Self-Reported Level of Cultural Competence of Midwives in the North-West Province of South Africa.

INTRODUCTION: Limited research on cultural competence in nursing, midwifery, and education exists within low- and middle-income countries such as South Africa (SA). This study aimed to describe midwives' self-reported levels of cultural competence toward women receiving maternal care. METHODOLOGY: A descriptive, cross-sectional survey design and an all-inclusive sample of (N = 104; n = 82) midwives yielded a 79% response rate. Data were collected using the Transcultural Self-Efficacy Tool (TSET) questionnaire. Participants included midwives recruited from maternity units of five hospitals in South Africa: different hospitals that included one large district, two regional, and two tertiary hospitals in the North-West Province of SA. An all-inclusive sample of (N = 104; n = 82) midwives participated, representing a 79% response rate. RESULTS: Midwives reported an overall moderate level of competence regarding their knowledge and understanding of cultural factors; it was concerning that their confidence in interviewing patients from different cultural backgrounds on factors such as acculturation and worldview were the lowest. DISCUSSION: To the best of the authors' knowledge, this was the first study to assess the cultural competence of midwives in SA using TSET. The study highlighted the need for midwives' training to improve their cultural competence.

Cultural competence of nursing educators at medical universities of 2nd regional planning in Iran.

BACKGROUND: One of the facets of nursing care, as a holistic profession, is cultural care. Considering the role of culture in individuals' health behaviors, nurses are recommended to be mindful of cultural care. Since nursing educators should be culturally competent to teach cultural care to students, this study aimed to determine the cultural competence of nursing educators of medical sciences universities in the 2nd regional planning in Iran. METHODS: The current research was a descriptive and survey study framed within Campinha-Bacote's cultural competency model. All nursing educators of universities of medical sciences in the 2nd regional planning of Iran (Tabriz, Urmia, Ardabil, Khoy, Maragheh, Sarab, and Khalkhal) were considered as research units, and the cultural diversity questionnaire for nursing faculties (CDQNE-R) was sent to them. Out of 129 questionnaires sent, 84 were turned back. The data were analyzed by the SPSS 22 software. RESULTS: The results of this study showed that the research participants agreed with the subscales of cultural awareness, cultural knowledge, cultural skill, and cultural desire according to Sealey and Yates' interpretation scale. Also, the research units cast doubts on the cultural encounter subscale. The mean scores of the participants' responses to the questions of every subscale equaled 4.11, 3.52, 3.71, 3.38, and 3.93 for the subscales of cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire, respectively. Likewise, the mean scores of participants' responses to the subscales of transcultural educational behaviors and general cultural competence equaled 3.90 and 3.73. CONCLUSIONS: The nursing faculties participating in the present study agreed with the 4 sub-models of Campinha-Bacote cultural care and the presence of cultural competence criteria. Also, the research units had doubts about the cultural encounter subscale. This result means that the research participants were undecided about their level of participation in face-to-face interactions with people from different cultural, racial, and ethnic groups. According to the results of the study, it is important to hold transcultural nursing training workshops and courses to maintain and improve the level of cultural competence of nursing faculties at universities of medical sciences in the 2nd regional planning in Iran.

A Call to Action for a Programmatic Approach to Addressing Health Disparities and Cultural Competency in Pharmacy Education.

Pharmacy has recognized the importance of education in health disparities and cultural competency (HDCC) for two decades. More recently, there has been emphasis on incorporating equity, diversity, and inclusion (EDI) in pharmacy programs. While many institutions identify a need to incorporate a programmatic approach to HDCC education to meet the growing needs of a diverse population, pharmacy curricula continue to lack a holistic, programmatic approach. More than ever, Doctor of Pharmacy (PharmD) students should graduate with the knowledge, values, and skills to provide culturally appropriate care for a diverse patient population. This commentary advocates for a holistic, programmatic approach to integrating HDCC education and serves as a call to action for curricular development. It is hoped that this commentary will also set the foundation for additional scholarly work and recommendations regarding a programmatic approach.

The Experience of Colombian Medical Students in a Pilot Cultural Safety Training Program: A Qualitative Study Using the Most Significant Change Technique.

