Guidance for meeting the ICM Global Standards for Midwifery Education (2021):

Practical/Clinical Experience

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 Guidance for meeting the ICM Global Standards for Midwifery Education (2021):

Practical/Clinical Experience
Introduction
Practical/clinical experience is a critical component of midwifery education programmes. The ICM
Global Standards for Midwifery Education (2021)1 define midwifery education as: The process of
learning theory and developing the necessary skills and behaviours to become competent midwives.

Developing competency depends on bringing together theory, skills, and behaviours in a variety of
interactions with childbearing families. Clinical/practical experience is where students increasingly
integrate knowledge and skills, demonstrate critical thinking, and formulate plans of care that
contribute to health and well-being. The practical experience component must be well planned and
afford sufficient time to meet the Essential Competencies for Midwifery Practice (2019).2

This document contains advice and suggestions to help midwifery educators3 meet the ICM Global
Standards for Midwifery Education that pertain to practical/clinical experience. Readers should review
the entire Global Standards document to understand the context of the specific standards about
practical/clinical experience.

Using this Document

The ICM Global Standards for Midwifery Education about practical/clinical experience are grouped into
two categories:

(1) Standards about the physical sites for obtaining clinical experience, and the maternal-infant services
provided in those sites;

(2) Standards about the roles of midwife educators3, clinical preceptors/clinical teachers and students.

This document presents each standard regarding practical/clinical experience followed by a brief
discussion and points for consideration when analysing how a programme of study meets the standard.
The points for consideration help in determining what faculty and programme administrators need to
put in place to ensure that the practical/clinical experience meets the ICM Standards and provides a
positive and supportive experience for both the student and the clinical preceptor/clinical teacher.

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 I. Practical/Clinical Experience and Sites for Learning

Standard 4.7 The midwifery curriculum includes both theory and practice elements with a
minimum of 40% theory and a minimum of 50% practice in clinical settings.

Discussion
The programme curriculum must demonstrate the balance of theory and practice and ensure that
students obtain practical/clinical experience in clinical settings for at least half of their programme.

The “hands-on” clinical component provides opportunities for students to apply theory, acquire skills
and behaviours, and develop relationships with women, families, and multiple health care providers.

Simulation activities are useful in a classroom setting for introducing students to new skills and
behaviours, for review of seldom used but necessary skills, and for testing skills, but simulation is not a
substitute for the realities of providing care in a variety of circumstances and engaging in multiple
interactions with childbearing families.

Standard 3.6 Students have sufficient midwifery practice experience in facility-based and
community care settings, including women’s homes, to attain the current ICM Essential
Competencies for Midwifery Practice.

Standard 5.5 The midwifery programme has a variety of clinical learning sites, e.g., community
and institutional settings, in sufficient numbers to meet student learning needs.

Discussion
Practice experience in a variety of sites is essential for developing competence in all aspects of
midwifery care. The number and variety of sites available for student learning will differ according to the
location of the midwifery education programme. Potential sites range from households to tertiary level
complex medical institutions. Increasing the number and type of practice placements in the community
(including family households) may offer more opportunities for students to provide care to
women/families from diverse social, cultural, and economic backgrounds.

The list below is typical of clinical learning sites relevant to midwifery education programmes:

• Family households
• Community health centres
• Community clinics

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 • Community Birth Centre(s)
• Outpatient clinics within a hospital
• Rural or small community hospitals (primary care)
• Referral/ specialist hospitals (secondary and/or tertiary care)

Student access to a variety of sites provides learning opportunities to achieve the Essential
Competencies for Midwifery Practice, 2019 2 which address all aspects of the childbearing cycle and
newborn care, including:

• Pre-pregnancy and antenatal care

• Care during labour and birth
• Ongoing postnatal care and parenting support
• Teaching and support for breast feeding
• Care of newborns/infants
• Family planning counseling, teaching and provision of contraceptive methods

In some states/countries students may be required to develop competence in added areas of maternal-
child health, such as care of the well-child to age 5, or post abortion care, or well-woman health care
beyond childbearing, or care of sick children. Such added competencies increase the type of sites
needed for clinical learning.

