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The Frontier School of Midwifery and Family Nursing (FSMFN) provides training to clinical preceptors with this continuing education handbook, An Act of Hope, a Labor of Love: A Handbook for Precepting FSMFN Students. At FSMFN we are acutely aware, and deeply appreciative, of the importance of the clinical preceptor faculty to the success of the students and, ultimately, to the quality of the professions of advanced practice nursing. Today's practicing nurse-midwives and nurse practitioners have broad responsibilities and work under time and accountability pressures that are unprecedented. This Handbook is offered as a guide and resource to support and make clear the day-to-day, "nuts-and-bolts" of precepting.
The handbook is divided into five parts. The first three parts address the role of clinical faculty (preceptors) at FSMFN. Parts four and five take a more general view of clinical education and include sections on adult learning and tips for successful precepting. An appendix is included of documents specific to FSMFN and also the core competencies of both the American College of Nurse-midwives and the National Organization of Nurse Practitioner Faculties. We have also included a Checklist to guide you through the information.
One of the requirements for the Amercian College of Nurse-Midwives (ACNM) is that all preceptors participate in preceptor training. This handbook has been approved by the ACNM as a CEU for preceptor training for .2 CEUs/2 contact hours. If you are interested in receiving CEUs for this preceptor training, you must Register and complete the included Post Test.
Precepting is a "labor of love" for midwifery and nurse practitioner students and the families of the future. Preceptors need support, recognition, and tools that simplify, rather than complicate, their already complex lives. FSMFN hopes to accomplish that.
rev. 4/28/04
With the completion of this training manual the preceptor will be able to:
rev. 2/23/04
This is a checklist of things you will want to be comfortable with, as well as a reference to more details about each item found in this workbook.
rev. 2/23/04
This section provides an overview of the Frontier program and how students proceed through the various levels of the curriculum. It shows what is expected of the clinical preceptors at each level. We will describe the faculty support for students and preceptors. The section also addresses the benefits of precepting Frontier students.
FSMFN clinical students have the following characteristics, which, taken together, make them and their needs unique:
rev. 2/23/04
The FSMFN is a graduate school open to nurses with a baccalaureate degree. It offers both a full-time and a part-time option for study. Completion of the basic nurse-midwifery certification program usually requires about 24 months for full-time students and 36 months for part-time students. Nurse-midwifery students have the option of completing the certificate program and completing the Masters of Science in Nursing (MSN) through the FSMFN or through Frances Payne Bolton School of Nursing at Case Western Reserve University. Family nurse practitioner students are required to complete the MSN.
The FSMFN education is a community-based, distance-learning model in which students learn in their communities, with class activities distributed and completed via the Internet. The design is modular. The curriculum and learning activities are directed by a faculty of nurse-midwives and nurse practitioners who are available to students and to each other primarily by phone, Internet, or mail. Twice during the program students interact in person with the faculty and with each other as learners on our campus in Hyden Kentucky.
During Level IV, with the skillful guidance of our Clinical Faculty (preceptors), students progress from novices to safe beginning level practitioners. This usually takes six to nine months. The duration of Level IV is dependent on variables unique to the site, the preceptors, and the student. Students must be in clinical for a minimum of 16 weeks and 675 hours.
Usually, it is possible for a student to work with a preceptor or a practice near or in their local community during the Level IV clinical practicum, but occasionally distant sites need to be arranged. Sites may change due to unforeseen events that occur during the time between Level I and Level IV, but this is the exception rather than the rule. The variation in time for Levels I and II has to do with the students' personal situations as well as learning styles, how they organize time, and their approach to study. In Level IV, site volume and dynamics are additional factors affecting the time needed for completion. Click here for the nurse-midwifery and family nurse practitioner curriculum in Appendix A.
rev. 2/23/04
As a distance-learning program, Frontier students are responsible for setting a timeline that is realistic for their learning needs within the context of the timeline and deadlines established by the school.
The following is an overview of the program that will help you understand your responsibilities to your student and the FSMFN in relation to the student’s timeline.
