Teaching the Senior Student
Elizabeth AllemangClinical Education Coordinator
Loreto FreireExperiential Learning Coordinator
│Spring 2019
Content
slide #
3 MEP clinical curriculum and the senior year
6 C&C clinical objectives and learning to lead
9 Common learning and teaching challenges
11 Teaching tips and learning strategies
28 Feedback, evaluation and competency standards
37 Building effective student-preceptor relationships
43 When challenges arise
48 Placement structure, workload and planning
53 Ryerson MEP and university resources
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MEP clinical curriculum
NC16+ weeks
3rd IP Year24 weeks
MNP 12+ weeks
Clerkship 12+ weeks
C&C11+ weeks
Normal conditionsVariations of normal conditions
Atypical conditions Abnormal conditions Professional issues
Kn
ow
led
ge
Skill
s
Basic midwifery skillsManagement of normal
IP collaborationFill in NC skills for senior yearAdvanced clinical skills intensives
Management of atypicalLearn to lead careConsolidate normal skillsAssist with emergency management
Management of abnormalLead careEmergency management with assistance
Entry level care under supervisionEmergency management with minimal assistance
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Senior year overview
Complications &
Consultation
Maternal & Newborn
PathologyClerkship
Academic learning
• Atypical conditions
• Weekly PBL tutorials
• 2 papers/2 exams
• Abnormal conditions
• Weekly PBL tutors
• 2 papers/2 exams
• Professional issues
• Bi-weekly tutorials
• 2 comprehensive exams
Clinical learning
• Learning to lead care
• Consolidate normal
• Integrate aytpical
• Assist with emergencies
• Confident to lead care
• Consolidate atypical
• Integrate abnormal
• Initiate emergency care
• Entry level care under
supervision
• Final consolidation and
refinement
Placement length • 11 weeks + 4 days • 12 weeks + 3 days • 12 weeks + 3 days
Birth numbers• ≥ 12 primary
• ≥ 6 seconds
• ≥ 12 primary
• ≥ 6 seconds
• ≥ 12 primary
• ≥ 8 seconds
Expanded role• 1 routine postnatal visit
after day 3, before 6 weeks
• 2 routine postnatal visits
after day 3, before 6 weeks
• Hospital birth: 1 of 2
midwives
• 3 routine postnatal visits
after day 1, before 6 weeks
• Hospital/OOH birth: 1 of 2
midwives
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C&C clinical placement objectives
A student who is Satisfactory in C&C:
• Displays an expanding base of knowledge about maternal and newborn conditions in situations outside of normal where consultation is required
• Demonstrates primary care responsibility in the provision of midwifery care
• Seeks advice and consultation from the supervising midwife as needed
• Demonstrates clinical decision making skills in normal situations with confidence and in situations outside of normal where consultation is required with minimal assistance
• Routinely initiates the planning of care and debriefs with preceptor
• Conducts prenatal and postnatal visits in normal situations with confidence and in situations outside of normal where consultation is required with minimal preceptor supervision
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C&C clinical placement objectives
• Responds to pages and phone calls appropriately and provides clear information/direction to clients
• Manages normal labour and birth, including third stage, with confidence
• Manages labour and birth in situations requiring consultation with minimal assistance
• Identifies the need for intervention and/or consultation and participates in consultations with preceptor supervision
• Recognizes emergency situations and initiates care with preceptor assistance
• Establishes effective, professional relationships with clients, midwives, administrative staff, student midwives and other health professionals
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Consolidating ‘normal’ knowledge and skills
Gaps identified with learning plan
Understanding components of MRP role
Learning knowledge and skills to manage ‘atypical’ conditions
Learning to communicate and lead care with assistance and prompts
Shifting from task orientated approach to seeing ‘big picture’
Understands MRP role
Moves from task oriented approach to big picture
Takes increasing responsibility as lead provider
Initiates communication about assessments and plans with decreasing prompts
Makes assessments and plans for normal conditions with confidence and for atypical conditions with decreasing assistance and prompts
Organizes and follows up care with minimal assistance
Uses systematic approaches
Leads care for normal and variations of normal with confidence and independence
Initiates communication about assessments and plans with minimal prompts
Leads care in atypical situations with minimal preceptor assistance and prompting
Able to assist in emergencies
Basic midwifery skills well consolidated
Plan for simulation or consolidation of skills with limited clinical opportunity, e.g. IVs, suturing, NRP, emergencies
Learning to lead – sample C&Cpathway
Entry to C&C
Midterm C&C
Final C&C
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Common learning challenges
Skill/knowledge/experience gaps entering placement
Adapting to new practice environment
Managing/balancing primary care responsibilities
Communicating assessments and care plans, i.e. thinking out loud
Learning to lead care without prompting
Being systematic
Responsible and consistent follow up
Time management
Structured time for debriefing and teaching
Establishing effective/trusting student-preceptor relationship
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Common teaching challenges
Handing over clinical care and decision making, especially for newer
preceptors still developing competence and confidence
Integrating student into senior level care with clients
