10 Approaches to Midwifery Education
Jayne Marshall, PFHEA, PhD, MA, PGCEA, ADM, RM, RGN
This chapter will outline the standards informing the development of midwifery education programs internationally and the methods used to assess the knowledge, skills and attitudes of the future midwife. In addition, a range of learning activities and teaching methods will be explored to demonstrate that the individual needs of students should always be at the heart of midwifery education.
10.1 Standards for Midwifery Education
The International Confederation of Midwives (ICM) developed the Global Standards for Midwifery Education (1) in 2010 to strengthen midwifery worldwide by preparing fully qualified midwives to provide childbearing clients, their babies and families with high quality, evidence-based health care. However, these standards represent the minimum expected from a quality midwifery program with emphasis on competency-based education rather than academic degrees, as detailed in the Essential Competencies for Basic Midwifery Practice (2) that were initially developed in 2002.
All midwifery education programs should comply with the standards for pre-registration midwifery education endorsed by the recognized professional regulatory body of the country in which the program is undertaken. The national regulatory body should be guided by the international definition of the midwife (Table 10-1).
| Table 10-1. International definition of the midwife |
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10.1.1 The Mission and Philosophy of Midwifery Education Programs
It is essential when designing a midwifery education program to first have consensus from all those facilitating the program on the mission and philosophy of the program. These declarations will shape not only what is taught but also how it is taught. The mission statement should represent the program in one or two sentences and address points such as:
- Purpose: Why does the program exist?
- Core values: How will this program be implemented?
- Integrity and passion: Why is this program important to society?
- Specificity: What is the level of academic award/degree offered?
The statement should also reflect the mission of the educational institution Table 10-2.
| Table 10-2. Example mission statement for a midwifery education program | |
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| Purpose | …to prepare a safe, competent and confident graduate midwife |
| Core values | Our program embraces the diversity and equity of students and works to provide accessible education, which is culturally sensitive. We foster critical thinking in the academic setting that will extend into the practice setting and forms the basis for sound professional practice. |
| Integrity and passion | …to positively contribute to the health of childbearing women and their families |
| Specificity | …Bachelor of Midwifery… |
| Educational institutional values | Our program embraces the diversity and equity of students and works to provide accessible education, which is culturally sensitive. Our faculty engage in active clinical practice, leading edge research, and professional leadership. |
Reflect
Does your university have a clear mission statement for its midwifery education program? Do you think it adequately reflects the appropriate points? Create your own mission statement considering the questions above.
The World Health Organization (WHO) outlines that the philosophy of midwifery education should recognize that individuals are unique and should promote equal rights, regardless of sex, race, religion, age and nationality. (4) The training should embrace the whole of a client’s life continuum rather than focusing specifically on pregnancy, birth, and the postnatal and neonatal periods. Training should also specifically address the circumstances of the country in which the family resides, including the particular public health challenges. Ultimately, midwifery education should be client- and family-centred to promote safe childbearing and birth, with the midwifery student being adequately prepared to deliver health services in a full variety of settings, including the local community, ensuring they have some understanding of the realities of the lives of childbearing clients.
The education of the future midwife should focus on meeting the holistic needs (psychological, emotional, physical, social and spiritual) of the client in a sensitive and competent manner, acting as their advocate and working in partnership with the client and their family to promote a safe and satisfying experience of childbearing and the transition to parenthood. The program should prepare students to be quick thinking and caring midwives, possessing a sound knowledge base and competent clinical skills, by using student-centred learning methods that develop critical thinking, analytical and problem-solving skills. Students should be encouraged to reflect on their practice and to take responsibility for their own learning so they develop into life-long learners capable of recognizing their own needs for continuing professional development.
Reflect
Does your university have a clear philosophy that shapes its midwifery education provision? How does this compare with the WHO’s philosophy?
Construct a statement that reflects your personal philosophy of what midwifery education should consist of. You may wish to consider the following questions:
- How do adults learn?
- How can learning be facilitated for adults?
- What elements should be considered best practice in midwifery?
