Pearls of wisdom for clinical teaching: expert educators reflect

BRIEF REPORTS

Pearls of Wisdom for ClinicalTeaching: Expert Educators ReflectRonnie Lichtman, CNM, PhD, Helen Varney Burst, CNM, MSN, DHL (Hon),Nancy Campau, CNM, MS, Betty Carrington, CNM, EdD, Elaine K. Diegmann, CNM, ND,Lily Hsia, CNM, CPNP, MS, and Joyce E. Thompson, CNM, DrPH

A group of expert educators, each with more than 20 years of experience in midwifery education, was askedto contribute a “pearl (or pearls) of wisdom” for clinical teaching. Despite minimal instructions regardingwhat type of wisdom was being solicited, remarkable similarities emerged from the educators’ contributions.Themes included the need for self-evaluation to become a competent preceptor, the role-modeling functionof the preceptor, the development of critical thinking in students, the need to appreciate students’ varyinglearning styles and individual ways of functioning, and the use of positive reinforcement. Although thesemay seem like universally accepted concepts in clinical teaching, one contributor related stories she heardfrom students about “hazing” behaviors that have a negative impact on learning. This points to the need forongoing education about being an educator, another theme echoed in several of thecontributions. J Midwifery Womens Health 2003;48:455–463 © 2003 by the American College ofNurse-Midwives.keywords: clinical teaching, midwifery education

When midwifery education programs write their self-evaluation report to qualify for accreditation by the Amer-ican College of Nurse-Midwives’ (ACNM) Division ofAccreditation (DOA), they must address a criterion thatstates “Nurse-midwifery/midwives in the faculty are qual-ified in that they…have preparation for teaching (includeboth didactic and clinical teaching) as applicable.”1 Inmaking teaching preparation a criterion for becoming eithera classroom or clinical teacher, the DOA has acknowledgedthe importance not only of the clinical component ofeducation, but also of training for the delivery of clinicaleducation. Today, midwives who are clinical teachers areexpected to be competent in clinical practice and inimparting expertise to students. They are encouraged torecognize their own teaching styles and have an apprecia-tion of varying learning styles2,3 as well as principles ofadult learning.4 Competencies have been identified forteaching that require formal educational preparation.5 Clin-ical teachers must be comfortable with the provision ofconstructive feedback and methods of evaluation. Studieshave demonstrated that effectiveness in teaching can belearned.6–8

In both clinical practice and teaching, experience con-tributes to expertise.9 In the absence of a research base formidwifery clinical education, it is appropriate to look tothose with this experience for advice and guidelines—even

for a framework to apply to research. The purpose of thisarticle is to share with midwives who teach clinically the“pearls of wisdom” from recognized experts in midwiferyeducation. Throughout this article, the terms “precept,”“preceptor,” and “precepting” are used interchangeablywith the terms “teach clinically,” “clinical teacher,” and“teaching clinically.” Both sets of terms apply to anyonewho provides supervision to a student in the clinicalarea—academic faculty members or clinicians.

Several teaching experts, each of whom has been ineducation for more than 20 years, were identified for thisarticle. Participation was based on national stature, personalcontacts of the author, and willingness to participate.National stature was based on experience as a midwiferyeducation program director, leadership in ACNM, and/orlocal or national recognition. An effort was made to havediversity in ethnic backgrounds of contributors and educa-tional programs represented. Contributors included fourCaucasians, one African American, and one Asian Ameri-can. Their midwifery education and/or academic teachingexperience were acquired at eight different midwiferyeducation programs, although all are on the East Coast. Therelative lack of geographic diversity can be attributed inpart to the authors’ residence on the East Coast and to thelongevity of education programs in the eastern UnitedStates. Each individual contributor speaks for herself,however, not as a representative of any education program.

The contributors were given broad and minimal instruc-tions. They were told that theJournal of Midwifery &Women’s Health was preparing a home study issue onmidwifery education. They were asked to contribute a

Address correspondence to Ronnie Lichtman, CNM, PhD, Midwifery Educa-tion Program, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box1227, Brooklyn, NY 11203.

Journal of Midwifery & Women’s Health • www.jmwh.org 455© 2003 by the American College of Nurse-Midwives 1526-9523/03/$30.00• doi:10.1016/j.jmwh.2003.09.002Issued by Elsevier Inc.

“pearl (or pearls) of wisdom” regarding clinical precepting.Contributors were told that their piece could be a theoreticaldiscussion or a “ tip” that they acquired over years ofinvolvement in education. They were also told that this wassimilar to programs entitled “Pearls of Wisdom” regardingclinical practice that have been presented at past ACNMAnnual Meetings.10 Of interest is that with such broadinstructions, the contributions complement and even over-lap each other—attesting to the universality of certainprecepts in clinical teaching.

Although pieces were edited due to constraints of spaceand overlap of some ideas, the “person” in which thecontributor wrote was not changed. One piece, coauthoredby Lily Hsia and Nancy Campau, was strikingly differentfrom the others. It provided practical tips as opposed to themore personal and/or theoretical discussions of the othercontributions. Hence, it was not included in this article, butsections of it have been used throughout this journal issue.

