The purpose of this Policy & Procedure is to outline the National Midwifery Institute’s (NMI) selection criteria and assessment process for clinical learning sites to ensure facilities and resources are adequate and that practice model, scope, and student supervision are appropriate to enable safe and effective learning environments for students to achieve their learning goals.

This policy applies to all clinical sites approved by NMI for clinical learning.

AUTHORITY AND RESPONSIBILITY

The Clinical Director is responsible for the implementation and management of the Clinical Site Guidelines Policy and Procedure.

DEFINITIONS

Assessment process - a systematic process used to collect qualitative and quantitative data to measure, evaluate or appraise a clinical site.

Clinical sites/ facilities / learning sites - any facility, site or space in which a student observes or participates in client care.

Preceptor - individual enrolled and actively precepting a student at the National Midwifery Institute.

Student - individual actively enrolled in the National Midwifery Institute

POLICY

NMI is a distance education program without a physical campus. Clinical preceptors provide the learning sites in which the students apprentice to learn midwifery skills which complement the academic component of the NMI midwifery certificate program. The Clinical Site Guidelines Policy & Procedure provides a transparent, objective and procedurally fair clinical site selection criteria and assessment process in accordance with MEAC Benchmark IV.C2.

All clinical sites must demonstrate how they ensure/provide the following:

Legal status of the facility and preceptors working there;
Culturally responsive and respectful midwifery care practices;
Non-discrimination in the provision of care;
Equipment and supplies needed for the provision of midwifery care;
Quality and process standards for accepting donated equipment, pharmaceuticals, and other medical supplies;
Safety standards for facilities, equipment, and supplies in line with federal, state, and local requirements;
Universal precautions, hazardous waste and hazardous materials management;
Adequate staffing for responsible care of clients;
Provision for culturally responsive and respectful treatment of the student;
Provision for rest for the student;
Direct supervision of students;
Appropriate student to preceptor ratio;
Adequate opportunities for students to provide supervised primary care to clients;
Access to perinatal testing according to current standards for CPMs;
Access to medical consultation, referral, and hospital transfer;
Practice scope according to community standards of care, within scope of practice appropriate to state and/or local regulations;
Provision for continuity of care;
Provision for informed decision making.

International clinical sites must abide to additional clinical site selection criteria and demonstrate how each of the following are considered:

Culturally responsive and respectful midwifery care practices
Responsibilities to students, local midwives, and clients regarding safety, language barriers, cross-cultural engagement
The student and precepting midwives are aware of and have made an informed choice regarding CDC recommendations for immunization
The student and precepting midwives are aware of and have made an informed choice regarding CDC recommendations for international travel

Legal Status of the Facility and Preceptors

Clinical sites and preceptors must operate legally and provide NMI with documentation to review the following:

Clinical sites that use facilities other than clients' and/or preceptors' private homes must provide the following:

proof of inspection by local and/or state authorities for building and fire safety. Clinical Sites that do not have access to this proof of inspection should submit a completed Clinical Site Safety Checklist with their application.
proof of license to operate or facility accreditation.

Preceptors must provide proof that they are currently certified professional midwives, nurse midwives, licensed midwives at enrollment and ongoing when precepting students.

Preceptors who do not have a midwife credential such as OBGYN’s or licensed MD’s may be approved but need an exception to policy outlining a rationale on decision to approve.

NMI must have permission to operate in the state where the learning site is located, unless exempt from licensure requirements.
The state where the learning site is located must legally allow the preceptor to practice.

Culturally Responsive And Respectful Midwifery Care Practices

All NMI’s preceptors must complete a Cultural Competency course every 3 years and submit documentation of completion. NMI will provide a 3-month grace period to preceptors who do not have this documentation on file.

Non-Discrimination In The Provision Of Care

All of our clinical sites must certify that they have a non-discrimination statement or policy outlining the sites’ commitment to eliminating barriers, overt and implicit bias, and discrimination in care provision.

Statements or policies should describe commitments to creating inclusive and enabling environments through clinical care for all, independent of race, skin color, creed, religion, gender, gender expression, age, national origin, heritage, ancestry, ethnicity, culture, disability, marital status, sexual orientation, or other status, in activities and operations. Non-discrimination statements or policies must, moreover, encompass non-discrimination related to the diverse potential intersections of students and staff.

