedicineMakerere UniversityP.O. Box 7072KampalaUganda
4Midwifery Research and Education Unit, Department of Obstetrics, Gynaecology & Reproductive MedicineHannover Medical School (MHH)Carl-Neuberg-Str. 16410, 30625HannoverOEGermany
Authors: Grace Komuhangi¹*, Florian Neuhann¹, Jürgen Wacker², Brian Mikka3, Charlotte Bach4, Valerie R Louis¹
Author Affiliations: ¹Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany ²Department of Obstetrics and Gynecology, Faculty of Medicine, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
3 Department of Clinical Epidemiology, College of Health Sciences, School of Medicine, Makerere University, P.O. Box 7072, Kampala, Uganda
4Midwifery Research and Education Unit, Department of Obstetrics, Gynaecology & Reproductive Medicine, Hannover Medical School (MHH)
OE 6410, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
Corresponding author: *Grace Komuhangi, Email: greciakm@gmail.com
Abstract
Background
The academization of midwifery education in Germany since January 2020 required a transition from traditional vocational training to university-based programs emphasizing evidence-based practice (EBP). This shift necessitates implementation of modern teaching strategies, yet educators' experiences with these approaches remain poorly understood. Understanding these experiences is crucial for developing effective pedagogical frameworks that enhance EBP competencies among midwifery students.
Methods
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An exploratory descriptive qualitative study was conducted using semi-structured in-depth interviews with 11 midwifery educators from six German universities across five federal states. Participants included lecturers, practice coordinators, research assistants, and professors with teaching experience ranging from 1–19 years (median: 5 years). Interviews lasting 45–60 minutes were conducted in German, audio-recorded, and transcribed verbatim. Data were analyzed using inductive thematic analysis in OpenCode version 4.03.
Results
Three main themes emerged from the analysis. Experiences with modern teaching approaches revealed educators' active involvement in spiral curriculum design and implementation of diverse pedagogical methods including problem-based learning, case-based learning, simulation-based learning, blended learning, and reflective journaling [29]. Implementation barriers encompassed institutional challenges (financial limitations, inadequate staffing, bureaucratic processes), gaps in educator competencies particularly among those transitioning from clinical practice without formal pedagogical training, and significant theory-practice gaps creating student confusion. Implementation enablers included access to critical resources, strong peer collaboration, interdisciplinary partnerships, and generally positive student engagement despite some resistance to group work methods.
Conclusions
German midwifery educators demonstrate innovative commitment to implementing modern teaching approaches despite significant systemic challenges. However, optimal implementation requires comprehensive institutional support, targeted faculty development programs addressing pedagogical competencies, and enhanced collaboration between academic institutions and clinical practice settings to bridge theory-practice gaps that currently undermine student learning.
Keywords:
Midwifery Education
Evidence-Based Practice
Modern Teaching Approaches
Qualitative Research
German Universities
Faculty Development
Background
Evidence-based practice (EBP) is internationally recognized as the optimal approach for improving maternal and newborn outcomes. Research increasingly links inadequate and inappropriate maternal and neonatal outcomes to EBP competence issues among skilled birth attendants [1, 2]. EBP teaching is currently identified as an important core competency in undergraduate midwifery curricula [3, 59].
Modern teaching strategies in midwifery education, such as problem-based learning, experiential learning, and blended learning, aim to provide midwives with critical thinking skills, cognitive abilities, and the capacity to integrate theory and practice [4, 5, 6]. These approaches have been increasingly implemented in midwifery education curricula globally [7].
However, research indicates that most teaching strategies focus primarily on developing information literacy skills, with fewer concentrating on developing EBP implementation skills [8, 3]. Studies also reveal that engaging students in EBP learning can be challenging [9, 10], though modern teaching approaches such as problem-based learning and blended learning show effectiveness in developing cognitive skills among undergraduate students.
The German Midwifery Education Transformation
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The transition represents a fundamental paradigm shift from traditional teaching strategies that primarily involved memorization and rote learning to evidence-based, research-informed pedagogical approaches designed to develop critical thinking and clinical decision-making skills necessary for contemporary midwifery practice [15]. Prior to 2020, midwives in Germany were trained through apprenticeship-style programs where "students were taught through rote learning and hands-on training, where they were instructed that 'if you do this, this should be the outcome.' They had to follow orders, and their teaching methods didn't encourage critical thinking and problem-solving" [13].
Midwifery education in Germany underwent a revolutionary transformation with the implementation of the Midwifery Reform Act (Hebammenreformgesetz) on January 18, 2020. This legislation mandated the complete academization of midwifery education, transitioning from traditional three-year vocational training programs at specialized schools to university-based bachelor's degree programs [11, 12, 61, 62]. Germany was the last country in the European Union to implement this transition, following an EU directive that required all member states to provide degree-level midwifery education by this date [13, 14].
Current State of German Midwifery Programs
As of 2025, approximately 40 universities and universities of applied sciences across all 16 German federal states now offer bachelor's degree programs in midwifery science or midwifery studies [24, 63]. The programs are structured as dual, practice-integrated studies comprising minimum 2,200 hours of theoretical instruction and 2,200 hours of practical training in clinical and community settings [17].
The transformation has shown positive outcomes: the German Midwifery Association (DHV) reported that "the attractiveness of the midwifery profession has increased, applicant numbers have risen, and Germany is keeping pace with the EU" one year after academization [13]. Current data indicates approximately 3,455 study places are available nationwide, with around 1,000 graduates entering the profession annually [21, 22, 63].
Student intake varies considerably by institution: larger programs like Charité Berlin admit 60 students annually [60], while smaller programs typically accept 20–30 students per semester [64]. Most programs are offered at public universities and universities of applied sciences, with a smaller number at private institutions. The programs maintain the dual structure with students receiving study remuneration throughout their education, addressing concerns about accessibility and financial barriers [17].