10.2 Curriculum Design: Competency-based
Models for curriculum design for midwifery education have been prepared by the ICM within a series of four resource documents and are conceptually framed by the ICM Definition of the Midwife, the ICM Philosophy and Model of Care (5) and the ICM International Code of Ethics. (6) Furthermore, the curriculum outlines adhere to the ICM Global Standards for Midwifery Education and include all the ICM Essential Competencies for Basic Midwifery Practice Education. The curriculum outlines and the suggested content organization are based on the principles of adult learning and are competency-based in their design, and teaching and learning strategies. The curriculum model should be independent of the design of midwifery education programs within a country’s educational system, that is whether the program is direct entry, as part of a nursing program, or following completion of nurse training.
Midwifery educators have the responsibility to ensure that the curriculum content aligns with, but does not exceed the regulatory authority for midwifery practice in the country, however this may include some knowledge and skills that the ICM would identify as additional. A midwifery curriculum must also include teaching, learning and assessment activities that facilitate the acquisition and demonstration of the required midwifery competencies, as well as their associated knowledge skills and behaviours/attitudes (KSB/A) for commencing midwifery practice in a dynamic, complex and multicultural context. Although curriculum development may appear linear and is expected to follow a logical progression, it could also be described as a spiral process, building on knowledge and skills gained from one year to the next.
10.2.1 Setting Learning Outcomes & Objectives
Learning outcomes specify the intended endpoint of a period of engagement in specified learning activities. They are written in the future tense and should clearly indicate the nature and/or level of learning required to achieve them. They should be achievable and assessable, use language that student midwives can easily understand, and avoid any ambiguity or over-complexity. They should relate to explicit statements of achievement and always contain verbs. Objectives should be SMART: Specific, Measurable, Achievable, Realistic and Timely.
Individual outcomes should relate to one of the three domains in the taxonomy described by Bloom (1956) (7):
When describing outcomes, it is usual to begin with a stem phrase, such as: ‘At the end of this session, the student midwife will be able to…’ A verb is then used to state specifically what the student midwife will be able to do (e.g. ‘…demonstrate…’ or ‘… describe…’) in relation to the relevant domain described by Bloom (1956) (in terms of knowledge, skills or attitudes) followed by a clear statement of the topic of interest (e.g. ‘…the anatomy of the breast’). (7)
10.2.1.1 Cognitive Domain (Knowledge Outcomes)
As shown in Table 10-3, there are six major categories of cognitive processes. (7) At the bottom of the diagram are the simplest processes, and at the top the most complex. The expectation is that the simplest categories should be mastered before moving onto the more complex ones: taking the learner on the journey from a novice to an expert. (8)
| Table 10-3. Bloom’s Taxonomy of Learning (1956) (7) | ||
| Higher Order Thinking Skills
Lower Order Thinking Skills |
COGNITIVE PROCESS | LEVEL OF SKILL |
| Evaluation | Expert | |
| Synthesis | ||
| Analysis | ||
| Application | Trainee | |
| Comprehension | ||
| Knowledge | Novice | |
Anderson et al., (2001) revisited the cognitive domain and modified it; referring to verbs rather than noun forms as well as rearranging the higher order cognitive skills as shown in Table 10-4. (9) The revised taxonomy reflects a more active form of thinking.
| Table 10-4. Revised taxonomy of learning from Anderson et al., (2001) (9) | ||
| COGNITIVE PROCESS | LEVEL OF SKILL | |
| Higher Order Thinking Skills
Lower Order Thinking Skills |
Creating | Expert |
| Evaluating | ||
| Analysing | ||
| Applying | Trainee | |
| Understanding | ||
| Remembering | Novice | |
Table 10-5 lists the elements and a brief description of the cognitive domain and also provides some useful verbs that can be used to map the learning outcome on to the relevant level. An example of a knowledge-based objective, at the level of comprehension, might be: ‘At the end of this session, the student midwife will be able to discuss the physiological changes that occur in pregnancy and their significance to the assessment of maternal and fetal wellbeing.’
