German Midwifery Educators Navigate Evidence-Based Practice Shift Across University Programmes

A qualitative study examining the transition of German midwifery education into university bachelor’s programmes shows that educators are actively implementing modern evidence-based practice instruction despite facing notable institutional and structural hurdles. According to findings published in BMC Medical Education, faculty members across five higher education institutions have introduced active learning methods, scaffolded spiral curricula, and clinical simulations to foster critical appraisal competencies among undergraduate students. However, this pedagogical transformation takes place alongside persistent operational constraints, including severe time pressure, administrative burdens, procurement bottlenecks, and a recognized disconnect between academic coursework and clinical placement routines. Conducted through in-depth semi-structured interviews with educators across three German federal states, the exploratory descriptive research highlights how faculty members are transforming their teaching practices independently, often without formal pedagogical preparation or unified national curricula. While educators reported meaningful improvements in student inquiry and professional identity, systemic obstacles challenge the long-term sustainability of evidence-based practice instruction within newly established degree programmes.

The background for this transition stems from the German Midwifery Reform Act, the Hebammenreformgesetz of 2019, which took effect in 2020. This legislative reform transposed European Union Directive 2013/55/EU into federal law, shifting midwifery training from hospital-based vocational schools into university bachelor’s programmes. Under this dual-programme model integrating theoretical instruction and practical training, graduating midwives must practise according to current scientific evidence. While traditional vocational courses could admit cohorts until late 2022 and must conclude by late 2027, all future midwives qualifying in Germany will be required to hold an academic degree. In line with the Midwifery Act, the Study and Examination Regulations for Midwives, and International Confederation of Midwives competencies, evidence-based practice has transitioned from an optional module into a central curricular objective. This reform aims to ensure students learn research appraisal directly from research-trained university faculty, preparing them to critically evaluate clinical practices throughout their careers.

To examine how educators navigate this transitional mandate, researchers deployed an exploratory descriptive qualitative design focused on implementation experiences, perceived facilitators, and operational barriers. The study employed purposive maximum-variation sampling to capture varying institutional contexts across German universities and universities of applied sciences. Eleven educators from five institutions across Bavaria, Lower Saxony, and Rhineland-Palatinate participated, with no more than three educators from any single university. Eligible participants were employed in accredited undergraduate midwifery degree programmes established between 2019 and 2022 and were actively teaching modules containing evidence-based practice content. The sample represented diverse academic roles, including research assistants, lecturers, scientific employees, practice coordinators, programme directors, and professors. Participants were between 40 and 55 years old, with a median age of 48 years, and possessed teaching experience ranging from 1 to 19 years, with a median of 5 years. Nine participants held master’s degrees and two held doctorates.

Data collection involved semi-structured, face-to-face individual interviews conducted in German at participants’ academic institutions between January and June 2025. Interviews lasted between 45 and 90 minutes and explored four designated areas: teaching experiences, perceived facilitators, implementation barriers, and recommendations for strengthening evidence-based competencies. All interviews were audio-recorded with written consent and transcribed verbatim in German by the principal investigator, who shared the professional background of the participants. Analysis followed Braun and Clarke’s six-phase thematic analysis framework using OpenCode software. Independent coding of the first four transcripts by two researchers achieved an agreement rate exceeding 85 percent, with disagreements resolved through collaborative consensus and supervisory debriefing. The research team maintained an audit trail and reflexive memos throughout the study. Methodological trustworthiness was reinforced through prolonged data engagement, peer debriefing, and member checking, during which educators reviewed and confirmed analytic interpretations. Recruitment stopped pragmatically after 11 interviews, evaluated through information power dimensions.

The inductive analysis identified three main themes and eleven sub-themes, beginning with educators’ personal experiences implementing modern instructional approaches. Participants described a fundamental personal shift from vocational training norms to academic teaching, noting an imperative to unlearn rigid clinical protocols in order to teach questioning and critical inquiry. Despite the absence of a prescriptive national curriculum, educators across all five institutions independently developed spiral curricula that mapped evidence-based practice across all eight semesters. These curricular frameworks deliberately revisited core competencies with advancing complexity, commencing with clinical question formulation, moving into literature searching, critical appraisal, and synthesis, and culminating in clinical application. Educators actively collaborated within teaching teams to sequence classroom theory alongside laboratory practice and clinical placement activities, aiming to bridge academic instruction and practical clinical execution. This convergent structural development emerged as faculty sought to help students integrate research appraisal systematically throughout their undergraduate degree programmes.

In delivering these curricula, educators utilized active, constructivist teaching methods to position students as active participants in learning. Problem-based learning was the most frequently cited instructional approach, utilized at all five institutions, followed by case-based learning, simulation, and flipped classrooms. Several educators incorporated gamification strategies, such as educational escape rooms and Lego Serious Play, while two universities integrated virtual reality simulations for obstetric emergency training featuring embedded evidence-based decision-making. Furthermore, educators highlighted the constitutional principle of Lehrfreiheit, or academic freedom of teaching, as an influential factor in curriculum delivery. This autonomy allowed educators to pilot innovative pedagogical formats and select instructional approaches based on professional judgement without seeking institutional approval for each methodology. However, participants observed that such unstandardized instructional freedom could also introduce inconsistency in evidence-based teaching depth across modules, because universities lacked shared assessment rubrics or formalized guidelines to ensure uniform competency delivery across academic programmes.

