Teaching Strategies for Preceptors of Beginning Intrapartal Students

Linda Wheeler, CNM, MN, EdD

NuRemkiwifey pmgmms that an- ploy conxnunity nurse-midwives as preceptors for beginning “urse- midwifery stink are increasing in number. Bexause many practicing “US+midwives have hati n&her for- “lal educaaon in toaehing nor a su- pavired teaching pmcti&n, the ex- change of ideas about how to teach can be an imprlant source of pmc- acal Infu~tiu”. Thk aIt& k meant to lnuiate a ciihgue amn?g muse- mldwkea engaged in clInkA teach- ing. The putpox k to shaw ideas that can fadkate leaning and in- - the co”ffde”ce of novice pre- ceptors.

lEARNlNGslw.E

Indiadual differences in perceiving and processing information are known as leaning s&s. Learning style i”ch& 1) the operations that c.xur fn a” indhddual’s braln when lemling occurs, 2) the cNtk5 of the phy&4 e”vim”me”t that ex- wditekamingfczani”dttiual, and 3) adaptatkms a” i”dividu& body Pdduling~ofdudy(l,2j.

Mdmsmmrpondmam”*-kr, 1905 55 Larch. Pm&d OR 97214.

Learning style may be influenced by personality type. Consequentfy. some nurse-midwifery education programs admlnister personality- kwe ~uestionnaira such as tbe Mv- &-B& Person& hwntoy, & both sludenkar.d facultv. The rest& of thee tesk can help-students use and appeciate their mast effective leaming sty&. Students can also be more accepting and appreciative of !eaming differences in others. PIP ceptols benefit because this informa- Uon allows the preceptor to individu- alize leaming situations.

Because fxlxJ”aluy type “lay in- fluence teaching and managerial slyles as well as lea”ling sty!% pre- ceptors may wish to take the same tests that are administered to stu- dents to gain insight into their own kaming sty!es and petsanality haik. Preceptors who have lnfonnation about their own teachina skk should share this information $4 students at the tinnina of the students’ din- ical ex&%nce.Whe” students have not bad a” opportunity to oxplors how they lean best, the preceptor may wish to encourage students to obtain this information and can sug- gest personal or library resources (1-a

PREvlous EXFZRIENCE ANDBELIEFS Just as a” e&a birth experience may influence a” expecknt mother’s behavior in labor. u”dergraduate “Using experience may influence a student’s behavior in the inimpar!A area Prevfaus irteractlw perceived as demeaning to the student (x clin- ical evaluations ~eiwl as unfair can put studenk on the defensive and “lake any sw$wtio”s 01 Cd& ckm by the &e&r unacceptable. To determine whether neaative intlu- ences exist, ask sludenk-about past clinical ex@aees and evaluations a we!l as re!alio”stdps with uncler- graduate nursing school faculty mornborn Determine student con- cerns about the cum?“t experience.

Student behavior may also be in- fluenced by the phflwaphy of care that guided matemity nursing pmc- te in a previous job s&ing. If the student’s prior labor and d4ivey ex- perience took plafe in a” institution where gucd nursing care was defined i” ways that are generally for&g” to nursomidwifey. the preceptor may expect a ldnd of care that is unfami- far to the student To avoid tisun- derstandings. ask students to de- scribe componenk of care that of-

*en differ among settings. Pmcttces for relieving pain, second-stage push- ing techniques, methods of hydm- tion, type and frequency of fetal monitodng, acceptable length of set- and stage, indications for episiotomy, family involvement In labor and birth, and the student’s concept of labor support should be explored.

REDDiZ-l’lON OF ANXIETY

Teem Teaching

Regtnning students approach the in- trap&al experience with a hlgh level of anxiety. This anxiety may be low- ered if the student is relieved of the responsibility of “putting everything @ether” for the Rrst few births. A team approach with the preceptor end shldent working together to exe for a laboring woman and her family allows the student to share responsi- bllity with a knowledgeable col- league. For example, a student’s anxiety might be diminished by knowing at the outset that, for the ftrst few labors and blrthe, the pre- ceptor will function es the teem leader and will think out loud. Then, es the chart Is retiewed together, the preceptor can highlight impxtent in- formation and identify for the student additional data thet are needed. The components of the ph*cal assess- ment es required by the situation should also be jointly discussed be fore the initial pettent encounter by both the preceptor and the student.