Timeline |
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| 24 months = Full-time | Full-time students generally start clinical 16 months after beginning the program |
| 36 months= Part-time | Part-time students generally start clinical 24 months after beginning the program |
Student Responsibilities |
Preceptor Responsibilities |
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Application Process |
The student interviews with the preceptor. Before they are officially admitted into the school an applicant must have an interview with a potential preceptor who agrees to accept them as a student. Either the student themselves or a faculty member from the school will contact you and ask to set up an interview. In some cases, when the original clinical site is no longer available to the student, this interview may take place after the student has begun the program. |
Preceptor receives a manual from FSMFN. Within two weeks a representative from the school will contact you to review the packet and answer any potential questions. In this packet is an interview form, which you will use to interview the potential student. The primary preceptor completes the Summary and Recommendation form and Faxes it to the FSMFN. |
Acceptance to FSMFN |
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Frontier Bound |
Attends Frontier Bound a six day on-campus intensive to orient the student to the school and build a community by interaction with classmates faculty and staff. |
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Level I |
The student begins Level I. During this first six-nine months for full time and 12 months for part time students, the student completes level I didactic courses. |
It is a good time for preceptors to complete the other forms in the preceptor manual. One of these is the contract between the preceptor's site and the FSMFN. Many times this contract may take several months for approval between attorneys and Medical Education departments. Another form is the Site Self-Evaluation Report. There is minimal contact between the student and preceptor during this time except to inquire about the contract process. If the student lives close to your site, they may ask for an occasional observation experience to accompany an assignment. |
Level II |
The student starts Level II. During this next six-nine months for full time and 12 months for part time students, the student completes Level II didactic courses. |
If this is your first Frontier student, a faculty member, usually the Regional Clinical Coordinator will make arrangements to come to the site to do a "pre-clinical site visit". This is a good time to review and start to become familiar with the checklist for preceptors. Students may ask to interview you about your site for one or more of their papers. |
Preparation for Level III |
The student is completing Level II and making plans to attend Level III (a two week hands-on intensive on campus in Hyden) |
The student will set up a pre-clinical meeting with you to be oriented to your site and to discuss the expectations of your clinical site (See Part 2.A-2: -Pre-clinical Meeting.) In some cases, this will need to be done after level III if the student is relocating to the clinical site for their experience. You will complete the credentialing process by submitting a current license, certification, updated CV, official transcripts and evidence of preceptor training. |
Level III |
Student attends two week intensive on campus at the FSMFN to learn psychomotor skills and prepare for clinical. |
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| Clinical / Level IV | It is now about 16 months for full time and 24 months for part-time students since you first met the student and she/he is starting their clinical rotation with you. It is the student’s responsibility to keep up with course work that is required during the clinical rotation. At times, it may be necessary for the student to be taken out of clinical for a short time to complete some of the course work. The student must follow the site guidelines and practice agreement. However, the student needs to be able to suggest alternative management ideas for discussion with preceptors even if they cannot be followed. |
During clinical you will need to:
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Clinical Site Visit |
Mid Clinical (about 3 months after beginning clinical) student should be progressing to Stage 2 on their Monthly developmental Assessment Tool (MDAT) |
Meet with the student to discuss progression on the timeline, check visit numbers and clinical hours to that half of each are completed and make adjustments as needed. -Sometime around this point, the RCC will do a site visit to observe the student and her interactions with the preceptor. See Part 2.C-1: RCC Contact and Site Visiting. |
Finishing |
The student is functioning at the level of a safe beginning practitioner and has completed the required clinical hours and visits. |
You will send her Declaration of Safety to the FSMFN See Part 3.A: Declaration of Safety (DOS). The RCC will contact you for a final update. You will receive the paper work for your honorarium and an evaluation. Please complete and return both of these items to the FSMFN Quality Assurance Officer. |
rev. 2/23/04
Preceptors are classified as Clinical Faculty by FSMFN. They are trained, supported, and paid an honorarium by the School to acknowledge the valuable work that they do in developing nurse-midwives and nurse practitioners.
