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

C. Ongoing Responsibilities

1. RCC Contact and Site Visiting

The RCC will regularly contact the student and preceptor (usually every two weeks) during the clinical experience. The primary preceptor should advise all the other preceptors who will work with the student of the RCC's role and availability. The RCC serves as an advisor for both the student and the preceptor. The RCC can help preceptors as they design the clinical experience in their unique sites, and serves as a resource for understanding students' learning styles and behaviors. The RCC uses ongoing verbal feedback and clinical evaluation tools from the preceptors to evaluate progress and facilitates the assignment of the clinical grades for the student.

A pre-clinical site evaluation and orientation visit is done before the first FSMFN student comes to a site.

Each student will be visited at least once by the RCC during the clinical practicum. This site visit usually is made midway through the practicum, but may be scheduled earlier if problems are identified. The purpose of the visit is to see the student and preceptor in action together. The RCC will evaluate the student's use of the critical thinking process by review of documentation of care, observation of clinical care, and the student's presentation of a clinical case. The RCC and preceptor can also discuss teaching strategies during the visit. Preceptors will be asked to provide written evaluation of the RCC's visit to the appropriate Department Chair.

2. Required Paperwork for Preceptors

A consistent method is needed to assess the clinical experience and the students' growth in skill performance, critical thinking, and professional role acquisition. This is commonly done by use of a clinical assessment tool, based on the competencies for safe beginning practice in the discipline. These assessment tools must be used thoughtfully to be helpful for learning. These tools should encourage introspection and thus provide an opportunity for growth. In addition, these tools become the "paper trail" that documents success or failure within a program. If a student is not doing well and especially if a student is unsafe, it is critical that this be documented. The FSMFN must be able to document that there is good reason not to allow a student to complete the program. Sometimes a student can pass didactic examinations but is unable to demonstrate clinical competency. In this case it is crucial that the clinical preceptor provide the program with an accurate assessment of the student's abilities and deficiencies.

The clinical assessment tools utilized by FSMFN are based on four developmental learner stages, which reflect progress from beginner to competence. Competencies appropriate for each level are delineated, with definitive behaviors specific to midwifery/nurse practitioner practice used for measurement. The behaviors are grouped by categories reflecting: skill performance (assessment skills; verbal interaction; psychomotor skills), critical thinking (identification of problems and need; establishing a plan; prioritizing action; knowledge base and use of resources), and professional behavior (communication with preceptor/staff; role transition).

The FSMFN utilizes two clinical assessment tools, the Daily Developmental Assessment Tool (DAT) and the Monthly Developmental Assessment Tool (MDAT). Please see Appendix D. The DAT is completed each day a student attends clinical. The form allows both the student and the preceptor a chance to evaluate the progress made that day and plan for continued progression by setting goals for the next clinical day. A MDAT builds on the information discussed from the daily review and identifies how far the student has come in the learning process. Both the student and the preceptor are responsible for completing these forms.

The DATs require subjective written evaluative comments, and the student and preceptor use different forms (different sides of one sheet of paper), which together comprise the DDAT. The goal for the student is reflection on the day's work including the actual hours spent and clients seen, self-criticism, and self-praise. The student is advised to have the form completed and to the preceptor for discussion at post-conference.

The preceptors' portion of the DDATs allows for feedback from the preceptor to the student on how the day went. It also sets the stage for planning for the next clinical day and identifies any clinical experiences that the student will need to improve performance. The DDAT also serves as a communication tool for the preceptor to the RCC and as documentation of the student’s clinical progress.