Points for Consideration

Midwifery educators who have responsibility for identifying suitable clinical sites for student learning
need to consider the following when selecting a site:

• Is the location of the site accessible for students?

• Are students permitted to provide direct care or are there policies that restrict what
students can do?
• Is there space and equipment for students to practice skills?
• Are there learning resources accessible to students such as a computer and/or reference
textbooks, journals, manuals to support their learning?
• Are students assigned to situations that are consistent with learning needs?
• Do midwifery students compete with other health care learners who also need to gain
clinical experience?
• Are there high rates of medical complications that limit opportunities for midwives to
make decisions on their own responsibility about appropriate care?
• Are students considered part of the workforce rather than learners? Do the needs of the
site have greater priority than learning needs of students?

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Having access to a variety of clinical sites can be helpful in promoting learning about a range of maternal
and infant care services and the families who access the services. Gaining experience in a variety of sites
contributes to the students’ abilities to adapt to different environments and acquire competence.

If the learning environment is not supportive of students, midwifery educators need to seek additional
sites or engage with sites to modify factors that limit student learning.

Annex 1 contains a chart for midwifery educators to use when considering the variety of clinical sites to
be selected or developed. The chart is a worksheet where sites can be cross-referenced with the kind of
clinical care experience available to students. It is helpful during the planning of practical/clinical
placements and can be used by students to “map” their individual placements and accumulating
experience. The chart can easily be adapted to meet local needs.

Standard 3.7 Students participate in providing midwife-led continuity of care to

women/families through pregnancy , birth and the postnatal period.

Discussion
Very often student placements are organized to concentrate on one part of the childbearing cycle for a
defined number of days/weeks. For example, students may be assigned to an antenatal clinic and see
many women at various gestational ages, but they seldom see the same women throughout their
pregnancies. Students assigned to a labour and birth unit are unlikely to have met women before they
are in labour, nor will they see those women in the postnatal period.

This model of placements fails to recognize the well documented benefits of midwifery-led continuity of
care.4,5 Students also benefit from experiencing this model of care. They gain an invaluable perspective
on the life course of women and their families across the continuum of pregnancy, labour, birth and
post-birth care of mother and infant. They build a relationship over time rather than experiencing
episodic short- term encounters. The longer-term relationship provides opportunities to understand the
physiological, social, and psychological changes that occur during the childbirth cycle and to offer
support that strengthens women’s capabilities for childbirth and parenting.

Points for Consideration

It is important for midwife educators to:

• Be familiar with the evidence4,5 that supports continuity of midwifery-led care and
incorporate the evidence into the curriculum.

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 • Prioritize placements for students where the midwives practice continuity of midwife-
led care.
• Create opportunities for every student to experience continuity of care with a small
number of women, even where continuity of midwife-led care is not the local norm.
• Be committed to making arrangements for students to follow women/families through
time and across settings, for example permitting students to miss an occasional
scheduled class to be present for labour and birth, arranging with clinical sites for a
student to be with the woman/family for appointments, for hospital care.
• Incorporate into assessments of student learning the objectives of providing continuity
of care, such as establishing rapport with the pregnant woman and her family;
understanding the impact of the childbirth process on family relationships; building
confidence in women to communicate their needs; providing health teaching about
childbirth and parenting; facilitating exclusive breastfeeding.

Standard 5.6 The quality of care provided in the clinical learning sites supports students to become
competent midwives.

Discussion
Student learning is enhanced when they witness quality care in clinical sites and are rewarded for
establishing positive relationships and providing respectful safe and effective care. Students who
experience coercive or rude behaviour toward themselves, or witness those behaviours toward women
and families, or observe neglect of women’s needs may need increased support to overcome those
negative experiences and develop positive interpersonal communication skills with the people they care
for and healthcare team members.

