Clinical Teaching and Learning in Midwifery and

Women’s Health
Jeanne Raisler, CNM, DrPH, Michelle O’Grady, CNM, MS, and Jody Lori, CNM, MS

Although there is an abundance of literature about clinical teaching in the health professions, a much smaller
body of information focuses on the art and science of clinical teaching in midwifery and women’s health.
We reviewed preceptor handbooks, training manuals, and Web sites created by nursing and nurse-midwifery
education programs, medical and pharmacy schools, and national associations of health professionals. Using
the search terms 具clinical teaching, clinical learning, preceptor, clerkship, residency training, and midwifery
education典, we searched the MEDLINE and CINAHL databases and health sciences libraries for relevant
articles and books. The information and practical strategies about clinical teaching that we found are
synthesized and presented in this article. It includes a discussion of challenges in clinical teaching; an
overview of expectations and responsibilities of the education program, students, and preceptors; sugges-
tions about orienting students to clinical sites; clinical teaching strategies and skills; suggestions for
incorporating critical thinking and evidence-based care into clinical teaching; guidelines for giving
constructive feedback and evaluation; characteristics of excellent clinical teachers; and suggestions about
how education programs and professional associations can support and develop clinical sites and preceptors.
The Appendix contains manuals, books, and Web sites devoted to clinical teaching. J Midwifery Womens
Health 2003;48:398 – 406 © 2003 by the American College of Nurse-Midwives.
keywords: clinical teaching, clinical learning, preceptor, clerkship, residency training, midwifery education

Clinical teaching* lies at the heart of midwifery and strategies for educating health science students. This article
women’s health education. The contribution that clinical reviews effective strategies for clinical teaching based on a
preceptors make to students’ professional development review of the literature.
cannot be overestimated. Midwives and Advanced Practice
Nurses (APNs) have an exemplary tradition of serving as CHARACTERISTICS OF EXCELLENT CLINICAL TEACHERS
clinical preceptors, and most welcome the challenge and
stimulation of working with students. Precepting is a way Excellent clinical teachers integrate knowledge about
that clinicians stay up to date, improve their critical teaching and learning, clinical skills, critical thinking, and
thinking skills, and enhance their self-esteem and confi- evidence-based care into their clinical teaching.3,4 Behav-
dence.1 Yet given the demands on clinicians to provide iors and characteristics demonstrated by expert clinical
evidence-based care and to be highly productive, it is teachers are listed in Table 1.
essential to find ways of making clinical teaching efficient, Kennedy’s study of exemplary midwifery practice points
intellectually rigorous, and well integrated into clinical out clinician characteristics that are especially intertwined
practice. with the midwifery model of care. Midwife-clinician role
models in her study have mastered the art of “doing nothing
FROM EXPERT CLINICIAN TO EXPERT TEACHER well,” by supporting the normalcy of pregnancy and birth,
remaining vigilant to attention and detail, respecting the
Although the importance of clinical teaching is universally uniqueness of the woman, and helping her to control the
acknowledged in the health professions, little formal train- birthing process.5
ing is offered to prepare practitioners for this important
role. Joyce Thompson, who pioneered the Teacher Educa-
tion Program at the University of Pennsylvania, disputes CLINICAL TEACHING CHALLENGES
the myth that good clinicians will automatically be good Several factors make clinical teaching a challenge for
teachers and argues that clinical teaching workshops and preceptors, students, and faculty today:
courses are important for preceptor development.2 Most
nurse practitioners and midwives can become better clinical Preceptors are pressured to see more patients in less
teachers when they are exposed to information and teaching time and worried about being slowed down by stu-
dents. It can be difficult to arrange additional exam-
ination rooms or call rooms for learners. The atmo-
sphere in the health facility may be chaotic and
Address correspondence to Jeanne Raisler, CNM, DrPH, University of stressful, as hospitals and practices merge, dissolve,
Michigan School of Nursing, 400 North Ingalls, Room 3320, Ann Arbor, MI and change to survive.
48109-0482.
Students face multiple stresses that affect their clinical
* In this article, clinical teaching refers to clinical supervision of students,
whether by academic or clinical faculty, community midwives, or nurse- experience, including time and financial pressures;
practitioners. long commutes; juggling responsibilities for family,

