Assignment: Review the following information which will help you to approach you apprenticeship with strategies for optimal learning.

Defining and Supporting the Student’s Role Within the Practice

It is of utmost importance that preceptors and students communicate with clients at the onset of their care regarding the role that students play within the practice. This type of communication sets a foundation for healthy student/preceptor relationships that inspire cohesive client care. It is recommended that these messages be communicated both verbally and in writing to clients at the initial visit or consult.

The following is an example of an appropriate verbal and/or written message from the preceptor: “Students are an integral and important part of this midwifery practice. The art of midwifery has long been passed on through the apprenticeship model where students learn through hands on clinical experience. This means that I will be teaching my student(s) as I provide your care. Students will be learning through observation, assisting and (as they are ready) taking a lead role in your care.”

And here is an example of how the student might introduce themselves to a client: “I’m a student midwife learning through the apprenticeship model of education. That means I’ll be an integral part of your care under the supervision of the midwife (or midwives) and I’ll be learning the art of midwifery through hands on clinical experience. I’ll be learning through observation, assisting and (as I’m ready) taking a lead role in your care.”

While there are many different ways to approach a student’s role within a midwifery practice, it’s vital that there be no ambiguous messages about student participation in client care. Some midwives will ask clients at each encounter if it is okay for a student to be there and, before the student does any procedure, they will ask the client if it was okay that the procedure be done by a student.

Other preceptors choose to uphold the students’ role in the practice as the celebrated status quo and thus do not give clients the choice upfront as to whether or not they want student involvement in their care. In this case, it is vital that preceptors leave room for clients to express if they do not feel comfortable with the students’ care and must remain continually prepared to respond appropriately.

Whatever approach is taken while communicating a student’s role to the client, it’s important that students maintain and impart a solid sense of belonging and rapport within the practice. When pride is exhibited in the apprenticeship model, it inspires confidence and respect within the clients. When preceptors and students model a deep sense of trust in their relationships, confidence is naturally instilled in the client.

Inevitably there will be disagreements between students and preceptors, yet these differences should always be worked out through respectful communication outside of the clinical setting while a sense of cohesion should be consistently exhibited in front of the clients. More detailed guidelines for respectful communication and problem solving are addressed in other sections of this document.

When the client experiences that the preceptor/student relationship is sound, that client holds trust in an undivided team and often students become a primary resource for the clients. In order for this trust to be established, certain ground rules need to be established and practices need to be maintained. The following sections address the foundations of a healthy student/preceptor relationship.

Setting Goals for Learning

Learning goals will need to be clarified prior to working together but also throughout the duration of the apprenticeship by a process of dialogue and documentation. Students and preceptors will fill out a "Plan of Completion” prior to starting work together that clarifies the timeframe and expectations of progress throughout the program. The "Plan of Completion" can also be used throughout the program to reassess progress and goals. This form can be found HERE.

Meetings between student and preceptor which are scheduled on a regular basis provide opportunity for adjusting expected learning outcomes as the student progresses through different stages of their apprenticeship.

Communicating Clear Expectations Before Each Clinical Encounter

Before a clinical experience, it is important for preceptors and students to have a face to face encounter to define expected roles and to determine specific skills that will be worked on during that clinical experience. Depending upon the fluidity of the relationship and and level of complexity of the clinical encounter, this might be accomplished in a few minutes (i.e. before entering a routine prenatal visit) or might require considerable thought and intention (i.e. leading up to a birth in which the client has a predisposition to potential complications). If the student will be performing a skill with the help or guidance of the preceptor, determine what help specifically will be needed.

Consider what stage is the student in. Will they be observing, assisting, or leading? This is determined by:

the student’s self assessment (“I need more time to observe ______" or "with ______ help, I feel confident I can ______", or "I feel ready to _____”)
the preceptor assessment of student (“I feel it is most appropriate for you to observe the way that I _____", or "with _____ help/guidance from me, I trust that you can _____", I trust that you can competently perform that skill completely independently with me observing”)

Students should be given the opportunity to lead this process as much as is reasonable. This way, students can learn to take responsibility for guiding their own education at their own pace. Inevitably, some students are more willing to try new skills than others. This means that some students will need extra encouragement while others will need to be reminded of their limitations.

Likewise, it is much easier for some preceptors to “let go of the reigns” than others. Students must be given the opportunity to move through the different stages of observing, assisting and leading all types of clinical encounters in order to gain competency in all areas of midwifery care. This must be part of the ongoing conversation between preceptors and students. While it is expected that students take the lead in determining what they are ready for clinically, it is the preceptor’s critical responsibility to keenly observe and openly acknowledge student milestones while increasing responsibilities in response to their accomplishments.

Scrupulous review of clinical requirements must be part of this process. For example, a student may intend to fulfill a particular clinical requirement such as Birth as Assistant Under Supervision. Preceptor and student must be aware of the requirements outlined in the NCM Clinical Record Form and must agree that the student is ready to take on this role. In this example, A Birth as Assistant Under Supervision consists of “most of the following, but is not limited to: Set-up, assistance to the midwife in whatever they request, assisting the client and their family, participating and learning about charting, evaluating pre-labor, practicing admission evaluation and admission procedures, keeping track of progress and normalcy of labor, practicing taking and charting vital signs, counting baby's heartbeat, practicing evaluating FHT, practice providing comfort measures, preparing and coaching mother/client for actual birth, preparing client's partner to provide comfort measures or to participate in delivery practice assisting with the birth and actual birth, preparing client’s partner to provide comfort measures or to participate in delivery, practice assisting with the birth and placenta, practice evaluating newborn response and vitals, practice assisting with newborn exam, evaluating the placenta for normalcy, practice with the establishment of immediate breastfeeding, assisting midwife with clean-up, sterilizing, repairing, restocking, re-ordering equipment, making plans for follow-up visit.” Student and preceptor would therefore be responsible for ensuring that these roles and responsibilities were adhered to throughout the clinical experience unless clinical judgement warrants a shift in roles.

