Preceptorship for midwifery practice in Africa: challenges and opportunities

Jemima A Dennis-Antwi PhD, HP, MSc, PHN, RM, RN, BScN.
Anglophone regional midwifery advisor (ICM), 85 Freetown Avenue, La Bawaleshie, East Legon, Accra, Ghana, West Africa. Email: jdennis_antwi2004@yahoo.co.uk



Abstract
Background. Commonly, preceptorship is an individualised teaching-learning method in the practice or field setting, whereby students or novice midwives are paired with experienced practitioners to develop or improve their skills.
Objectives. This paper provides a synopsis of trends in preceptorship documented through focus group discussions held with key midwives and stakeholders in the African countries of Ethiopia, Ghana, Uganda and Zambia, where the International Confederation of Midwives and United Nations Population Fund are in partnership with the health sector to strengthen midwifery systems.
Method. A qualitative study design was used as the main method for data collection. Data were collected from 100 respondents including midwifery tutors (25), preceptors/practitioners (25), retired midwives/midwifery consultants (20), young midwives (15) and relevant maternal and child health stakeholders (15). The study used one-on-one interviews, observation of skills laboratories, preceptor sites, desk reviews and review of country-based 2008 to 2010 needs assessment reports.
Findings. The quality of pre-service education of midwives falls short of the enabling environment and adequate numbers of committed and well-informed preceptors to ensure optimal competency-building. There is a need for action.
Implications. Current weak preceptorship trends in midwifery pre-service education in Africa will undermine country-based efforts to reduce maternal and infant mortality due to limited practical skills and poor attitudes to care. This calls for innovative, coordinated and sustained approaches to improving on students and young midwives’ practical skills.

Key words: Preceptorship, African midwifery research, clinical experience, evidence-based midwifery

Introduction
The International Confederation of Midwives (ICM) and the United Nations Population Fund (UNFPA) have been collaborating since 2008 on a joint programme known as the ‘Investing in Midwives Programme’ (IMP) and others with midwifery skills to accelerate progress towards millennium development goal (MDG) 5. The aim of this collaboration is to improve the state of maternal health towards achieving MDG 5 in Africa, Asia and Latin America. The IMP focuses on four major areas for strengthening midwifery services: education, association strengthening, regulations, and advocacy. The programme has made major strides, and is now operational in 26 countries in Africa, Asia and Latin America. The impetus to establish the IMP was informed by the stark statistics in MDG 4 and 5 in Africa and the critical workforce shortage of midwives needed to achieve these goals.

Midwifery pre-service education systems in most of the programme countries are driven by political decisions to train more midwives to meet human resource needs. But the effort of training more midwives is challenged by limited infrastructure, few tutors, and large student numbers, outdated teaching/learning materials, unstandardised curricula across schools in the country, poorly-resourced clinical sites, and too few preceptors (ICM and UNFPA, 2009).

The rationale for determining current preceptorship systems and influencing factors on them was identified as an important step to inform strategic plans for strengthening midwifery. A 2008 to 2010 various assessment of midwifery systems in 12 African countries had been conducted as a prelude to initiating the UNFPA/ICM IMP in Africa, Asia, Latin America and the Caribbean. Since the inception most of the countries have reviewed and improved outdated curricula to include: 1) relevant topics relating to emerging diseases and conditions such as HIV/AIDS; 2) ICM global standards and basic essential competencies for pre-service education; 3) training of tutors and midwifery clinicians; 4) supply of teaching/learning materials and equipment to address gaps in skills training; 5) library and information and communication technology improvements, among other plans. This study explored the status of preceptorship in Ghana, Ethiopia, Uganda and Zambia between March and September 2010 as a follow-up to that initiative, with a view to assessing current systems of preceptorship in supporting students to acquire clinical skills for competent quality care. It also appraised continual concerns from senior midwives on the deteriorating attitudes to care, coupled with poor clinical skills exhibited by new graduate midwives posted to the clinical facilities.

The aim of the study was to document the state of preceptorship in selected programme countries to serve as a body of knowledge that will inform the design of effective preceptorship guidelines as a contribution to quality midwifery pre-service training in Africa. The objectives of the study were to: a) assess the preceptorship patterns in study countries and their benefits to student training; b) appraise senior midwives’ perception of midwifery preceptorship and practice from the past and their observations or experiences of current preceptorship; c) document challenges to quality preceptorship; d) recommend strategies for improving on preceptorship systems in programme countries specifically and Africa in general.
Mainly, qualitative methods were employed for the study through focus group discussions held with midwives and stakeholders in stated countries. Observations made by senior midwives in a general forum held in Ghana in 2009 to discuss midwifery strengthening in the West African sub region served as key data to inform the study.