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

© 2003 by the American College of Nurse-Midwives 1526-9523/03/$30.00 • doi:10.1016/j.jmwh.2003.08.005
Issued by Elsevier Inc.
 Table 1. Characteristics of Expert Clinical Teachers to help the preceptor and student to build an effective
teaching-learning relationship. Because today’s preceptors
may be working with students from several different
Competence educational programs, it is important to clarify each pro-
A broad base of knowledge in their chosen field gram’s structure, curriculum, and educational philosophy.
Enjoyment of teaching and patient care
Respect for students and patients Providing monetary compensation to clinical sites is a
Accessibility and supportiveness thorny issue, because some midwifery programs are able to
Being well-organized pay clinical sites, whereas others are prohibited from doing
Giving clear direction to students about what is expected. so. Other types of compensation that are often offered
Limiting the amount of content that they teach in a given encounter include free or reduced-price continuing education pro-
Teaching in a practical, engaging manner
Providing frequent, nonthreatening feedback grams, Internet/e-mail accounts, and library privileges.
Preparing materials and planning teaching experiences ahead of time When making a clinical placement, faculty should con-
Taking advantage of teachable moments that arise in the clinical sider the fit of the student with the preceptor and practice.
setting In some programs, students fill out a Clinical Preferences
Teaching at the student’s level Form before clinical assignments are made; they detail their
Continuously reflecting on their teaching successes and failures
Remaining open to change and experimenting with new approaches prior experience, personal constraints (e.g., family, travel
constraints), and desires for the next clinical rotation (e.g.,
patient population, volume, risk level, and precepting style
that is most helpful to them). It is helpful to have a class
work, and school; insufficient time to study; and, for discussion about clinical survival skills before the begin-
some, the role change from expert nurse to novice ning of the clinical rotation. During this session, students
midwife or APN. appreciate hearing from more advanced students or recent
Faculty in research-intensive universities face increasing graduates who recently completed similar clinical rotations.
pressure to publish and secure research grants, leav- Some education programs have created a Clinical Coor-
ing less time available to work with students and dinator position to link the academic program and clinical
preceptors. Candidates for tenure may be discouraged sites more effectively. The Clinical Coordinator has a key
from engaging in more than token clinical practice. role in recruiting and retaining preceptors and clinical sites
As teachers move further from practice, their ability and arranging student placements. S/he may also provide
to support and evaluate the clinical learning process teaching and learning resources to faculty and preceptors
may be compromised. and supervise clinical activities. This multifaceted role
requires clinical and academic competence, creativity, flex-
PREPARING FOR CLINICAL TEACHING ibility, and good communication skills.6
Preceptors, staff, clients, students, and faculty must all Before taking students, preceptors should first assess
prepare for the student’s entry into the clinical setting. their site to determine whether there is sufficient time,
Plans should be made for getting to know the student, space, patient volume, and facility support for a positive
finding out how s/he learns best, orienting him/her to the clinical learning experience. Clinical sites should inform
site, and clarifying expectations and responsibilities of the the education program of their own criteria for acceptable
education program, the student, and the clinical preceptor. students; for example, a midwifery practice may be unwill-
All the teaching materials we reviewed stressed the impor- ing to precept students who lack prior obstetrical nursing
tance of clarifying expectations early in the process. Guide- experience.
lines for how to do this were similar in the fields of It is helpful to let other staff know that the student will be
midwifery, advanced practice nursing, medicine, and phys- coming and to involve them in welcoming and orienting the
ical therapy; they are summarized in Table 2. student to the clinical setting. For example, a staff member
The education program should provide information and who knows the neighborhood might enjoy orienting the
resources for preceptor development, including suggestions student to local resources, such as the WIC program,
childbirth classes, or women’s shelters, or informing her/
him about a local factory or store where many patients are
employed. Some clinical sites post a welcome notice in the
Jeanne Raisler, CNM, DrPH, FACNM, is an assistant professor at the waiting room with the student’s picture and biosketch along
University of Michigan Nurse-Midwifery Program and a consultant to the
Global AIDS Bureau of the Human Resources Service Administration with a message from the practice describing her role during
(HRSA). the rotation.
Michelle O’Grady, CNM, MS, is a Lecturer in the University of Michigan Students will get the most out of clinical rotations by
Nurse-Midwifery Program and the Faculty Director of the Health Sciences cultivating an attitude of friendliness and respect for pa-
Scholars Program at the University of Michigan.
tients and staff and trying to learn as much as possible.
Jody Lori, CNM, MS, is a Lecturer at the University of Michigan Nurse-
Midwifery Program, where she is working to develop student clinical rotations They should be punctual, appropriately dressed, learn the
in Latin America. names and responsibilities of staff members, and become

Journal of Midwifery & Women’s Health • www.jmwh.org 399

 Table 2. Expectations and Responsibilities in Clinical Teaching

Faculty/Program Preceptor Student

Provide learning objectives Demonstrate safe, evidence-based practice Dress professionally
Provide tools for feedback/evaluation Hold current licensure Be prompt and courteous
Clarify grading criteria and responsibility Be aware of curriculum, learning Know own learning needs
Initiate student and preceptor contact objectives, evaluation forms, grading Be familiar with clinical objectives,
Resolve clinical problems in collaboration criteria evaluation forms, grading criteria
with preceptor and student Orient student to site Develop personal learning objectives
Provide to preceptor: orientation to Hold realistic expectations for student Evaluate self, preceptor, site
clinical teaching, student bio, program performance Take responsibility for own learning
objectives, curriculum, and evaluation Create optimal learning opportunities Adapt life to clinical placement
forms Provide timely, constructive feedback Provide needed documents and information
Provide to student: description, location, Evaluate student performance fairly and Follow clinical site policies
and contact information for the accurately Know how to contact site and preceptor
practice and preceptor, clinical Optimize clinical schedule for teaching Notify site/preceptor/program in advance of
objectives, evaluation tools, are absence or lateness
grading criteria

knowledgeable about resources and issues in the surround- breaks, orient her to the facility’s forms and charting
ing community. They should bring copies of the program’s procedures, describe how the student will review charts and
clinical objectives, evaluation forms, and grading criteria present patients, and discuss how much supervision the
and be ready to share these with preceptors as needed. They preceptor will provide. It is helpful to review the education
should let the preceptor know their learning needs, includ- program’s evaluation forms together, highlighting the
ing the need to work on specific skills, such as interpreting learning objectives to be accomplished, special needs of the
fetal monitor tracings or starting IVs. student, and the time frame for evaluations.