The remaining “Pearls” are offered in an appropriateorder based on content. Betty Carrington’s contributionincluded a historical perspective, so it appears first. Thecontributions of Joyce Thompson and Helen Varney Burstare complementary because Thompson discussed positiveteaching methodologies and Burst emphasized respect forstudents. Elaine Diegmann’s contribution, including her“Hallmarks of Preceptorship,” can be viewed as a summaryof the first three pieces.

Statements that the editors and lead author identified asparticularly relevant pearls of wisdom are highlighted initalics. We thank the midwifery educators who contributed,

and we hope the reader will enjoy this experience of sharedwisdom, a time-honored method of teaching.

BETTY WATTS CARRINGTON

The most intense period of my clinical midwifery practicewithout students occurred following my graduation andsuccessful certification examination in 1971 and lasted until1979 when I entered academic clinical education. Recog-nizing that this period preceded midwifery performance ofphysical assessment, the incorporation of modules intomidwifery education and the adoption of the principles ofadult learning puts this period into context and explains itsrelevance. How one learned and practiced the managementrole in providing clinical care depended on the knowledgeand experience of instructors who comprised the extremelysmall cadre of role models.

The certified nurse-midwife (CNM) in the limited legaljurisdiction of New York City in the early to mid-1970susually expected to wait for the obstetric resident physicianto assign a patient for midwifery management. Assignmentwas accomplished after the physician completed the initialphysical, including the heart and lung assessment and thepelvic examination. Once the laboring woman was assignedto the CNM, management of labor and birth could com-mence, often with steady physician oversight and consul-tation until and unless the individual CNM had establisheda proven and trusted collegial practice relationship with thephysician.

My desire to be an academic teacher grew out of acuriosity to learn what many new CNM graduates hadlearned and demonstrated as they rotated through theMaternity-Infant-Care (MIC) Service-affiliated hospital inBrownsville, Brooklyn, where I coordinated the nurse-midwifery service. By the late 1970s, nurse-midwiferyeducation had made tremendous strides toward incorporat-ing educational principles and approaches to learning, andthe curriculum had become markedly more structured withthe use of modules, the inclusion of academic and clinicalobjectives, and guided learning.

My becoming an academic and clinical educator oc-curred only after a great deal of personal effort andexpanded learning that were to be very fulfilling. Thisinvolved becoming familiar with new content, such asphysical assessment and newborn physiology, using mod-ules for curriculum delivery, developing comfort with adultlearning principles, incorporating alternate hand place-ments for birth, and recognizing the intentional applicationof the management process and consistent use of appropri-ate rationale for managing every aspect of care.

To be an effective preceptor, preparation should beginwith the individual appraisal of one’s self and enhanced bydrawing on education courses taken previously during under-graduate and graduate studies, workshops, continuing educa-tion, and preparation for teaching seminars or modules.

For a midwife to be an effective clinical educator, several

Ronnie Lichtman, CNM, PhD, is Associate Professor and Chair of theMidwifery Education Program (SUNY) Downstate Medical Center, Collegeof Health Related Professions (CHRP), Brooklyn, NY. Previously, she wasProgram Director of the midwifery education programs at Columbia Univer-sity and SUNY Stony Brook.

Helen Varney Burst, CNM, MSN, DHL (Hon), FACNM, is a Professor in theYale University School of Nursing Nurse-Midwifery Specialty. Ms. Burst hasdirected nurse-midwifery education programs at the University of MississippiMedical Center, the Medical University of South Carolina, and Yale Univer-sity.

Nancy Campau, CNM, MS, is currently in clinical practice and has previouslybeen on the faculties of the midwifery programs at Columbia University andSUNY Downstate Medical Center.

Betty Carrington, CNM, EdD, FACNM, is Chair of the ACNM Division ofAccreditation and has served in a variety of capacities with the Division. Shewas on the faculty of the midwifery program at SUNY Downstate and wasProgram Director of the midwifery program at Columbia University.

Elaine K. Diegmann, CNM, ND, MS, FACNM, is Professor and ProgramDirector of the midwifery program at University of Medicine and Dentistry ofNew Jersey.

Lily Hsia, CNM, CPNP, MS, FACNM, was Associate Professor and Chair ofthe Midwifery Education Program at the State University of New York(SUNY) Downstate Medical Center, College of Health Related Professions(CHRP).

Joyce E. Thompson, CNM, DrPH, FAAN, FACNM, is the Lacey Professor ofCommunity Health Nursing, Western Michigan University. She has been themidwifery Program Director at SUNY Downstate Medical Center, ColumbiaUniversity, and the University of Pennsylvania.

456 Volume 48, No. 6, November/December 2003

elements should be in place. (1) The midwife should reallywant to share with students what has been learned andexperienced. (2) The midwife should have the capacity andconfidence to conduct a personal self-evaluation. What arethe strengths as well as weaknesses of that person’spractice? If opportunities were to exist for continued study,what would the individual work on and strengthen? (3)What have been the midwife’s feelings about peer reviewand constructive criticism from others? (4) Is the midwifeable to identify with the beginning learner who has not yetlearned to integrate and synthesize knowledge and skillsadequately to make accurate assessments and developcomprehensive plans?