Literature review
The literature search included journal articles, grey literature, and book references. Programme reports were consulted for background information and journal articles were searched for relevant titles and abstracts using key words, such as ‘preceptor’, ‘preceptorship’, and ‘clinical experience’. In order to limit the search, qualifying words were also used to ensure focus. The review focuses on definitions, approaches, challenges of preceptorship, attributes and attitudes of preceptors to students’  training and effects on knowledge and skills acquisition.

The term ‘preceptorship’ originated within religious practices in 15th and 16th century Europe, but re-emerged in nursing in the 1960s in the US to describe the teaching of nurses (and midwives) within a clinical environment (Myrick and Yonge, 2003). Preceptorship emerged from the need to teach junior or newly engaged staff of hospitals what the administrative, management and clinical procedures were. This apprenticeship-style was used to support hospitals’ needs, rather than to address the educational needs of individual nurses (Myrick, 1988).

Different but related definitions exist for preceptorship. In simple terms, it is a method of student teaching that gives the student the opportunity to experience day-to-day practice with a role model and resource person. Such a role model is a person who is always available within the practice area and willing to impart knowledge and skill. Furthermore, it is a supervised clinical experience that allows students to apply knowledge gained in the didactic portion of a programme to clinical practice (University of Texas School of Nursing, 2011; Myrick and Yonge, 2003; Ohrling and Hallberg, 2001). 

Clinical preceptors are relevant to student development in diverse ways. They serve as the bridge for the integration of theory and practice; create opportunities for students’ socialisation into the art of the profession; and act as role models, facilitators and consultants to gradually build student competencies and confidence at work through insightful guidance and sharing of experiences (Fullerton and Ingle, 2003; Jordan and Farley, 2008; Licqurish and Seibold, 2008). However, for their work to be effective, much depends on guidance and continual updates from the teaching faculty to both students and preceptors on the achievement of educational objectives through synthesis in practice (Oklahoma Board of Nursing, 2010).

The organisation of preceptorship systems share similarities and differences across continents. Burns et al (2006) describe the nature of preceptorship organised in the US as involving a set number of hours assigned to supervised clinical practice. In such a situation, the preceptor, who may be an experienced nurse practitioner or a physician, develops a one-to-one relationship with the student and as part of teaching, assigns the student to patients’ assessment, diagnosis and care plans for preceptor validation before the student implements the plan with their support. The preceptor further engages the student in reflective discussions to determine implications of care on patient prognosis and provides constant evaluative feedback and support to the student as well as the faculty. The result is that over the period of assignment, the student would have increased knowledge and skills, refined practice efficiency and become increasingly independent in managing patient care.

There are challenges associated with this approach in that teaching is conducted in a setting where the ward dynamics are ever-changing, with different patients presenting with unpredictable conditions and complexity with variable demands on the time and skills of the preceptor (Burns et al, 2006).

In contrast to the US approach, findings of a study by Ohrling and Hallberg (2001) state in Sweden, most preceptors held discussions with their student at the beginning of the practice period on goals and expectations. By so doing, the preceptors gained insight into the students’ previous experience and learning needs. As part of the process, preceptors sometimes employed study guides in identifying students’ goals for learning. They then tried to follow the students’ wishes when planning their learning. The challenge noted with this approach was similar to that of the US situation, as since the ward was a special environment, it called for continual daily or weekly adjustment to set procedures and plans to ensure student objectives were met.

In a related dimension, Lennox et al (2008) describe mentoring, preceptoring, and clinical supervision as supportive approaches to educational preparation of students and further elaborate on their differences as a way of ensuring more consistent standards of support. 