ORIENTATION TO THE CLINICAL SITE

THE PROCESS OF CLINICAL TEACHING
All the teaching materials we reviewed emphasized the
Efficient Clinical Teaching
need to provide students with a thorough orientation to the
clinical site. It is helpful to schedule the orientation prior to A major challenge for preceptors is integrating clinical
the first clinical session and to reserve 45 to 60 minutes for teaching efficiently with patient care, so that the workload
this initial meeting, at a time that does not compete with is not unduly increased and the patient flow does not bog
patient care responsibilities. One primary care program has down. Clinical teaching does take extra time; one family
the student accompany a patient through the entire care practice study found that having a learner in the practice
process from check-in to discharge to learn about patient increased the workload by about 45 minutes per day.9
flow through the facility.7 Preceptors in that study dealt with this in several ways:
The initial meeting is a time to begin to know each other some worked longer days, whereas others scheduled fewer
and clarify expectations and responsibilities. The student’s patients or different kinds of appointments when a learner
schedule should be described and negotiated, and s/he was present. Midwifery and APN preceptors in the outpa-
should be informed of rounds and conferences that s/he is tient setting may be able to block out appointment slots in
expected to attend. The student may want to describe her the schedule, which can be used for clinical teaching or
prior clinical experiences and explain what kinds of feed- catching up with patient flow.
back are most helpful for her. The preceptor may also want Several sources emphasized the utility and efficiency of
to share insights from her own student experiences and teaching in the patient’s presence10 while listening and
explain how these have influenced her precepting style. responding to the student’s report. This gives the woman
Reading Varney’s essay on the Circle of Safety in clinical more face-to-face time with the preceptor and the chance to
teaching8 together could stimulate the preceptor and student correct information that the student has misunderstood. It
to discuss issues of clinical supervision and student inde- also gives the student valuable practice in conveying
pendence. sensitive information in a neutral, nonjudgmental manner.
The orientation should include a tour of the facility; Once students can partially conduct a visit alone, a more
guidance about where to review patient records and write efficient pattern can be developed, in which the preceptor
notes; and explanations about the computers, telephone and student see patients simultaneously. When the precep-
system, and parking. The preceptor should inform the tor completes her/his visit, s/he joins the student and
student about the schedule and timing of patient visits and patient, reviews the findings and care plan, and checks any

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

questionable physical findings. The preceptor can then see Table 3. The One-Minute Preceptor
another patient while the student completes patient teaching
and writes up her/his findings. Because there may not be
time for discussion after every visit, it can be helpful for the Precepting Strategy Example
student to carry a notebook in which to record questions Get a commitment from the “Do you think she needs to be
about patient management for later discussion. student about some admitted to the hospital
Beginning students should start out with a small number aspect of the diagnosis today?”
of less complicated patients and progress to seeing higher Probe for supporting “What aspects of the physical
evidence exam support your
numbers of patients with more complex needs as their diagnosis?”
clinical knowledge and skills develop. Asking a beginning Reinforce what was done “Your presentation was well
student to shadow a busy midwife who is rushing through well organized, and included a
a series of clinical encounters may result in much frustra- focused history, physical
tion and little learning. Reviewing the schedule before findings, and lab results.”
Point out errors and “By listening to her more
clinic may indicate which patients are most appropriate for omissions in the closely, you might have
the student to see; the preceptor and student can also presentation and care discovered the main reason
determine how many patient visits is a reasonable goal at a plan for today’s visit.”
given point in the rotation. To teach efficiently, it may be Teach a general principle or “In urinary tract infections, the
necessary to set time limits on student assignments (e.g., indicate how to find urinalysis will most often
more information about show. . . .”
“Get as much history as you can in 10 minutes”) and on the issue
your interactions with students (e.g., “You can have 5 Conclude the teaching “Let’s go back in and see her
minutes to present the patient, then I will need 5 minutes to encounter together. I’ll recheck the
give you feedback and ask questions”). In a busy labor physical exam and confirm
ward, it may make sense to assign the student to provide your diagnosis.”
in-depth care to only one or two patients, even if the Adapted from: University of Kansas.12
preceptor is responsible for the care of a greater number.
Finally, it is important for the preceptor to be realistic
about how much s/he attempts to teach. Although every Most beginning students crave consistency and the security
patient interaction offers innumerable teaching points, there of learning one approach; as they become more experienced
may be time to address only one or two in the busy clinical and confident, they are better able to appreciate the diverse
setting. Ask yourself: What are the most relevant teaching styles of different practitioners. However, it is worthwhile
points I can make now for this student? to encourage other practitioners to call the student in to
observe unusual findings, such as malpresentations or signs
The One-Minute Preceptor Strategy of sexually transmitted infections.
A clinical teaching strategy that has been taught and tested
in physician training is the “One-Minute Preceptor” mod-
el.11,12 This strategy recognizes that much clinical teaching How Much Supervision?
involves the learner interviewing and examining the patient In the beginning of an ambulatory care rotation, most
and then presenting the findings to the preceptor. Studies
preceptors and education programs recommend that the
show that these interactions last around 10 minutes, includ-
preceptor remain in the room and observe the entire patient
ing 6 minutes of the student’s presentation, 3 minutes of
questions and clarifications, and 1 minute of preceptor visit. In fact, some preceptors remain in the room with
teaching. The One-Minute Preceptor method can be used to students throughout the rotation, albeit assuming a more
maximize clinical teaching time (Table 3). passive, observational role as the student grows in ability
and confidence. Preceptors generally practice close super-
How Many Preceptors? vision and validate physical findings until they gain confi-
dence in the student’s clinical ability and reasoning. As the
The beginning student and the student beginning a new
student develops clinical competence, many preceptors will
rotation or clinical site will benefit from having a consistent
allow her to conduct patient visits semi-independently,
preceptor. A single preceptor will be better able to evaluate
the student’s clinical progress and to structure meaningful while listening to her report, reviewing the chart, and
clinical experiences. In addition, one-to-one interaction coming in to confirm findings and interact with the patient
usually facilitates the development of a supportive relation- at the end of the visit. Ongoing formative evaluations will
ship. When a student is assigned to multiple preceptors, it provide evidence to increase independence level. No
may take longer for the group to recognize strengths or woman who has been cared for by a student should ever
difficulties, especially in a busy practice that lacks a leave the office or birthing unit until her case has been
mechanism for preceptor communication about students. reviewed with the preceptor.