Linda Wheeler is on essc.%tt pr0fe.w.r et Oregon Health Scienca Uniwrsi~ Nurse-Mtdtijew Edumfion F’mgmm. She receiued her cedifimie in nurse-midwifely jmm the Uniuemity of MMSSIPPI Medicczl Center in 1971. Her MN b fmm Me UnivenUy of WaJhingion, and her EdD is fmm Highland “niuen&. She teaches and pmctlur fill-saw midw,,e,y within the Oregon Health Sciences Uniue&y nurse-midwifery iaculty pm&e.

After essenttal information is getb ered, the preceptor and student might write seoarete lists of what ee;h considers’ important with this particular family. The lists should then be compared and the differ- ences discussed Remarks such as, “This makes me think .I’, I‘d like to know more about :‘. and “I wonder if .” show the student what is going on in the preceptor’s mind.

As labor mwresses. the idea of choice pain&, r&n& when op- tions may be exercised, should be in- tmduced. The preceptor mtght ask, “What are our choices now?” Useful comments to help the student keep en open mind could include “What would you think of ., ” +.Vould there be any advantage to .,I’ “What might happen if _,‘I or “Perhaps you’d be Interested in something that I’ve tried before end found helpful.”

Complex Skills

Students in the intmpxtel erea may also be anz&n,s knowing whet com- plex skills need to be mastered. Teachinq these skills In uerts may help decrease this anxk%y.‘For exa&- ale. a student’s efforts at first births might be directed solely to hand ma- neuvers with the preceptor pmvidtng support and dtrect!-an to the @tent. Initial attempts at eptsiotomy repair may be conftned to the euba~ttcular and eubcuteneous hyers, as proper plecement of sutures in these tissues is more readtly apperent to the inex- perienced eye.

EXPANSION OF KNO!MEDGE. SKULS.ANDJUDGMEh-t

Emergence Situations

Appropriate preparation for handling emergency Situation3 is always e gal of nurse-midwifey education pro- grams. Because students cannot be guaranteed supervised experience

with every poss1%l0 emergency, they should be required to anticipate the appropriate acttons for a ve*ety of clinical situations that require an im- mediate, competent reeponse. For example. fetal distress, shoulder dys- tocta, and postpartum hemorrhage might be chosen. In cor%mction with the orece~tor. the student miqht -ani6 a pl& of action for each sit&- non on e 3 x 5 cad that the student is to keep readtly accessible while on the labor and delivey unit Period& ally throughout the shift or on-call hours.. the student couldbe drilled on the actions that should be taken to deal appropriately with one of the eit- “atiO&

The beginning student should know that a perfect response to each emezgency situation ts somethiig to- ward which to work. Four points should be emphasized:

1. The It.4 of actions must be mem- orized. Repeatedly listing the steps to take may bring them to mind more readtly when the etu- dent Is alone encountering tbe emergency for the firet few times.

2. The student should refer to the cards if the CaKect elmvers ale not forthcoming.

3. In the beginning, rerponees to only one eihJatlon ehould be elk+ ited A novice wtll find tt too con- fusing to be asked to provide U-a enswers to multtple e.ituetione.

4. As appropriate, students should be asked to demonshate ee well as lii the actions to be taken. This will be pertkularly helpful to kin- esthettc learners who learn best by doing. It also allows the pre- ceptor to verify that the etudent knows exactly where and how hands should be p&toned when manual dexterity is required to M- complish the action listed.

What Is the Student Thinking?

Preceptas can also wnmbute to ex- panding the student’s rep&&e of

3¶2 Joumel of Nurse-?Uwifay . Vet. 39. No. 5. SeptembalOctd,er 1994

skills by tmcing the student’s think- ing. Knowledge of the student’s thought processes helps the Precep- tor know whether a decision made by the student is a result of chance or of logical thinking. Misinformation can be corrected; and it then be- comes possible to determine whether other options were appropriately considered. To determine the stw dent’s thought processes it is usually necessary to ask questions.

For example. a student’s initial as- sessmed of a patlent admitted to the labor and delivery unit at 4.cm dtla- tion may include e diagnmis of active labor. ihe preceptor could ask, “How do you know she is in active labor?” The student may respond, “Because she Is &cm dilated.” Infor- mation about the student’s knowl- edue base can then be pursued by w&g, “How do you dii&oee acti”; labor? Whet ctiterie should YOU use

to - labor stehl?? Although students may be ““com-

fottable initially with these questions, they learn to have fatth in their cog- nitive processes By helping students to think through a situation, students understand that they have the knowl- edg+ base and the decision-making abtlfty to act thoughtfully and appro- plwly.