Points for Consideration

Midwifery educators need to assess the quality of care for women and infants in sites where students
have practice placements. The questions below can contribute to an assessment of quality of care in the
clinical site.

• Has the site been evaluated by an external health organization for its quality of care and
received positive results?
• Is the site well known in the community and does it have a positive reputation?
• Does direct observation show that women are treated with kindness and respect; that
they are included in discussions about procedures and that consent is required for
interventions?
• Are family members welcome and included in visits/discussions?

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 • Are normal processes for labour and birth explained, encouraged and is labour support
provided?
• Are mothers and babies in hospital maternity units kept together? Is early and frequent
breastfeeding encouraged, supported and assistance provided when needed?
• Does the site conduct regular reviews of practice as teaching sessions for the healthcare
team? When complications or errors occur, do they inform policies and practice for all
health team members? Are students welcome to attend quality improvement teaching
sessions?
• Are attitudes and behaviours of staff members welcoming and supportive of students?

The midwifery programme has policies about:

Standard 3.4.5 Protection of students’ personal health, safety, and wellbeing in learning
environments, such as hours of continuous work, exposure to infectious or environmental
hazards, modes of travel, verbal or physical abuse.

Discussion
Midwifery educators have a responsibility to promote the safety and wellbeing of students to enable
them to engage in effective learning. Program policies need to promote not only physical safety but also
psychological safety of students in clinical sites. Learning new information, skills and behaviours
requires concentration and time. It is a stressful experience for students. They should neither be
expected to function at the same pace as experienced midwives nor experience long periods of time
without sleep.

Points for Consideration

Midwifery education programmes need to have policies about aspects of student safety and wellbeing.

A range of topics that policies might address are listed below:

• Are there policies that limit the length of time students are expected to provide care
without sleep? For example, should a student be up all night with a labour and birth and
be expected to attend a class, or other clinical activity during the following day?
• Does the program ensure students have time away from clinical work for study time
when major exams/assignments are scheduled?
• Are there policies about students’ personal immunization status that protect them and
the persons in their care?
• Are there policies about reporting illness symptoms and the duration of allowable
absence from a clinical site?

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 • Is the education programme responsible for travel to clinical sites? If students travel on
their own, are there policies about who is responsible for safety, especially if there is
concern about certain locations or times of the day or night when students travel?
• Is travel to family households feasible and safe for prenatal and/or postnatal visits? For
planned home births?
• Do clinical sites provide a safe space to store personal belongings, change clothing?
• Is there a space for students to have food and rest?
• Is there instruction in the proper use of equipment and its disposal?
• Is there an adequate supply of soap and water, PPE including gowns, masks, gloves
available to students?
• Do midwifery educators and/or clinical preceptors intervene if midwifery students are
demeaned and unduly criticized by health care workers in a site?
• Are there policies that protect students if they are asked to carry out aspects of care
beyond their level of competence, jeopardizing their safety and that of
mothers/infants?

II. Midwifery Clinical Preceptors/Clinical Teachers

Note: The terms clinical preceptor and clinical teacher are used in preference to clinical mentor to
ensure the important role of evaluating students is captured. To meet ICM standards, a programme
that uses the term clinical mentor should ensure they have the qualifications set out in Standard 2.3 for
clinical preceptors/clinical teachers.6

Standard 3.8 Students provide midwifery care primarily under the supervision of a
midwife teacher or midwifery clinical preceptor/clinical teacher

Discussion
Student experience in clinical placements needs to align with the overall goals of the programme,
facilitate the achievement of the ICM Essential Competencies for Midwifery Practice (ICM 2019), and
enable graduates to meet regulatory requirements for entry to practice as a midwife in their
state/country. The quality of supervision and teaching in the clinical environment is the responsibility of
the midwifery programme.