Journal of Midwifery & Women’s Health • www.jmwh.org 401

CRITICAL THINKING AND THE MANAGEMENT PROCESS guidance about what to do, or proposes a management plan,
the preceptor can (1) ask whether evidence exists relevant
A core aspect of clinical precepting is teaching students to
to the question or plan; (2) help the student to locate
use the management process and incorporate critical think-
evidence; (3) guide her in appraising the quality of the
ing as they provide individualized, evidence-based patient
evidence; and, if warranted, (4) develop a new management
care. Because knowledge evolves so quickly in the health
plan based on the evidence. This approach is facilitated if
sciences, cognitive information may rapidly become out-
resources, such as the on-line Cochrane database, current
dated. But the student who learns to think independently
practice guidelines, and library facilities, are readily avail-
and seek out the best evidence while applying the manage-
able in the clinical setting. If not, the search for evidence
ment process has a framework within which emerging
can be assigned as clinical “homework,” and the student
information can be continuously integrated.
can report back to the preceptor with the results of her
The management process consists of a series of well-
investigation. Lack of time, energy, reference materials,
known steps: Data collection (history, physical examina-
and research training can all be barriers to incorporating
tion, labs), Assessment, Planning, Implementation, and
evidence-based care into clinical teaching. Yet, once the
Evaluation. Critical thinking is characterized by Thompson
evidence-based care strategy becomes integrated into prac-
as a process involving reflection, reasoning, and exploration
tice, it can provide preceptors with a consistent, up-to-date,
of the unknown and unexpected before making a decision.2
and safe approach to teaching the management process to
When applying critical thinking to the management pro-
students.
cess, the student is forced to recognize anew the old precept
that every woman, every pregnancy, every labor, and every
patient encounter is different; thus, she must approach the
Giving and Receiving Report
patient with a mind that is open to new data and new
approaches. Critical thinking is not standardized, and stu- Learning to “give report” about a client’s condition concisely
dents who are critical thinkers may sometimes irritate their and accurately is an important skill that should be taught in the
faculty and preceptors, who may remind them that “this is classroom and honed during clinical rotations. It is helpful for
what the textbook says about X,” or “this is how we the education program to teach a standard format for giving
manage that here.” Reflecting on this challenge, Thompson report, which is also shared with preceptors. The beginning
ruefully notes that “the dominant teaching modes used student may need to give report about each patient several
during nursing education actually curtail the development times: after reviewing the chart and before seeing the patient;
of critical thinking…it is possible to turn off the inquisitive, after interviewing the patient and before performing the
reflective impulses in learners by the way we teach.”2 She physical examination; and to summarize the visit at its
encourages teachers to create an atmosphere that fosters conclusion. Following a consistent format in which informa-
critical thinking, risk taking, discovery, and trust. tion is presented in an expected sequence helps both the
presenter and the listener to comprehend the situation. The
Fostering Evidence-Based Care preceptor can help the student learn to give brief, accurate
reports that focus on important issues and use correct medical
Providing evidence-based care requires basing patient man-
terminology. The student’s report provides a window onto her
agement on three essential elements: (1) the best evidence
clinical thinking and offers a teachable moment during which
from research, (2) the clinician’s experience and judgment,
the preceptor can ask questions and assess the completeness of
and (3) patient preferences. Evidence from randomized
care, even if she was not present during the entire patient visit.
controlled trials and systematic reviews is well developed
in the fields of midwifery and obstetrics, and there is an
abundance of high-quality information on which to base
CREATING STRUCTURED LEARNING EXPERIENCES
clinical decisions.13,14 Midwifery and APN education pro-
grams are increasingly stressing the need for evidence- Creating structured learning experiences enhances students’
based practice and requiring students to read and evaluate clinical experiences and helps them achieve learning objec-
current research in addition to their textbooks to learn to tives that might not otherwise be met in a particular clinical
apply emerging evidence to clinical decision making. In setting. If, upon reviewing the objectives for an ambulatory
“the real world,” the student also may encounter practitio- care rotation, a preceptor realizes that s/he does not rou-
ners who are functioning under time pressures or institu- tinely provide certain required experiences, s/he might be
tional constraints and basing practice on prior experience, able to plan alternative ways to provide them. For example,
personal preference and/or habit.15 Such differences can a midwifery preceptor might ask a neonatal nurse-practi-
confuse the student and inhibit learning. tioner to supervise the student in perfecting newborn exam
Erickson-Owens and Kennedy have emphasized the skills or arrange clinic time for the student with a women’s
importance of evidence-based care in clinical teaching, and health nurse-practitioner who excels in caring for perim-
they encourage preceptors to seize teachable moments to enopausal women. Preceptors and the education program
promote a four-step strategy.16 When the student asks for can work together to develop alternative learning experi-