Feeling confident in assessment of student’s level of competency
Comfort with indirect supervision
Providing difficult feedback
Understanding MEP competency expectations
Assisting the struggling student
Lack of familiarity with MEP curriculum and expectations if non-MEP grad
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General teaching tips
Break skills and responsibilities into ‘chunks’ or building blocks
Mentor/teach a systematic approach to skills and clinical thinking
Recognize a plan is the outcome and assist students to build a care plan
Role model reflective practice and encourage students to self reflect on
the care they provide
Assist student to understand if at or above appropriate level
Assist student to recognize gaps and when to go back to theory and skills
basics, e.g. Leopold’s manouevres for abdominal palpation
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‘Chunking’ skills
Break down skills into discrete components
Assists with transparency of skills and staged skill development
Assess where student is at in mastering components and where learning need starts
Have the student take on one step at a time and gradually add other components with increasing competency and consolidation
Expand to encompass the full skill or role
Suitable for clinical skills and clinical responsibilities, e.g. first call, primary care role
Supports systematic approach
Assists with feedback and evaluation
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Mentorship
Mentoring is an effective teaching strategy
What you do and say has a powerful impact
Plays a significant role in learning to make clinical decisions and care plans
Explain why you do what you do, i.e. evidence, protocol, standards, etc.
Ask the student to provide a rationale for their recommendations or actions
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Reflective practice
Reflective practice is an effective teaching strategy
Contributes to constructive analysis of care for improvement
Do self reflection first and ask student to self reflect before critiquing care of the others
Share rationale for your clinical actions or improvements
Explore context for you or others that may contribute to care provided
Clarify safety and evidence based practice vs style
Models professionalism, critical generosity and humility
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Safety, best practice vs style
Distinguish safety vs best practice vs style
Clarify style differences in what student is seeing or being taught with co-preceptors
Be transparent about your style preferences
Consider if you can ‘tolerate’ style difference in student’s practice
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Using structured approaches
Chart review
• Preceptor mentors student to do thorough yet efficient chart review followed by student supervision with constructive feedback
Making care plans
• Student does thorough 36 week chart review for primary clients, prepare admission history notes and writes anticipatory plan of care for labour
Giving concise reports
• Student presents concise report of client history and plan of care for a prenatal visit, starts visit, provides concise report to preceptor for what has been completed, assessment and plan of care prior to asking preceptor to step in and what priorities are for preceptor attendance at visit
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Using structured approaches
Communicating assessments and care plans
• Student does initial assessment at labour, prepares report for preceptor with short term (1 hour) and long term (4 hour) plan of care
• Every hour, student updates short term and reviews 4 hour plan and reformulates as needed
• At the end of 4 hours, the student formulates a new 4 hour plan, reports hourly to preceptor and any revision to 4 hour plan
Immediate postpartum roles and responsibilities
• Student prepares list of immediate postpartum responsibilities for primary and second midwife
• After birth, student reviews list and assesses priorities
• Provides a concise report of roles and responsibilities and recommended priorities for preceptor feedback, revises as needed, implements plan
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Using scripts*
‘First words and actions’ for the student to use when seeing conditions
Supports student-led communication
Facilitates student-preceptor conversation with client present
Allows for preceptor ‘correction’ in front of client
PPH e.g. – I am seeing more blood than we usually see. I recommend 10 IU oxytocin IM. [Preceptor] do you agree?
FHR e.g. – The baby’s heart rate is slow. I would like to change your position and reassess. [Preceptor] do you agree?
*Thanks to Jennifer Gardiner, The Midwives Clinic of East York-Don Mills
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Using tools
Sample tools:
Primary care – Seeing the big picture of midwifery care
Developing care plans – Making care plans using ASOAPER
Communicating assessments and plans – ‘Traffic light’ model
Communicating plans and rationale – Using 3 questions
Preceptor pause – Rule of 3s
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Seeing the Big Picture of Midwifery Care
This simple model breaks down midwifery
care into discrete components. It helps the
student to understand the midwife’s role
and responsibilities. Details for each area
of responsibility can be added (see
reverse). Illustrated as a series of balls
balanced around the central concept of
midwifery care, this model provides a
visual cue for students learning to multi-
task and prioritize the elements of
midwifery care. It is adaptable to clinical
learners at all levels, including the
struggling student. It provides a framework
for clinical teaching and for feedback and
evaluation. The areas shaded in green are
the focus of learning in the senior year.