| Table 10-5. A comparison of Bloom’s original taxonomy of learning and Anderson et al.’s revised taxonomy of learning (7,9) Grey boxes indicate the shift in Anderson et al.’s taxonomy where ‘creating’ and ‘evaluating’ are flipped. | ||||
| BLOOM’S TAXONOMY | ANDERSON et al.‘s TAXONOMY | DESCRIPTION | USEFUL VERBS FOR OUTCOME-LEVEL STATEMENTS | |
| Higher Order Thinking Skills
Lower Order Thinking Skills |
Evaluation | Creating | Ability to judge X for a purpose | Judge, appraise, evaluate, compare, assess |
| Synthesis | Evaluating | Arranging and assembling elements into a whole | Design, organize, formulate, propose, create, summarize | |
| Analysis | Analysing | Breaking down components to clarify | Distinguish, analyse, identify compare, contrast | |
| Application | Applying | Using the rules and principles | Apply, use, demonstrate, illustrate, practise | |
| Comprehension | Understanding | Grasping the meaning but not extending it beyond the present situation | Describe, explain, discuss, recognize, interpret | |
| Knowledge | Remembering | Recall of information previously presented | Define, list, name, recall, record, describe | |
To achieve a learning outcome, a range of teaching and learning methods might be utilized such as an initial lecture, followed by a group seminar or tutorial, reflection on practice or case scenarios. The students will then apply their knowledge and reflect on their clinical experiences, and then an assessment can be made as to the extent they understand the subject matter. Using the knowledge objective example above, the corresponding assessment would relate to how well the student understands the chronology of changes that occur in pregnancy and their significance to midwifery practice when undertaking antenatal examinations with pregnant women.
10.2.1.2 Psychomotor Domain (Skills Outcomes)
Bloom (1956) suggested that skills outcomes should be written in terms of competence which are ascribed to five levels as shown in Table 10-6. (7) An example of a skills-based outcome at the competency level of imitation would be: ‘At the end of this session/placement, the student midwife will be able to listen to the fetal heart using a Pinard stethoscope.’
| Table 10-6. Bloom’s (1956) five levels of psychomotor competence | ||
| COMPETENCE LEVEL | DESCRIPTION | |
| Higher Order Competence
Lower Order Competence |
Naturalization | Completes skilfull tasks competently and automatically |
| Articulation | Combines one or more skills in sequence with harmony and consistency | |
| Precision | Reproduces skill with accuracy and proportion | |
| Manipulation | Performs skill from instruction | |
| Imitation | Observes skill and tries to reproduce it | |
Teaching and learning methods for this domain includes the student acquiring some background knowledge (in this case anatomy and physiology related to pregnancy and the range of equipment required) but for students to perform this skill accurately, they need to practise. This may be on models or, on the childbearing client, with supervision and feedback from their lecturers, mentors and the client. Assessment of competence involves a number of observations, not simply asking the student to describe what they would do. As students develop their knowledge and skills, a subsequent skills-based outcome at the level of articulation may be as follows: ‘At the end of the session/placement, the student midwife will be able to safely undertake an antenatal examination of the pregnant client and accurately document and report the findings to others.’
10.2.1.3 Affective Domain (Attitudinal Outcomes)
Attitudinal outcomes are often seen as the most difficult to write because they describe patterns of observable behaviour. Bloom (1956) called this the affective domain which also has five levels as shown in Table 10-7. (7) An example at this domain at the level of responding might be: ‘At the end of this session, the student midwife will be able to demonstrate awareness of the importance of respecting cultural differences when undertaking an antenatal examination on a pregnant client.’ This learning outcome focuses on student midwives being able to show that they have understood and can respond to different cultural issues with which childbearing clients may present.
| Table 10-7. Bloom’s five levels of attitudinal competence (7) | ||
| LEVEL | DESCRIPTION | |
| Higher Order Competence
Lower Order Competence |
Characterizing | Behaviour consistent with a value system |
| Organizing | Shows commitment to a set of values by behaviour | |
| Valuing | Displays behaviour consistent with a single belief without coercion | |
| Responding | Complies with expectations in response to stimuli | |
| Receiving | Aware of external stimuli, e.g. listening | |
Reflect
Using Tables 10-3, 10-6 and 10-7, as a guide, develop two learning outcomes for each of the three domains (cognitive, psychomotor, and affective) of Bloom’s (1956) Taxonomy. Remember that the level at which you write the outcomes will be determined by the stage at which you are at in your midwifery education program.