Table 1 presents a model of clinical supervision/teachingin the ambulatory care areas of antepartum and well-womangynecology for the basic, beginning student. The emphasisis on each step of the midwifery management process forevery clinical encounter. Prior to entering the clinical area,the student should have become familiar with the social andemotional preparations needed to manage patient care andhave the necessary equipment and learning material athand. The student should have completed a self-study andbe able to articulate a personal learning style. The instructorand student in a preclinical meeting should understand thenecessary slow pace needed for the student to develop

facility with the management process. Once thoroughlycomprehended, the process can be applied consistently. Thestudent’s pace will quicken naturally when the studentdevelops growing confidence and facility with the manage-ment process. The expectation should be that the averagestudent might see only one or two patients for the first andpossibly the second clinical session.

JOYCE E. THOMPSON

There are two primary functions or responsibilities inherentin the role of clinical preceptor. One is that of teaching, andthe other is that of evaluation. Both of these importantresponsibilities require a change or “ transition” in thinkingand doing from being primarily a clinician to becomingprimarily a teacher-midwife in the development of newpractitioners.11 Until a clinician is willing to share clientswith students and obtain a joy in teaching others to do whatone does similar to the joy obtained in taking care ofwomen directly, the role of preceptor is merely a burden inone’s busy practice life. Although teaching and evaluationmay be viewed as of equal importance, this article focuseson the teaching function of the clinical preceptor and offerssome reality-based examples I learned as I became a goodclinical teacher.

Table 1. Betty Carrington: Clinical Teaching in Ambulatory Care: Steps Proven to Be Effective in Establishing Confidence

Activity Comment

1. Chart review The student is to spend the necessary time doing a chart review. The student should be able to provide a structured,thorough, and organized presentation about the patient. The student is to understand that the chart review andanalysis serve as guides for the patient interview. The student should be quizzed on what questions have beenraised by the chart review and are to be used in the patient interview.

2. Report to the instructor Once the student has completed this step satisfactorily, as appropriate to the student’s experience and validated bythe clinical instructor, the student should proceed with the interview.

3. Patient interview The patient interview is to determine what actions have been taken on previous plans and what has been thepatient’s health in the intervening period since the last visit. The student consciously understands the importanceof the interval history as a component of data gathering that is achieved by listening to the woman.

4. Report to instructor toprovide new data

The student reports again to the instructor to review the interval history and the patient’s impression of her currenthealth status and needs. The instructor queries the student about the information that requires follow-up based onthe data gathering from the chart review and interval history. What components of the physical examination are tobe performed and why? What information is provided by the laboratory tests? The instructor and student agree onthe elements of the physical examination and their rationale.

5. Physical examination The appropriate physical examination is to be performed and any additional laboratory tests taken or ordered asindicated by the patient’s problem(s) and concerns, practice guidelines, and/or examination findings.

6. Third review with instructor The student meets again with the instructor to validate the previously agreed plan and to analyze the data todevelop a comprehensive management plan.

7. Student developsmanagement plan

The student develops a comprehensive management plan with the clinical preceptor.

8. Second patient interview andcompletion of encounter

The student returns to the patient to review the plan and assess her response.

9. Charting The student completes charting in a practice format and, when approved by the instructor, transfers the note to thepatient record.

10. Student self-evaluation The student reflects on the encounter and completes a self-evaluation of knowledge, skills, and synthesis ofinformation.

11. Student/instructor postconference

The student and preceptor hold a postsession conference to assess strengths and areas for future learningobjectives.

12. Anticipatory planning for thenext session

The student and preceptor identify areas related to the patient visit that the student needs to read about to discussat the next clinical session.

Journal of Midwifery & Women’s Health • www.jmwh.org 457

The “Self” as Teacher

One of the best insights into the complex reality of what ittakes to be a good teacher in any realm of formal educationcomes from the writings of Parker J. Palmer.12 He notesthat the “ tangles of teaching” come from three importantsources: (1) the adults we teach who are involved in manyactivities along with their desire to become midwives andthe fact that we rarely have time to really know who theyare; (2) the content we are expected to remain knowledge-able about, which keeps changing as new research, practicemodalities, and patient needs add new dimensions to ourown practice, making our knowledge base limited or partialand always evolving; and (3) our limited knowledge of theself as teacher, including an understanding of our intellec-tual, emotional, and spiritual dimensions and how theyaffect who we are as teachers.

In my own teaching for more than three decades, I havecome to realize that good teaching stems from my passionfor the subject matter, my love of learning, and mycommitment to better health and health care services forwomen and families throughout the world. My success asteacher has come from accepting that I am a teacher firstand foremost—it is my calling; it is who I am! Teaching ismy life’s work, and it brings me both inner peace (whole-ness) and joy on those days that I do it well. I teach becauseI love to share what I have learned with others and continuelearning with those who want to be the best clinicians andteachers they can be. I love to connect with the inner soulsof my learners, face to face, event to event, life to life, andthen search for meaning and understanding of how ourconnectedness affects learning.