Though preceptorship is reportedly a tried and tested approach to bridging the gap between theory and practice for skills development, preceptor attributes and attitudes to teaching and skills mentoring go a long way to determine the extent of achievement of educational objectives of assigned students. In their studies on students’ clinical practice, placement and competencies, Burns and Paterson (2005) and Khomeiran et al (2006) report that interactions between preceptors and students are important for student learning while expert clinical teaching is vital for the development of skills and knowledge for midwifery and nursing students. The ability of the preceptor to teach effectively, applying good teaching methodologies, such as critical thinking methods for competency building, is crucial for the achievement of objectives. The preceptor’s ability to foster a positive interpersonal relationship that focuses on passing on an exemplary professional ethical code of conduct and clinical skills, willingness to be a preceptor, leadership qualities and assertiveness are also important for successful and impactful preceptorship (Myrick, 2002; Mamchur and Myrick, 2003; Licqurish and Seibold, 2008).

Published literature so far indicates that much documentation on preceptorship in student learning exists mostly from developed countries, while little information is available in relation to trends in the African setting.

The ICM/UNFPA IMP was established with the goal to ‘increase and improve skilled attendance (midwives) at birth in low-income countries by developing the foundations for a strong midwifery workforce’. It recognises the need to strengthen preceptorship systems in programme countries as a means to graduating competent midwives for quality care towards achieving MDGs 4 and 5.

In The state of the world’s midwifery report (UNFPA, 2011) at the 29th ICM Triennial Congress in South Africa (June 2011), findings from 58 countries with high rates of maternal, fetal, and newborn mortality indicate that although there have been modest improvements in the training and deployment of midwives to increase access and quality of services, there remain many challenges and barriers that affect the midwifery workforce, its development and its effectiveness. It outlines a triple gap, encompassing competencies, coverage and access.

In the executive summary of The state of the world’s midwifery report (UNFPA, 2011), Ban Ki-Moon, the UN secretary-general, states: ‘In most countries there are not enough fully-qualified midwives and others with midwifery competencies to manage the estimated number of pregnancies, the subsequent number of births, and the 15% of births that generally result in obstetric complications.’ Preceptorship in the 12 IMP countries in Africa, with extension plans to six more countries, is critical for competency building if the midwifery profession in Africa is to sustain its mark in maternal, newborn and child health (MNCH) services. The vision is to develop highly skilled, confident, assertive midwives and positions to advocate for such services.

Therefore, this study set out to investigate preceptorship systems in programme countries, to provide information about the success and challenges to student midwives in Africa.

Method
Having reviewed the literature surrounding preceptorship, common strategies of choice used in the studies have been qualitative or quantitative in nature ranging from grounded theories using in-depth interviews (Licqurish and Seibold, 2008) to reviews of grey literature and books and publications (Lennox et al, 2008), and structured interviews (Lange and Kennedy, 2006; Jordan and Farley, 2008). Qualitative methods, similar to those used by Licqurish and Seibold (2008) were chosen, including the use of interview guides to inform focus group discussions and in-depth interviews with 100 key informants and respondents with backgrounds as midwifery tutors (25), preceptors/practitioners and policy leaders, such as regulators and directors of nursing and midwifery services (25), retired midwives/midwifery consultants (20), young midwives (15) and relevant maternal and child health stakeholders (15)  through in-depth interviews and focus group discussions. Other supporting techniques included observation of skills laboratories and preceptor sites to determine resources available, desk reviews, and reviews of country-based needs assessment reports to identify relevant information on preceptorship.

The qualitative methods were chosen to afford the opportunity for close personal interactions to derive respondents’ views, perceptions, impressions, and expectations surrounding preceptorship in their countries, with reference to improved competencies for better MNCH services. The methods allowed for an understanding of the educational and clinical social world from the point of view of the respondents while also acknowledging the wider structural influences helping to produce the adaptive experiences associated with preceptorship (Layder, 1998).

In the conduct of this study, efforts to reduce the limiting factors were what led to the use of multiple techniques including observation of skills laboratories and preceptor sites to determine resources available and desk reviews. Another technique employed was the review of country-based needs assessment reports to identify relevant information on preceptorship. These methods were employed to confirm and enhance information generated from the in-depth interviews.

The sample was accessed through country midwife advisors who were requested to invite the respondents to the in-country focus group meetings facilitated by the author. In the sessions, respondents were put in groups ranging from six to ten people. Independent respondents were contacted directly through letters or telephone calls for their participation. Of the 120 people invited to participate, 20 declined due to their changed schedules. 