As the preceptor completes the preceptor portion of the DDAT, it is suggested that she/he use three broad areas of clinical performance as a guideline for the evaluation:

• Skills (assessment, verbal interaction, psychomotor)
• Critical Thinking (identification of problems and needs, establishing a plan, prioritizing action, knowledge base and use of resources)
• Professional Role and Behavior (safety of performance, documentation, communication with preceptor/staff, role transition)

The preceptor may choose to comment on only one area at each session. Identifying the complexity of the clinical situation contributes greatly to evaluation of the experience, and gives insight into the student's growing ability to manage situations of increasing complexity, to handle a workload volume, and to contribute with flexibility to the clinical team. The DDAT form uses a ranking approach to assess:

• Pressures of the environment:

  Was the environment challenging or more difficult than normal (e.g., shortage of nursing staff and many admissions, very busy clinic)?

• Pressures of client need:

  Were there many clients with greater needs than time allowed?

  Were there more patients than usual with urgent clinical problems?

• Difficulty/complexity of client situation:

  Were there one or more medically or socially complex cases today?

  Was a client medically of low complexity, but in a situation requiring immediate or in-depth interventions?

Once a month, prior to the student's required monthly report to the RCC, the student and preceptor should plan a time to complete and discuss the Monthly Developmental Assessment Tool (MDAT). The student and preceptor should each fill out a copy of the MDAT separately and then discuss their assessments. 

The MDAT requires the student and preceptor to evaluate whether or not specific clinical competencies have been met. The evaluation begins with the Stage One MDAT. When all objectives are met on Stage One, the evaluation moves on to Stage Two. This provides an opportunity for recognition of growth over time. The developmental sequence of behaviors is also clearly spelled out for the teacher and learner, to assist both in setting goals and formulating approaches to address those goals. The four stages of development for the learner also closely relate to the developmental "stages" of clinical precepting. Please see Part 4.D. The preceptor can use the MDAT diagnosis of the student's developmental stage to plan approaches most likely to support the student's growth.

3. The Daily Pre- and Post-clinical Conferences

At the beginning of each clinical day the student should present their goals for that session to the preceptor. This is the time to outline the schedule for the day and what the expectations are for the student to accomplish.

At the end of each clinical session it is important that the preceptor give the student some feedback about how the session has gone. It is a good time for both preceptor and student to assess whether the goals planned for the day have been met. Written comments are best done during or immediately after the clinical session. Even a day's delay reduces the specificity and decreases the value of the comments to both the student and the School.

Here follows a suggested approach to the post-conference using the DAT:

• The student takes 10-15 minutes before the session ends to complete the student portions of the DAT.
• The student and preceptor discuss the student's self-assessment.
• The preceptor completes the preceptor portion of the DDAT. The preceptor may summarize key points from the post-conference discussion here for brevity's sake.

Post conference discussions…ask the student these questions.

1. “Describe one thing you felt good about in this clinical session.”
2. With this question the post conference starts on a positive note. If the student can't come up with something positive about the day, the preceptor should be able to point out something. If the student cannot think of anything positive about the day, consider the possibility of depression or fatigue.
3. “What new learning or new way of looking at things came out of this session?” It is helpful to the student to identify that learning has occurred. If the student cannot identify any learning in the clinical session this should be addressed. Is the student already accomplished in this area? Is the student too stressed to learn? Is there an affective problem?
4. “Thinking back to your decisions, actions, and interactions (with client, family, staff, MD, preceptor), is there anything that you would change?”
5. With this approach the student has a chance to identify his/her own mistakes before the preceptor points them out.
6. “Evaluate one decision or intervention that you initiated.”
7. In some situations, the preceptor may choose to define the decision to be evaluated by the student. If a student doesn't pick the intervention that the preceptor wants to be critiqued, the preceptor can suggest it anyway. Note that students frequently interpret "evaluate" to mean, "describe." Evaluation must include an assessment of the decision or intervention.
8. “Identify one learning goal for future experience.”
9. The student evaluates the learning experience and is able to identify areas of weakness.

