Part 2: Nuts and Bolts 101-Facts, Rules and Other Structures

B. Guidelines for the Clinical Experience

1. Working During Clinical

Students are strongly advised not to work during clinical, because the academic and clinical loads are heavy and availability for clinical should be maximized. However, circumstances for some students require that they continue working. Three RULES apply:

1. Students MAY NOT work in any capacity in an out-of-hospital (such as a home birth practice or birth center) birth setting where they are a clinical midwifery student.
2. In a hospital or office setting, the students MAY NOT work as a nurse in any unit in which they are a clinical student. They must practice within the scope of their license, and not assume any additional responsibilities based on their advanced knowledge base.
3. A student may not work as a nurse-midwife or nurse practitioner at any time while in clinical unless legally licensed to do so.

2. Clinical Supervision Requirements

The level of direct supervision expected of a preceptor will depend on:

• The student's demonstrated ability and readiness for unobserved practice of a skill or task.
• The comfort level of the patient with the student.
• The negotiated comfort level of both student and preceptor.
• The complexity of the clinical situation.
• Clear, effective communication between the student and preceptor.
• The program's requirement for direct supervision of all student-attended births and all suturing.

Progressing from student observation of the preceptor performing all functions in an encounter will be gradual and will require demonstration and return demonstration of many skills. Seeing patients together provides the student with the opportunity to watch and reflect on the skills, critical judgment, and behaviors of the preceptor. The preceptor can also see the student grow in ability to do "parts" of the visit and try new skills, while receiving preceptor feedback.

In the labor setting, CNM direct presence is required for all births. When a student has reached the level of ability that enables the preceptor to stand back against the shadows, ready but not required, the preceptor will proudly see the best result of all their efforts. In the event than an emergency requires the preceptor to be unavailable for a birth, the student should step aside and allow nursing personnel to attend the birth.

Physicians who work with the practice may supervise student experiences, if it is felt it would be of value and they are interested. However, these experiences cannot be counted toward the required clinical numbers for nurse-midwifery education.

The FNP students may work with physicians as their preceptors and it is advised if possible to spend some clinical time working with a physician. The guideline for maximum clinical time spent with a physician preceptor is twenty percent. 

The FNP students are required to have direct supervision by their preceptors for all suturing and or lesion removals.

3. Advanced Practice Skills

Many advanced practice nurses regularly perform advanced skills. Students are encouraged to watch these skills, whether performed by physician, midwife, or practitioner--but, as students, they MAY NOT perform them, even if they have expertise from prior roles. The FSMFN's malpractice insurance does not cover these activities:

• Vacuum-assisted birth
• Ultrasound
• Colposcopy
• Repair of fourth-degree lacerations
• Circumcision
• "First assisting" at cesarean section or other major surgery
• Suturing face or hands

4. When The Student Has Multiple Sites

Individual student needs and site concerns may necessitate the student's use of more than one site for clinical experience. Students will record time spent with each preceptor in clinical care or learning experiences. The Quality Assurance Officer will use this information to prorate each site's honorarium. The RCC will be responsible for facilitating a smooth transition between clinical sites.

5. Adverse Events And Risk Management

The FSMFN carries malpractice insurance coverage for students. Coverage begins at Level III and continues until clinical is completed and the student has taken the Comprehensive Examination. All preceptors must be covered by malpractice insurance in any setting in which the student practices. An Affiliation Agreement must be signed and on file at the School for each setting in which a student practices as well.

Any occurrence involving an incident report, or any situation in which the student has potential liability, must be reported within 24 hours to the Department Chair. The Department Chair will advise the student and convey the information to the FSMFN Risk Manager. The Incident Report Form is discussed with the student at Level III and is available in the Student Handbook located on the FSMFN website. The student with the help of the preceptor should complete this form. Only information contained in the chart should be included in the Incident Report. It is the student's responsibility to do this reporting; however, preceptors must insure that students recognize reportable events and fulfill the reporting requirement. Incidents should not be discussed in e-mail.

6. Academics and Student Deadlines

Nurse-midwifery Student Assignments and Deadlines

The nurse-midwifery students must satisfactorily complete all coursework for the Antepartum and Intrapartum courses within 14 weeks of completing Level III. Failure to accomplish this may result in suspension from clinical until the courses are completed. The preceptor and RCC monitor progress in academic coursework. In the event that a student must begin clinical in a well woman (gynecologic) setting as the first clinical option, the Women's Health Care III course should also be started. An extension for the Antepartum and Intrapartum courses can then be negotiated with the student's RCC, Department Chair, and course faculty.

Students may need some actual cases from which to develop case studies for their academic courses. These cases may include:

• postpartum depression
• postpartum hemorrhage
• antepartum exposure to a potential teratogen
• a newborn with an abnormal condition or outcome
• an interesting labor management, preferably utilizing midwifery skills
• clients with co-morbity and complex social situations
• family for a complete family assessment

Family Nurse Practitioner Student Assignments and Deadlines

 Most academic coursework for FNP students is completed soon after Level III. There are two courses; a Health Care Policy course and a Complex Issue course; remaining in Level IV. Both of these courses contain written assignments that the students’ will be consulting the preceptor for appropriate projects. One assignment is for a quality assurance peer review with allows the student to chose a clinical guideline and complete a chart review to assess for compliance. This assignment is done with the preceptor input concerning the chosen guideline. The other assignments relate to co-morbid conditions and the student may assistance identifying an appropriate client.

rev. 2/23/04

“Don’t suture yourself into trouble.” - Ruth Hope, CNM, Women’s Care Northern Michigan Midwifery

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