Frequently, clinical preceptors/clinical teachers are staff members in a clinical site and provide direct
teaching and supervision of students. The ICM Global Standards for Midwifery Education align with the
WHO definition of a clinical preceptor/clinical teacher as “an experienced midwife engaged in the
practice of midwifery who is competent and willing to teach students in the clinical setting. A

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preceptor/clinical teacher works closely with the student midwife to provide guidance, training, support,
assessment, evaluation, and constructive feedback, and serves as a role model for the student
midwife.”,7

Points for Consideration

Integrating clinical preceptors/teachers into the overall programme is important for establishing the
best experience for students in clinical placements. Some guiding questions for considering the
involvement of clinical preceptors/teachers within the midwifery education programme include the
following:

• Does the education programme employ or select clinical preceptors/teachers, or are

they assigned as part of their employment in the clinical placement site? If they are
assigned, does the programme have influence in the selection of clinical preceptors/
teachers?
• Does the education programme provide specific orientation and training for clinical
preceptors/teachers?
• Are the goals and objectives of placements, and the methods of evaluating students
clearly defined for clinical preceptors/teachers and learners?
• Do clinical preceptors/teachers contribute to planning future placements?
• Do the evaluations from students and midwifery educators indicate the clinical
preceptors/teachers are positive role models for students?
• Do the clinical preceptors/teachers demonstrate commitment to teaching and
supporting students?
• Are continuing education opportunities provided to clinical preceptors/teachers by the
midwifery programme about midwifery best practice? About teaching and learning?
• Do clinical preceptors/teachers receive recognition from the practice site for their role
in education?
• Does the midwifery program provide recognition of clinical preceptors/teachers, such as
invitations to program events, letters to preceptors’ employers, financial support?

Standard 2.7 The ratio of midwifery students to clinical preceptors/teachers is based on the
learning context and the needs of the students.

Discussion
It is the role of clinical preceptors/teachers to oversee students in their clinical placement experience.
The relationship between clinical preceptors/teachers and students is crucial to students attaining the

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objectives for the experience. Prescribed ratios may not suit every circumstance and programmes
should have the capacity to adjust them. The needs of beginning students differ from more advanced
students and preceptors should adjust their oversight accordingly. In situations where added support
and guidance is required for a student(s) to achieve the objectives, a ratio of 1:1 may be needed.

Points for Consideration

• Are there established ratios of students to a clinical preceptor/teacher?

• Who sets the ratio, and on what basis?
• Does an established ratio take account of beginning level versus more experienced
students?
• Is there a mechanism to vary the ratio to meet students’ needs?
• If there is dual accountability to the education program and the clinical site employer, is
the work of the preceptor determined jointly or primarily by the site?
• Is there flexibility in the ratio so that greater attention is provided to students who have
trouble achieving learning goals?
• Is the clinical preceptor/teacher’s workload in the clinical setting adjusted to account for
responsibilities for students?

Standard 2.6 Midwife teachers and clinical preceptors/clinical teachers communicate regularly
to facilitate and evaluate students’ learning

Discussion
Midwife educators who provide the theory component are expected to maintain clinical competence
and be familiar with settings where students are assigned. This fosters a collaborative relationship
among the educators and clinical preceptors/teachers and assists students to integrate theory and
practice.

Points for Consideration

Midwife educators need to collaborate with clinical preceptors/teachers to appraise the student’s
achievement of the required knowledge, skills and behaviours.

• Do midwifery educators in charge of the program create opportunities that build

positive working relationships among classroom and clinical preceptors/teachers?
• Does the midwifery education programme provide training sessions for clinical
preceptors/teachers to promote consistency of expectations of students and
consistency of assessing students using agreed upon criteria/tools/ratings?

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 • Do midwifery educators and clinical preceptors/teachers conduct joint assessments with
students at regular intervals using defined criteria for determining progress?
• Where added supports are needed to address gaps in achievement, does the midwifery
educator along with the clinical preceptor/teacher create, with the student, a plan to
meet the identified learning needs?
• Are there programme policies about who makes the final pass/fail (or other grading
system) decision about the student’s progress during the placement? Clear and
consistent criteria are necessary to facilitate agreement among the midwifery educators
and the clinical preceptors/teachers.