4. SOAP Documentation

The FSMFN requires students to learn and use the SOAP method (derived from the Problem-Oriented Medical Record) throughout the program. They need to use the SOAP format in clinical, and clinical preceptors need to be familiar with its use. The FSMFN has students use SOAP documentation for following reasons:

• To learn a consistent, systematic method of documentation of care.
• To demonstrate on paper how they think clinically.
• To practice communication of their critical thinking skills

The FSMFN does not require preceptors to use SOAP documentation or to adapt record-keeping systems to include it. Students can write SOAP notes on separate paper if necessary. What is important is that the preceptor read the student’s SOAP notes and uses them as a basis for teaching and learning.

At first, the preceptor may choose to give the student time after each patient to sit and construct a SOAP note for the encounter, while the preceptor goes on to see another patient. Later on the student will be able to complete the SOAP note after each patient is seen and still move promptly to the next one. The FSMFN provides the students with a format for these notes, which they have used in didactic case studies before Level IV, so they should be prepared to make the leap as they collect data from real patients.

If the practice does not use SOAP format for their records, the student will need to be directed by the preceptor on how to document in the record to meet the practice and the preceptor standards. It is really up to the preceptor to determine when they are satisfied with the student's SOAP demonstration of critical thinking and clinical judgment with uncomplicated patients. At that time, the preceptor can decrease the frequency of Soaping those encounters. We recommend that the SOAP format be used for all well and new visits, as well as all "problem" visits and primary care encounters. The goal is to develop a concise and appropriate documentation of each client encounter.

5. Problems Along the Path

Recognizing and helping a student having difficulty functioning or learning in the clinical setting is the most challenging experience preceptors face. Unfortunately, the complex and stressful nature of learning how to put knowledge into practice in the clinical setting challenges students' emotional, spiritual, and physical resources. Sometimes these challenges become obstacles to learning. Naming and assessing the problem is crucial to planning a strategy likely to succeed in helping a learner grow from the experience and accomplish the learning objectives.

Signs of a problem with clinical learning can include:

• Student and preceptor have very different assessments of the student's level of functioning.
• Failure to correct behaviors or technique after instruction by the preceptor or failure to maintain corrected technique.
• Lack of progress on competencies in the Monthly DATs.
• Unprofessional or unsafe behavior or judgments.
• Difficulties with communication between student and preceptor.
• The preceptor feels consistently reluctant to work with the student.
• The preceptor or student feels that "it isn't working."

FSMFN has a detailed and well-established problem-management process that is quite simple to initiate. The process documents a problem and develops a strategy. The preceptor is not alone in this process. The RCC is the support for the preceptor. The RCC will listen, provide perspective and help the preceptor to understand and proceed with the Problem Resolution Process. The Department Chair is also available to assist in problem solving. The student is an adult learner and partner in his/her education and needs to be involved in the Problem Resolution Process and may initiate the process as well.

The Problem Resolution Process uses four tools, which build upon each other:

1. The Developmental Assessment Tools. If a problem is not documented, it is as if it did not happen. See Appendix D.
2. The Problem Identification Sheet helps the student and preceptor clarify the problem. It is a learning opportunity for both. Often, simply identifying the problem leads to rapid resolution. The preceptor should not hesitate to use this sheet. See Appendix D.
3. The Learning Plan is student-designed, and modified by discussion with the preceptor. It is goal-focused, and prompts a complete strategy for learning. The RCC is a resource and guide in this process. See Appendix D.
4. If rapid resolution of the problem does not occur, the Department Chair writes the Performance Plan, with input from the student, preceptor, and RCC. Complex problem situations or inability to complete the Learning Plan require a Performance Plan. The Department Chair will coordinate management of the Plan with the student, the preceptor, and the RCC. Preceptors are not responsible for the decision to fail a student.

Sometimes a student’s learning problem results in removing the student from the clinical site. This is a decision made by the Department Chair. It reflects the student’s learning needs, and is not a negative assessment of the clinical site. 

rev. 5/2/05

“Take a minute just before your pre-conference with the student each day to bring your attention in.” - Anonymous Preceptor

Act of Hope HOME

Frontier School Home

Midwifery RCCs

FNP RCCs

Contact Us