Every moment I teach also brings me face to face withmyself—my values, my sense of integrity, my strengths,and my limitations—not just as a teacher but as a humanbeing. This is the challenge of being a teacher, and this isalso the reward of teaching. One pearl of wisdom is that assoon as one accepts and integrates the “teacher self” as apart of who they are, the more fun and effective his or herteaching will be. The caution to all is that this teacher selfonly works if one wants to continue to examine her or hislife, work, and integrity on a daily basis and use thisreflection wisely in interaction with others as learners.

Teaching and Learning Cannot Be Separated

Becoming or being a clinical teacher requires the samecommitment to learning that we expect in our students. Aswe strive to stay ahead of their learning about how toprovide quality health services to women and families, wemust also pay attention to our need to learn how to be agood or better teacher.13 Techniques for sharing knowl-edge, coaching, and supporting others in their learning andallowing the time needed for learning are vital elements ofgood teaching—and all require time to learn. None of thesebehaviors are automatic, yet all can be learned if you havethe will to do so. I learned very early in my teaching career

that my students were always watching me very closely,and, whether I accepted it or not, I was a role model.Having someone watching you, especially when you areunaware of this, reminds me daily of the importance ofbeing true to whom I am wherever and with whomever Iam. My sense of integrity, of striving to always do the rightor good thing as a person, is an integral part of who I am asteacher. I now worry less about being watched by othersbecause it is who I am—warts and all. I have managed overthe years to peel away unnecessary layers of self and beauthentic in all relationships.

Humor, Timing, and Controlled Mistakes

Humor is a vital teaching tool and relieves a lot of tensionin both preceptor and student when used appropriately. Ilearned how to laugh at myself when I am less than thegood example I wish to be, and I learned how to help otherslaugh at and learn from their own mistakes—provided theywere not devastating to either patient or student. Forexample, I remember with vividness the day one of mymidwifery students finally “got it”— the “ it” being a com-bination of sterile technique and composure in a difficultsituation. We were in a delivery area requiring steriletechnique, and this learner kept letting her hands driftbelow her waist. She was also very nervous and kepttouching the sterile field. I finally stepped close andwhispered in her ear, “Watch your hands. Get a hold ofyourself.” She promptly grabbed her breasts and held on fordear life. We had a good laugh when we reflected on heractions in postconference, and she had no further problemswith maintaining a sterile field.

An example of using humor and timing relates tocoaching midwifery students when learning to repair anepisiotomy. First, I set the time period for the total repair atapproximately 20 minutes. Because I can repair almostanything in 5 to 7 minutes, I share at the outset that thelearner would have the first 10 to 15 minutes to sew, andwhat was not completed at the end of that time, I would do.For the beginning learner to have experience with all tissuelayers, I would suggest that each time one begin in adifferent layer until the learner could do the complete repairin 20 minutes or less. One day as a particularly meticulouslearner who I knew could do the repair completely wasproceeding in a slow and deliberate manner, I gentlywhispered in her ear, “Pretend you are in a hurry!” I hadheard another colleague use this, and it worked! Wisdomsuggests that humor needs to be used cautiously and withexquisite timing—not every learner will respond and hencethe need to know whom you are teaching.

We all recognize the truism that one can learn from one’smistakes—but have you ever thought about allowing “con-trolled” mistakes for learning? My definition of controlledmistakes is allowing the learner the opportunity to see whathappens, within the boundaries of safety for the patient,when they do not pay attention to what the woman in labor


is saying or doing or make wrong decisions in other areasof care. In my early years of teaching, I remember severalexperiences with learners who were having difficulty inte-grating their knowledge of the progress of labor with anindividual’s labor pattern. This event occurred before theadvent of birth in bed or LDRs. The woman needed to bemoved from a labor room to a birthing area, and usually thismove required 5 to 10 minutes, depending on how small thedoors were and how large the bed or stretcher was. One dayI decided, after much coaching and Socratic questioning onthe behavior of a particular woman in labor (multigravida intransition), that I would step back and allow the woman todeliver in the labor bed and then help the student under-stand what cues had been missed so that she would not dothis again. This worked with several students over theyears, but as a preceptor, one needs to be aware of theeffects of such learning experiences on the parturientwoman and family. On the other hand, I had no difficultyignoring the warnings of my nurse colleagues who would“write me up” because I had not moved the woman to thedelivery room in good time.

Midwifing the Student

Wisdom gained from teaching for many years is based onmy willingness to continue to learn. I enter a relationshipwith each learner in which I expect them to teach me aswell as learn from and with me. I also enter this relationshipknowing that each of us is an individual, and we will notalways agree on approaches to care, but we will agree thatwomen deserve high-quality care. I genuinely like andrespect my students as adults and expect that same respectin return.