Data analyses were done thematically by the author.  By this method, categories of data that emerged from the transcribed text in the form of patterns, processes, common ideas and differences and found to be related to the specific issues raised in the discussion guides were grouped together as a basis for generating themes or interconnections relevant to the research topic (Bryman, 2001; Braun and Clarke, 2006). Key themes that emerged included preceptorship, ‘the good old days’ and preceptor selection, learning environments, tutor communication, student attitudes, roles and responsibilities, clinical supervision and clinical skills. These eight themes were further categorised under four main broad headings namely: 1) current state of preceptorship; 2) contributions to good midwifery services; 3) current challenges to preceptorship; 4) changing the face of preceptorship in Africa. These headings were chosen for ease of presentation and coordination of the data. Findings and discussions are outlined guided by these headings.

In order to assure data reliability, the author was supported by an assistant (country midwife advisor or representative) to take notes from the discussions while at the same time the author took notes on the proceedings of the meeting including respondents’ reactions and comments. Data generated from the author and that of the assistant were compared with each other to ensure completeness while references were also made to previous assessment reports as secondary sources of data to confirm findings or to add on to the findings.

Ethical issues
Permission was sought from the respective bodies and partners and verbal consent was obtained from participants.

Findings
Preceptorship
Preceptorship, according to all respondents, was being carried out in study countries to pass on new knowledge, trends and skills to students and to teach, build, direct and strengthen students for future leadership as midwifery advocates.

However, the extent of implementation varied and may be non-existent in certain training institutions. For example, Zambia had developed preceptor guidelines for potential preceptors to guide actions while respondents from other countries indicated that there were no nationally approved policies providing standard guidelines to preceptorship. In a statement, a participant in Ethiopia noted:
“There are no uniform strategies and evaluation of what we do in preceptorship; clear guidelines, protocols or uniform process to follow are lacking though we are aware that we have a responsibility to pre-service education.”

Rather, principals and tutors of the institutions generate their own directives based on experience. Training may or may not be offered to preceptors to enable them to fit effectively into their roles.

The choice of preceptors was reported as those available in the clinical facilities and not by choice and willingness, experience, competencies or personal attributes. One participant in the Ghana discussion stated:
“Preceptorship at clinical sites is done by few experienced midwives because most midwives are not interested to be preceptors.”
A participant in Uganda reported:
“We are providing preceptorship on a small scale knowingly or unknowingly. There is a lot of competition and selfishness as midwives do not want to share knowledge gained.”

On who are selected to be preceptors, findings indicate that by description, preceptors are registered midwives (with or without bachelor degrees) or nurses assigned to clinical facilities and offering care as part of their day-to-day services. These midwives and nurses are generally not members of the faculty of the training institutions, but are staff that may be requested, by virtue of their presence in the facility, to pass on skills to various categories of students who will be posted to the site. Requests for service may be by a letter submitted by the student on posting to the site, delivered by the director of nursing at the facility, or by personal contact with a tutor of the training institution. Where the institution has a formalised system in place, preceptors may be invited by the institution to participate in preparatory seminars or updates at least once a year. Students are assigned to the facilities with specific expectations and may be given log books for preceptors to endorse objectives achieved for the time period. It was further reported that preceptors commonly used the apprenticeship method where the students were assigned to midwifery tasks as an apprentice to a more experienced midwife. Opportunities for one-on-one meetings to assess daily performance and objectives achieved may not occur. Opportunities for generating critical thinking tasks may never be a focus of the process. Respondents from Ethiopia added that often preceptorship offered to students on rural posting were by young and inexperienced midwives who have had no supporting senior midwives to build competencies.

‘The good old days’: contributions to good midwifery
Respondents recounted times past when midwifery services boasted highly competent senior midwives who ran the clinical facilities with skill, commitment and dexterity. These midwives were perceived as role models who portrayed high standards of the code of ethics of midwifery practice, exuded confidence and defended the profession. Their judgments were also respected and an enabling environment for quality care was available. Respondents from the key informants’ interviews gave vivid descriptions. In Ghana a key informant stated:
“In the good old days, midwifery was a call or a vocation. Now it is an income-generating profession where people who are not really interested are trained and paid to work.”

Another added:
“In those days, there was commitment coupled with effective supervision, good working relationship with other professionals in the healthcare team.”

In Ethiopia, the group of discussants indicated that midwives were the queens of the ward. Midwives loved their profession and had power to change students. Midwives were in charge of the wards and knew what they were about. But, over generations, these attributes have been lost as schools recruit students who have no interest but because the government has assigned the course to them. 