Equipment And Supplies Needed For The Provision Of Midwifery Care

All supplies necessary for provision of midwifery care and completion of skills assessed by NMI are required by all learning sites offering clinical instruction, unless prohibited by law in the local jurisdiction to carry them. These supplies will also be required for completion of all skills specified by NARM.

These items include:

Sterile and Non-sterile gloves

Doppler and Doppler gel

Fetoscope

Gestational Age Wheel OR Calculation App

Thermometer

BP cuff

Stethoscope

Measuring Tape

Amnicator Swabs OR Nitrazine Paper

Amnihook OR Amnicot

Cord clamp / Tape / Tie etc.

Antihemorrhagic medications

Suction device (2 oz Bulb Syringe or Delee Traps)

Heel Lancets

Sharps containment system

Hemostat clamps

Episiotomy scissor

Oxygen tank with regulator and tubing

Adult bag/mask

Infant bag/mask

Infant scale

Speculum

Cervical Cytology and Gynecological Swab Equipment

Miscellaneous Clinical Supplies/Equipment

Syringes

Urine sample and blood sample equipment,

Local anesthetic

IV fluids

Physical Examination Equipment

Blood Collection Supplies/Equipment

IV Equipment

Suturing Equipment

Urinary Catheterization Equipment

Quality And Process Standards For Accepting Donated Equipment, Pharmaceuticals, And Other Medical Supplies

When submitting a clinical site form, all preceptors must affirm and electronically sign that if their learning site accepts donated equipment, pharmaceuticals and other medical supplies, the following is true:

Before use, donated equipment should be cleaned, disinfected, inspected and in good working order.
Donated pharmaceuticals and other medical supplies should be in unopened packaging.
Sterile supplies should be within expiration dates or be resterilized.
Pharmaceuticals should be within expiration dates.

Safety Standards for Facilities, Equipment, and Supplies in line with Federal, State, and Local Requirements

Learning Site Safety

Clinical sites located in facilities (public or commercial buildings) must provide evidence of building and fire safety inspection by local authorities. All clinical sites must be well maintained with repairs conducted in a timely manner. For example, lightbulbs must be replaced when burnt out, seating and furniture repaired as needed, windows and doors operational and heating and/or cooling systems in functional condition.

Clinical Preceptors must have ready access to emergency contact information for all students which is available in the NMI Clinical Tracking App. All preceptors and clinical sites must follow policies and procedures that meet federal and state safety standards. NMI recommends periodic practice drills to keep all prepared. The following safety plan based upon OSHA standards is recommended for all clinical sites.

Safety Plan Items:

potential hazards, types of potential emergencies, worse case scenarios and proper emergency responses
special hazards you may have onsite such as flammable or explosive materials and toxic chemicals
specific information on how to respond to emergencies involving hazardous materials and hazardous waste operations (for more information, refer to 29 CFR, Part 1910.120(q) and OSHA Publication 3114, Hazardous Waste and Emergency Response Operations. Both are available online at www.osha.gov).
the identity of the individual(s) responsible for leading and coordinating emergency and evacuation plans
location and functionality of all emergency alarms
location of operating fire extinguishers, first aid supplies and any other special equipment or warning devices necessary for hazards unique to your facility
method for reporting fires and other emergencies
conditions under which evacuation would be necessary
the method for evacuation including emergency escape routes and exits from the facilities and safe or refuge areas
assembly areas where evacuees should gather and be accounted for
procedures for assisting any persons with disabilities
designation of people responsible to continue or shut down critical operations during an evacuation unless it is deemed necessary to evacuate as well.
names, titles and telephone numbers of individuals to contact for additional information or explanation of duties and responsibilities in the case of an emergency
any updates to procedures

Maintenance of Equipment and Supplies

All equipment, supplies and material, including aids for clinical and didactic learning must be inspected, maintained, and/or replaced as needed. All must be in safe working order with regularly scheduled cleaning. Regular maintenance may include but is not limited to: replacement of batteries, lightbulbs, or other equipment parts; calibration of monitoring devices such as scales or blood pressure cuffs; or repair of any broken parts.