10.3 Learning Styles & Teaching Methods
The midwifery educator must recognize that each student midwife may prefer a different learning style and teaching method to acquire and develop their knowledge and skills. As such, the techniques used to deliver theory and practice should be tailored accordingly. Each learning style should be incorporated into the curriculum activities so that every student is able to learn effectively and be successful in their studies.
10.3.1 Learning Styles
Employing a variety of teaching methods and styles will enable individuals to learn more effectively such that they are able to remember more of what they learn and apply it. The seven learning styles are outlined in Table 10-8. There is no correct mix of learning style nor is a style fixed. An individual may develop ability in less dominant styles and/or further enhance dominant styles that they already use effectively.
| Table 10-8. The seven learning styles | |
| LEARNING STYLE (also known as) | DESCRIPTION |
| Visual (spatial) | You prefer using pictures, pictures and spatial understanding and depend on the midwife educationalist’s non-verbal cues such as body language to help with understanding. Usually visual learners sit in the front of the classroom and also take descriptive notes over the material being presented. |
| Aural (auditory-musical) | You prefer using sound and music and discover information through listening and interpreting information by the means of pitch, emphasis and speed. Usually auditory learners gain knowledge through reading out loud and may not have a full understanding of information that is written.
The temporal lobes of the brain control aural content with the right temporal lobe focussing on music. |
| Physical (kinesthetic) | You prefer using your body, hands and sense of touch, learning best with an active ‘hands-on’ approach. Physical learners favour interaction with the physical world and may have difficulty staying on target/remaining focussed.
The cerebellum and the motor cortex (at the back of the frontal lobe) deal with the majority of our physical movement. |
| Verbal (linguistic) | You prefer using words in both speech and writing.
The temporal and frontal lobes manage this particular style. |
| Logical (mathematical) | You prefer using logic, reasoning and systems.
The parietal lobes, particularly the left side control our logical thinking. |
| Social (interpersonal) | You prefer to learn in groups or with other people.
The frontal and temporal lobes handle much of our social activity. The limbic also influences both the social and solitary styles and affects our emotions, moods and behaviour. |
| Solitary (intrapersonal) | You prefer to work alone and use self-study.
The frontal and parietal lobes as well as the limbic system affect this style. |
It is vital that each student is aware of their own preferred learning style and the characteristics of this style so they can acquire the constantly changing and increasing amount of information. When students take responsibility for their own learning they attribute meaning to the process of learning, becoming increasingly more satisfied with the environment in which they interact. Analyzing one’s own learning style in terms of personal strengths and weaknesses is beneficial for the student. It assists them in becoming a more focussed and attentive learner that should ultimately lead to educational success. Educators therefore should be mindful in matching teaching strategies to the students’ unique learning styles in order to increase motivation and efficiency to enable all students to grow as learners.
10.3.2 Teaching Methods
Once content has been created, specific learning activities and teaching methods, which are consistent with the learning outcomes and required content, must be identified. The teaching methods chosen also need to reflect each of the learning domains: cognitive, psychomotor and affective. Having an appreciation of the focus of the teaching will enable selection of the most appropriate method(s) to facilitate student learning. A summary of different teaching methods is included below Table 10-9.