Transition Challenges and Ongoing Issues
Despite the positive reception, significant challenges remain. The DHV emphasizes the urgent need for federal states to create sufficient university places to ensure all interested candidates can access midwifery studies [13]. The transition period allows traditional vocational training to continue until 2027, creating a dual system where both traditionally-trained and academically-educated midwives enter the workforce simultaneously [13].
This transitional period presents unique challenges for educational institutions, clinical practice partners, and students themselves, particularly regarding the integration of evidence-based practice principles into clinical environments that may still operate according to traditional, experience-based approaches [14, 16, 54, 56]. Understanding educator experiences during this critical transition period is essential for optimizing pedagogical approaches and ensuring successful implementation of evidence-based practice education.
The existing evidence about EBP teaching strategies does not provide in-depth insights about their effectiveness on midwifery students' competencies during this unprecedented transition period. Additionally, there is limited literature examining the impediments, facilitators, and policy gaps associated with implementing designed curricula in the German context. Therefore, this study sought to explore experiences, facilitators and barriers toward implementation of modern teaching approaches for evidence-based practice among midwifery undergraduate educators in German universities during this transformational period.
Aim and Research Questions
Aim: To explore experiences, facilitators, and barriers towards implementation of modern teaching approaches for evidence-based practice among midwifery undergraduate educators in German universities, providing insights into the current state of pedagogical innovation in this transitional period.
Research Questions:
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What are the experiences of midwifery educators with modern teaching approaches for evidence-based practice in German universities?
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What are the facilitators that support the implementation of modern teaching approaches for evidence-based practice in midwifery education?
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What are the barriers that hinder the implementation of modern teaching approaches for evidence-based practice in midwifery education?
Definition of EBP teaching: Evidence-based practice (EBP) in midwifery education combines clinical expertise, best available research evidence, and patient values/preferences to provide optimal care [3]. Core components of EBP include: integration of current research evidence with clinical expertise and unique needs/preferences of childbearing people; critical appraisal skills to evaluate research quality and applicability; practical application of evidence to clinical decision-making; and understanding how to adapt care based on individual circumstances while staying evidence-informed.
Theoretical Framework
To understand the efficacy of modern EBP teaching strategies and their effectiveness on midwifery undergraduate students' EBP competencies, this study was underpinned by the constructs of the Social Cognitive Learning Theory (SCLT) [31]. This theory was chosen because it has been identified by various medical education researchers as useful in creating new knowledge and understanding the efficacy of EBP teaching approaches. In addition, evidence from systematic and scoping reviews highlights educational strategies and theory-based approaches for teaching EBP to undergraduate health students, which informed our lens [33, 37], alongside broader health promotion theory resources [38].
The Social Cognitive Learning Theory recognizes the ongoing interaction between the individual and their environment, both structural and social, in shaping behaviour [32]. The environment influences three personal cognitive factors that influence behaviour: observational learning, outcome expectations, and self-efficacy.
Observational learning
Individuals are more likely to perform a desired behaviour if they observe others modelling that behaviour and experiencing subsequent positive rewards [32]. In this study context, through observation of EBP implementation during clinical teaching, educators can influence undergraduate students' EBP behaviour.
Outcome expectations
Individuals are more likely to practice a desired behaviour if they believe the benefits of performing that behaviour outweigh the costs [32]. For undergraduate midwifery students to learn EBP effectively, they should understand the advantages by observing benefits from others.
Self-efficacy
Individuals are more likely to practice a desired behaviour if they perceive that they have the necessary skills and capacity to do so [35, 36]. In this context, confidence obtained from EBP education enhances implementation of EBP during undergraduate studies.
Methods
Study Design
An exploratory descriptive qualitative study design was employed to gain deeper understanding of the phenomenon and provide rich context for further investigations. This approach was selected to explore educators' lived experiences with modern teaching approaches for EBP in the context of Germany's recent midwifery education academization.
Setting and Participants
The study was conducted in five German universities/universities of applied sciences offering undergraduate midwifery programs across five different federal states (Table 1). Participants were recruited using purposive sampling with maximum variation to include diverse perspectives from midwifery lecturers, practice coordinators, research assistants, and professors involved in undergraduate midwifery education.
Inclusion criteria
Midwifery instructors teaching B.Sc. undergraduate students with midwifery backgrounds at selected universities, including midwifery educators, course coordinators, and practice instructors. Participants needed to be accessible for data collection, willing to participate, and able to speak German.
Exclusion criteria
Educators without midwifery backgrounds teaching other courses in midwifery programs, those unwilling to provide consent, and individuals unavailable during the data collection period.
Data Collection
Semi-structured, in-depth interviews were conducted with midwifery educators between January and June 2025. The semi-structured interview guide was developed specifically for this study by the research team. Its content was informed by constructs of Social Cognitive Learning Theory [32, 35, 36] and prior literature on pedagogical strategies for teaching evidence-based practice [4, 16, 20, 33, 37]. An English version of the complete interview guide is available as a supplementary file (Additional file 1).
Interviews were conducted face-to-face in German in quiet, private rooms at the participating institutions to ensure confidentiality. Each interview lasted 45–60 minutes, was audio-recorded with permission, and complemented by brief contextual notes (e.g., setting, non-verbal cues).
To illustrate the scope of the conversations, sample prompts from the guide included:
“How do you define modern teaching approaches in the context of EBP in midwifery?”
“What specific examples of modern teaching approaches have you used to teach EBP?”
“How do students respond to these approaches? Can you share concrete feedback?”
“What resources or institutional supports have facilitated implementation?”
“What challenges or resistance have you encountered, and how have you addressed them?”
“How do you envision the future of teaching EBP in the midwifery curriculum?”
The guide ensured consistent coverage of four areas-experiences, facilitators, barriers, and future directions-while allowing flexible probing so educators could elaborate on issues most relevant to their institutional context. The same interview guide was used across all sites; minor wording adjustments were made as needed to improve clarity without altering content. An English version of the complete guide is cited in the manuscript and available as Additional file 1.