All clinical equipment must be inspected, maintained and/or replaced, as needed, prior to each client's Estimated Due Date. Equipment for appointments including but not limited to prenatal, postpartum, newborn and well-person care must be inspected, maintained and/or replaced, as needed, on a monthly basis. Additional supplies held within the clinical site(s) and/or equipment bag(s) are inspected, maintained and/or replaced, as needed, after each clinical experience.

Universal Precautions, Hazardous Waste and Hazardous Materials Management

All preceptors and learning sites must abide by federal and state standards as they pertain to universal precautions, hazardous materials management (e.g., bleach, chemicals), and bio-hazardous waste management (e.g., proper storage and disposal of bodily secretions and sharps). Additionally, prior to engaging students to work with hazardous materials, clinical sites must orient and train students in universal precautions, hazardous materials management and biohazard waste management, to complement student academic coursework.

Adequate Staffing For Responsible Care Of Clients

The Clinical Site ensures at least two birth attendants at each birth who are trained in NRP & Adult CPR or BLS. One of these providers can be a student, however, it is ideal for this student to be in the PMUS phase or has another healthcare provider credential, such as Registered Nurse. Additionally, there should be one additional credentialed perinatal provider available to provide back-up/support, in the instance of two or more births (or perinatal emergency) occurring simultaneously.

At least one active NMI-approved preceptor must be present with the student at all clinical experiences the student participates in. Clinical learning sites must provide a reasonable justification that staffing levels are adequate for ensuring responsible care of clients. This justification is reviewed and approved or denied by the clinical director. It is not acceptable for a student to attend clinical experiences without an NMI-approved preceptor present.

Back up or substitute preceptors: In the event that the student’s primary preceptor is unable to attend clinical experiences with the student, the student may request that the substitute or backup midwife be approved as an NMI preceptor.

Our students are discouraged from participating in more than 3 simultaneous clinical care encounters, including 3 births occurring at the same time in the Clinical Site.

Provision For Culturally Responsive And Respectful Treatment of The Student and Clients

In addition to the previously outlined Cultural Competency and Non-Discrimination requirements focusing on intersections such as race and other forms of privilege, inequities, and implicit bias as they relate to education and healthcare delivery; preceptors must also take a course every 3 years that addresses enabling safe, culturally responsive and respectful treatment of students. Evidence of course completion must be filed with NMI.

Acceptable course topics include (but are not limited to):

Anti Bullying (including micro and macro aggressions)
Trauma Informed Supervision
Leadership (with focus on transformational, adaptive, servant, collaborative or collective approaches which move away from management approaches to emphasize human components of workplace supervisor-supervisee engagement)
Psychological Safety in the Workplace
Asset-Based Approaches
A 2nd Cultural Competency course

Please reach out to the clinical director if you need orientation regarding courses or materials that could qualify in this category, to catalyze culturally responsive and respectful learning environments for all students.

Examples of how NMI defines cultural responsive and respectful treatment of the client includes but is not limited to: using a client/patient’s preferred name/not dead-naming, having a non-discrimination policy in place, directing clients to resources such as books, websites, handouts that are culturally-matched with their individual clients/patients, using gender-inclusive language, having a myriad of referral resources that support access to language, financial, food security, housing security, etc, offering affinity groups for perinatal support and education, cultural advocacy during transports, and actively pursuing additional training in cultural humility and social justice.

Examples of how NMI defines cultural responsive and respectful treatment of the student includes but is not limited to: using a student’s preferred name/not dead-naming, providing time off for religious and other holidays of cultural significance to the student, providing alternative strategies for students to participate in client care that is considerate of a disability, referring to/utilizing language resources, actively pursuing additional training in cultural humility and social justice.

Additionally, NMI’s Clinical Faculty Performance Evaluation process solitics in-depth feedback from students and preceptors about working relationships and areas for growth. Preceptors must complete the periodic assessments for each NMI student in apprenticeship, and are expected to use this space for critical reflection on successes and areas for growth in terms of creating supportive, constructive feedback mechanisms that center the student’s emotional, cultural and psychological safety.