The student progresses in all settings simultaneously, until competence in skills and clinical judgment is achieved to the satisfaction of the preceptors. For preceptors, nurturing this transformation is intensive, but extremely rewarding as the maturation of the student yields success. The curriculum of the FSMFN is rigorous and exceptional and students come academically well prepared to their clinical experience. The majority of the course work for both specialty tracts is “front loaded” so the students come to clinical having completed the majority of their didactic education.
Precepting for the FSMFN does not preclude precepting for other schools; indeed, the experience of FSMFN precepting will improve clinical precepting skills in general.
The rewards of precepting are mainly these:
rev. 2/23/04
Students are assigned to a Regional Clinical Coordinator by region once admitted to the program.
rev. 3/9/05
As the leader of the FSMFN faculty and staff, the President and Dean implements policy and directs all functions of the Frontier School of Midwifery and Family Nursing. Policy development and all functions of the FSMFN are in keeping with the philosophy of the FSMFN. The Board of Directors of the FSMFN participates in these processes. The President and Dean provides direction to the Department Chairs, faculty, staff and students to ensure the efficient, economical and effective use of all organizational resources to meet the identified needs of the School.
rev. 6/16/04
Provide leadership to the faculty staff, and students. Assume responsibility for the overall administration of their department and the smooth functioning of the specialty educational programs and faculty practices in their department. They are the administrative liaisons with the President and Dean. They are your contact for development of your plan of study and for issues that are not resolved with the course coordinator, student advisor or RCC.
As the academic leaders of the specialty program(s) in their departments, the DCs are responsible for the overall integrity of the specialty curriculum including the quality of the clinical sites for area of specialty.
Assure the smooth functioning of their programs, compliance with accrediting bodies, and adherence to the by-laws and policies of the FSMFN. TheDCs are always available to students and faculty.
Are knowledgeable concerning distance education practices and techniques and assist faculty and staff in remaining current in these areas.
Assumes responsibility for the assigned education program curriculum development and distance education implementation using criteria of the appropriate specialty option credentialing organization, regulatory bodies, and/or relevant organizations if appropriate.
Work with the Quality Assurance Coordinator to ensure the highest quality of clinical experience for the students.
Evaluates transcripts and allows transfer of credits as appropriate.
Provides individual and group student guidance and monitors individual and group student progress.
Reviews student evaluations related to curriculum and teaching effectiveness of faculty and provides necessary feedback for faculty. Works to assure quality of the curriculum.
Works with course faculty to develop and maintain criteria for success in academic and or clinical courses.
Work closely with student, Course Faculty and the RCCs on the resolution of student academic or clinical problems.
Attends Frontier Bound to orient students to the School and the education program.
Attends Level III to monitor student feedback related to curriculum and discuss clinical and/or Level IV coursework as appropriate.
Work closely with Faculty, student leaders, and individual students in relation to student issues.
Supervise the work of the Regional Clinical Coordinators, including management of site information and evaluation and preparation of students for entry into the clinical practicum.
Interviews applicants for admission.
rev. 5/28/04
FSMFN has a central campus in Hyden, Kentucky. FSMFN is a part of the historic Frontier Nursing Service. In Hyden, there are learning facilities that include classrooms, computer laboratory, and a multimedia library specializing in distance education.
The staff in Hyden supports students through the admissions process, helps them with financial aid, and provides them with course materials and library services. They also support students and faculty during their on-campus courses and meetings.
rev. 2/1/02
The MM Team is responsible for assisting students and faculty with computer skills, trouble-shooting computer problems and maintaining our communications bulletin board system, the Banyan Tree. The Multimedia Team also designs and maintains the FSMFN website, www.midwives.org. All of the didactic courses are delivered via the website.
rev. 3/4/04
This section presents the basic structure of the FSMFN clinical experience. It explains guidelines for planning clinical time and assignments. Basic expectations for the student and the preceptor are reviewed.
Students are responsible for establishing, at the initial preceptor interview, when they expect to begin clinical. If there are factors in a student's progress that affect the anticipated clinical start date, the student must inform the preceptor as early as possible, in order to determine whether this will affect the ability to precept.
