In the review study, the documents related to the accreditation standards of midwifery education in the United States, the United Kingdom, Australia and the ICM were examined (Table 1).
The results show that the standards of accreditation of midwifery education are different in different countries. For a comparison of different domains, accreditation standards in selected countries are presented in Table 1.
The standards and criteria of the selected countries were thoroughly reviewed by the research team several times. Based on this, a set of criteria and sub-criteria of each country was obtained to be used for comparison. The final review was performed by the research team through repeated examinations of clinical accreditation standards in midwifery education in the selected countries. Finally, after making the necessary corrections and modifying categorization according to the midwifery curriculum and job description of midwives in Iran, the main categories (axes) were extracted. The results of extracting accreditation standards and criteria for midwifery schools were divided into 6 areas: Mission and goals; Curricula; Clinical instructors; Students, Clinical setting; and Assessment".
Participants in the second phase of the study included members of the Midwifery Board, policy makers and senior managers of midwifery, faculty members of departments of midwifery who had clinical teaching experience, clinical midwifery instructors, and final year undergraduate midwifery students studying at Iranian universities who were selected by purposive sampling (n = 15). The characteristics of the participants in this phase of research are presented in Table 2. Participants ranged in age from 22 to 56 years. There were 3 undergraduate students, 3 postgraduates and 9 doctoral degrees.
The axes extracted from the review study in the first phase were used as a guide in formulating questions and conducting semi-structured interviews in this phase. Interview questions were prepared and posed by the interviewer in a semi-structured manner based on the areas of Mission and goals; Curriculum; Clinical instructors; Students, Clinical setting; and Assessment. Data analysis in this phase led to the extraction of 131 codes, which were divided into 35 sub-subcategories, 15 sub-categories, and 6 main categories (Table 3).
Mission and goals
This category involves creating the desired vision and perspective by managers with the participation of faculty members and related groups. It also includes agreement on the mission and leading goals according to which educational institutions can fulfill their mission and achieve the desired vision. The participants in this study emphasized this category as one of the accreditation standards in midwifery clinical education. This category has the following two sub-categories.
Objectives of clinical education
The participants in the study insisted that the goals of clinical education be based on the curriculum, the needs of the community, and the prevailing culture of that community. “Clinical midwifery education is valid as far as its goals are correctly defined. I mean, it should be according to the curriculum and the needs of society and should have the right strategy to achieve these goals” (P10).
The midwives participating in the present study recommended formation of a working group to review the goals of clinical education and, if necessary, modify it as needed. “We should have a working group to review and modify the objectives of clinical education from time to time according to the needs of the community, if necessary” (P8).
Clarity of mission
The participants considered it a basic principle to educate capable students who are diligent in maintaining and promoting the health of the community under different circumstances including crises. “An academic department should always know that its main mission is to train capable students” (P3). “In the midwifery department, we must seek to train students who can demonstrate their unique abilities during critical situations” (P11).
Curriculum, which was appreciably emphasized by the participants in the research, is defined as any activity or activities that include achieving productivity, skills and knowledge. This category consists of two sub-categories.
The participants believed that clinically teachable content should be specified in the curriculum. “The content of the clinical education curriculum must be clear” (P10).
The midwives who participated in the study acknowledged that a lesson plan must be precisely derived from the curriculum. “When I am writing a lesson plan, the alignment between the curriculum and the lesson plan is very important” (P15). According to the participants, the alignment of the contents of their logbooks with the content of the curriculum and careful monitoring of the completion of these logbooks are of paramount importance. “The content of the logbook should be consistent with the content of the curriculum, and the instructor should oversee the completion of these logbooks” (P3).
The midwives participating in this study also placed enormous emphasis on the use and inclusion of hidden curriculum topics in the student curriculum. “Whatever a midwifery student should be taught, I believe, should be included in the curriculum. It should be made clear in the curriculum how to behave professionally and ethically, how to communicate well with people, how to be fair in dealing with others, etc. When there is enough information and up-to-date books in this field, and we have excellent experts in this field, why not show it in the curriculum!” (P1)
The participants emphasized the need for clear clinical training methods and the use of evidence-based education. “Clinical teaching methods should be very clear in the curriculum” (P3). “Evidence-based education is very important. Not everything is based on experience. I mean, the education you give and the action that is taken should be based on scientific articles and texts.” (P8)
Participants in this study believed that a codified program for using the skill lab and performing the first educational procedures by students in these centers is very important. “In the midwifery department, a part of the training, especially the initial part, should be offered in the skill lab” (P12).
Virtual clinical education
According to the participants in this study, the use of distance education along with in-person clinical education is fruitful provided that there are appropriate facilities and equipment. “I myself believe in distance education. If anything, clinical education should not necessarily be on the patient's bedside” (P13).
“Telemedicine and distance assessment has a long history in the world. I have a positive opinion about distance education. This virtual education should not be limited to pandemic conditions. Some clinical courses should be offered through this modality, but by meeting the requisites first. Finally, its value should be equal to or even higher than in-person education”. (P10)
In clinical education, the presence of a good clinical instructor is very important due to the sensitivity of the health of community. This category is very critical in clinical research on midwifery education. It consists of 3 sub-categories.