Repnt Forms

New students often make incomplete assessments of women in labor. p&y because it is hard to remember all of the things they need to assess. A form listjng information to be gath- eted at spectfted inter&s can help students address the many issues that are tl”po*“t f” evaluating a woman in labor. The form should be com- prehensive and should speak to both the eri and the science of nurse- midwtfey. An example is provided in Rgwe 1. After being inkoduced to the form. studenk should report to the p”ptor at age&upon inter- vals with the information requested on the form.

Professional Language

In the work e”vim”,“e”t. it is easy to forget the nuances of the words we use. Abbreviations and slang tern,, as well es inaccurate dewripdons of what is really happening become common: for example. “We are pit- ting her,” rather than “she is receiv- ing Pitoci”” may be head “She’s a V-BAY is also familiar. Nurse- midwifew preceptors ca” encoureqe students-t; “se ianguage that is pr;- cise and factual. Thev can also invite stodents to think of words that avoid “egetive connotations when dewib- i”g pregnanci~j or labors that have seemingly gone awry. Failure to progress and cervical incompetence imply that the pregnant woman is in- adequate, deficient. or negligent.

Nurse-mkkvtfery preceptors might also rethink the use of the word “management” es it applies to women in labor. Although students are taught to use the management process while p&ding care. in low- risk situations nurse-midwives sup- port rather than manage. “How are you going to manage this lab-or?” is more likely to be approptiete in me- dium- and high-risk situations. In most low-risk situatto~. “Let’s talk about yaur plans for suppoldng this family through labor” might well be more appropriate than, “What is your maMgemo”t plan?”

Lkxumenting the Student’s Mivftfes

Evaluadon of the tident in the din- icel area can indeed be difficult A particularly herd area to evaluate is the birth itself. &cause of the excite- ment, tension, and speed that ac- company the entw of a baby into this wodil a&umte r&l of the evenk is often &asible. Fortunately, video- tape is available to provide visual and auditory documentation of what takes place as the baby is being born. Studenk see where they placed their

hands The” hear what thev said and the tone ofvoice they us&

The most helpful videotapes show ule birth from crowning through ex- p&on of the placenta. Although the video recorder can be placed on a trIpa during the birth, designating a person. such as a second student or a willing family member as the photog- rapher. increases the chances of get- ting good pictures. Without a person free to move about with the camera as necessary, the birth attendants are ltkeiy to get in the way and the re- sulting picture may be of the nu- dent’s shoutder or back

When videotaping equipment is not avaifable. or the family refuses permission to videotap?, audiotapes Wth the femily’s pem&ion) allow the verbal potion of the birth to be recorded. Tke information obtetwd from listening to the tape can be ex- ceedingly helpful even though the vi- sual piece is missing.

Both preceptor and student may hesitate to see themselves on video- tape or hear their vokes on audio- tape. Their hesitation ts often related to fear that their ections tiff be less than perfect. Cwrcomtng this reluc- tance may be possible if students are initially given the option of sharing the videotapes with the preceptor. ff the student chooses to view the vid- eo@++ without input from the pre- ceptor. a form listing gutdelioes for th; student to use while studying the videotax should be give”. Knowins what to look for guides the learner.-

RELATlONSHlPS WITH NURSING STAFF

ProvidingsuPport tolabadngwome” is a ro4e shared by nwses and nurse- midwives. At times. however. it is un- clear who should do what. Either the nu,se or the student may feel that their role is being usurped by the other. Receptor can facilitate inter- action with the nurss caring for the patient by discwing with the student

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I. MATERNAL

II. FETAL

1 well-being 1

1 Energy level

FHR

1. Baseline 2. Variabilitv 3. Decelerations

color Of amniotic fluid

IV. SUPPORT SYSTEM

1. Who is present?

2. Relationship to laboring woman?

3. Emotional climate, communication of those present

fl Contractions 1

1. Dilatation/ effacement

2. Stage of labor H 3. NOrmal vs. abnormal

V. LABOR

1. Fetal position

FIGURE 1. IniraPati aswssme”L

how to commu”icate to the nursing vey to the ““M ahead of time a de- staff what the student needs to Prac- sire to employ a” approach that is

a set6ng where directed pushing IS

iice or demonstrate. The orecqltor may also suggesi

outside the usual way of doing the noml. ways lo enlii the *ulqlMt of the ““me should be su&ed be.

things. For example, If the student ways in which the student can con-

lore pushing kghls. I” tbii manner wants to use nondirective pushing in coniliting i”SbuCUQi~ to the padent

324 ~oumal cd Nune+ud&,y . Vol. 39, No. 5. Sqtember/Oc~&er 1994

WIG be avoided and the nurse will not feel undermined.