Data Analysis
Audio recordings were transcribed verbatim in German and saved it in a computer file following transcription to ensure participant confidentiality. To ensure anonymity, the names of the participants were not included in the transcripts. Instead, each participant was assigned a code consisting of a consecutive number (e.g., IDI1, IDI2, ..., IDI6). The German transcripts were then translated into English by three bilingual researchers to maintain accuracy and cultural nuances. Translated transcripts were uploaded to OpenCode version 4.03 for analysis.
While the study employed inductive thematic analysis to allow themes to emerge naturally from the data, the Social Cognitive Learning Theory (SCLT) provided a theoretical lens for understanding the findings. The analysis was conducted without predetermined theoretical constraints, but the SCLT constructs of observational learning, outcome expectations, and self-efficacy informed the interpretation of results and provided a framework for understanding educators' experiences with modern teaching approaches.
The analysis followed six phases of thematic analysis: familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the final report. Two researchers independently coded initial transcripts to enhance reliability, with disagreements resolved through discussion. The theoretical framework was used post-analysis to interpret findings and understand how educators' experiences aligned with or challenged the SCLT constructs.
Validity and Reliability of the Study
To ensure methodological rigor and trustworthiness of findings, this study employed Lincoln and Guba's four criteria for establishing trustworthiness in qualitative research: credibility, transferability, dependability, and confirmability [19]. These criteria were specifically selected as they provide comprehensive evaluation standards for qualitative research quality and are widely recognized in health education research.
Credibility
Multiple strategies were employed to establish credibility and ensure accurate representation of participants' experiences:
Rigorous Participant Selection
Explicit inclusion and exclusion criteria were established and consistently applied to ensure appropriate participant selection. Purposive sampling with maximum variation was used to capture diverse perspectives across different universities, roles, and experience levels.
Dual Researcher Analysis
All interview transcripts were analysed independently by three researchers (GK, BM and VRL) to minimize individual bias and enhance analytical rigor. Initial coding was conducted separately, followed by comparison and discussion of emerging codes and themes.
Peer Debriefing
Regular meetings were held between the research team throughout the analysis process to discuss interpretations, challenge assumptions, and ensure consistency in theme development.
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Co-researchers (FN, BM and JW) provided methodological oversight and participated in reviewing preliminary findings.
Rich Data Collection
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In-depth interviews lasting 45–60 minutes provided comprehensive exploration of participants' experiences. The interview guide, developed based on Social Cognitive Learning Theory, ensured systematic coverage of key research areas while allowing for emergent themes.
Bilingual Accuracy
All interviews were conducted in German and translated by bilingual researchers to maintain cultural and linguistic accuracy. Translation accuracy was verified through back-translation checks for key quotes and concepts.
Transferability
Several strategies enhanced the transferability of findings to similar contexts:
Detailed Contextual Description: Comprehensive descriptions of the German midwifery education transformation, participating universities, and the unique transitional context were provided to enable readers to assess applicability to their settings.
Rich Participant Characterization
Detailed demographic and professional background information for all participants was documented, including age, educational background, current roles, and teaching experience. This enables assessment of similarity to other educator populations.
Thick Description of Findings
Extensive verbatim quotes and detailed descriptions of experiences were provided to allow readers to understand the depth and nuance of participants' perspectives. Multiple perspectives on similar experiences were presented to capture complexity.
Theoretical Framework Application
The use of Social Cognitive Learning Theory provides a transferable framework for understanding similar educational transformations in other healthcare professions or countries.
Maximum Variation Sampling
By including participants from six universities across five federal states with varying institutional contexts (public/private, different program start years), the study captured diverse implementation experiences that enhance transferability.
Dependability
Multiple approaches ensured consistency and reliability of the research process:
Member Checking
Interview transcripts were returned to participants for verification of accuracy and appropriate interpretation. Participants were given opportunity to clarify statements, add additional insights, or correct misunderstandings. All participants confirmed the accuracy of their transcribed interviews.
Audit Trail Maintenance
Detailed documentation of all methodological decisions, analytical processes, and interpretive choices was maintained throughout the study. This included records of coding decisions, theme development evolution, and researcher reflections.
Inter-rater Reliability
Two researchers independently coded initial transcripts using OpenCode 4.03, achieving high agreement on initial codes (> 85% agreement). Discrepancies were resolved through discussion and consensus-building.
Systematic Data Management
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All interviews were audio-recorded with participant consent, transcribed verbatim, and immediately anonymized. Audio files were destroyed after transcription verification to protect participant confidentiality while maintaining data integrity.
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Consistent Interview Protocol
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A structured interview guide was used across all interviews while maintaining flexibility for follow-up questions and participant-driven discussions.
Confirmability
Several strategies minimized researcher bias and enhanced objectivity:
Expert Review
Two faculty members with expertise in midwifery education and evidence-based practice research independently reviewed the research design, analytical approach, and preliminary findings. These experts provided critical feedback on interpretation validity and theoretical framework application.
Reflexivity and Researcher Positionality
The primary researcher's background as both a practicing midwife and doctoral student in global health was acknowledged as bringing both insider knowledge and potential bias. Regular reflection on how this positionality might influence data collection and interpretation was maintained throughout the study.
Transparent Methodological Documentation
All aspects of the research process were clearly documented, including sampling decisions, interview conduct, transcription procedures, analytical approaches, and interpretive frameworks. This transparency enables external assessment of research quality.
Multiple Data Sources Integration
While the primary data source was educator interviews, findings were contextualized with publicly available information about German midwifery education transformation, university program characteristics, and policy documents to triangulate perspectives.
Negative Case Analysis
Instances where data contradicted emerging themes or theoretical expectations were actively sought and analysed. For example, cases of educator resistance to modern teaching methods were examined alongside the predominant pattern of enthusiastic adoption.