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

 Table 4. Characteristics of Constructive Feedback view of her clinical performance and her readiness to
change. Feedback for a student who is oblivious to perfor-
mance deficits will be quite different from that given to a
Constructive Feedback self-critical student who is trying to improve.
Constructive Feedback IS. . . IS NOT. . . Although it can be difficult to find time to give feedback
Descriptive Evaluative promptly, the teaching materials reviewed all emphasized
Specific and precise General that feedback is most meaningful when given as soon as
Focused on behavior Focused on personality possible after the event. Every effort should be made to
Timely Delayed
Nonthreatening Hurtful schedule time for feedback regularly during the clinical
Clearly communicated Assumed day, perhaps at lunch hour, while commuting with the
Limited in scope Overwhelming student, or at the end of the day. If necessary, feedback and
A stimulus for reflection and change Punitive or shaming discussion can also take place by phone or e-mail within a
Followed by a plan for action A stand-alone event day or two of the session. The student should fill out her
daily evaluation form and give it to the preceptor before
leaving the clinical area; and the preceptor should try to
respond while the day’s events are fresh in her mind.
ences such as informal conferences, independent study, and Putting off the daily evaluations and dealing with them in a
clinical homework.17 bunch toward the end of the rotation results in much less
Informal conferences could include having the student meaningful feedback and denies the student an important
present a “case of the week” to the preceptor and other opportunity to improve clinical performance.
available clinicians in the practice; an “end of the day Compared with feedback, evaluation is a more formal
summary,” in which the student reflects on what s/he assessment of the student’s performance. It summarizes the
learned that day and discusses patient management with the preceptor’s daily observations and assessments and is
preceptor; or participating in a journal club focusing on usually scheduled at the midpoint (formative evaluation)
patient management issues. and at the end of the rotation (summative evaluation).
Independent study activities can help students focus on Formative evaluation is ongoing and leads to specific plans
problems or skills that may not arise in the course of the for improvement, whereas summative evaluation reflects
day’s work. They could include suturing placentas or progress over a completed time period. The grade resulting
performing newborn examinations during quiet times in the from the evaluation usually reflects a joint determination by
labor ward; having available independent study modules the preceptor and program faculty of whether (and how
and question banks that focus on patient management well) the student has met the objectives of the rotation. If
issues; and sending students on home visits to postpartum the course objectives and expectations have been reviewed
mothers, perhaps accompanying a visiting nurse or breast- by the preceptor and student, and if feedback has been
feeding peer counselor. Alternatively, a student could given honestly and regularly, the evaluation and grade
deepen her public health perspective by visiting the Mater- should come as no surprise.
nal & Child Health section of the state health department to It is always uncomfortable to give students negative
learn about work they are doing to prevent low birth weight feedback or evaluations. To add to the difficulty, the student
or maternal mortality. who is not meeting the clinical objectives may be unaware
Clinical homework can mean assigning students to look of her deficits and/or unwilling to accept critical input.
up information about patient conditions or management When a preceptor becomes aware that an unsatisfactory
encountered in the clinical setting and then honoring their evaluation may be on the horizon, she should seek the
effort by listening to and discussing their findings on your involvement and support of the program faculty. The
next day together. faculty member should then meet with the preceptor and
student to discuss the problems identified and measures to
correct them. If necessary, a Learning Plan or Learning
FEEDBACK AND EVALUATION
Contract to address the issues can then be jointly created.
Giving feedback and evaluating student performance are The same management framework that is used in patient
critical clinical teaching skills. Characteristics of construc- care can also be applied to student learning problems. Table
tive feedback and evaluation are listed in Table 4. The 5 is an example of how clinical teachers can apply the
purpose of feedback is to help the student by providing management process to help to identify and address stu-
concrete observations and suggestions about how to im- dent-learning difficulties.
prove clinical performance. The most effective feedback is
specific, objective, and timely. Many education programs
Site Visits
require students to complete daily self-assessments, and it
is important to carefully consider these before giving Faculty members generally contact the preceptor several
feedback, because they offer a window into the student’s times during the rotation. They usually visit each clinical