In Uganda and Zambia, the majority of respondents reported that in the good old days, student numbers were small; staffing was adequate, proper orientation was given and care plans were followed to the letter. Equipment was available, the health system functional, and it was prestigious to be a midwife.
 
Current challenges to preceptorship
Findings from the study indicated several challenges militating against effective preceptorship for competency building in midwifery in all countries studied. These challenges ranged from young and inexperienced midwives, inadequate numbers of midwives in the clinical sites due to high turnover, heavy workload and limited competent tutors to implement strong preceptorship approaches. Other challenges included lack of interest to be preceptors due to no remuneration or perceived self-benefit, large student numbers that push training institutions to post students across the nation to areas that tutors are unable to follow up. An Ethiopian participant asserted:
“Preceptors are expected to role model but because of low preceptor-student ratio, capacity is limited. Also, preceptors and tutors are disinterested because of lack of confidence and knowledge to perform competently.”

There are small-sized skills laboratories that challenge tutors’ abilities to prepare students for skills training before their release to the clinical sites. There are ill-equipped and overpopulated clinical sites due to the fact that students from various institutions and professions are all assigned to these few facilities to demand attention from the few clients. Policies and standardised guidelines from the regulatory bodies on preceptorship are largely unavailable, except in Zambia, which had developed a training guide for preparation. The most common challenge reported was the persistence of poor attitudes of midwives at clinical sites.

Countries reported that such challenges affect supervision and contact with preceptors. These challenges are reportedly the underlying causes for the changing face of midwifery from that of the ‘good old days’ to the present state. Some experienced midwives also saw mentoring as an added burden.

Changing the face of preceptorship in Africa
Preceptorship was observed by respondents in the study countries as a very important approach to student training and acquisition of skills. Respondents strongly indicated the need to revisit the concept of the good old days. They called for a multi-pronged approach to addressing the weakening state of preceptorship in countries. Respondents indicated that preceptorship should be implemented within a wider milieu where strong mentoring and clinical supervision systems are running in synergy within a nationally approved framework or policy. An Ethiopian participant noted that to change the face of preceptorship, countries must develop preceptorship guidelines; improve the competencies of tutors and midwifery clinicians who act as preceptors and mentors; lobby governments for improved clinical sites, equipment and supplies and identify willing role models for leadership training and asignment.

In Zambia, respondents said that to change preceptorship, African countries should develop clear guidelines, re-introduce continual professional education of midwives to keep them abreast with knowledge and skills and reinforce clinical meetings that create opportunities for discussing cases and their management. Procedure manuals should also be made available to all, including students for reference.

In Ghana, respondents indicated the need for clear assignment of roles for the various stakeholders who need to play significant roles in ensuring success of preceptorship. Retired midwives, chief nursing and midwifery officers, midwifery associations, nursing and midwifery councils, training institutions and midwives in clinical practice were recognised as interconnected partners in achieving an improved preceptorship system.

Discussion
Evidence from the analysis on the current state of preceptorship suggests that it is recognised as crucial for students’ competency building as indicated by Fullerton and Ingle (2003), Jordan and Farley (2008), Licqurish and Seibold (2008). However, contrast exists in the manner preceptorship is organised in study countries when compared to the organised systems in the US and Sweden. Ohrling and Hallberg (2001) and Burns et al (2006) indicate different forms of organised systems to students competency building governed by set guidelines coupled with continual evaluative mechanisms to influence daily and weekly plans to preceptorship and informed by students’ learning needs. Findings suggest that preceptorship systems are at various degrees of implementation in study countries, which may not contribute to effective competency and professional confidence building. There are unstandardised systems where midwifery clinicians may be assigned as preceptors to support and facilitate students for skills acquisition without prior orientation to the expectations of the training programme or regular updates to ensure relevance of knowledge.

Moreover, preceptors are assigned to the task without necessarily expressing their willingness to be a preceptor. This finding is incongruent to the assertions of the North Carolina Board of Nursing and that of the University of Texas School of Nursing (2011) where, within their definition of preceptorship, it must be conducted in the purview of a structured system where preceptors agree to function to provide supervision to a student for a specified period of time using identified learning objectives. The evidence from the study further points to the lack of policies that govern preceptorship implementation in contrast to the provisions outlined by the Oklahoma Board of Nursing Preceptor policy (2010), the University of Texas School of Nursing policy (2011) and Myrick and Yonge (2003). In this study, Zambia was the only country with documented guidelines on training preceptors developed by the Nursing and Midwifery Council to direct actions. Respondents from the other countries indicated that training institutions recognise the role of preceptors and take the initiative to also conduct training based on available resources to orient preceptors to their tasks and teaching methodologies. Though this is a good initiative, according to the Oklahoma Board of Nursing Preceptor policy (2010), not all ‘preceptors’ scattered across the nations in the study benefit from the training, which is commonly ad hoc.
 