Midwifery Education Program • 350 Victoria St Toronto ON Canada M5B 2K3 • www.ryerson.ca/midwifery/20
• Mentor/assist the student to identify and learn
the components of midwifery care
• Have the student be responsible for those
components where skilled and confident
• Add one new or challenging component at a
time until each one is mastered and integrated
• Set discrete goals with the student and a long
term plan to be responsible for all components
• Develop a multistep, gradual process for the
student to multitask all components at their
expected level of competency
• Use this model for student self-reflection and
to provide feedback re: progress for each
component and overall
• Reformulate goals and expectations for the
struggling student to build from their level of
skill and confidence, identify priorities and
make a staged learning plan
Elizabeth Allemang RM Associate Professor • Vicki Van Wagner RM Associate Professor • Spencer Sawyer SM
Using the Big Picture learning tool
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Making Care Plans Using A-SOAP-ER
This expanded SOAP model provides a
visual cue that care plans are built on a
series of steps or building blocks. It
guides the student to use a systematic
approach and provides a tool for
preceptors to mentor clinical thinking.
Anticipation is added to guide students
to think ahead and consider a range of
options based on potential outcomes.
It assists the student to be better
prepared to act rather than react,
especially in the unpredictable, fast-
paced environment of intrapartum
care. Evaluate and reformulate are
added to remind the student to assess
the effectiveness of the care plan and
modify as needed.
Midwifery Education Program • 350 Victoria St Toronto ON Canada M5B 2K3 • www.ryerson.ca/midwifery/22
Using the A-SOAP-ER learning tool
• Assist the student to understand the discrete components for making clinical decisions and care
plans and the importance of making a differential diagnosis before a likely diagnosis
• Assist the student to understand when to use this or another standardized tool like CHAT or
SBAR
• Assist the student to develop anticipation skills. Ask what findings they expect prior to making
an assessment and what actions may be needed with each potential finding
• When asking the student ‘What is your plan?’, remember a plan is an outcome that is built on a
series of steps
• Mentor how to sequentially move through each step to come to a likely diagnosis and plan
• Have the student demonstrate each step in a particular clinical situation, verbally or in writing
• Encourage the student to consistently and systematically use a step-by-step approach until
confident and competent
• Assist the student to develop reflective practice skills. Do case review and ask if the outcome
could have been anticipated and if so, when in the care. Ask what could have been done
differently and if the plan needed to be reformulated, when and how. What will the student do
differently another time
Elizabeth Allemang RM Associate Professor • Vicki Van Wagner RM Associate Professor • Spencer Sawyer SM23
Communicating Assessments and Plans
This model provides a structured
pathway that encourages the student
to communicate their assessments
and plans. The script provides an
‘easy’ starting point beginning with
observation. The simple framework
organizes assessments and actions
into three categories and the
management plan flows directly from
the assessment. It allows for staged
entry into clinical decision making as
the student’s learning progresses from
normal, to atypical to abnormal. Using
this tool helps to facilitate preceptor
‘correction’ in the clinical setting.
Midwifery Education Program • 350 Victoria St Toronto ON Canada M5B 2K3 • www.ryerson.ca/midwifery/24
• Encourage the student to use the
pathway in common situations to
develop confidence
• Encourage the student to use the
pathway systematically
• Have the student follow the script
and state their responses aloud
• The symbol of a traffic light links the
assessment to an appropriate plan
• Use the pathway if prompting is
needed, e.g. What are you seeing?
What are the parameters for normal
(or abnormal) for the situation? If
atypical, what would increased
surveillance look like?
Elizabeth Allemang RM Associate Professor • Vicki Van Wagner RM Associate Professor • Spencer Sawyer SM
Using the Communication learning tool
‘Traffic Light’ model: Green = proceed Yellow = caution Red = action
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Communicating plans and rationales –using 3 questions*
Assist/encourage the student to use the following 3 questions to provide their plan and rationale:
What?
Why?
Why now?