Journal of Midwifery & Women’s Health • www.jmwh.org 403

 Table 5. Applying the Management Process to Clinical Learning Problems PROVIDING SUPPORT FOR CLINICAL TEACHING
Our review revealed a rich variety of clinical teaching
The management process can be usefully applied to clinical learning resources and strategies that have been developed by the
problems, as well as to patient management. Consider student health professions. Yet it also indicated the need for more
midwife Mary who is half-way through her second clinical rotation. As training and support for clinical teaching in midwifery and
Mary’s preceptor, you harbor the following concerns: “She doesn’t APN education programs. Developing high-quality teach-
seem to understand how to make a differential diagnoses. Sometimes ing and learning resources is a time-intensive and expensive
she can’t even identify the most likely diagnosis or recognize an
obvious abnormality.” process, and these tasks could be shared among education
programs and professional associations for the mutual
1. Collect data. Is Mary having difficulty gathering all the necessary benefit of all. Some excellent resources (Appendix A) have
information on which to base her decision? Does she lack skills in been developed and could be shared more widely, both
interviewing or physical assessment? Does she obtain all the needed among education programs and with preceptors and stu-
information but then have a problem making sense of it? What are
her thought processes as she tries to arrive at a clinical diagnosis? dents.18 –21 We noted with interest that both the National
How does Mary view her own clinical progress? Organization of Nurse Practitioner Faculties (NONPF) and
the American Physical Therapy Association (APTA) have
2. Assess the problem. After observing and talking with Mary, you produced extensive clinical education manuals for their
realize that while she collects history and physical exam data quite professions. The NONPF manual sets out clear expecta-
accurately, she has difficulty synthesizing it to develop a differential
diagnosis. Furthermore, she does not know the clinical significance of tions for all persons involved in nurse-practitioner educa-
many lab tests. tion and offers an extensive bibliography and Web-based
resources for preceptors.22 The APTA manual consists of
3. Plan the intervention. This problem needs immediate attention, because voluntary guidelines for education programs and clinical
Mary will continue to flounder until she learns to synthesize and interpret preceptors about how to develop and enhance clinical
clinical data. After discussing the situation with the academic
coordinator, you tentatively conclude that Mary has a cognitive learning education.23 Such a manual could be a powerful national
problem, related to processing information. You decide to remain with resource for clinical education in midwifery as well.
Mary for the entire visit with the first two patients each morning this
week, and to role-model how you gather and synthesize information to
arrive at a list of differential diagnoses. After each visit, it may help if
CONCLUSION
you will think out loud with Mary, explaining your reasoning process. Mary In conclusion, we offer the following recommendations to
will then see the next few patients and present them formally to you,
including history, physical exam, chief complaint, and differential
support and enhance clinical teaching in midwifery and
diagnosis. Make sure the student understands and agrees to the plan women’s health: (1) Develop a national Midwifery and Wom-
prior to implementing it. en’s Health Preceptor Training Manual, which could then be
customized by education programs. This could be authored by
4. Implement the plan. As you and Mary carry out this plan, you note a national working group of educators and clinicians. (2)
that it seems to be helping her to stay organized. By the end of the
week, she can more easily formulate differential diagnoses based on
Create a Clinical Preceptor Web page, including a Clinical
the data she gathered. To consolidate learning, you agree to continue Teaching Resources Archive, linked to the Web sites of the
the plan for another week. American College of Nurse-Midwives, the American College
of Nurse-Practitioners, and the American Academy of Nurse
5. Evaluate the effectiveness of the plan. Was the educational Practioners and their respective education programs. (3) Offer
intervention successful? Are further steps needed? Follow up with the
academic coordinator.
Preceptor Development Programs with continuing education
credit at state, regional, and national professional meetings. (4)
Offer short Clinical Certification Courses for preceptors with
site at least once during the semester, and they should be CE credit.
readily available to help to resolve learning problems that By working together and sharing resources, midwifery and
may arise. It is very helpful for the faculty member to talk women’s health APN education programs will increase our
with both the preceptor and the student before a site visit to ability to support and nurture one of our most precious
learn more about how the clinical experience is going from resources— our dedicated and hardworking clinical precep-
both of their perspectives. It is not unusual for problems that tors.
were not noted on the clinical evaluation forms to surface
during the phone conversation. Site visits can take many REFERENCES
forms, but they usually include reviewing charts with the 1. Sload ED, Feroli K, Bearss N, Beecher J. Preparing the next
student, observing the student working with patients, case generation: precepting nurse practitioner students. J Am Acad Nurse
discussions, and observation of the preceptor-student work- Pract 1998;10:65–9.
ing relationship. During site visits, it is very helpful to use 2. Thompson JE, Kershbaumer RM, Krisman-Scott MA. Educat-
a structured observation tool to collect information about ing advanced practice nurses and midwives. New York: Springer
the student’s performance and the clinical site. Publishing, 2001.