Standard 4.9 Midwifery faculty use fair, valid and reliable formative and summative assessment
methods to measure student performance and progress in learning related to knowledge,
behaviours, decision-making and skills.

Discussion
The education programme specifies the assessment methods to be used by midwifery educators and
clinical preceptors/teachers to measure student acquisition of skills and behaviours expected in the
clinical environment.

An assessment is fair when the student knows what the assessment will cover and that it relates to the
course /module objectives. Different assessment methods are needed to measure aspects of
competence. For example, is it an assessment of required knowledge, or an assessment of a newly
acquired technical skill, or an assessment of counseling about a health behaviour? A behaviour or a skill
can be observed whereas other forms of evaluation are needed to assess underlying knowledge.

Formative assessment is provided “along the way” with the purpose of directing improvement so that
attainment of the skill/behaviour/knowledge is acquired by the end of a designated time period.
Formative assessment is ‘for’ learning and does not contribute to the final grade. Summative
assessment is assessment ‘of’ learning (e.g., assessments are graded). It is carried out at the end of a
course/module and ultimately at the end of the programme as the final determination of meeting all
requirements.

Points for Consideration

Midwife educators and clinical preceptors/teachers need to specify in advance the learning outcomes
for the placement. Checklists of skills, for example, and their level of mastery need to be agreed upon
and available to teachers and students. Knowledge about topics, conditions, etc. must be specified as
well as behaviours in the placement site.

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Formative assessment of the clinical learning and progress in acquiring competence requires multiple
observations over time to show progress, identify gaps and help the student achieve the overall goals of
the placement experience.

Preceptors need to observe on multiple occasions a student’s actions and behaviours, followed by a
discussion with the student about what was heard/observed and what the student sees as next steps in
a plan of care. Multiple observations are needed to form a reliable assessment.

Students need to self-evaluate to compare with feedback from the clinical preceptor about what was
done well and what could be improved. This form of assessment provides direction to the student for
continuous improvement. The student and preceptor can track development over time and identify if
continuing gaps/needs exist and plan for greater support/instruction.

Preceptors can also foster group discussion when several students are assigned to a clinical site.
Students can review and analyze clinical situations and exchange views about the care that was
provided. These discussions model peer inquiry about practice and are an added formative assessment
of applying theory to practice. Students should generate questions to explore with health experts,
textbooks and current literature, etc. and bring back information for further discussion.

A variety of methods are used for summative assessments of skills and behaviours. Examples include
oral exams, skill demonstration with models, role play in a simulated situation, and structured clinical
exams that integrate problem-solving and clinical skills.

Note: A limited number of additional resources8-13 about assessment of learning in clinical sites can
be found in the list of references.

Standard 3.4.3

Student policies include:

Mechanisms for students to provide feedback and ongoing evaluation of the midwifery
curriculum, midwifery faculty, and the midwifery programme.

Discussion
Midwifery education programmes should ensure students contribute to all aspects of program
evaluation, including providing feedback about clinical preceptors/teachers at the completion of a
course/module or when moving to a different clinical placement site.

Standardized forms with rating scales and/or areas for comments that are consistently provided to
students will help guide the feedback and keep it focused on relevant topics. Students are more likely

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to complete evaluation forms if their feedback is requested after the student has received her/his own
evaluation and the feedback is anonymous and confidential.

Points for Consideration

Listed below are sample topics that can be included in evaluation tools that seek student feedback
about clinical teachers/preceptors:

• Provides orientation to clinical site, introduces members of health team

• Promotes a positive learning environment for student
• Provides demonstrations, direction and learning resources to student
• Acts as a role model in interactions and provision of direct care
• Encourages student to ask questions and reflect on own performance
• Assists student to provide care, as appropriate for level of student and to ensure safe
care
• Provides feedback that is objective and specific; includes suggested improvements
• Motivates student to continuously improve

Conclusion
ICM recognizes that midwifery education programmes vary widely around the world. Suggestions about
ways to meet the ICM Global Standards for Midwifery Education will not apply uniformly across the very
different contexts in which midwifery programmes operate. In settings where midwives are severely
constrained in their practice and teaching, the ICM Global Standards for Midwifery Education (2021) can
provide a stimulus for change to increase the quality of education programmes and the competence of
midwives. The guidelines provided here help midwifery programmes strive for the best practical/clinical
learning for their students.