The preceptor will be contacted in advance of arrival at the clinical site to confirm availability and readiness. Plans need to be made for the student and preceptor to meet together to discuss the following:
As the student begins in each new clinical setting or role, a period of observation is recommended, both for orientation and for role and skill modeling purposes. It is often preferable that:
4. Length of Clinical Experience
Students are encouraged to plan at least 20-30 weeks in clinical. This allows time for finishing course work, together with adequate time to integrate didactic material and clinical skill practice. The marriage of practice and theory is the essence of the clinical experience and students must demonstrate ability to do this in order to graduate from the program.
The minimum duration of clinical experience is 16 full clinical or call weeks for the nurse-midwifery students and 675 clock hours. Students must remain in clinical until they have completed the academic work for their clinical courses.
Students who are experienced Certified Nurse Practitioners, Certified Nurse-Midwives, or Physician's Assistants may be eligible to "challenge" 50% of the required clinical experiences in the area/s in which they are certified. This may result in a shorter duration of the clinical practicum, but the minimum of 16 weeks is still required. Minimum hours may be adjusted in this situation by the Department Chair. The Clinical Challenge is available only if students meet established criteria. Preceptors of these students will receive detailed information about the Clinical Challenge mechanism from the RCC and clear guidance through the process.
Minimum numbers of experiences are required for all FSMFN students.
Sometimes the specified categories of visits overlap for individual patients; therefore, a single visit may count in more than one category.
The Division of Accreditation of the American College of Nurse-Midwives sets minimum criteria for clinical experiences for nurse-midwifery programs, including numbers and types of experiences. The FSMFN requires a greater number of experiences in most areas than the minimum.
In Level IV the student is expected to master, at a safe beginning level, the Core Competencies of the ACNM. These competencies are included in the NM601 course.
The following are the requirements for clinical experiences in all areas of practice:
Some of these categories overlap and a single visit may therefore count in more than one category. These numbers must be completed before the RCC assigns clinical grades.
rev. 3/15/05
In Level IV the student is expected to master the clinical skills necessary to become a safe beginning level Family Nurse Practitioner.
The following are the requirements for clinical experiences in all areas of practice:
Some of these categories overlap and a single visit may therefore not count for more than 2 categories. These numbers must be completed before the RCC assigns clinical grades.
Students are expected to master SOAP charting as a way to integrate critical thinking. Each month students will chart 2 SOAP notes on each type of patients seen. RCC will review these at the time of the clinical site visit. Students are required to send their RCCs 10 SOAP notes representing different types of pvisits for the first month. The Rcc willl then use their own judgement regarding continued submission of SOAP notes based on the student's progress.
rev. 3/15/05
Note: Not all clinical sites will be able to provide the required number of clinical experiences. Many students may need to work with additional preceptors to gain the required clinical experience. If you anticipate difficulty meeting any of the required number of visits at your clinical site, please discuss this with the student, the regional clinical coordinator and or the department chair.
rev. 2/23/04
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:
The level of direct supervision expected of a preceptor will depend on:
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.
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:
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.
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.
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:
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
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.
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:
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:
Was the environment challenging or more difficult than normal (e.g., shortage of nursing staff and many admissions, very busy clinic)?
Were there many clients with greater needs than time allowed?
Were there more patients than usual with urgent clinical problems?
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.
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:
Post conference discussions…ask the student these questions.
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:
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.
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:
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:
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
Eventually, the student will achieve the Clinical Competencies! When the preceptor is confident that the student is a safe beginning level practitioner, the RCC will provide a Declaration of Safety (DOS) form. The preceptor should sign it and return it to the FSMFN Registrar as directed. Timing of the DOS is at the preceptor's discretion. Regardless of when it is signed, the student needs to complete the clinical numbers and time requirements.
All honorariums are paid at the time that the students complete their entire clinical requirements. All students record the hours they spend with the preceptor in the clinical area. The student sends this documentation to the RCC. The RCC then prorate the hours for each site if the student has been in multiple sites and submits this to the Quality Assurance Officer at the FSMFN. The Quality Assurance Officer then sends the preceptor and invoice to complete and return to the school. The invoice requires the name of the recipient and the social security or tax ID number for either the preceptor or the practice. A check will be sent promptly to the preceptor once the school receives the invoice.