We teach who we are. Good preceptors obtain as muchjoy from midwifing a student as from midwifing a womanor new family. Good preceptors understand how adultslearn and facilitate that learning with varying techniques ormethods. And good preceptors are willing to share theirown experience in learning and practice with the students,including how they developed a preferred way of “doing”and “being” a midwife. Together, preceptors and learnersevaluate progress in learning that fosters continued learn-ing. They share a love of lifelong learning. And above all,we love our learners and love to teach.

HELEN VARNEY BURST

An insider rendition of an important annual event gave mepause to again reflect on the basic key concept of respect fora student in the teaching/learning process. The event wasthe ACNM student session during which the students’report to the membership is written. According to mysources, a large portion of the session was dedicated to thetopic of “hazing” by teachers (academic faculty and clinicalpreceptors) within a variety of midwifery programs acrossthe nation. Tears were shed and fears were expressed—fears so great that none of this was included in the written

report. Underlying all the fears was the fear of failing andof being “kicked out.” This results in being afraid to be alearner because of the fear that to ask questions revealsknowledge gaps or deficits in skill levels.

Table 2 enumerates negative behaviors that show a lackof respect for the student and lead to negative learningexperiences and fears.

A teacher has to start with the basic premise that astudent wants to learn. It behooves individuals who teach tohave thought through what their purpose is as a teacher. Theshort version of my personal purpose in teaching is tofacilitate the efforts of a student to learn. What I do to fulfillmy purpose varies because each student has an individualway of learning, which may differ from another student orfrom my way or that of another teacher. Adult learnerscome with a rich background of prior learning and experi-ence that will influence as well as give depth and breadth tothe current learning process. Respect for a student beginswith asking about and getting to know that student’sindividual way of learning and what one brings to theprocess.

Two teaching methodologies that I have found mostuseful in working respectfully with a student are thepreclinical and postclinical experience conference and theCircle of Safety (Figure 1). The preclinical experienceconference is absolutely critical if you have not workedpreviously with a student. It takes place 10 to 15 minutesbefore the student sees the first patient in an outpatientsetting or postpartum or before the student sees a woman inlabor (progress permitting). During this conference, thepreceptor elicits and provides information summarized inTable 3, recognizing that responses will vary widely,depending on where the student is in the education pro-gram.

The postclinical experience conference is a combinationof debriefing, learning, and planning. If you have had morethan one student during a session or a birth, obtainpermission from the students to hold the postclinical

Table 2. Helen Varney Burst: Negative Behaviors

1. Criticizing the student in front of a patient or other health careproviders

2. Ridiculing the student—ever3. Demanding clinical performance expectations that are beyond the

student’s current knowledge and skill levels4. Insisting that things be done the preceptor’s way when the

student’s different way is safe5. Showing lack of responsiveness to a student’s learning needs6. Showing lack of understanding of and responsiveness to a

student’s personal needs7. Being nonsupportive in the student’s efforts to learn8. Yelling at the student9. Wasting time

10. Hazing because that is the way the preceptor “learned” when astudent


conference with all the students involved so they can learnfrom each other’s experiences. Ask the student(s) what theythought of their experience. Their perceptions must betaken into account as you go through the experience in amanner similar to a case study. In the process, the partsdone well or correctly should be praised, and the parts leftundone or lacking thoroughness, or with which the studentneeded help, should be identified. The latter forms thebeginning of a plan for further learning. Theoretical under-pinnings should always be discussed because they are thefoundation on which clinical practice is built. Gaps inknowledge are identified and added to the plan for furtherlearning. Identification of the student’s needs in clinicalexperience, laboratory practice, and content learning be-comes the important component in the plan for furtherlearning and comprises the goals for the student’s nextclinical experience. The student’s evaluation tool can alsobe used to identify learning needs and to develop a plan tomeet these needs. Students often feel inept in an uneventfulbut new situation or helpless in a suboptimal situation. Suchfeelings need to be identified and the experience recast intoa rich learning opportunity. Students should leave thepostclinical experience conference feeling respected andreinforced in their efforts to learn.

The Circle of Safety14 is grounded in the philosophy thatlearning takes place best when reinforced and obstacles tolearning are removed. The Circle of Safety removes acommon obstacle that clinical preceptors often unwittinglycreate and that is the insistence that a student do somethingthe way the preceptor does it without thought to how thestudent has already learned to do it. Unless the preceptor isa consistent preceptor, this means that a student is not

having reinforced learning but instead is having to startover again and inevitably will once again feel inept. Thisimparts disrespect of the student’s efforts to learn andmeans that the student will spend time trying to “psych out”how the preceptor wants things done to please the precep-tor. The Circle of Safety is a basic concept that however thestudent wants to do something is OK as long as it is safe.The boundary of safety is set by the preceptor. A preceptorshould discuss the Circle of Safety with the student beforethey work together in a laboratory or clinical setting andinvite the student to share when the student has anotherway of doing something. Safety can then be determined bythe preceptor, and the student can decide whether toreinforce what has already been learned or to learn anotherway of doing something.

Finally, respect for a student means that teachers willself-evaluate their precepting and classroom interactionand skills. Critical to this process is requesting and receiv-ing student evaluations. Self-evaluation by a teacher in-cludes scrutinizing ourselves for the many forms by whichrespect, or lack of respect, for a student is evidenced.