*Thanks to Sandy Knight, Niagara Midwifery Practice
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Preceptor ‘pause’ – rule of 3s
Students will not make decisions or take action as quickly as preceptors - it can feel uncomfortable to wait for the student to formulate a plan or take the initiative needed
Some preceptors use the ‘rule of 3s’ to help them give the student more time before they prompt or take over
For example you could give the student:
• 3 seconds in shoulder dystocia or other emergency
• 3 minutes in with increased postpartum bleeding that does require immediate response
• 3 hours to identify the need to arrange a non urgent consult
• 3 weeks or even months to follow up an issue identified in history taking that is non urgent
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Student feedback about feedback
Students report anxiety of feedback due to:
• Feeling ‘watched’ and being evaluated
• Preceptor-student power dynamic and preceptor responsibility to evaluate
• Working with multiple preceptors with different expectation and styles
• Critical vs constructive feedback for learning
• Lack of positive feedback
• Lack of structured opportunities for feedback
• Timing and place of feedback, e.g. being critiqued in front of clients, other care providers
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Contextualizing feedback and evaluation
Preceptor responsibility for evaluation contributes to (real and perceived) power imbalance in student-preceptor relationship
Expect your student is far more anxious than you perceive
Even students who are excelling need to know where they are meeting expectations
Knowing where they are doing well provides a ‘safety net’ for students to hear and integrate feedback and evaluation
Students integrate more feedback if they are not afraid they are failing
Students who are struggling need to know where they are doing well as well as areas for improvement and benefit from a team approach with clear expectations
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Effective feedback and evaluation
Role model reflective practice
Role model professionalism re: feedback
Debrief regularly
Provide written feedback
Coordinate feedback from other preceptors
Be timely and specific
Be positive, transparent and constructive
Focus on learning rather than performance
Be open and straightforward about challenges and how to work together to address them
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More on feedback and evaluation
Use MEP materials (course clinical evaluation form, MEP Guide to Teaching, Learning and Assessment) to set expectations and goals
Tell students what they are doing well and what needs to be improved
Don’t isolate yourself with your student if things are not going well
Get input and support from practice members, experienced preceptors
Get help early from the tutor
Request additional faculty support as needed, e.g. Course Coordinator
If a student is not at the level they should be, make a clear and active plan to remediate with tutor assistance
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Feedback and evaluation strategies
Checklist feedback forms – student or preceptor led (see ‘Guide’)
Reflective feedback, e.g. 1 thing did well, 1 thing to be improved, 1 thing to review or look up
Informal debriefing ‘on the fly’
Structured/regular debriefing times
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Evaluation meetings
Opportunity to model professional behavior
Book in a timely and cooperative way, cancel only for births
Be on time and treat the evaluation as a formal meeting
Follow MEP policy for evaluation procedure, i.e. preceptor and student complete form independently, meet together to review, then meet with tutor to report
Evaluate at appropriate level and be clear about learning needs to be addressed
Too high expectations is not fair, but failure to fail is not kind to the student
Tutor can assist preceptor and student with grading
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Grading
Midterm – Satisfactory or Unsatisfactory
Final – Satisfactory, Unsatisfactory, Provisional Satisfactory
Provisional Satisfactory – 4 week remedial placement with objectives and goals, suitable for discrete ‘gaps’
Placement extension – up to 4 weeks if learning opportunities have been limited
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Clinical competency standards
Clinical course objectives and competencies defined in clinical evaluation forms
• Care management skills• Assessment skills• Communication skills• Clinical skills• Pharmacology skills• Professional skills
Levels of competency and teaching suggestions defined in MEP Guide to Teaching, Learning and Assessment
• Introductory• Intermediate• Entry to practice
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Clinical course benchmarks
Provide a baseline for what is needed to achieve a Satisfactory grade
Developed as guideline by Ryerson faculty for faculty to support appropriate grading
Developed for midwifery clinical courses and pre-clinical midwifery skills course to support grading
Developed for midterm and final evaluations
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Effective student-preceptor relationships
Coordinate with co-preceptor(s) re: clinical workload, student priorities and feedback/evaluation
Mentor and assist student to prioritize clinical responsibilities to meet MEP workload standards
Support students to prioritize academic work
Foster an environment for open dialogue
Make structured time for debriefing/check in
Ask for feedback about your teaching
Use ‘Ask-Connect-Reflect’ cards to facilitate communication between preceptors and students (next slides)
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Preventing and minimizing problems
Create an environment that welcomes students to raise concerns
Identify issues early
Take a problem solving approach
Ideally resolved by student and preceptor speaking directly with one another
Tutor is first point of contact within the MEP
Identify a person other than preceptor who student can go to within the practice if needed, ‘Teaching Practice Coordinator’