The preceptor will be asked to communicate in writing with the FSMFN as part of the preceptor's faculty role. The RCC will provide the preceptor with a form for evaluating site visits. There will be a final evaluation form sent with the invoice also that allows the preceptor to evaluate the FSMFN. The FSMFN welcomes any comments or suggestions the preceptor has for the program faculty. Preceptor contribution to the faculty of the FSMFN is critically important for program and student success. The school welcomes clinical faculty ideas and suggestions.
rev. 4/28/2005
Basic concepts of adult learning theory are applied to learning and teaching the art and science of advanced practice nursing in this section.
rev. 2/23/04
Teaching nurse-midwives and nurse practitioners is an act of hope and commitment. The effort to perpetuate the art and science of midwifery and advanced practice nursing honors the commitment to midwifery and advanced practice nursing and that of the midwives and advanced practice nurses from whom it was all learned.
At the same time, teaching midwives and practitioners causes all clinicians to reflect critically on their profession and their practice. It therefore challenges everyone to examine the assumptions that underlie decisions and actions and to explain the ways whereby clinicians "know" their patients. Passing on a tradition requires its articulation. It must be described as well as demonstrated.
The processes of self-examination and critical evaluation of the profession, as a whole, strengthen advanced practice care. Nurse-midwifes and advanced practice nurses have a history of practicing under conditions of adversity. Such care will survive the complexities of today's practice environment. Those who teach play a key role in assuring the future of the profession.
A prime job is to prepare intuitive, caring midwives who are fully able to be "with woman," as well as intuitive, caring, nurse practitioners who are fully able to do the same for their patients. Both midwives and nurse practitioners also need to be skilled at making clinical judgments based on evidence and inquiry. They must be capable of accepting professional accountability within the larger social system and capable of applying the economic concepts basic to sustaining practice. The Hallmarks of Midwifery Practice and Core Competencies of Basic Midwifery Practice of the American College of Nurse-Midwives (Appendix B) describe in detail the attributes of midwifery practice and the model that is sought and passed on. The Domains and Competencies of Nurse Practitioners' Practice by the National Organization of Nurse Practitioner Faculties describe in detail the generic practice behaviors of nurse practitioners as they enter into practice (Appendix C).
rev. 2/23/04
A few concepts about how adults learn are important fundamentals to the practice of adult education.
Understanding adult motivations and behavioral approaches to learning can also benefit the preceptor.
rev. 2/23/04
Three major skill areas, encompassing many different behaviors, are simultaneously developed during the clinical practicum:
Examples: Pelvic examination, hand maneuvers for birth, suturing, use of voice and touch, efficiency of movement.
Examples: Making connections between data and possible meanings; ordering priorities for attention and action; selecting appropriate options for diagnosis and therapeutics; seeing "the whole patient" in "the whole picture"-targeting outcomes, considering resources, projecting consequences.
Examples: Personal bearing and demeanor; resource recognition within the whole team and community; use of self; discovery of appropriate patient/clinician boundaries; differentiating caring from encouraging dependency; responsibility for actions and choices; appropriate interactions with consultants; accuracy and completeness of documentation.
Despite aptitudes and previous experiences, students’ start as beginners. They are often surprised and discouraged by the experience, as they have been proficient in their previous roles. With the preceptor's help, they will progress from novice to advanced beginner to competent beginning practitioner during the clinical practicum.
The job of the preceptor is to recognize the student's stage and her/his progress and to use an effective approach to precepting for that stage. There are four developmental stages of successful precepting that to some extent relate to the student's developmental stage. The use of a particular approach to precepting will (we hope) be a conscious choice of the preceptor, based on assessment of the student's needs and abilities in a given situation.
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The preceptor must be able to gradually release control of the management of patient care as the adult learner begins to take on that role. The preceptor must respect and encourage the student's growth. Differences in the learning style of the student and the preceptor can create a struggle over how much or how little control of patient management is appropriate.