Collaborative Interpretation
All major themes and interpretations were developed collaboratively among the research team, with particular attention to alternative explanations for findings and potential researcher bias in interpretation.
Additional Quality Assurance Measures
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Ethical Oversight: The study received comprehensive ethical approval from the Ethics Committee of the Medical Faculty, Heidelberg University (Reference number: S-709/2024, dated December 23, 2024). The ethics committee confirmed that it had no concerns regarding the conduct of the study ("Die Ethikkommission hat keine Bedenken gegen die Durchführung der Studie").
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This approval ensured adherence to research ethics standards, participant protection protocols, and compliance with the Declaration of Helsinki principles and ICH-GCP guidelines.
Enhanced Participant Protection
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Written informed consent was obtained from all participants using standardized consent forms approved by the ethics committee. Participants received detailed information sheets explaining study purposes, procedures, potential risks, data protection measures, and their rights. The ethics committee specifically emphasized the importance of immediate audio file destruction after transcription to ensure proper pseudonymization of data, which was strictly implemented to protect participant confidentiality.
Data Protection Compliance
The study adhered to GDPR Article 13 requirements, including provision of institutional data protection officer contact details to participants. Comprehensive data handling procedures were established, with secure storage systems and access restricted to the research team. All identifying information was anonymized in transcripts and analyses.
Cultural Sensitivity
Given the international context of the research team and the specifically German educational setting, particular attention was paid to cultural nuances in data interpretation and reporting. The bilingual nature of data collection (German interviews translated to English) required additional verification procedures to maintain accuracy and cultural appropriateness.
Methodological Expertise
The research team included members with expertise in qualitative research methods (VRL) and (BM), medical education (FN, JW), and midwifery practice and education (GK, CB), providing comprehensive methodological oversight and ensuring appropriate interpretation of findings within the professional context.
These comprehensive validity and reliability measures, combined with robust ethical oversight, ensure that the study findings accurately represent participants' experiences and can be trusted as a foundation for understanding modern teaching approaches in German midwifery education during this critical transitional period.
Results
Eleven midwifery educators participated in the study between January and June 2025. All interviews were conducted in German and translated into English for analysis.
University Characteristics
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Table 1 below presents the characteristics of participating universities, demonstrating the institutional diversity across Germany's federal states and illustrating the recent establishment of midwifery degree programs following the 2020 legislative mandate for academization of midwifery education.
Table 1
Characteristics of Participating Universities in German Midwifery Education Transition
University
State
Type
Program Start Year
No.Parti-cipants
No.of students intake per year
Program
status
OTH Regensburg
Bavaria
Public
2019
3
30–50
Established
Ludwigshafen university of business &society
Rhineland-Palatinate
Public
2020
3
25–35
Early implementation
Hannover Medical School
Lower Saxony
Public
2020
3
40–50
Well-established
HAW Göttingen
Lower Saxony
Public
2021
1
20–30
Recently Established
Catholic University of Applied Sciences Munich
North Rhine-Westphalia
Private
2019
1
20–25
Pioneer Institution
Note
Program start years reflect the transition period following the 2020 Midwifery Reform Act. Student numbers represent typical annual intake based on available data and interview information. All programs follow the dual study model with 2,200 hours theoretical and 2,200 hours practical training.
Participant Characteristics
The median age of participants was 48 years (range: 40–55) with median teaching experience of 5 years (range: 1–19). Educational backgrounds varied: 2/11 held doctoral degrees, 9/11 held master's degrees. Professional roles included: 2 professors, 3 lecturers, 2 scientific employees, 2 research assistants, 1 practice coordinator, and 1 program director (Table 2).
Table 2
Characteristics of Germany midwifery educators who participated in the study
Variable
Categories
Frequency (N = 11)
Age (years)
Median (Range)
48 (40–55)
Highest Education qualification
Doctorate
2
 
Master’s degree
9
Current role
Professor
2
 
Lecturer
3
 
Scientific employee
2
 
Research assistant
2
Teaching experience (years)
Median (Range)
5 (1–19)
Thematic Analysis Results
Three main themes emerged: (1) Experiences with modern teaching approaches, (2) Implementation barriers of modern teaching, and (3) Implementation enablers of modern teaching (Table 3).