Be aware of power dynamics
See MEP template protocol for preceptor-student communication
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Giving and receiving feedback
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When learning challenges arise
Identify issues early
Notify tutor and seek assistance ASAP
Document your feedback and evaluation in relation to competency expectations
Set goals and depersonalize – use the Guide to Teaching, Learning and Assessment and clinical evaluation form
Make a learning plan with tutor assistance
Create an appropriate time frame for improvement
Facilitate clinical/simulation learning opportunities
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When challenges are significant
Adjust expectations to where a struggling student is at rather than where they should be and assist them to progress from that point
Be transparent about learning needs (and document) and support remediation plan
Students may require more time, e.g. provisional placement, failure and repeat course
Students may be assigned to another preceptor or practice
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Problem solving/conflict pathways
Developed following consultation with for preceptors, students and tutors and literature review on conflict in health professions education
Encourage direct communication and give both student and preceptor the option of seeking guidance from the tutor first
Guide tutors to make clear plans and be in frequent contact with students and preceptors when they experience problems or conflict
Seek to resolve issues within the placement but acknowledge that a tutor may recommend the student be relocated to a different placement if the conflict is not resolved
Students may take concerns directly to other offices in the university
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Structuring an effective placement
Placement orientation, including preceptor/call model
Assign a coordinating preceptor
Plan appropriate clinical workload and experience with scope of practice considerations
Assist student to plan off call time and study time
Review student learning plan/needs and course competencies
Provide Active teaching/learning opportunities
Use ongoing and structured feedback mechanisms
Follow formal evaluation processes according to course standards
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Common student placement challenges
Balancing clinical & academic responsibilities
On call models and multiple preceptors
Excessive workload – often clinic workload and seconds
Insufficient clinical experience – new MEP workload policies, scope of practice issues
Learning-teaching ‘fit’ with preceptor(s)
Managing stress and anxiety
Finding time for structured feedback, teaching and evaluation
Transitioning into lead role
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Placement planning considerations
MEP policies related to clinical placements - see the Ryerson MEP Preceptor Policy Book
MEP birth number and clinical workload standards
Off call and study time
Preceptor caseload/call models
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MEP workload policies
MEP Student Workload Report and Recommendations (2019):
• Average prenatal and postnatal visits per week: increased from 15 to 20
• Birth numbers: maximum planned birth numbers increased and minimum
number of primary births attended defined per course
• Time off call per month: 4 days away from the placement, not including
study day
• Study time: 24 hour off call ‘academic day’ Thurs 5pm-Fri 5pm
• Safety policy: off call time increased to 12 hours and clarified after 24 hours
awake
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Academic study day variations
Variations to the study day may be requested by the preceptor and
approved by the tutor for all students and for students at risk of a shortfall
of attended births
Variations for all students:
• Start time of 24 hour study day may be delayed into late afternoon/early
evening on Thursday to accommodate routine clinic times needed to meet
prenatal/postnatal workload standard (requires advanced tutor approval)
• Student may attend birth up to 2359 on Thursday (student to notify tutor)
Variations for students at risk of birth shortfall (requires advanced tutor
approval)
• Student on soft call during study day and may miss one or more tutorial(s)
• Start/stop time of study day may be varied to stagger with other students in the
practice to maximize availability for student attendance at births
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Policies/Resource Where to find
Ryerson Preceptor Policy Bookhttps://www.ryerson.ca/midwifery/Placements/Preceptor-Events-and-Resources/
Ryerson Policy & Information Handbook
https://www.ryerson.ca/midwifery/Placements/Preceptor-Events-and-Resources/
MEP Policy and Information Handbook
Student can share access
Guide to Teaching, Learning & Assessment for Midwifery Preceptors and Student Midwives
http://www.ryerson.ca/content/dam/midwifery/students/Revised-and-Finalized-Guide-to-T-and-L-July-2013.pdf
Clinical evaluation form Student to share online form at onset of course
Student Guide to Professionalism https://www.ryerson.ca/midwifery/students/
MEP Equity Statement https://www.ryerson.ca/midwifery/about/equity/
MEP policies and resources
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Ryerson/MEP student services
Ryerson MEP• Student-faculty equity, diversity and inclusion (EDI) committee
• Indigenous student coordinator
• BIPOC student collective and mentorship program
• Student awards
Ryerson Student Services• Academic accommodation support office (AAS)
• Ryerson Aboriginal student services (RASS)
Faculty of Community Services • Personal counsellor
• Learning strategist
• English language specialist
• Student awards
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For more information
Ryerson MEP Faculty Clinical Education Coordinator:
Elizabeth [email protected]
Ryerson MEP Experiential Learning Coordinator:
Loreto [email protected]
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