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 3. Irby DM, Papadakis M. Does good clinical teaching really 14. The Cochrane Library. Available from: http://www.update-
make a difference? Am J Med 2001;110:231–2. software.com/Cochrane/.
4. Pinsky L, Monson D, Irby DM. How excellent teachers are 15. Carr C, Schott A. Differences in evidence-based care in mid-
made: reflecting on success to improve teaching. Adv Health Sci wifery practice and education. J Nurs Scholar 2002;34:153–8.
Educ 1998;3:207–25.
16. Erikson-Owens DA, Kennedy HP. Fostering evidence-based
5. Kennedy HP. A model of exemplary midwifery practice: Re- care in clinical teaching. J Midwifery Womens Health 2001;46:137–
sults of a Delphi study. J Midwifery Womens Health 2000;34:4 –19. 45.
6. Sobralske M, Naegele LM. Worth their weight in gold: The role
17. Kleffner JH. Becoming an effective preceptor. 1998. Texas
of clinical coordinator in a family nurse practitioner program. J Am
Tech Health Science Center School of Pharmacy. [cited March 12,
Acad Nurse Pract 2001;13:537–44.
2002]. Available from: http://ismo.ama.ttuhsc.edu/Continuing Ed/
7. MAHEC Office of Regional Primary Care Education. Asheville EffectPreceptor.htm.
(NC): Educational monographs for CORE clinical faculty. [cited January
16, 2003]. Available from Ohio University College of Osteopathic 18. Partners in NP education: A preceptor manual for NP pro-
Medicine Web site: www.oucom.ohiou.edu/fd/monographs/setting. grams, faculty, preceptors and students. National Organization of
Nurse Practitioner Faculties.
8. Burst H. The circle of safety: a tool for clinical preceptors. J
Midwifery Womens Health 2000;45:408 –10. 19. Guidelines and self-assessments for clinical education. Alex-
andra (VA): American Physical Therapy Association, 1999.
9. Vinson DC, Paden C, Devera-Sales A. Impact of medical
student teaching on family physicians’ use of time. J Fam Pract 20. Nurse-Midwifery Program Faculty. Instructions for self-study
1996;42:243–9. module: Precepting at the beginning of the 21st century. Portland
(OR): Oregon Health & Science University School of Nursing, 2002.
10. Hedenreich C, Lye P, Simpson D, Lourich M. The search for
effective and efficient abbulatory teaching methods through the lit- 21. Lichtman R, Jurow D, Cunningham V, Harmon P, Rouhana N,
erature. Pediatrics 2000;105:231–7. Schelling K, et al. Nurse midwifery preceptor manual. Stony Brook
11. Nehrer JO, Gordon KC, Meyer B, Stevens N. A five-step (NY): SUNY-Stony Brook, Health Sciences Center, 2002.
“microskills” model of clinical teaching. J Am Board Fam Pract 22. Avery M, Ringdahl D. Preceptor education: Clinical teaching.
1992;5:419 –24. Minneapolis (MN): Nurse-Midwife Program and Women’s Health
12. One minute preceptor: Microskills of clinical teaching. Univer- Care Nurse Practitioner Program, University of Minnesota School of
sity of Kansas School of Medicine, Family & Community Medicine Nursing, 2002.
Preceptor Handbook 2001 [Internet]. [cited January 23, 2003]. Avail-
23. Institute of Midwifery, Women & Health, Nurse-Midwifery
able from: http://wichita.kumc.edu/fcm/precpdev/minute.html.
Certification Program. Clinical faculty introduction to teaching man-
13. Sakala C. New resources for evidence-based practice. J Mid- ual. Philadelphia (PA): Institute of Midwifery, Women & Health,
wifery Womens Health 2003;48:69 –71. Nurse-Midwifery Certification Program, 2000.