Table 3
Table 3: Summary of the themes, sub-themes and codes from the in-depth interviews with German midwifery educators
Themes
Sub-themes
Codes
1. Experiences with Modern Teaching Approaches
1.1 Revolutionary Shift from Traditional Training
• Transition from vocational to academic education
• Reconceptualization of pedagogy
• Departure from rote learning
• Shift toward critical thinking
• Challenge to entrenched teacher-centred culture
 
1.2 Innovative Curriculum Design and Implementation
• Active educator involvement in curriculum design
• Embedding EBP principles throughout
• Spiral curriculum structure
• Coherence and progression across modules
• Curriculum as collaborative product
 
1.3 Innovative and Creative Approaches
• Freedom of teaching and research
• Experimentation with diverse methods
• Use of digital tools (Padlet, Mentimeter)
• Self-produced instructional videos
• Responsiveness to student needs
 
1.4 Academic Freedom and Pedagogical Innovation
• Freedom of teaching and research
• Experimentation with diverse methods
• Use of digital tools (Padlet, Mentimeter)
• Self-produced instructional videos
• Responsiveness to student needs
2. Implementation Barriers of Modern Teaching
2.1 Systemic Institutional Barriers
• Financial constraints
• Bureaucratic procurement processes
• Heavy workloads
• Staff shortages
• Time pressures in teaching
 
2.2 Gaps in Educator Competencies
• Limited pedagogical training
• Reliance on textbooks
• Lack of experience with evidence-based approaches
• Need for time to acquire teaching skills
 
2.3 Theory–Practice Divide and Institutional Response
• Disconnection between theory and clinical practice
• Resistance from clinical staff
• Conflicting practices confuse students
• Training for practice instructors
• Use of practice coordinators
• Structured communication with practice sites
 
2.4 Student Resistance and Learning Challenges
• Overwhelm from workload
• Resistance to group work
• Preference for traditional frontal teaching
• Difficulty with academic writing tasks
3. Facilitators of Modern Teaching Approaches
3.1 Robust Resource Infrastructure
• Access to library resources and databases
• Well-equipped skills labs
• Simulation centres
• Advanced equipment (simulation models, ultrasound
 
3.2 Strong Collaborative Networks
• Interdisciplinary teamwork
• Co-teaching with other professionals (e.g. physicians)
• Engagement with professional societies (DGHHW)
• Peer support and knowledge sharing
 
3.3 Transformation in Student Learning and Engagement
• Active student participation
• Development of critical thinking
• Evidence evaluation skills
• Research interest and inquiry
• Shift from authority acceptance to evidence-seeking
 
3.4 Institutional Innovation and Adaptability
• Continuous curriculum revision
• Flexibility in newer programs
• Gradual adaptation in older programs
• Ongoing negotiation between traditional and evidence-based practices
Theme 1: Experiences with Modern Teaching Approaches
Sub-theme 1: Revolutionary Shift from Traditional Training
Educators described the transition from vocational training to academic education as fundamentally transformative, requiring complete reconceptualization of pedagogical approaches. This transformation challenged deeply entrenched educational cultures that had dominated German midwifery education for over a century:
...I come from the cohort where I learned it this way: someone stood in front, the teacher told us something, and we all did something. But not really listening. And evidence-based was also more experiential knowledge, but not really evidence. And now that's already a huge difference... (IDI5)
The magnitude of this transformation became evident when educators with international perspectives contrasted German approaches with global standards:
...In Germany, I think most teachers still use traditional pedagogical methods... Students were taught through rote learning and hands-on training, where they were instructed that 'if you do this, this should be the outcome.' They had to follow orders, and their teaching methods didn't encourage critical thinking and problem-solving... (IDI8)
The transformation was so significant that some educators described it as moving from "kindergarten-like" approaches to university-level education:
...I have a real problem with the pedagogical methods that other colleagues use - it's like kindergarten. They behave with students like kindergarten children. They should do handmade activities and act exactly like in kindergarten, and they're proud of it. I don't understand why such pedagogical methods exist... (IDI8)
Sub-theme 2: Innovative Curriculum Design and Implementation
All midwifery educators interviewed reported active participation in designing specific course modules and/or general curriculum frameworks for their respective university midwifery programs. This collaborative approach to curriculum development emerged as a foundational element in creating coherent, evidence-based educational experiences.
The educators emphasized the deliberate and systematic integration of contemporary teaching methodologies throughout their programs, moving beyond traditional didactic approaches to embrace more interactive and student-cantered learning strategies. This integration was not implemented as an isolated intervention but was woven consistently throughout the curriculum architecture, from foundational courses through to advanced clinical modules.
The consistent application of evidence-based practice (EBP) principles emerged as a cornerstone of curriculum design, with educators recognizing the critical importance of embedding these competencies early and reinforcing them consistently. Rather than treating EBP as a separate theoretical concept, educators integrated these principles as a fundamental lens through which all midwifery content was delivered and assessed.
Educators demonstrated sophisticated understanding of curriculum development, implementing spiral learning approaches that build complexity progressively [46]:
A spiral curriculum approach was universally adopted across institutions, representing a sophisticated pedagogical strategy where foundational concepts are systematically revisited with increasing complexity and depth across successive semesters. This approach ensures that students develop both breadth and depth of understanding while building confidence through repeated exposure to core concepts.
...As a team, we developed the curriculum and design of the course... (IDI4)
...We call it a spiral approach in our curriculum so we start from very general things at the beginning of the studies and then during the course of their studies they learn more and more complicated things but the issues are repeating themselves within the curriculum... (IDI1)
The curriculum design process involved collaborative efforts with significant educator autonomy:
...I designed the original module handbook for the model study program, and when it transitioned to a fully accredited program, I helped shape it again. Now I'm currently working on the evaluation and redesign of the module handbook... (IDI9)
Sub-theme 3: Innovative and Creative Approaches in Modern Teaching
Educators utilized a wide range of innovative and creative pedagogical strategies, extending well beyond traditional lectures and incorporating methods that even exceeded the researchers’ expectations:
Problem-Based Learning (PBL)
...We introduced PBL at the beginning of studies and have some content structured this way. We have skills and simulation training - for example, in our second semester, we do simulations in postpartum care where we expect students to respond to problems they encounter with evidence-based knowledge... (IDI5)
Case-Based Learning
...It is case-based. They work a lot with case examples, and in the case examples they see different approaches. Through these approaches, they can see the difference between whether an intervention was evidence-based or was only experience-based... (IDI6)
Simulation-Based Learning
...I also use simulation where one student identifies as a woman giving birth and others are partners or medical staff. I think it's important to get into context and support self-organized learning and professional education... (IDI7)
Advanced Simulation and Technology
...We just bought completely new simulation models, for example, or for the sonography module it was no problem at all to purchase ultrasound devices. So, we can always say what we need, what we'd like, what we'd like to have for Skills Lab in terms of materials... (IDI5)
Creative Materials and Approaches ...We just bought Lego for our students, for example. There's a series from Lego called Serious Play. It's more oriented toward communication, team building, supervision. And we just purchased that for Skills Lab to bring students into reflection with this creative work. That's going over really well..." (IDI5)
Detective-Style Learning ...Sometimes we have cases that we let them work on, then I let the students work like Sherlock Holmes - we have a woman who has symptoms, what could that all be now, are there differential diagnoses, and then we work on it, then they get the next task. So it's really playful... (IDI11)
Escape Rooms and Gaming ...We also give a lot of independent study... We have case studies, we have planning games, we have flipped classroom, we also have VR technology to some extent, we do escape games, we do problem-oriented learning... (IDI9)
These findings align with research demonstrating simulation effectiveness in midwifery education [57, 58]. Such innovative methods reflect emerging trends in healthcare education [34, 65].