ELAINE K. DIEGMANN

Midwives are shaped by the sum of their learning encoun-ters in life situations, in the academic environment, and inthe clinical area. The past learning that comes with studentsand the current learning provided by the educationalprogram are brought together by the preceptor in theclinical setting. The preceptor holds the key to unite thecomponent parts into a new effective practitioner. Withstudent input, the clinical preceptor sets the goals andobjectives for the clinical encounters, develops the time-frames for student development, and uses evaluation tech-niques.

Role of the Education Program

The education program’s responsibility is to ensure appro-priate preparation of the preceptors to whom it entrusts itsstudents. Workshops or programs should be planned toprovide instruction for new preceptors in the principles ofteaching and learning, different learning and teachingstyles, and valid evaluation techniques. For experiencedpreceptors, education programs should provide resources tomaintain theoretical competence. The key to successfulstudent encounters begins with communication during thepreceptor’s orientation to the education program’s expec-tations and never ends.15

Role of the Preceptor

Precepting midwifery students is a crucial phase in thebirth of a midwife. In the precepting environment, studentmidwives should be motivated and guided to embrace theart and passion of midwifery. Students must be nurtured tolearn to nurture women and their families.

Figure 1. Circle of Safety. Reprinted with permission from Varney Burst H.14


The preceptor must create a learning climate that rewardssuccesses, builds professional safety and esteem, and pro-vides a sound foundation for learning and critical thinking.The preceptor faces the task of guiding without leading andassisting without directing.16

Clinical precepting is unique and vital because it linksthe theoretical learning and framework in the educationprogram to the reality of patient care and interaction.Clinical precepting makes both the teacher and the studentvulnerable to the clinical situation because each encounterprovides new material presented by an individual throughunrehearsed, unexpected physical and emotional re-sponses. Only when the preceptor knows the subject areawell and has excellent clinical skills can the depth ofknowledge be considered broad enough to be able toexplain the basis for action and decision within the bound-aries of safety in the clinical arena. The preceptor must beable to organize and control the learning experience for thestudent and provide appropriate care for the patient whilegiving appropriate responsibility to the learner.17

By word, action, and deed, the preceptor forges the newpractitioner to be safe in practice, to educate patients andconsumers, and to promote the midwifery philosophy ofcare through appropriate professional behavior and com-munication skills. Communication is the foundation upon

which all teaching and learning must be built. It keeps thelearner’s attention. It sets the objectives for the clinicalencounter. It helps the preceptor balance clinical teachingand responsibility in a way that meets the productivityrequirements of the workplace without sacrificing studentlearning, patient safety, or the midwifery model of care.

There should be three common goals for all preceptors:(1) provide information, (2) motivate the student to learnand improve, and (3) have alternative teaching/learningmethods available to ensure student success.18

Provide Information

Learning is facilitated by a preceptor who has expertise inthe subject material. Students learn quickly how knowl-edgeable the preceptor is, how much the preceptor likeswhat she/he does, and how serious the preceptor is aboutteaching. The preceptor must be enthusiastic and energeticand open to student ideas and input. The preceptor shouldbe able to provide honest constructive feedback reinforcingstrengths and identifying needs for improvement.

Motivate the Student to Learn and Improve

The worth of the preceptor is measured by the motivation ofthe student. A successful preceptor promotes active in-

Table 3. Helen Varney Burst: Information to Elicit and Share During a Preclinical Conference

Question Examples

1. What are the student’s learninggoals for this experience?

An intrapartal student might have a goal of helping a woman who wishes to give birth in a particular birthposition; or an antepartal student might have a specific goal of learning first trimester uterine sizing.Obviously, these goals affect which women you select for the student’s clinical experience.

2. How much experience does thestudent already have in thisclinical area?

How many births has the student attended? Normal? Complications? Labor support? Maternal birthposition? Third stage management? Suturing? How much and what kind of help does the student think isneeded from the preceptor?

3. Which skills have the studenthad experience with? Are thereany particular skills with whichthe student needs moreexperience?

A student in a family-planning clinic may want to fit diaphragms. Has the student done this before? Howmany times? Did the student ascertain the correct type and size? Can the student do the rest of the visitand only need you just for the diaphragm fitting?

4. A brief discussion ofexpectations of each other:what the student expects ofyou in helping and what youexpect of the student inkeeping you informed.

Preceptor expectations of a fairly early student in an outpatient setting include having the student give youa report after reviewing the chart. This ensures that the student has identified all the information oneneeds to solicit from the woman. After taking the history, while the woman is getting undressed, havethe student give you another report. This confirms that the student got all the information needed andhas identified all the things one is going to look for during the physical/pelvic examination. It alsoenables you to ascertain if the student needs your help with any parts of the examination. After theexamination, while the woman is getting dressed, have the student give you another report to review allthe physical/pelvic findings and to ensure that the student has thought of all the components indicatedfor the plan of management. Finally, have the student give you one last report at the end of the visitbefore the woman leaves to ensure that nothing was left undone. Sharing expectations prior to theclinical learning experience facilitates communication and reduces the possibility of frustrated studentsand upset preceptors.