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References

1. ICM GLOBAL STANDARDS FOR MIDWIFERY EDUCATION (REVISED 2021)

2. ICM ESSENTIAL COMPETENCIES FOR MIDWIFERY PRACTICE, 2019

3. Midwifery educator refers to midwives who are responsible for the content of a midwifery education
program and for overall assessment of student progress. They are qualified as midwives and meet the
definition of midwife teacher as described in Standard 2.2 of the ICM Global Standards for Midwifery
Education (2021).

4. Sandall, J., Soltani, H., Gates, S., Shennan, A., Devane, D. 2016. Midwife-led continuity models versus
other models of care for childbearing women. Cochrane Database of Systematic Reviews.
Apr 28(4): CD004667.doi:10.1002/14651858.CD004667.pub5. Available at:
https://pubmed.ncbi.nlm.nih.gov/27121907/

5. Sandall J, Soltani H, Shennan A, Devane D. Implementing midwife-led continuity models of care and
what do we still need to find out? August 13, 2019. https://www.evidentlycochrane.net/midwife-led-
continuity-of-care/
6. Standard 2.3 of the ICM Global Standards for Midwifery Education (2021) describes the qualifications
of the clinical preceptor/clinical teacher as follows:
• Is qualified according to the ICM Definition of a Midwife
• Demonstrates competency in practice, generally accomplished with a minimum of two
years of full scope midwifery practice
• Maintains competency in both midwifery practice and teaching
• Holds a current license/registration or other form of legal recognition to practise
midwifery
• Has formal preparation for clinical teaching or undertakes such preparation as a
condition of continuing to hold the position

7. Strengthening quality midwifery education for Universal Health Coverage 2030: framework for
action. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. Cited in Glossary of
terms. ICM Global Standards for Midwifery Education (2021).

Supplementary resources about teaching and learning in clinical sites

8. Raisler J, O’Grady M, Lori J. Clinical Teaching and Learning in Midwifery and Women’s Health. J of
Midwifery and Women’s Health. 48: 398-406, 2003.

9. Licqurish S, Siebold C. Bachelor of Midwifery students’ experiences of achieving competencies: The

role of the midwife preceptor. Midwifery 24(4): 480-489, 2008.
https://doi.org/10.1016/j.midw.2007.05.001

10.Creagh A. Assessing clinical competency. Assessment Zone Issue 1: 16-18, 2013.

https://www.academia.edu/5085725/Assessment_Zone_Issue_1

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11. Coulson-Bonner C. Assessment in the clinical setting: A challenge for midwifery education.
Assessment Zone Issue 2: 33-35, 2014 https://www.academia.edu/7250032/Assessment_Zone_Issue_2

12. Mahoney S. How do we assess midwifery students’ competence to practice? Assessment Zone Issue
3: 41-43, 2016. https://www.academia.edu/26043521/Assessment_Zone_Issue_3

13. Online module for training of preceptors: www.preceptor.ca

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ANNEX 1

The following chart may be a useful inventory of actual and/or possible clinical practice sites and the
clinical services available in sites for midwifery student clinical placements.

Health Care Actual or Possible Practice Sites

Services
Family Community Hospital Rural / Referral/
households health centre/ outpatient community specialist
clinic / birth clinic hospital hospital
centre
Health education &
Antenatal care

Labour and birth

(include volume of
births /month

Postnatal care to 6
weeks or more

Newborn care to 6
weeks

Family planning
counseling/services

Post abortion care

Well infant/ well

child care to age
one year or more

Perinatal mental
health counseling;
parenting support

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Breast feeding
support

Well woman health

care

Comments

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