Sub-theme 4: Academic Freedom and Pedagogical Innovation
This freedom fostered creativity and responsiveness to student needs, as evidenced by one scientific employee who described how they actively explore diverse teaching methods, incorporating both established digital tools like Padlet and Mentimeter alongside self-created instructional videos developed collaboratively with colleagues (IDI5). This freedom is reflected in the application of a variety of teaching and learning tools, either more traditional or innovative. German universities' academic freedom enabled educators to experiment with diverse approaches:
...It's a freedom, in Germany we have a freedom of teaching and freedom of research, so each of the educators can decide the approaches they want. We just have to follow the curriculum, so that's the requirement... (IDI1).
Theme 2: Implementation Barriers of Modern Teaching
Sub-theme 1: Systemic Institutional Barriers
Financial constraints emerged as major impediments to innovation:
...As a state institution, we operate under strict constraints that require us to submit formal applications and requisitions for all resources and funding needed to finance our activities. Every expenditure must go through an approval process. We have to be careful what you invest where... (IDI7)
Bureaucratic processes significantly hindered pedagogical innovation:
...The next are the structures at the university. I come from out-of-hospital work where there are short service paths. If you need something, you call somewhere and clarify it quickly. And at the university, written applications must be submitted for everything... (IDI5)
Staffing inadequacies created overwhelming workloads that compromised teaching quality:
...Well, I think the biggest challenge for us is simply the time. These tight study schedules -- that is the biggest challenge for us. To convey as much knowledge as possible in as little time as possible in a way that somehow stays in the minds... (IDI11)
Sub-theme 2: Critical Gaps in Educator Competencies
The transition from clinical practice to academic teaching revealed significant pedagogical knowledge gaps:
...At the moment, we are in a phase where many of our teachers are traditional teachers. They are not used to using evidence-based approaches, so they remain traditional teachers. Many of them rely only on textbooks without verifying whether the information is still current or evidence-based... (IDI6)
Lack of formal pedagogical training created substantial challenges:
...Sometimes it's the case that we teachers aren't always pedagogically educated, so it's difficult for the person to implement it... you first have to be competent yourself for it. And that also costs a lot of time to acquire that, especially when you don't have so much teaching experience yet... (IDI10)
Sub-theme 3: Critical Theory-Practice Divide and Institutional Response Efforts
The most significant barrier was the profound disconnect between university teaching and clinical practice environments, creating substantial challenges for student learning. However, educators and institutions were actively working to address this divide through various collaborative mechanisms. Universities with integrated hospital relationships showed more promising approaches. A program director described their systematic efforts:
...We try to accompany this process as a university by regularly offering training for practice instructors on various topics where there have been scientific changes, so practice instructors can function as multipliers and support students in carrying evidence-based knowledge into practice... (IDI2).
However, even with established relationships, fundamental tensions persisted. Students encountered stark contradictions that created confusion:
...So, they see something in practice that is routine but is not evidence-based. It belongs to the hospital standard or routine, but it is not evidence-based. Sometimes they are also overwhelmed by this difference... (IDI6)
Some universities had developed structured communication channels. An experienced professor noted:
...Good cooperation with practice partners is essential. Otherwise, evidence-based work, no matter how well researched or understood theoretically, cannot be implemented properly in practical training placements if old procedures persist rather than evidence-based practices... (IDI7)
Despite these efforts, active resistance from clinical staff remained problematic: ...So, our students often experience people complaining to them about why they have to study now... And when they try to counter, to say, yes, but look, we now also learn to work scientifically, they immediately get such massive opposition that they all don't say anything anymore... (IDI9)
The most successful programs appeared to be those with dedicated practice coordinators and mandatory training for clinical supervisors, though implementation remained inconsistent across practice sites.
The impact on students was so severe that many simply gave up trying to advocate for evidence-based practices:
...That they say, yes, then I'll just let them talk and say nothing against it - that hurts me more... (IDI5)
However, educators also noted remarkable transformations in students who learned to navigate these conflicts:
...Students develop critical thinking. They can observe what happens in the hospital, but they know exactly that it might not be correct, or might not be evidence-based, or they could have done it differently... (IDI6)
Sub-theme 4: Student Resistance and Learning Challenges
Despite overall positive reception, educators encountered specific student resistances:
...They have to follow us because they enrolled... Very often they are sometimes a bit overburdened especially in writing things. They always think it's too much; they always feel a bit overwhelmed... (IDI1)
Group work presented particular challenges:
...They sometimes don't like teamwork. Group work is not so their favourite thing very often. I don't know why, but they think it's too demanding... (IDI1)
Some students preferred traditional approaches:
...We want frontal teaching. That's quite clear - students want frontal teaching... They don't want to work much in groups... (IDI9)
Theme 3: Implementation Enablers of Modern Teaching
Sub-theme 1: Robust Resource Infrastructure
Despite financial limitations, universities provided substantial foundational resources:
...We can access everything possible at the library, including many online sources... The university also licenses various databases and e-journals and provides money for this... We have very well-equipped skills labs and simulation centres... (IDI5)
Access to cutting-edge technology enabled innovation:
...Actually, quite a lot. We just bought completely new simulation models, for example, or for the sonography module it was no problem at all to purchase ultrasound devices... (IDI5)
Sub-theme 2: Strong Collaborative Networks
Peer support emerged as crucial for successful implementation:
...We have interdisciplinary team work, because we have medical doctors in our team... we lecture together, so for example, the module on family health, we share, so she is teaching half of the lectures, and I'm teaching half of the lectures... (IDI1)
Professional networks provided valuable resources:
...We do this through our research society, the Deutsche Gesellschaft für Hebammenwissenschaft, and so the students can easily access this information... (IDI1)
Sub-theme 3: Dramatic Transformation in Student Learning and Engagement
Despite challenges, educators observed profound positive changes in student learning and engagement that validated their innovative approaches:
Students Becoming Active
...It's fun when you notice everyone is taken along... to see everyone brought to the point where they contribute themselves in every hour, where they have to think along themselves, where they don't just sit there and let themselves be lectured to, but learn so much through participation, through working things out themselves, also in peer learning... (IDI5)
Critical Thinking Development
...Students develop critical thinking. They can observe what happens in the hospital, but they know exactly that it might not be correct, or might not be evidence-based, or they could have done it differently... (IDI6)
Student Becoming Evidence Evaluators
...Otherwise, I notice when they come from out-of-hospital placements or from the clinic, they quite often say - this situation, they did this and that. I didn't think that was right. And then I looked afterward and found, okay, I found something completely different in the literature... So, they're already in the evaluation process somewhat, even in the first and second [semesters]. They didn't apply it themselves but observed it. Can evaluate it and determine - okay, that has no evidence, that's not good what they did there. Or that has evidence, that's great... (IDI5)
Student Research Engagement
...I can't really cite it right now, but yes, I have, for example, one case that was very interesting, and I had it researched. The students found it totally great and then in that context also wished to research this topic... and then unfortunately had to find out for herself that the study situation actually gives something different than what the midwife says... She was then totally sad because she would have liked to have learned something else and then decided that she wouldn't recommend it because she can't prove it scientifically... (IDI11).