APPENDIX A. Resources for Clinical Teaching

Manuals and Books

Oregon Health and Science University, School of Nursing, Instructions This self-study module helps preceptors to assess themselves and their
for Self-Study Module: Precepting at the Beginning of the 21st clinical site for teaching readiness and discusses various
Century. 2002 approaches to teaching. It has four articles about precepting and an
insightful FAQ section about what to consider before becoming a
preceptor. A video of two students discussing their clinical learning
experiences accompanies this module. (35 pages)
State University of New York at Stoney Brook, Health Science Center, This well-organized manual is based on a literature review of
School of Nursing: Nurse-Midwifery Preceptor Manual. 2002 educational concepts and mentoring as well as the authors’
teaching experience. It reviews teaching and learning styles and
includes a thoughtful section on cultural competence for clinical
preceptors with an extensive bibliography. It also has sections on
feedback and evaluation, supervision of student in the inpatient and
outpatient areas, and working with the student who has problems.
Case studies are included that offer examples of precepting
situations requiring intervention. The manual is ACNM approved for
.5 CEUs upon completion and submission to SUNY. Examples of
SUNY’s clinical evaluation tools are included. (97 pages)
The National Organization of Nurse Practitioner Faculties (NONPF), This manual is divided into nine modules and includes a section
Washington, DC, Partners in NP Education: A Preceptor Manual for devoted to Preceptor Guidelines. It lists clear expectations for all
NP Programs, Faculty, Preceptors and Students. 2000 involved in NP education and gives resources for preceptors in the
form of a bibliography and Web-based citations. (128 pages)

Journal of Midwifery & Women’s Health • www.jmwh.org 405

 APPENDIX A. Continued

University of Minnesota School of Nursing, Nurse-Midwife This manual aims “to provide clinical preceptors with additional
Program and Women’s Health Care Nurse Practitioner educational tools for use in the clinical learning environment.”
Program: Preceptor Education: Clinical Teaching. 2002 Although some information is relevant only to University of
Minnesota preceptors, general information is also included about
preceptor guidelines, rights and responsibilities of preceptors, and
clinical teaching. There is a reference list of current articles, a hard
copy of a slide presentation on teaching and learning, and examples
of preceptor evaluation tools used at the University of Minnesota.
(33 pages)
Institute for Midwifery, Women, & Health: Clinical This manual was developed as a self-study module for clinical
Faculty Introduction to Teaching Manual. 2000 preceptors, particularly those in distance education programs. It
includes principles of adult education, descriptions of diverse
learning styles, methods of clinical teaching and evaluation,
examples of clinical learning problems and strategies to resolve
them, and guidelines for collaboration between the preceptor and
the education program. (17 pages of text plus 22 articles and
handouts about clinical teaching)
Thompson, J.E., Kershbaumer, R.M., Krisman-Scott, M.A. This book is a guide for new teachers of APNs and midwives. The book
Educating Advanced Practice Nurses and Midwives: developed from the post-master’s teaching certificate program that
From Practice to Teaching. 2001 Thompson and colleagues offered to APN and midwifery faculty in
the 1990s. It provides a concise overview of the theories, principles,
and challenges of teaching and learning. The authors move from
broad issues of philosophy and values to more specific concepts
(with examples) such as critical thinking, classroom teaching
methods, clinical teaching strategies, learning difficulties, and
evaluation guidelines. Sample evaluation forms, teaching guidelines,
and curriculum schema are included.
On-line Resources for Clinical Teachers
Columbia University, School of Nursing, Preceptor Contains general information for preceptors. Geared toward
Handbook. http://www.nursing.hs.columbia.edu undergraduate nursing education with short, concise sections. (14
pages)
MAHEC Office of Regional Primary Care Education: Geared toward clinical education of primary care medical care
Setting Expectations. http://www.oucom.ohiou.edu/fd/ practitioners. Covers orientation, setting objectives, expectations for
monographs/setting.htm learners, skills of effective precepting, bedside teaching, giving
feedback and evaluation, and dealing with difficult learners.
Emphasizes time management and efficiency in clinical teaching.
Describes the One Minute Preceptor technique. (55 pages)
Texas Tech University: Becoming An Effective Preceptor. Developed for pharmacist preceptors. General teaching/learning
http://ismo.ama.ttuhsc.ed/ContinuingEd/EffectPreceptor.htm concepts and skills with preceptor self-assessment exercises. (36
pages)
The University of Kansas, School of Medicine, Strategies An extensive site developed for preceptors and faculty at the University
in Clinical Teaching. http://wichita.kumc.edu of Kansas School of Medicine. Emphasizes practical clinical teaching
strategies. Although it is aimed at family practice physician
preceptors, much of the information applies to other health science
preceptors. Features case studies of difficult teaching situations and
solutions to common precepting problems. Each section has post-
test questions. (over 30 pages with additional links)
University of Toronto School of Nursing: ACNP Preceptors. A concise guide for acute care nurse practitioner preceptors. Discusses
http://www.nursing.utoronto.ca/preceptors/default.phtml preceptor and learner roles, teaching strategies and student learning
plans. Features forms specific to the University of Toronto programs.
(7 pages with links)
University of Utah College of Nursing: Becoming a Great A short document which discusses ground rules, expectations and tips
Preceptor. http://www.nurs.utah.edu/np/preceptor.htm on how to become an efficient, successful preceptor of nurse
practitioner students. Contains a short bibliography. (4 pages)
University of Washington, Department of Family Developed for community preceptors of family medicine. While some
Medicine: Clinical Teaching Handbook. information is specific to precepting medical students, other
http://www.washington.edu generally relevant sections discuss orienting students to the
practice, establishing expectations, giving feedback and evaluation,
developing clinical teaching expertise and honoring diversity. (20
pages with 15 linked appendices)

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