5. Reassurance that you are thereto help the student learn, thatyou will ensure safety for thepatient, and where the studentcan find you at any moment intime.

Never leave the clinical setting without ensuring that the student does not have immediate or shortlyanticipated need of you; let the student know where you’re going, be sure the student knows how toreach you, and tell the student how long you will be gone.


volvement of the learner and shows interest in the student’ssuccesses. The preceptor makes learning fun by usinghumor in the learning encounters to defuse stress andimprove teacher/learner rapport. Because learning is anongoing process, the clinical preceptor should infuse intoall students the desire to continue to learn independentlythroughout their lifetimes.

Because of the nature of the student/preceptor encounter,the preceptor can provide effective role modeling that thenew practitioner can emulate during her/his own roledevelopment. The preceptor has the unique opportunity toportray a midwifery model of care within today’s workenvironment.

Have Alternative Teaching/LearningMethods Available to Ensure Student Success

Because people learn differently, the preceptor should beopen to various learning styles of students. The teaching/learning environment is further complicated by the fact thatmidwifery students are adult learners. Learners in thiscategory like to have some control over their learning. Theymust see the link to real-life situations to understand andembrace the basis for clinical action and/or decision mak-ing. Most adult learners like freedom in achieving clinicalgoals, but they desire support and guidance of the preceptorto keep them focused. The effective preceptor gives feed-back regarding desired performance without hinderingself-directed decision making.19

Some adult learners are totally self-directed and like asense of equality with the preceptor. They prefer to set theirown learning goals. Other learners prefer a more traditionalapproach to learning. They need to see the teacher/precep-tor as the expert. They need structure in assignments andsetting goals. Another learner may enjoy challenge inlearning. For this student, the preceptor is more effective ina mentor role than in the teacher dominant/student subor-dinate role. Still other students need to meet challenges andexperience new and unexpected situations in their clinicalassignments. They thrive on taking chances and changingroutines.20 In this situation, the effective preceptor suppliesexpertise and sets safe limits.

In summary, just as the Hallmarks of Midwifery are partof midwifery core competencies, the “Hallmarks of Precep-torship,” listed in Table 4, should be part of every studentencounter.

DISCUSSION

A consistency of approach to clinical teaching is evidentthroughout this article. Much of what is recommended bythese midwifery teaching experts is supported in a multi-disciplinary, worldwide literature on clinical teaching.21–30

All contributors recognize the need for learning to be apositive experience for student, preceptor, and patient.Negative behaviors, called “hazing,” are listed by onecontributor (Helen Varney Burst), but clearly unacceptable

to all. In fact, in Elaine Diegmann’s “Hallmarks of Precep-torship,” negative behaviors such as using the student as asounding board are proscribed. Contributors reinforce theneed for formal education about teaching, preceptor self-evaluation and reflection, as well as acquiring familiaritywith adult learning styles.

Reflection on their own development as a preceptor is akey component of the contributions of Betty Carrington andJoyce Thompson. The development of critical thinking instudents is mentioned. Humor as an effective technique isnoted by both Joyce Thompson and Elaine Diegmann. BothBetty Carrington and Helen Varney Burst talk about con-ferencing with the student, and Elaine Diegmann alludes tothis in her discussion of setting goals for the learningexperience. Betty Carrington and Helen Varney Burst offerguidelines for student reporting to the preceptor in theambulatory setting; their guidelines are remarkably similar(Tables 1 and 3). Joyce Thompson and Helen Varney Burstsuggest allowing students to do things their own way,within the context of safety. Each contributor emphasizesthe need for creating a safe environment for learning andfor patient care. The preceptor as a role model is discussedby each expert.

In summary, clinical teaching is depicted by experiencededucators as a communicative interaction between teacherand student, with mutual respect and recognition of varyingways of learning and doing. Within the limits of safepractice, set by the clinical teacher, students should bepermitted to make their own management decisions. For-mal teacher training and self-evaluation are recommended.The use of positive feedback and reinforcement creates themost useful clinical learning experiences.

REFERENCES

1. American College of Nurse-Midwives. Division of Accredita-tion Criteria for Accreditation of Education Program in Nurse-Mid-wifery, 1998, Amended, 1999. Washington (DC): American Collegeof Nurse-Midwives, 1999.

Table 4. Elaine Diegman: Hallmarks of Preceptorship

1. Care about the subject.2. Apply the material to real-life experiences.3. Foster a comfortable learning environment.4. Be attentive to individual needs and various learning styles.5. Show professional integrity at all times. Never use a student as a

sounding board. Do not complain about other students orpractitioners. Don’t complain about the work environment. Bepositive and productive.

6. Be excited about teaching and learning.7. Have effective communication skills.8. Understand what the student needs to know. Keep the lines of

communication open with the academic faculty.9. Be a role model.

10. Be with woman and do no harm.


2. Smith DM, Kolb DA. The User’s Guide for the Learning-StyleInventory: A Manual for Teachers and Trainers. Boston (MA):McBer & Company, 1986.