| Table 10-9. Summary of teaching methods | ||
| FOCUS | METHOD | DESCRIPTION |
| Lecturer/Teacher (transmitting learning) |
Direct instruction | Lecturer determines what is important for student to learnStudent is expected to remember or replicateDeep understanding and recombining of information are minimal
Emphasis on acquiring information or procedural skills |
| Skills, drills and practise | Limited synthesis of new understanding
Emphasis is to provide a strong link to the information to improve remembering it or, on repetition to focus on developing skill |
|
| Lecture | Serves to impart information
Limited intellectual exchange between student and lecturer Significant amount of information can be conveyed to large group in short amount of time Can be more effective when lecturer includes discussion with participants |
|
| Dialogue between Lecturer/Teacher and Student |
Question and answer | Requires reflection from student and understanding of core content to enable a two-way exchange between partiesCan help with both recall and acquisition of informationStimulates thought and encourages divergent thinking
Lecturer can assist with formatting and reformatting learner’s ideas without diminishing the value of their original ideas |
| Discussion | Differs from question and answer method as lecturer and student exchange ideas on an equal footingLecturer aims to develop a greater depth of thinking and foster the manipulation of information for solving problemsMore of a debate of different points of view rather than exchanging ideas | |
| Student (discovery learning) |
Mental modelling | Reflects an individual’s internal, personalized, contextual understanding of how something worksEnhances student ability to direct their own learning by modelling the use of cognitive processes in the solving of some problemFormed either through direct or shared experience of what the individual believes to be related content, services or systems |
| Discovery learning | An inquiry-based, constructivist learning theory where student is expected to draw on past and existing knowledge to discover facts, relationships and new understandings to enhance their learning (10)Student may explore and manipulate objects, ponder questions or perform experimentsPromotes increased recall of concepts and knowledge | |
| Role play | Involves participants taking on a particular role in a given situation and with a scenario and explanation of the characters, playing out the roles in the safe environment of a classroom before embarking in the real worldRequires adequate briefing beforehand and debriefing afterwards by the lecturer otherwise it will be of little useShould only be used with consensus of the group, with no one being coerced into participating against their will | |
| Simulation | An extended role play that has structure and rulesStudents are expected to make definite decisions and/or define an end product | |
| Inquiry-based learning and problem-based learning | Involves the use of prior knowledge and the discovery of new knowledge, and also expects the student to generate the question to be answered.
Students define their own learning outcome and undergo independent/self-directed study before returning to the group to discuss and refine their knowledge. Motivates and deepens autonomous learning Teacher takes on role of facilitator, to channel inquisitiveness, provides structure and support |
|
| e-learning | Electronic learning using a computer/internet to deliver part or all of a courseEncapsulates a wide range of learning tools such as virtual learning hubs, online simulation, games for learning, learning blogs, ebooks, etc. | |
| Blended learning | A combination of all the methods discussed above to optimise learning and develop lifelong learners of all their students | |
| The flipped classroom | An instructional strategy that reverses the traditional learning environment by delivering content often online, outside of the classroom, then moves activities, including those that may have been considered ‘homework’ into the classroom.A type of blended learning | |
Reflect
Consider the teaching methods listed in Table 10-9 and provide an example of a typical learning experience from your midwifery education program that would address each of these methods.
10.4 Assessment Methods
The curriculum’s assessment strategy should include a range of methods and tools that accommodate the student midwife’s acquisition of knowledge, psychomotor skills, professional behaviours/attitudes and critical thinking that leads to appropriate decision making. As a result, the student midwife will be expected to undertake both theoretical and clinical assessments that should not only comply with the standards required by the professional regulatory body of the country in which the program is undertaken for entry to the professional register, but also the academic regulations of the higher education institution facilitating the program. Whatever method is chosen to assess the student midwife’s knowledge, skills and attitudes, the assessment tool should be both valid and reliable.
10.4.1 Formative Assessment
The goal of formative assessments is to promote learning and gather constructive feedback that can be used by the teacher and student midwife to guide improvements in the ongoing teaching and learning context either in written or clinical work. These types of assessments are an integral part of effective teaching and do not contribute to an overall module/final program grade.
10.4.2 Summative Assessment
The goal of summative assessments is to measure the student midwife’s level of success or competence that has been obtained at the end of a module/clinical component or program. This type of assessment uses a standard or benchmark to compare the student’s level of attainment.
10.4.3 Assessment Tools
An assessment tool can be used for different assessment methods. Examples of assessment tools include written essays, written examinations, case studies, oral examination, oral or poster presentations, Objective Structured Clinical Examination (OSCE), and portfolios. It is helpful for the assessment strategy to be continuous to encourage the student midwife to maintain their learning throughout the program rather than postponing their studying for an end of year examination.
10.4.4 Giving Effective Feedback
Providing feedback to student midwives is an essential part of their education and training program as it helps them to maximize their potential at different stages of the learning process, raises their awareness of their strengths and areas for improvement and identifies actions to be taken to improve performance. Feedback can be directive, which informs the student of the aspects of performance that require correction, or facilitative, which assists the student to develop their practice.