There are four developmental stages in successful precepting that to some extent relate to how much clinical experience the student has had. However, just as in human psychological development, students (and preceptors) move in and out of the various stages in a non-linear fashion. (Armstrong, 1991).
At the earliest stage the preceptor is primarily responsible for the client's clinical care and for how much/how little the student participates in the care. The preceptor:
As the student progresses the preceptor begins to turn over more of the care and decision-making to the student. Together they decide on the amount of participation in care that the student will provide. The preceptor:
With progress, the student takes the lead. The preceptor:
By stage IV the preceptor trusts the student to identify the problem and accepts the student's plan, as long as it remains within the boundaries of safety. The preceptor:
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This section offers practical suggestions for working with students in the clinical setting.
Preceptors often accept clinical students, especially beginners, with reluctance because they see patients at a busy pace. One preceptor summed it up:
“I enjoy teaching, and I feel that I really should “give back” by taking students. But I hardly have enough time to see patients as it is! A student who needs a full hour for an annual visit can slow me down. I don't have time to answer all those questions while I'm seeing patients.”
These preceptors express real and important concerns that need creative solutions. In this part, some suggestions are offered that may help. They are based on the following assumptions:
The student is responsible for coming to clinical ready to learn from the preceptor and the patients of the preceptor. This means coming on time, to the right place, professionally dressed, clean, and rested. Students must always wear their FSMFN picture ID badge, and any other identification the setting requires. They need to carry a "pocket brain," which is their personal resource notebook of useful information. They should wear a watch, and (if not provided) have a stethoscope. They also should have a notebook with assessment forms for preceptors to review and use for documentation. Coming prepared to clinical is a required professional behavior.
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The preceptor must determine how patients will be introduced to the idea of student participation in their care. It is important that all staff members of the practice meet the student and know when the student is there. The attitude the staff displays toward the student is key to the patient's perception of the student, as demonstrated by these contrasting introductions:
Some sites have a written informed consent mechanism for patients who will participate in clinical education. Other sites post a picture and/or a biography of the student in the waiting room to give patients a chance to “get to know” the student. Whatever approach the preceptor uses, an attitude of inclusion of the patient in a valuable process, of openness about what to expect, of the patient's right to decline, and of confidence in the student helps patients feel valued and safe in the process.
Not all days are created equal. Sometimes preceptors will be unable to stay on time, no matter what is done. Though students are not with preceptors to lighten their clinical burden, they do not need to make it harder. How the student and the preceptor work together is key to providing education and care at the same time.
When the student starts working with the preceptor, both will benefit from a period of observation while the preceptor gives care. This decreases the student's initial anxiety, allows both to become comfortable interpersonally and orients the student to the site and the preceptor role. Observation is also a great learning tool later in the clinical experience. Students observe and pick up things differently once they have had some experience and their anxiety level has decreased.
When the preceptor is ready to begin “hands-on” practice, it is best to start in one area (routine exams, for instance) or one or two skills at a time. The preceptor needs to use a directing style of precepting, and have the student focus on one aspect of care with each client. The preceptor may introduce several new skills each session this way, depending on the opportunities of the practice and patients present. As confidence is gained, the student will be able to complete several parts of an encounter. The following example describes one student's progression over a week, and the skill areas being developed.
Day 1: reviews charts, identifies difference between data, assessments, and plans (critical thinking); observes demonstration of a physical exam, pelvic exam technique, documentation of care, interview skills, education about good nutrition, selection of appropriate medication etc. (critical thinking)
Day 2: as above and returns demonstration of a physical exam; takes a diet history once (skill development); writes SOAP notes of two visits performed by the preceptor and observed by the student (critical thinking and professional behavior); suggests plan for diagnosis of UTI and options for treatment (critical thinking)
Day 3: continues to observe and performs delegated pieces of visits; because time “appears” in the schedule, assists to conduct pelvic exam portion of physical assessment (skill development); continues to SOAP short visits, and adds an interview of one problem visit; performs interval history for routine exams (critical thinking, professional behavior)
By selecting patients carefully, starting small, and limiting and discussing expectations, the preceptor and the student will be able to combine clinical education and practice, while keeping the needs of the patients primary. Both preceptors and students can keep a small notebook in which to record questions that come up while seeing patients. Questions and explanations should not slow down the preceptor's office schedule. Instead, find time during breaks, at lunch or during the post conference to answer questions. When clinical questions arise that neither the student nor the preceptor are sure about, the student can be assigned to research the question either immediately or before the next clinical session.