Provision For Rest For The Student

Each active NMI preceptor at the Clinical Site will agree to specific clinic times and on-call times for each student through a NMI Student-Preceptor Work Agreement (SPWA). Additionally, the SPWA must indicate how the student may request time off and affirm the importance of rest by approving time-off requests, as appropriate. When multiple preceptors are at the same Clinical Site, the Clinical Site is encouraged to have all of the preceptors in agreement with the individual’s student expectations for availability.

At a minimum, this must include the following elements:

Specific clinical times or clinical schedule
A specific on call availability schedule
A process for requesting time off

At a minimum, preceptors must affirm the importance of rest in order for the student and midwife to provide adequate client care.

Direct Supervision of Students

At least one active NMI preceptor is physically present with our students at each and every clinical encounter. This means being physically present to diagnose, authorize, and approve all student work performed during client care, including any counseling, clinical encounters, births, and/or skills performed with the client. The preceptor must be physically present and is responsible for care at all times during the clinical experience activity; must catalyze important decision-making processes; elicit the student’s rationales for the student’s decisions; and oversee the student’s charting.

Preceptors may ONLY sign off experiences that the preceptor personally and directly supervised and witnessed.

Appropriate Student To Preceptor Ratio

Clinical sites must provide an appropriate student to preceptor ratio and must provide a reasonable justification that this ratio is adequate for ensuring: responsible care of clients, provision of rest for the student, adequate student oversight, and adequate opportunities for students to acquire clinical experience. This justification is reviewed and approved or denied by the clinical director. NMI supports an ideal student to preceptor ratio of 1:1 or 2:1.

Adequate Opportunities For Students To Provide Supervised Primary Care To Clients

All clinical sites must affirm and electronically sign that the site can provide adequate opportunities for students to provide supervised primary care to clients.

Access to perinatal testing according to current standards for CPMs

All clinical sites must affirm and electronically sign that the site maintains access to perinatal testing according to current standards for CPMs.

Access to Medical Consultation, Referral, and Hospital Transfer

All clinical sites must affirm and electronically sign that the site maintains access to medical consultation, appropriate referral, and hospital transfer.

Practice Scope According To Community Standards of Care, Within Scope of Practice Appropriate to State and/or Local Regulations

All clinical sites must affirm and electronically sign that the site and its providers’ practice scope is within the scope of community standards of care, aligned to MANA core competencies, and within scope of applicable federal, state and/or local regulations. Birth centers and clinics must demonstrate proof of local or state inspections, state licensure, or accreditation where applicable. Clinical sites must ensure that preceptors supervising students are currently licensed or credentialed to legally provide care in the state where the care takes place. All clinical sites must ensure that preceptors provide direct supervision to students at all times and never leave students with a client/patient unsupervised by an approved preceptor. All clinical sites must ensure preceptors gain permission from clients for students to access records and assist with the provision of midwifery care.

Provision for Continuity of Care

All clinical sites must affirm and electronically sign that they can provide adequate opportunities for students to acquire Continuity of Care (CoC) experience (CIB, page 66).

Provision for Informed Decision Making

All clinical sites must affirm and electronically sign their site’s commitment to informed consent in all client encounters (CIB, pages 51-53).

Out of Country Clinical Placements

At this time, NMI is not accepting new international clinical placements (Student Handbook, page 17). In few select circumstances, NMI may make an exception to policy when students and preceptors are native or naturalized citizens of countries where a student hopes to acquire international clinical experience. Exceptions may also be made in cases where students and precepting midwives demonstrate sustained connections to the country of concern (i.e. heritage background, culture, race or ethnicity; students' foreseen post-graduation location of midwifery practice or target population; with adequate knowledge and understanding of the NMI certificate and CPM credential scope and jurisdiction).

Internationally located precepting midwives must be credentialed and legally practicing, and clinical sites in accordance with local jurisdiction. NMI must have permission to operate within the country or be exempt from licensure requirements. When exceptions are granted, students and preceptors must demonstrate additional criteria, including how the following are ensured:

Culturally responsive and respectful midwifery care practices
Responsibilities to students, local midwives, and clients regarding safety, language barriers, cross-cultural engagement
The student and precepting midwives are aware of and have made an informed choice regarding CDC recommendations for immunization
The student and precepting midwives are aware of and have made an informed choice regarding CDC recommendations for international travel

Prior to an exception's approval, students and all preceptors must work through the following global health orientation material, and submit a reflective summary.