Reflecting on the relevance of preceptors in students’ skills training as documented by various authors (Gray and Smith, 2000; Jackson and Mannix, 2001; Papp et al, 2003; Donaldson and Carter, 2005), the present situation in the study settings calls for initiatives that will direct an effective selection of preceptors capable of meeting student needs, especially in the areas of bridging the knowledge gap between theory and practice;  role modelling, competency and confidence building through insightful guidance and sharing of experiences, as outlined in the Oklahoma Board of Nursing Preceptor policy (2010).

In the study countries and in Africa, however, cognisance needs to be taken of the political, social, and economic terrain within which training programmes occur and the fact that resources are not easily available. However, the development of well thought-out guidelines on preceptorship and their implementation in countries is a necessity that should be pursued if well-qualified midwives are to be deployed to health facilities to provide the much needed care.

The study also revealed that attitudes to midwifery services were poor as senior midwives reminisced about the ‘good old days’ and the professional recognition they earned from the general public and colleagues in other professions. The recognition was because of their ability to meet the healthcare needs of clients and effectively facilitate students in midwifery and nursing in acquisition of knowledge, skills, professional socialisation and assertiveness (Burns and Paterson, 2005; Khomeiran et al, 2006).

As supported by Myrick (2002) and Mamchur and Myrick (2003), positive interpersonal relationships by preceptors are critical to passing on exemplary professional ethics, a code of conduct, and clinical skills. It is important for regulators and stakeholders to conduct research in the study settings to determine the extent to which current preceptors contribute to the current poor attitudes among midwifery clinicians. The study will also need to determine the extent to which students are observing the right attitudes from good role models (Donaldson and Carter, 2005). This has implications for training and professional socialisation for optimal care.

The future
Findings of the study show that there is a lack of standardised, synergised preceptorship systems in study countries, though there are pockets of efforts by certain institutions to run adhoc preceptorship systems. Much information exists on preceptorship trends in developed countries but there is very little documentation on the trends in sub-Saharan Africa.

This study has documented the current preceptorship trends in four countries in Africa that hitherto had not been focused on and described in the literature.

The ICM/UNFPA initiative is supporting country-based initiatives to strengthen midwifery education, regulation, and associations in 26 programme countries. In countries such as South Sudan there is a need for the development of an entirely new programme to promote preceptorship for effective student education in view of their political history. Developing generic preceptorship guidelines by the ICM/UNFPA programme, informed by the systems and processes utilised by the developed countries, will generate a culturally-sensitive approach to preceptorship that can be adapted by African countries to promote professional excellence in midwifery.

Lennox et al (2008) in their paper Mentorship, preceptorship and clinical supervision: three key processes for supporting midwives clearly distinguish between the three processes and their professionally supportive relationships. Success can be counted if the synergy of the quadriad of the midwifery educator, regulator, clinician and association leadership is connected in such a way as to clearly define individual roles, responsibility and commitment in preceptorship, mentoring and clinical supervision towards midwifery strengthening. The quadriad will focus on:
• Identification and strengthening of preceptors to include innovation in teaching
• Developing and promoting standardised guidelines for programmes implementation
• Granting opportunities for retired midwives as school-based preceptors or clinical instructors. This is being tested in Ghana but needs modifications
• Supporting tutors to take up clinical responsibilities in health facilities to maintain and improve skills and act as buffers to preceptors. Ghana has made a policy on this but implementation has not been strongly enforced
• Strengthening student adherence and devotion to  professional and ethical code of conduct
• Promoting peer exchanges and communities of practice, through local and regional interactions
• Twinning and establishment of projects through north- south; south-south collaboration
• Championing the preceptorship, mentoring and clinical supervision processes by chief nurses, midwives, regulators, association leaders, departmental heads, midwife tutors and other influential organisation, such as the UN, ministries, parliament, FIGO and WHO
• Setting up a monitoring and evaluation system to continually test, inform and direct progress
• Continually advocating for political commitment to competency-based training of midwives.