The student will not see all of the patients seen by the preceptor. Time must be provided for the student to look things up, to write client progress notes and the self-assessment form, and to observe roles of other members of the team (e.g. nutritionist, ultrasonographer, nurse educator, physician, and social worker). If the session is under intense time pressure, the student may just need to stand back until the preceptor brings things under control.
At every level of development, students have much to learn from observation. Watching the preceptor prioritize and juggle multiple simultaneous demands is a great opportunity for learning the clinical role. Students may convey anxiety about “getting their numbers,” or frustration with not getting enough “hands-on” experience at some times. This is normal. The preceptor must redirect the student to use the opportunities presented, reminding of the value of flexibility and reassuring that it is a transient situation. If managing time with a student is a persistent problem, the preceptor should seek the guidance of the RCC.
Though progress seems slow at the start, the pace of learning rapidly increases. Together, the preceptor and the student will make decisions about readiness for:
Preceptor decisions will be based on ongoing assessment of progress and skill. How the preceptor “frames” and communicates these assessments will be covered in the next section.
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Every clinical session ideally will begin with a brief (5-minute) pre-conference to:
Especially in the early weeks of clinical, it may be helpful for students to review charts before the clinical session begins, if feasible. This often helps allay anxiety and gives an opportunity for planning approaches to the conduct of visits. Although this is a quick process for an expert, it is a complex application of the nurse-midwifery/nurse practitioner process for students.
At the end of the session, the preceptor and the student need 5-10 minutes to review the major learning experiences of that session. It may be helpful if the student does not see the final patient on the session roster. She/he could take 15 minutes in advance of the post-conference to complete the Daily Developmental Assessment Tool for the preceptor. This can be used to guide discussion. The view of the preceptor or highlights from the post-conference should be briefly noted on the Daily Developmental Assessment Tool form. (See Part 2.C-3: The Daily Post Clinical Conference)
It is best for the student to start with one or two preceptors. Learning the different styles and focus of several preceptors can be a lot for a student to remember when she/he is already tackling a huge amount of new information. Once both the student and preceptor agree that the student is ready to follow more people in the group, a system for communication among the preceptors, about the student, should be planned. Sometimes it works well when the original preceptor coordinates the rest of the student’s experience. One person can review all of the DDATs and plan to do the monthly DAT consistently with the student after input from all partners.
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The DATs discussed in Section 2.C-2: Required Paperwork for Preceptors. are the primary tool for assessing progress through the clinical experience. It is equally important to give good verbal feedback to students on a daily basis. Students need to know when they are doing something right as well as when they need improvement. Here are some guidelines for giving feedback:
Example: Sitting in a private space after an encounter with a laboring woman, a preceptor says to the student: “I watched you do a very gentle vaginal exam after telling the woman that it was time to check her. I did not see you ask her permission to check her. Next time, try suggesting that it would be a good time to check because her water just broke and asking her if she would agree to let you first. This will not only help you build trust with the woman you are working with, it will build your respect for women and their integrity.”
We all picture the physician making rounds with her/his students and firing off questions to them when we think about assessing students in the clinical area. However, this “assertive” style of assessment is only one style that preceptors can use. Questioning can assess the knowledge level of students. A “collaborative” approach is more helpful for assessing critical thinking skills. In a collaborative style, the preceptor asks the student for their opinion, and then shares her experience. Together they develop a management strategy. It is also helpful to sometimes use a “facilitative” style.
In this style, the preceptor helps the student to look at her/his feelings and the role they are playing in decisions and interactions. Acknowledging how we feel, for example, about a “difficult” patient can help us be more aware and act in a more professional manner in our interaction. The facilitative style helps us assess professional role and behavior. It is important for preceptors to make on going assessments in all three areas of clinical performance, skills, critical thinking and professional role and behavior.