This story illustrates the dramatic shift in student mindset, from accepting authority to demanding evidence, even when it challenges established practices.
Sub-theme 4: Institutional Innovation and Adaptability
Universities demonstrated varying degrees of responsiveness to educational needs, with newer programs showing particular flexibility. A program director with extensive curriculum development experience noted:
...We constantly revise our curricula, and the ultrasound module - I built that up completely and am revising it now... (IDI9)
This adaptability extended to established programs as well, where continuous improvement processes enabled systematic refinement:
...We are basically all developing our own curriculum, this is the responsibility of each professor. We design the lesson plans; we use the existing curriculum but we design our own lesson plans of course... (IDI1)
However, the pace of change varied significantly across institutions. A research assistant with substantial practical background observed:
...Everything is new, and we try to integrate into the university setting as best we can and transfer theory to practice. It is not easy to transfer theory to practice... (IDI6)
This suggests that while institutions were adapting, the process required ongoing negotiation between traditional practices and evidence-based innovations.
Discussion
This qualitative study explored the experiences, barriers, and facilitators of implementing modern teaching approaches for evidence-based practice (EBP) among midwifery educators in German universities during the unprecedented transition from vocational to academic education. Three main themes emerged: (i) experiences with modern teaching approaches, (ii) barriers to implementation, and (iii) enablers of modern teaching implementation. The findings reveal both significant achievements and critical challenges in this educational transformation that align with, extend, and in some cases contrast with international literature on EBP education and midwifery academization.
Midwifery Educators’ Experiences with Modern Teaching Approaches and Revolutionary Pedagogical Transformation
The academization of midwifery education in Germany represents one of the most substantial professional education reforms in recent European healthcare history. Although this transition aligns with a broader pattern observed across multiple countries, Germany was the last among the European Union countries to shift from vocational training to university-based education [39, 40]. This late adoption created unique challenges not encountered during earlier, more gradual reforms elsewhere [41]. Participants described experiencing a profound paradigm shift from traditional, teacher-centred, and rote-learning approaches to student-centred, evidence-informed pedagogical models. This mirrors wider European trends driven by the Bologna Declaration and EU Directive 2013/55/EU [40], which emphasize embedding EBP principles within midwifery curricula from the outset [12, 13].
Educators reported implementing spiral curriculum designs that allow students to revisit foundational concepts with increasing complexity, a design known to support progressive competence development [14–16]. They described employing diverse active and experiential strategies including problem-based learning (PBL), case-based learning, blended learning, simulation, and reflective journaling, which are all recognised for fostering critical thinking, self-directed learning, and the application of evidence to practice [4, 5, 18–20]. This represents a marked departure from the lecture-based norm previously reported in European midwifery education [3], indicating substantial progress towards international best practices.
The findings reveal that German midwifery educators have implemented a spectrum of innovative teaching approaches that extend far beyond conventional pedagogical methods. While simulation-based and problem-based learning form the foundation of modern midwifery education, with systematic reviews confirming their effectiveness in developing clinical competencies and critical thinking skills [42, 43], the current study uncovered remarkably creative pedagogical experimentation rarely documented in existing literature.
Educators described implementing advanced simulation technology, virtual reality (VR), gamified learning experiences, Lego Serious Play for reflective practice, and "detective-style" escape-room learning scenarios. These findings corroborate systematic reviews demonstrating that simulation-based learning enhances clinical competency development and critical thinking skills in midwifery education [57, 58]. The widespread adoption of these simulation-based methods supports previous research demonstrating their effectiveness for developing procedural skills and clinical reasoning in midwifery practice [57].
However, the integration of VR, gamification, and serious play materials represents a significant departure from conventional simulation research, suggesting that German midwifery education is pioneering novel pedagogical territories within healthcare professional training [34, 44, 45, 65].
This level of creative experimentation contrasts markedly with the more conservative educational implementations reported in other contexts [44, 45]. The findings suggest that German educators are not merely adopting established evidence-based strategies, but actively innovating beyond current pedagogical boundaries. This educational evolution may reflect the unique pressures and opportunities created by Germany's mandated transition from vocational to university-level midwifery education, catalysing pedagogical innovation that extends traditional healthcare education paradigms.
