Nurse-midwifery education is in a state of crisis. Hsia1 and Carrington2 have already identified problems threatening educational programs. Since their editorials highlighted the dilemmas facing CNMs in the academic world, the situation has worsened. Loss of federal funding under the current government administration has forced already underbudgeted programs to subsist on an even smaller financial base while searching for alternate sources of support. Faculty lines have been cut, at times accompanied by pressure to accommodate even more students. The traditional faculty-student tutorial relationship in midwifery education is threatened because it is not cost-effective, even though our primary care management and responsibility role requires this intensive supervision. If the educational hierarchy does not fully accept the nurse-midwifery philosophy of education, support for maintaining this system will erode. Academic faculty are then trapped between the conflict of wanting to maintain high quality nurse-midwifery education and the reality of limited financial resources that demand that too few faculty bear responsibility for too many students. The potential for burnout becomes dangerously high; thus, the importance of finding innovative ways to maintain educational programs and increase student numbers, while accepting the realities of limited financial resources, cannot be overstated.
As this crisis in education has been developing, we have seen the widespread expansion of midwifery practice into more autonomous nurse-midwife-managed models. Many of the students who come into our programs have been attracted by the independent, personal midwifery care offered in these private practice or alternative birth settings. They therefore adjust with difficulty to the not-so-autonomous management protocols of the medical model tertiary care settings where much of midwifery education takes place. Discussions of midwifery management during student experience are often play-acted: the student must be able to discuss alternate plans, scientific rationale, and potential outcomes, knowing she has no choice but to follow a preordained protocol. This is frustrating for faculty as well, whose attempts to preserve midwifery options for the client and the student are often rebuffed by hospital staff, creating even more stress in an already stressful job. Most educators and practicing CNMs would tend to agree that both education and practice should take place in a broader variety of settings where true midwifery care of the low-risk client can flourish, and where the woman at higher risk can enjoy real collaborative medical/midwifery management.
The twin crises of nurse-midwifery faculty overload and dissatisfaction with medical model learning experiences collide with a third problem: an oft-heard complaint from service directors that many graduate nurse-midwives have had insufficient experience, making their employment a costly matter of supervised orientation. In fact, in attempting to provide a broader variety of experiences and management options, educational programs run the risk of weakening the learning process by insufficient reinforcement and repetition. If the student has the options of safely avoiding the use of intravenous fluids, fetal monitors, or episiotomy in most of her intrapartum management experiences, she may need more time in the program to become comfortable with these necessary skills. But open-ended modules are impossible when faculty must move on to other responsibilities and more students are waiting in the wings for experience in the site.
How are nurse-midwifery education programs to provide more and better experience in midwifery management when they are already stretched to the limits of financial resources and qualified personnel? One answer may lie in an increased dependence on clinical faculty: CNMs who take a student in a tutorial relationship within their own autonomous or semiautonomous practices. Integration experience in many programs has long existed outside the formal academic environment, but now the time and efforts of practicing CNMs are being requested for more basic student education as well. From formal off-campus educational programs already piloted3 to informal arrangements with services/practices near program sites, the increased use of clinical faculty in midwifery education is inevitable. It can answer some crucial educational needs by freeing program faculty from extensive clinical assignments, and permitting them to meet their academic responsibilities. Access to outside clinical sites provides more options for students, allowing them to experience low-risk midwifery management in private practice as well as high-risk collaborative management in the tertiary care setting. The use of more and varied sites intensifies the clinical experience as well, by reducing competition for management experience and increasing access to faculty who are no longer responsible for too many students in the site.
Although a seemingly ideal solution from the academic view, this increased reliance on clinical faculty may not be so readily acceptable to CNMs in practice. Already overburdened by long hours, skyrocketing expenses, obligations in the workplace, and professional organization responsibilities, these CNMs now are asked to shoulder an additional obligation to nurse-midwifery education. To do so is time-consuming if the students' educational needs are to be met. Client visits stretch on as the fine points of midwifery management are discussed. Time must be allotted for faculty conferences. The special bond that develops between midwife and client must accommodate a novice as yet unskilled in assessing and responding to the client's needs. The CNM must constantly suppress the urge to do or think for the student, allowing the fledgling clinician time to think things through, eliminate diagnostic and therapeutic options, and worry endlessly whether or not the best choice was made. And she must establish a comfortable relationship with a student who is full of new ideas and the latest clinical research, whose rose-colored view of midwifery is as yet untarnished by political and economic reality.
All this for what return? Standard recompense includes a faculty appointment without fringe benefits, an occasional wine and cheese party, sometimes minimal or no financial compensation, and the gratitude of the educational program. But there are other benefits. Working with a midwifery educational program provides direct access to the system that prepares the future of our profession. It offers an opportunity to mold the educational process to midwifery practice as it currently exists. Everyone benefits when graduate nurse-midwives are familiar with the realities of busy services, the conduct of private practice, and a broad approach to midwifery management. Individual services and practices are able to recruit new staff who need little orientation, and they can obtain first-hand knowledge of a candidate's ability to function. Up-to-date clinical knowledge and unfamiliar management options can be shared. And all of us can use an occasional dose of rosy idealism!
Working with students can be as exciting and rewarding as it is threatening or time-consuming. Given the present state of nurse-midwifery education, clinical faculty will be sought more frequently to assist in the preparation of tomorrow's midwives. In recent years, a small but gratifying number of practicing CNMs have answered the pleas of educational programs and taken students into their own services and practices. These successful experiments have to be repeated on a larger scale if our educational programs are to survive in the tutorial form we feel is best. Practicing midwives must reevaluate their ability to make themselves available as they negotiate contracts and insurance coverage, revise policy manuals, and interact with clients. Educational programs must devise ways to use clinical faculty more efficiently and to reward them better for their contributions. If the budget will not allow straight financial compensation, perhaps other forms of remuneration can be developed. (For example programs might explore the possibility of arranging for clinical faculty to participate in group medical or malpractice insurance coverage, or use university computer time to keep statistics and records.) Unfortunately, the economic realities of midwifery education will not change; it is up to us to create new models for educating our students. Midwifery education is our future; we must take an active role in safeguarding and shaping it.