Conclusion
With the clarion call on most African countries to meet the MDGs 4 and 5, midwives cannot afford not to exhibit professional excellence coupled with the right attitudes. Preceptorship facilitated by long-term mentoring and strong clinical supervision in regular practice is core to success.

References

Braun V, Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3: 77-101.

Bryman A. (2001) Social research methods. Oxford University Press: Oxford.

Burns C, Beauchesne M, Ryan-Krause P. (2006) Mastering the preceptor role: challenges of clinical teaching. J Pediatr Health Care 20: 172-83.

Burns I, Paterson IM. (2005) Clinical practice and placement support: supporting learning in practice. Nursing Education in Practice 5: 3-9.

Donaldson JH, Carter D. (2005) The value of role modelling: perceptions of undergraduate and diploma nursing (adult) students. Nurse Education in Practice 5: 353-9.

Fullerton JT, Ingle HT. (2003) Evaluation strategies for midwifery education linked to digital media and distance delivery technology. Journal of Midwifery and Women’s Health 48(6): 426-36.

Gray M, Smith LN. (2000) The qualities of an effective mentor from the student-nurse’s perspective: findings from a longitudinal study. Journal of Advanced Nursing 32: 1542-9.

Jackson DJ, Mannix J. (2001) Clinical nurses as teachers: insights from students of nursing in their first semester of study. Journal of Clinical Nursing 10: 270-7.

ICM, UNFPA. (2008-2011) Country-based needs assessment reports of 22 programme countries. Investing in Midwives Programme. ICM/UNFPA: The Hague.

Jordan R, Farley CL. (2008) The confidence to practice midwifery: preceptor influence on student self-efficacy. Journal of Midwifery and Women’s Health 53(5): 413-20.

Khomeiran RT, Yekta ZP, Kiger AM, Ahmadi F. (2006) Professional competence: factors described by nurses as influencing their development. International Nursing Review 53: 66-72.

Lange G, Kennedy HP. (2006) Student perceptions of ideal and actual midwifery practice. Journal of Midwifery and Women’s Health 51(2): 71-7.

Layder D. (1998) Sociological practice: linking theory and social research. Sage: London.

Lennox S, Skinner J, Foureur M. (2008) Mentorship, preceptorship and clinical supervision: three key processes for supporting midwives. New Zealand College of Midwives Journal 39: 7-12.

Licqurish S, Seibold C. (2008) Bachelor of midwifery students’ experiences of achieving competencies: the role of the midwife preceptor. Midwifery 24(4): 480-9.

Mamchur C, Myrick F. (2003) Preceptorship and interpersonal conflict: a multidisciplinary study. Journal of Advanced Nursing 43(2): 188-96.

Myrick F. (1988) Preceptorship: a viable alternative clinical teaching strategy. Journal of Advanced Nursing 13(5): 588-91.

Myrick F. (2002) Preceptorship and critical thinking in nursing education. Journal of Nursing Education 41(4):154-64.

Myrick F, Yonge O. (2003) Preceptorship: a quintessential component of nursing education: In: Oermann MH, Heinrich KT. (Eds.). Annual review of nursing education (volume 1). Springer: New York.

North Carolina Board of Nursing. (2007) Suggestions for utilization of preceptors in approved nursing education programs. See: www.Ncbon.Com/Content.Aspx?Id=420 (accessed 10 October 2011).

Oklahoma Board of Nursing. (2010) Preceptor policy. See: www.ok.gov/nursing/ed-precpt.pdf (accessed 10 October 2011).

Ohrling K, Hallberg IR. (2001) The meaning of preceptorship: nurses’ lived experience of being a preceptor. Journal of Advanced Nursing 33(4): 530-40.

Papp I, Markkanen M, von Bonsdorff M. (2003) Clinical learning environment as a learning environment: student nurses’ perceptions concerning clinical learning experiences. Nurse Education Today 23: 262-8.

UNFPA. (2011) The state of the world’s midwifery 2011. Delivering health: saving lives. See: www.unfpa.org/sowmy/resources/en/main.htm (accessed 1 November 2011).

University of Texas School of Nursing. (2011) UTH SON BSN preceptor guidelines. See: http://son.uth.tmc.edu/preceptor/bsn_preceptor_handbook.pdf (accessed 1 November 2011).