Barriers to Implementing Modern Teaching for EBP
Despite these advances, significant institutional and individual barriers constrained implementation. A particularly striking finding was the intensity of time pressure. Time constraints are widely cited as a key barrier to EBP implementation internationally, including in Denmark [49], Iran [50], Australia [51], and other European countries [52, 53]. However, the “tight study schedules” and “biggest challenge” descriptions in this study suggest even greater time pressure, likely driven by Germany’s compressed three-year implementation mandate, in contrast to decades-long transitions in other countries.
Institutional barriers, including bureaucratic procurement processes, financial constraints, limited staffing, and heavy workloads, mirror findings from other contexts where inadequate infrastructure and administrative resistance hinder educational reforms [21, 23, 25, 26]. The educator incompetencies also emerged as critical obstacles since many participants had transitioned from clinical practice to academia without formal pedagogical training, leading to difficulties applying modern instructional methods. This aligns with earlier studies reporting limited educator preparedness for EBP teaching [25, 27] and reinforces calls for comprehensive faculty development integrating both pedagogical and EBP content [20, 47].
The other profound barrier was the persistent theory-practice gap. Students often observed contradictions between evidence-based content taught at universities and entrenched practices in clinical sites, which led to confusion or disengagement. Similar challenges have been reported internationally, with clinical environments not aligned with EBP undermining students’ confidence and impeding knowledge translation [10, 28, 55]. Without coordinated change in clinical practice environments, students risk graduating with strong theoretical knowledge but limited opportunity to apply it [9, 55].
Facilitators of Implementing Modern Teaching Approaches
Several enabling factors supported the implementation of modern approaches. A robust resource infrastructure, including well-equipped skills laboratories, simulation centres, and digital resources, enhanced educators’ capacity to apply innovative methods, all of which re-echoes existing evidence that adequate infrastructure is essential for effective EBP teaching [22, 25, 66, 67]. The high degree of academic freedom reported by educators, allowing experimentation with diverse teaching approaches, appears to exceed that documented in many other healthcare education systems with more prescriptive curricula [68].
Peer collaboration and interdisciplinary teamwork also emerged as key enablers, consistent with previous research highlighting that collaborative networks support EBP integration [30, 20, 47]. Positive student engagement, particularly their evolving critical thinking and evidence appraisal skills, further motivated educators to persist despite barriers. Similar improvements in student outcomes have been reported following the adoption of PBL and blended learning [4, 18, 19]. These findings suggest that although students initially resist non-traditional methods, they eventually develop deeper engagement and autonomy.
Implications for Policy, Practice, and Research
The findings underscore the urgent need for structured academic-clinical partnerships to bridge the theory-practice gap. Potential strategies include joint faculty-practice appointments, regular joint workshops on EBP implementation, and mentorship programs linking academic educators and clinical supervisors. Additionally, establishing systematic faculty development programmes focused on both pedagogical skills and EBP content could enhance educator confidence and teaching effectiveness. These interventions are critical for sustaining the academization reform and embedding EBP within both academic and clinical environments.
Strengths and Limitations
This study provides unique insights into a critical transitional period in professional healthcare education, addressing an important gap in international literature. The inclusion of participants from multiple universities across different federal states enhances transferability. The use of Social Cognitive Learning Theory also provided theoretical grounding beyond the descriptive designs often reported in most midwifery education research.
However, some limitations require acknowledgement. The educator-only perspective may contrast with multi-stakeholder perspectives. Furthermore, the focus on implementation experiences rather than student learning outcomes limits comparability with outcome-focused studies.
Conclusions
German midwifery educators are demonstrating remarkable creativity and commitment in adopting modern teaching approaches to foster EBP competencies among students. However, without addressing persistent institutional barriers, educator competency gaps, and the theory-practice divide, the success of the academization reform may be compromised. Strengthening faculty development and academic, clinical collaborations will be essential to achieve sustainable EBP integration in midwifery education. Future research should therefore incorporate student and clinical mentor perspectives to inform comprehensive interventions supporting EBP implementation across both educational and practice settings.
Abbreviations
EBP
Evidence-Based Practice
IDI
In-Depth Interview
ICM
International Confederation of Midwives
PBL
Problem-Based Learning SCLT:Social Cognitive Learning Theory
VR
Virtual Reality
GDPR
General Data Protection Regulation
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Declarations
Ethics approval and consent to participate
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This study was conducted in accordance with the ethical standards of the institutional and national research committees and with the Declaration of Helsinki (2013 and its later amendments). The protocol was reviewed and approved by the Ethics Committee of the Medical Faculty, Heidelberg University (Reference S-709/2024, approval date 23 December 2024).
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All methods were carried out in accordance with relevant guidelines and regulations, including the European General Data Protection Regulation (GDPR, Art. 13) and applicable German data protection laws and institutional policies. All participants were adult midwifery educators; no vulnerable populations were included. Written informed consent was obtained from all participants prior to data collection, including consent for audio recording and the use of anonymized quotations. Participation was voluntary and could be withdrawn at any time without consequence. Audio files were transcribed verbatim, pseudonymized immediately, verified, and then permanently deleted; only the research team had access to de-identified data.
Consent for publication
Not applicable.
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Data Availability
The datasets generated and/or analysed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request. An English version of the complete interview guide is available as a supplementary file **(Additional file 1).**
Competing interests
The authors declare that they have no competing interests.
Funding
This study has not received any funding.
Authors' contributions
GK conceived the study, conducted interviews, performed data analysis, and drafted the manuscript. VRL supervised the study design and data analysis, and critically revised the manuscript.
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JW, BM, CB and FN provided methodological guidance and critically reviewed the manuscript. All authors read and approved the final manuscript.
Acknowledgements
The authors thank all midwifery educators who participated in this study for sharing their experiences and insights. We also acknowledge the participating universities for facilitating data collection.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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Author Contribution
GK conceived the study, conducted interviews, performed data analysis, and drafted the manuscript. VRL supervised the study design and data analysis, and critically revised the manuscript. JW, BM, CB and FN provided methodological guidance and critically reviewed the manuscript. All authors read and approved the final manuscript.
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