Global Health Orientation Material:

Northern Ventriloquism: how global south researchers talk to the north The Lancet. Youtube video (required)
Says who? Northern ventriloquism, or epistemic disobedience in global health scholarship. The Lancet. Full text essay by Thirusha Naidu, PhD (required)
Decolonizing Global Health: Perspectives from Nurses and Midwives Seed Global Health. Youtube video (required)
Ethical Challenges in Short-Term Global Health Training Johns Hopkins and Stanford. 10 case studies (10 required)

Student and preceptor reflective summaries should address some of the points below:

Verify you were able to complete and work through all of the above required orientation materials.
Situating yourself within a perspective of cultural humility, discuss your preparedness to address inequity, including health inequity and the pervasive effects of racism and colonialism on social determinants of health. You may want to discuss governmental policies and their impacts on the distribution of health services in the area of concern.
Discuss health equity and the concept of “social justice.”
Discuss your preparation in relation to the unique healthcare needs of the community/ies being served and strategies you identify for meeting those needs. Please consider local socio-economics-politics, health and wealth disparities, and cultural beliefs and influences.
Discuss advocacy strategies for health systems improvement, including but not limited to Interpersonal and Communication Skills, Cultural Competency and Humility, and Collaborative Care.
Discuss your understanding of Systems Based Practices and how the clinical site of interest interacts or does not interact respectfully and effectively within the larger unique health care system. Do you identify areas for improvement? If so, how might you approach clinical site systems change with sensitivity?
Describe your current language skills, cultural awareness skills and skills to navigate culturally to deliver collaborative, informed consent driven care with sensitivity to potential sociocultural and health literacy barriers.
Discuss whether these orientation materials prepare you to recognize clinical site and/or your own limitations. Please share additional resources you are knowledgeable of.

PROCEDURE

All clinical faculty or their clinical site manager must submit a Clinical Site Form during their application process and prior to their approval at NMI. This Clinical Site form establishes whether a clinical site meets the Clinical Site Guidelines criteria of NMI. Any clinical site application is subject to approval or denial by the Clinical Director or their designee in the case of a conflict of interest (COI). Any clinical site application that remains incomplete after 90 days shall be denied and the clinical site manager is invited to apply again, in the future.

In May 2022, the Clinical Site Form was expanded to include all components outlined in this policy and in MEAC Benchmark IV.C2. Clinical sites that were approved prior to this date must complete an “Expanded Clinical Site Form addendum”.

If a preceptor works at two or more facilities or within two or more different practices, then separate forms for each location must be submitted. This form shall remain valid for a period of five years; however, if new regulatory framework or clinical safety guidelines deem the criterion as no longer relevant, a new form will need to be submitted.

Clinical Sites are reviewed and approved by the Clinical Director. NMI requires written notification of any significant site changes (direct correspondence to clinicals@nationalmidwiferyinstitute.com).

IMPLEMENTATION

This policy has been published on the NMI Website, is referenced in the Apprenticeship portion of the student portal, and

Where is this policy referenced?
Handbooks	Student Handbook Clinical Handbook
Website	Policy and Procedure page Student Portal Apprenticeship page
Documents	Clinical Site Form Expanded Clinical Site Form

CONTINUING EVALUATION AND ADJUSTMENT

This Clinical Site Guidelines Policy & Procedure will be subject to periodic review and adjustment. Continued administration of the development, implementation, and maintenance of the plan will be the responsibility of the Clinical Director who will assign specific responsibility for implementation and administration as appropriate.

The Clinical Director, in consultation with the Executive Director, will review the standards set forth in this policy and recommend updates and revisions as necessary.

Date	Type of Change	Updates since last Change
2022-06-02	Major	Date of policy drafted and originally posted on website.
2023-10-31	Minor	Policy updated to include management of stalled applications, clinical site safety checklist.
2024-06-07	Minor	Updated Legal Status of the Facilities to include Clinical Site Guideline Checklist
2025.04.27	Major	Expanded explanation of clinical site criteria using internal clinical site criteria and audit documents

APPENDIX

Adapted from NCM’s Adequacy of Learning Site Policy - NCM Handbook 5-19-2022

NARM CIB

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