The second main theme encompassed substantial implementation barriers, led by structural and systemic institutional obstacles. All eleven participants identified time pressure as a significant operational constraint, citing sixteen-week semesters, extensive teaching loads, practical session supervision, marking assessments, and administrative tasks as leaving little time for pedagogical innovation. Financial limitations and bureaucratic procurement processes at four of the five institutions restricted access to simulation equipment, software licences, and digital learning platforms. Furthermore, staffing shortages at newer degree programmes forced individual educators to bear disproportionately heavy instructional workloads. Alongside institutional constraints, educator competency gaps emerged as a prominent barrier. Many educators reported entering university teaching directly from clinical midwifery practice without formal pedagogical preparation. Consequently, educators described relying on standard textbooks, learning assessment design through trial and error, and teaching themselves digital instruction methods. Even educators with doctoral degrees reported lacking specialized preparation in practice-based evidence-based practice pedagogy.

A persistent barrier across all five participating universities was the theory-practice divide between academic evidence-based practice instruction and clinical placement norms. Students frequently reported that hospital mentors dismissed academic research skills as irrelevant to daily clinical care, telling students that longstanding hospital routines took precedence over scientific literature. Although educators at three institutions piloted bridging initiatives—such as inviting clinical mentors to university seminars and constructing collaborative competency frameworks—these interventions lacked systemic institutional funding and coordination. Educators also documented initial student resistance to active and self-directed learning methods across all institutions. Having experienced passive learning in prior schooling or vocational tracks, students initially requested frontal lecturing, showed discomfort with collaborative group assignments, and struggled with academic writing. While this resistance typically diminished across subsequent semesters as students gained confidence in literature searching and appraisal, educators noted that the speed of adaptation varied widely between individual undergraduate learners.

The third theme highlighted critical implementation facilitators that supported educators in sustaining evidence-based instruction. At well-resourced institutions, educators cited comprehensive digital infrastructure—including electronic subscriptions to PubMed, CINAHL, and the Cochrane Library—alongside dedicated simulation skills laboratories as vital components enabling applied learning. Two institutions provided dedicated institutional funding for teaching innovation, which allowed educators to develop novel exercises. Interdisciplinary co-teaching within universities, especially partnering with colleagues from nursing and health sciences, enriched research instruction and distributed preparation workloads. Nationally, collaborative networks such as the German Midwifery Academic Society provided essential forums for exchanging teaching materials, designing assessments, and mitigating professional isolation. In addition, educators across all five institutions identified student learning transformation as their most rewarding facilitator. Educators observed students evolving from passive learners into critical thinkers who independently retrieved evidence, questioned clinical practices on placement, and developed strong evidence-based professional identities, providing educators with motivational resilience against institutional barriers.

Applying Competency-Based Education theory and Social Cognitive Learning Theory as post hoc interpretive frameworks, the researchers noted that spiral curricula aligned with competency progression principles, while observational learning explained both educator self-efficacy and the persistent theory-practice divide. To sustain evidence-based education, the study proposed structured faculty development programmes, formalized university-clinical partnerships featuring joint appointments and collaborative journal clubs, and a standardized national description of core competencies. However, the authors underscored notable study limitations. The research was conducted in only three of Germany’s sixteen federal states, with four institutions in Bavaria and Lower Saxony, restricting geographic transferability. Furthermore, the purposive sample of eleven educators likely overrepresented early adopters engaged with educational innovation, while relying exclusively on educator perspectives without assessing student or clinical supervisor views. Because the study evaluated implementation processes rather than measured student competency outcomes, future research must employ validated assessment instruments, such as the Fresno Test, across larger multistakeholder cohorts.

Subject of Research: Qualitative evaluation of evidence-based practice teaching in German undergraduate midwifery programmes

Article Title: Implementing modern teaching approaches for evidence-based practice in German midwifery university education: a qualitative study of educator experiences, facilitators, and barriers

Article References: Komuhangi, G., Neuhann, F., Wacker, J., Mikka, B., Fery, C., & Louis, V. R. (2026). Implementing modern teaching approaches for evidence-based practice in German midwifery university education: a qualitative study of educator experiences, facilitators, and barriers. BMC Medical Education, 26(1), Article 1804. https://doi.org/10.1186/s12909-026-10807-5

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10807-5

Keywords: Midwifery Education, Evidence-Based Practice, German Higher Education, Qualitative Research, Competency-Based Education, Curriculum Design, Problem-Based Learning, Health Professions Education, Implementing, modern, teaching, approaches