Skills of clinical instructors
Participants in the study were of the opinion that clinical instructors must possess the knowledge of up-to-date scientific procedures and the ability to offer clinical education. “A clinical instructor should be aware of the latest scientific achievements in the treatment of patients and be able to offer a proper education to the student”. (P1)
The participants in the study deemed clinical work experience very crucial for clinical instructors and placed immense emphasis on this experience. “We should not allow anyone to come and teach students in clinical settings! They must have at least a few years of experience in that field and be interested in teaching students” (P2)
Participants in the study accentuated clinical instructors’ communication skills including communication with patients, students, etc., and considered them as role models for students. “There are some professors who do not treat the patient well, and the student learns this because we do not learn it from somewhere else! The students follow the example of their professors!” (P6). “In my opinion, when choosing a professor, the way they communicate with students, patients and the hospital staff should be taken into account. Simply having a degree or qualification is not enough.” (P14)
Empowerment of clinical instructors
According to the participants in this study, clinical instructors should be trained in various fields such as teaching methods and clinical assessment. “Unfortunately, many clinical instructors do not pay attention to clinical education and assessment! Clinical educators need to be fully trained in this area”. (P8)
The midwives who participated in the study maintained that legal support for clinical instructors in internship programs leads to better education for students. “The clinical instructor should be legally supported so that if something happens they will not be held responsible for. This support will increase the instructor’s interest in doing clinical work with the student”. (P12)
Collaboration between hospitals and the faculty in terms of clinical education
The participants attached great importance to the collaboration of faculty members and clinical staff when it came to the students’ clinical education. “To teach an educational content, it is better if one part of it is taught by a faculty member and leave the other part to a person who works in clinical setting (i.e., the staff). This will increase the effect of the training.” (P3)
Students are individuals for whose scientific and practical advancement proper planning is done so that they are prepared to provide services in accordance with the needs of society. This category consists of two sub-categories.
Requirements of starting clinical education
The participants believed that it is useful to check the students’ readiness before starting clinical education and recommended that if necessary and in accordance with the goals of the internship programs, the students’ competence be strengthened by methods such as holding workshops, etc. “In my opinion, before the students enter the internship programs, their readiness should be checked and, if necessary, boost it in different ways.” (P8)
According to the participants in the study, a package to familiarize students with the clinical field and the rules governing the wards is useful for the success of clinical education. “The student must be familiar with the environment before entering the clinical field. A good clinical education is one that has a ready-made package for this purpose, and the student must be familiar with it before going to the clinical field. This means learning the ropes: whom they are in contact with, what the scope of their authority and duties in that ward is and with what purpose they have entered that ward.” ( P10)
Educational services for students
Participants in the study stated that a clinical counselor who can identify the educational problems of students in the clinical field and who tries to address these problems is needed. “It is good to have someone as a clinical counselor to identify the educational problems of students in clinical settings and try to solve those problems with the cooperation of faculty officials.” (P15)
A clinical setting is an ideal environment for teaching and learning and lies at the heart of clinical midwifery education. This category consists of three sub-categories.
Educational conditions in clinical settings
As far as clinical settings were concerned, the participants believed that a relevant number of students and patients referring to a particular clinical center is important. “One of the important points about clinical settings is the ratio of the number of students to a particular clinical field, and another is how general that field is. In some centers that are general, students need to see some rare diseases at least once”. (P9)
The participants also insisted that the suitability of the clinical setting to implement the relevant curriculum is useful in educating students. “The clinical setting must meet the necessary conditions to implement that curriculum.” (P3)
Participants in the study stressed that how the clinical staff accept the presence of students and their instructors in the clinical setting is very important. “Staff in hospitals, even some university hospitals, are not briefed on cooperating with the instructor and the student. The staff should be informed that students need to do a lot of things and that they have to treat the students more patiently” (P12)
Clinical facilities and equipment
The participants strongly recommended the existence of educational facilities such as conference rooms, resourceful libraries with up-to-date books, computers with Internet connectivity, and skill labs with appropriate facilities to meet the educational needs of students. “Students in the clinical setting also have a series of educational needs such as what they should do when there is no patient. There should be a series of educational assistance facilities such as the Internet, a library and a skill lab to empower the student”. (P10)
The midwives participating in this study found it necessary to provide clinical facilities for students and clinical instructors. “Basically, there should be a pavilion in the hospital for my students. I expect my students to work in night shifts but I do not expect them to stay up all 12 hours! The instructors must also have a suitable pavilion.” (P7)
Improving the quality of clinical education requires continuous assessment of its current status, identification of its strengths, and alleviation of its weaknesses. This category consists of three sub-categories.
Participants laid particular emphasis on how students were assessed. “Student assessment should be continuous. In every internship program and in every session, a score should be considered for all student activities and the students should evaluate themselves at the end of each session”. (P12)
According to the participants in the study, topics of student assessment were topics such as practical skills, communication skills, professional ethics and teamwork. “In addition to evaluating students’ practical and communication skills, another thing that should be evaluated, which is not, is teamwork. Our students must learn how to work together”. (P2)
Assessment of clinical instructors
The students participating in the study valued the importance of faculty assessment feedback. “In my opinion, assessment is worth thatbe affected and follow up if a professor has a weakness in a field she corrected herself or not ?!” (P5)
Assessment of clinical settings
As far assessment of clinical settings was concerned, the participants in the study pointed out that what is of particular importance is provision of an appropriate space for the students’ presence and another for educating them. “Internship programs should be offered in a well-prepared area for students to attend, work and train”. (P14)
Healthcare facilities should be evaluated in terms of the variety of patient coverage and patient care according to the guidelines of the Ministry of Health. “It is better to check the number of referrals in the hospital intended for student internship programs. Do all referrals range from low-risk to high-risk? Are they from all socio-economic classes in society? Do the hospitals take care of patients according to the clinical guidelines of the Ministry of Health?” All this affects the students’ educability”. (P10)