If circumstances warrant making adjustments to these agreements in the midst of a clinical experience, student and preceptor must communicate these adjustments clearly before the student takes on new roles. For example, if the student enters into a birth as Primary under Supervision but soon realizes that the needs of the family have become more complicated than their skill level can meet, they must communicate clearly with their preceptor and reach an agreement about the shift in their role.

Briefing and Debriefing

Briefing ensures that the student knows what the purpose of the visit is, what they are expected to learn or practice during the visit, what to do to be an effective assistant, and how to conduct themself during the visit. Briefing may include but is not limited to discussing:

Who is the Client?
Purpose / Goals for the visit?
Learning Objectives for the student: “By the end of this visit, you will be able to…____”
Special considerations for the particular client or for the procedures you are going to perform)
Clear expectations of student role during the clinical encounter. Examples:
- Student will stand to one side to observe and chart.
- Student will perform pelvic exam.
- Preceptor will demonstrate and then will ask the student to practice_____.
Clear expectations of student conduct during the clinical encounter. Examples:
- If the student disagrees with the preceptor's choices during the visit, they may discuss this with the preceptor afterwards when they are debriefing rather than in front of the client
- If the student has technical questions that are easily answered in a clinical setting, they may ask the preceptor in front of the client.
- If the student has more in depth questions that may not be easily answered during a clinical encounter, it may be best to wait until after the visit or during designated class time.
Step-by-step instructions for the skill that you as the preceptor are going to perform or that you are expecting the student to perform.
Important tips. For example:
- When you are going to touch the client, don’t forget to ask first
- When you use the stethoscope, don’t forget to make sure it is warm first, etc.

Before a birth/immediate postpartum experience, it is a great practice to have the student read through the client's chart from cover to cover, including reviewing the client's personal and family medical history and all lab work done during the pregnancy.

It is particularly important to clearly define roles before a birth by clarifying:

Roles that the client’s family or other people attending the birth (doulas, etc.) may play
Who is the Supervisory midwife/preceptor?
Who is the Primary midwifery student?
Who is the assistant midwifery student?
What specific role do each of these individuals play?
Do these roles shift in the case of an emergency?

It is also extremely important to discuss with students the specific fears, wishes, preferences, or needs of the client and their family.

Debriefing after the clinical encounter can ensure that the student takes time to reflect on what they learned or practiced. It can ensure that students receive instant feedback on what they did well and areas in need of improvement. Strategies for debriefing include:

Praise: “I really liked the way you _______”
Identify problems and give specific corrections: “I saw these problems:_________. Next time you may avoid the problem by doing: _______.”
Restate Learning Objectives: “You are now able to ______.”
Restate the value of the action by reflecting why it was helpful or necessary.
Ask the student if they have questions

Setting Roles in Emergency Situations

Setting clear roles in emergency situations can be particularly challenging as there is little time to reflect and the stakes are inherently higher. When role playing and emergency drills have been done before the actual emergency is encountered, a sense of the student’s ability has been established and the preceptor has had a chance to practice talking their student through emergency procedures. It is recommended that emergency drills and role playing be done on a regular basis and that agreements be made between students and preceptors about their readiness for handling specific emergencies. (i.e. “the next time we encounter a retained placenta, I feel confident that you could…, if I feel concerned about the birthing person's safety, I will need to step in…, etc.)

Provided that this type of groundwork has been done, the same process that was outlined above takes place in emergency situations yet decisions are made more instantaneously.

A student who is in a primary role needs to be given the opportunity to step in and handle emergency management skills with the calm and focused support of the preceptor. As difficult as it may be for a preceptor to let go of directly managing a situation such as a shoulder dystocia or a retained placenta, it can also be immensely satisfying to witness a student develop the competence and confidence necessary to function one day as an independent midwife. Mastering these life saving skills by performing them directly is an entirely essential part of a student’s training. However, in the case of emergencies it is particularly sensitive and vital that students not be placed in situations they are not ready for, that preceptors be ready to jump in as necessary to ensure that client safety is prioritized, and that students be respectful of the preceptor’s responsibility to make “the final call”.

Signing Off on Clinical Experience

Students are expected to be able to competently and confidently perform all skills when appropriate and demonstrate all clinical skills to mastery level prior to being signed off on Clinical Record Forms. It is the responsibility of the student to request that their preceptor sign off on clinical skills at the time that skills are acquired, thereby preventing accumulation of paperwork.

When a preceptor signs a student off on a particular skill, they essentially saying to the student, "I have witnessed that you are competently and confidently able to perform this skill at a level of mastery when appropriate." This is not a responsibility to be taken lightly as it is a powerful determining factor in how well the student responsibly and safely cares for clients within the preceptor's practice and after graduation. While preceptors are only to sign off on skills when entirely confident in the student's abilities, they also must be conscious of the power they hold over their student's educational path and should in no way abuse that power. Under no circumstances should preceptors withhold deserved signatures in order to manipulate student behavior, punish them, work out personal conflicts or needlessly keep them from progressing through the program.

Students as Teachers

Students solidify their knowledge and skills when they are not only given opportunity to practice but also to teach. When students are able to offer client education, it cements what they know and gives them the confidence that they know it. Providing occasion for students to teach each other both in practice settings and in clinical settings under preceptor supervision is also an invaluable opportunity for students to gain confidence.