The feedback can be written, verbal or numerical depending on the type of assessment undertaken. The detail given should be specific to the task but constructive to enable the student to make connections to related tasks or contexts. It can be informal or formal in nature. Good feedback is part of the overall dialogue or interaction between lecturer and student midwife and not simply a one-way communication. Providing structured, formal feedback can help reinforce, modify and improve behaviours. However, if feedback is not given or received in a safe and constructive way, it can also have negative, unintended consequences. Although feedback tends to be about observed performance, good feedback is forward-facing (feeding forward) and helps the student midwife to reflect on their performance and identify new goals, improvements or actions. If students do not receive feedback they may assume their performance is of a satisfactory standard and there are no areas they need to improve upon. Students value feedback especially when it is provided by credible individuals who they respect as a role model or for their specific knowledge or clinical competence. Grounding feedback within an overall approach that emphasizes ongoing reflective practice will assist the student midwife to develop the capacity to critically evaluate their own and other’s performance, to self-monitor and move toward professional autonomy.
Reflect
Consider feedback you have received as a student. From these experiences, identify the specific elements that have constituted good feedback and those where it could have been further improved.
10.5 Key Points Summary
- It is vital to the health and wellbeing of childbearing clients, their babies and families that all midwives are educated and trained to the ICM Global Standards for Midwifery Education as a minimum.
- Each midwifery education program should be based on an overarching mission statement and philosophy that reflects its core values and that all stakeholders subscribe to.
- Midwifery educators should acknowledge the different learning styles of each student midwife and ensure that a variety of teaching methods and assessment tools are included in the curriculum to accommodate their individual needs.
- It is essential that both midwifery educators and clinical-based midwifery mentors provide timely feedback and feed forward to support the ongoing growth and development of each student midwife.
References
- International Confederation of Midwives. Global Standards for Midwifery Education [Internet]. The Hague: International Confederation of Midwives; 2010. p. 9. Available from: http://internationalmidwives.org/assets/uploads/documents/CoreDocuments/ICM Standards Guidelines_ammended2013.pdf
- International Confederation of Midwives. Essential Competencies for Basic Midwifery Practice 2010 [Internet]. The Hague: International Confederation of Midwives; 2010. p. 19. Available from: http://internationalmidwives.org/assets/uploads/documents/CoreDocuments/ICM Essential Competencies for Basic Midwifery Practice 2010, revised 2013.pdf
- ICM. ICM International Definition of the Midwife [Internet]. 2017 [cited 2017 Sep 12]. p. 1. Available from: http://www.internationalmidwives.org/who-we-are/policy-and-practice/icm-international-definition-of-the-midwife/
- WHO. Module 5: Developing a midwifery curriculum for safe motherhood: Guidelines for midwifery education programmes. In: WHO, editor. Strengthening Midwifery Toolkit [Internet]. Geneva: WHO; 2011. p. 34. Available from: http://apps.who.int/iris/bitstream/10665/44645/5/9789241501965_module5_eng.pdf
- International Confederation of Midwives. Philosophy and model of midwifery care [Internet]. The Hague: International Confederation of Midwives; 2014. p. 4. Available from: http://internationalmidwives.org/assets/uploads/documents/CoreDocuments/CD2005_001 V2014 ENG Philosophy and model of midwifery care.pdf
- International Confederation of Midwives. International Code of Ethics for Midwives [Internet]. Glascow; 2008. Available from: http://internationalmidwives.org/assets/uploads/documents/CoreDocuments/CD2008_001 V2014 ENG International Code of Ethics for Midwives.pdf
- Bloom BS. Taxonomy of educational objectives: The classification of educational goals: Handbook I, cognitive domain. New York. 1956. 207 p.
- Benner P. From novice to expert. Am J Nurs. 1982;82:402–7.
- Anderson, Lorin W, Krathwohll DR, Bloom. BS. A taxonomy for learning, teaching, and assessing: A revision of Bloom’s taxonomy of educational objectives. Allyn & Bacon. 2001;12.
- Bruner J. The Act of Discovery [Internet]. Harvard Educational Review. 1961. p. 21–32. Available from: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:The+Act+of+Discovery#0