3. Lichtman R, Jurow D, Cunningham V, Harmon P, Rouhana N,Schelling K, et al. A Manual for Preceptors. Stony Brook (NY):SUNY Stony Brook, 2000.

4. Thompson J. Selected principles of teaching and learning ap-plied to nurse-midwifery clinical education. J Midwifery WomensHealth 1983;28:21–9.

5. Thompson JE. Competencies for midwifery teachers. Mid-wifery 2002;18:256–9.

6. White CB, Bassali R, Heery LB. Teaching residents to teach.An instructional program for training pediatric residents to preceptthird-year medical students in the ambulatory clinic. Arch PediatrAdolesc Med 1997;151:730–5.

7. Mazor SS, Devaney-O’Neil S, Starr S, Ferguson W, WellmanS, Jacobson E, et al. Development and implementation of an objectivestructured teaching exercise (OSTE) to evaluate improvement infeedback skills following a faculty development workshop. TeachLearn Med 2003;15:7–13.

8. Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD,Irby DM. Teaching the one-minute preceptor. A randomized con-trolled trial. J Gen Intern Med 2001;16:620–4.

9. Benner PE, Benner D, Benner P. From Novice to Expert:Excellence and Power in Clinical Nursing Practice. CommemorativeEdition (NJ): Pearson Higher Education, 2001.

10. Ventre F, Brewin D, Diegmann E, Groggel M, Mercer J,Murdaugh A. Annual Meeting of the American College of Nurse-Midwives. Workshop11: Midwife pearls of wisdom: Preparing forthe ACC exam, entry level of practice, refresher and beyond. May 29,1999. Available at: http://www.midwife.org/docs/AM99tapeorder.pdf.

11. Thompson JE, Kershbaumer RM, Krisman-Scott MA. Educat-ing Advanced Practice Nurses and Midwives: From Practice toTeaching. New York: Springer Publishing Company, 2001:15–28.

12. Palmer PJ. The Courage to Teach: Exploring the Inner Land-scape of a Teacher’s Life. San Francisco (CA): Jossey-Bass, 1998:9–34.

13. Thompson JE. The Courage to Teach: Exploring the InnerLandscape of a Teacher’s Life. San Francisco (CA): Jossey-Bass,1998:117–28.

14. Burst HV. The circle of safety: a tool for clinical preceptors. JMidwifery Womens Health 2000;45:408–10.

15. Gibson SE, Hauri C. The pleasure of your company: Attitudesand opinions of preceptors towards nurse practitioner preceptees.J Am Acad Nurse Pract 2000;12(9):360–3.

16. National Education Association. Understanding problem basedlearning. NEA Higher Education Advocate 2002;20(2):6–7.

17. McGlynn AP. The academic convocation as a teaching/learningworkshop. Hispanic Outlook 2002;121(23):15–17.

18. McKeachie WJ, Gibbs G. Teaching Tips. Boston: HoughtonMifflin Company, 1998:172–5.

19. Hewson MG. A theory-based faculty development program forclinician educators. Acad Med 2000;75:498–501.

20. Endorf M, McNeff M. Adult learner: Five types. Adult Learn-ing 1991;2:20–6.

21. Myrick F, Yonge O. Preceptor behaviors integral to the pro-motion of student critical thinking. J Nurses Staff Dev 2002;18:127–33.

22. Cele SC, Gumede HA, Kubheka BA. An investigation of theroles and functions of nurse preceptors in the clinical areas. Curatio-nis 2002;25:41–51.

23. Ohrling K, Hallberg IR. Student nurses’ lived experience ofpreceptorship. Part 2. The preceptor-preceptee relationship. Int J NursStud 2000;17:25–36.

24. Kaviani N, Stillwell Y. An evaluative study of clinical precep-torship. Nurse Educ Today 2000;20:218–26.

25. Myrick F, Yonge O. Preceptor questioning and student criticalthinking. J Prof Nurs 2002;18:176–81.

26. Myrick F, Yonge OJ. Creating a climate for critical thinking inthe preceptorship experience. Nurse Educ Today 2002;21:461–7.

27. Yonge O, Myrick F, Haase M. Student nurse stress in thepreceptorship experience. J Nurse Educ 2002;27:84–8.

28. Ferenchick G, Simpson D, Blackman J, DaRosa D, DunningtonG. Strategies for efficient and effective teaching in the ambulatorycare setting. Acad Med 1997;72:277–80.

29. Usatine RP, Nguyen K, Randall J, Irby DM. Four exemplarypreceptors’ strategies for efficient teaching in managed care settings.Acad Med 1997;72:766–9.

30. Epstein RM, Cole DR, Gawinski BA, Piotrowski-Lee S, RuddyNB. How students learn from community-based preceptors. ArchFam Med 1998;7:149–54.


http://www.midwife.org/docs/AM99tapeorder.pdf

http://www.midwife.org/docs/AM99tapeorder.pdf

Documents

Pearls of wisdom for clinical teaching: expert educators reflect