SUPPORT AND ENCOURAGEMENT

CoaltIcates of Achtwement

In some ways, nurse-midwifery SW dents are like women in labor. Roth need support and encouragement. Certificates of achievement, awarded when important milestones are reached or perceptve observations are made. can reassure students that they are doing well and ca” reinforce posiltve behaviors. For example, a student mlxht receive a” award for “Perseverance in Second Stage,” “Using Great Judment at 300 in the Morning.” “Remgniling the Fa- ther’s Need far Suppoti,” “lnmrpo- rating the Entire Family in the Birth,” ‘ylerponding Appropriately to Post- partum Homonhage,” and the like. These ceeiffcates may be made by hand or with the help of a computer software plcgmnl. Blank certificate forms are available commarklly.

lhe Art d Nurse-bUd&ery

In the sdencwalwd onvimnmenk in which much of nurse-midwifery education takes pface. the art of “ursQ-mkh&fay “lay become under- valued. Aftbwgh the indhedual tem- perament may dktate whether art or scfence domlnatos in the practice of any one person. pwxeptors must value and must model the art of nurse-midwifery. Modeling the de- sired behavior a”d tafkfng with the student about the ari of what we do telk WT students that tbo art of CUT plactkx k a core value.

One way to help students appred- ate the artkty of nurse-midwifey practice k to tell birth stories. Sharing paradigm cases and talking about ways that intuition guided or influ- enced one’s behavior can help stu- dents learn to respect. but not exclu- sively rely on, instinctual inner voices. These stories can also stimu- late thought about the influence of the fourth “P.” the “pub-psyche” fpsychel, on the outmme of labor.

CREATING coNNEcnoNs

Rttuafs for Students

Ritual and ceremony recwjnize tm”- swim, formalke “&sto”es, promote feelinss of acceptance. and acknowl- edge accomplkhment Their use in nurse-mtdwifey education can pro- mote a student’s feeltng of welcome and connectedness. For example, preceptors could cbww. to welcome a new student with ‘I special dinner or wnalf & a closir,g activity could include a” outing or @ing a remem- brance from the practice. A plaque. flowers, or a midwifery symbol are always appreciated. Some nurse- midwifery students feel a strong sense of connectton with the local communihl of midwives as well as with mid&ves throughout the wodd. Thus. the midwifery community might be Invited to a- farewell c&- many. with each nurse-midwife ex- pressing Qood wishes for the stu- dent’s fuhne.

CONCLUSION

Gad teaching “requires courage the courage to expose one’s &nor-

ante aS well as insight, to invite con- tradiction as well as cowznt. to yield wnne control in order to empower the group, to evoke other people’s lives as well as reveal one’s awn” (6). The suggestions in thii tick will not facilitate leaning for every student. “or will they fit the teaching style of every preceptor. The main v&e may lie in their ability to stimulate creative apprcaches to student learn- ing, and to encourage retkctio” on the role of tbe preceptor. Precepton interested in shaing their own teach- ing ideas with others are invited to send them to tbe author along with a self-addressed. stamped (two stamP5. please) envelope. The corn- paite of suggaions (with credit to the oIigi”atorl will be Sent to those who have submitted su@ons. as well as to the directors of the “use midwifery e&,cation prograns in tbii munby.

REFfaENcES

1. Dunn R, Dunn K. How to diag- nose learning styles hsbuctar 197281 1234%.

2. Guild P. Marching to different drummers PJaardiia NA): Aswiation fm Supervision and Cunieulum Develop “lent, 1990

3. Dunn R, Reaudty JS, Klavas A. Sway on -h of laming stylfa. Ed- ucati Leadership 19%48:538.

4. Keiwy K, Sates M. Pkase under- stand me: character and temperament tvper Del Mar WI: Prcmethas Nem-

esis Book Company, 1984.

5. G&w H. Frames of mind: the theory of multiple intelligences. New York Bask Bookr 1935 7&a 4.

6. palmer PJ. &d teaching: a mat- ter of living !he my&y. Change 1990; 22:10-6

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