The transition from a nurse to a Family Nurse Practitioner or Nurse Midwife can be a difficult one. Nurses are used to feeling competent and don’t like the feeling of not knowing what to do. Making management decisions and being responsible for them can be very scary. It can also be difficult for preceptors to ‘let go’ enough for students to make the transition. Remind the student that now is the time to practice being the professional. It is better to make their mistakes now, while the preceptor can rescue them. A preceptor can learn a lot about a student who demonstrates an ability to learn from their mistakes.
It is very important as a preceptor that you know and are able to articulate your philosophy of care and your values. A student with differing values can be a real challenge. This could be one of the greatest gifts to you as a preceptor. Understanding and accepting other peoples’ values is one of the best ways to grow and better understand our own. We respect the values of our patients so must also respect the values of our students. Help the student to articulate his or her own philosophy of care. This is what drives our management decisions. You can ask the student to follow your philosophy for “your” patients but consider trying some of the student’s ideas.
A problem identification and resolution plan was outlined in Section 2.C-5: Problems Along the Path and the tools used by Frontier are found in the Appendix D. Sometimes you will encounter a significant problem that will require confronting the student. Examples of this might be a tendency for the student to cover up their mistakes, tardiness or unprofessional dress, or approaching patients in a disrespectful manner. Some helpful things to remember when confronting a student are:
If the student does not acknowledge the issue and suggest a resolution, ask them if they think the issue can be resolved. Continue to listen, clarify their position and seek resolution. When the student has proposed a resolution, give your contribution to the resolution. When an agreement has been reached, determine how you will keep each other accountable for keeping it. Again, the problem identification sheet and resolution process can be used. The RCC should be informed if the resolution process is ongoing.
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The nurse-midwifery curriculum is composed of four levels of coursework. Each level builds on previous learned content. The first two levels are didactic coursework. Level III is an intensive skills and role transition learning experience which occurs on campus. Level IV provides both a clinical practicum and more complex didactic content. It is during the clinical practicum that students have the opportunity to apply theory mastered in coursework. FSMFN CNM and FNP students complete core courses together. These courses begin with PC or Primary Care.
The CNEP is composed of four levels of coursework. Each level builds on previous learned content. The first two levels are didactic coursework. Level III is an intensive skills and role transition learning experience which occurs on campus. Level IV provides both a clinical practicum and more complex didactic content. It is during the clinical practicum that students have the opportunity to apply theory mastered in coursework.
LEVEL I - Theoretical Foundations for Practice
|
Credits |
|
PC600 Health Promotion & Disease Prevention |
2-0 |
PC604 Pathophysiology for Primary Care |
3-0 |
PC605 Decision Making in Health Assessment |
2-0 |
PC606 Theories and Concepts of Advanced Primary Care Nursing |
3-0 |
NM601 The Role of Midwifery and Birth Centers in America |
2-0 |
NM602 Reproductive Anatomy and Physiology |
2-0 |
| Total Credits | 14-0 |
LEVEL II - Theoretical Foundations for Nurse-Midwifery Management
|
Credits |
|
PC612 Pharmacology for Advanced Practice |
3-0 |
PC613 Women's Health I |
2-0 |
PC617 Primary Health Care I: Acute and Common Problems |
3-0 |
PC618 Research |
3-0 |
NM611 Role Development II - Community Assessment and Market Research |
2-0 |
NM614 Antepartum Care I |
3-0 |
NM615 Intrapartum Care I |
3-0 |
NM616 Postpartum and Newborn Care |
1-0 |
| Total Credits | 20-0 |
LEVEL III - Development of Midwifery Skills
|
Credits |
|
PC620 Health Assessment |
1-0 |
PC621 Professional Issues in Health Care Delivery |
1-0 |
PC623 Women’s Health II |
1-0 |
NM624 Antepartum Care II |
1-0 |
NM625 Intrapartum Care II |
1-0 |
NM626 Postpartum Care II |
1-0 |
NM627 Newborn Care II |
1-0 |
Total Credits | 7-0 |