Problem: The Colombian government provides health services grounded in the Western biomedical model, yet 40% of the population use cultural and traditional practices to maintain their health. Adversarial interactions between physicians and patients from other cultures hinder access to quality health services and reinforce health disparities. Cultural safety is an approach to medical training that encourages practitioners to examine how their own culture shapes their clinical practice and how to respect their patients' worldviews. This approach could help bridge the cultural divide in Colombian health services, improving multicultural access to health services and reducing health disparities. Intervention: In 2016, we conducted a pilot cultural safety training program in Cota, Colombia. A five-month training program for medical students included: (a) theoretical training on cultural safety and participatory research, and (b) a community-based intervention, co-designed by community leaders, training supervisors, and the medical students, with the aim of strengthening cultural practices related to health. Evaluation used the Most Significant Change narrative approach, which allows participants to communicate the changes most meaningful to them. Using an inductive thematic analysis, the authors analyzed the stories and discussed these findings in a debriefing session with the medical students. Context: Cota is located only 15 kilometers from Bogota, the national capital and biggest city of Colombia, so the small town has gone through rapid urbanization and cultural change. A few decades ago, inhabitants of Cota were mainly peasants with Indigenous and European traditions. Urbanization displaced agriculture with industrial and commercial occupations. One consequence of this change was loss of cultural health care practices and resources, for example, medicinal plants, that the community had used for centuries. Impact: A group of 13 final-year medical students (ten female and three male, age range 20-24) participated in the study. The medical students listed four areas of change after their experience: increased respect for traditional health practices to provide better healthcare; increased recognition of traditional practices as part of their cultural heritage and identity; a desire to deepen their knowledge about cultural practices; and openness to incorporate cultural practices in healthcare. Lessons Learned: Medical students reported positive perceptions of their patients' cultural practices after participating in this community-based training program. The training preceded a positive shift in perceptions and was accepted by Colombian medical students. To the best of our knowledge, this was the first documented cultural safety training initiative with medical students in Colombia and an early attempt to apply the cultural safety approach outside the Indigenous experience.

Cultural respect in midwifery service provision for Aboriginal women: longitudinal follow-up reveals the enduring legacy of targeted program initiatives.

BACKGROUND: Culturally competent maternity care provision to Aboriginal and Torres Strait Islander women was identified as a priority area by Australia's National Maternity Services Plan in 2011. While midwifery programs responded by including core Indigenous content and community placements in curricula, little is known about whether knowledge learned, and insights gained in response to these initiatives have endured and been applied in clinical practice. This follow-up study explores the impact of a compulsory Indigenous unit and a remote clinical placement on two cohorts of non-Indigenous midwives who were participants in an earlier 2012-14 study. METHODS: Fourteen non-Indigenous participants who were either students or recent graduates in 2012-14 were located and re-interviewed in 2019-20. In-depth interviews based on a semi-structured interview guide were conducted by telephone or face-to face; recordings were transcribed and thematically analysed using standard qualitative procedures. RESULTS: Exposure to Indigenous content and settings during training had an enduring impact on participants' midwifery practice; most felt better prepared to provide culturally safe care, build respectful relationships and advocate for improved services for Aboriginal women. Despite this positive legacy, they also expressed apprehension about causing offence and recognised their own knowledge deficits with regard to Aboriginal cultural practices. Organisational constraints, including restrictions on the number of family members accompanying a birthing mother were identified as barriers to optimal care; some positive organisational initiatives were also described. CONCLUSIONS: This follow-up study provides encouraging evidence that well-designed and delivered Indigenous content and community placement opportunities in midwifery programs can have a lasting impact on service provision to Aboriginal women, contribute to a more informed, empathetic and culturally competent maternity workforce and help catalyse health service changes towards more culturally safe care.

Addressing ethnic disparity in antenatal care: a qualitative evaluation of midwives' experiences with the MAMAACT intervention.

BACKGROUND: In Denmark, 13% of all children are born by non-Western immigrant women. The public antenatal care has not adapted to this increased diversity of women. Compared to women coming from Western countries, non-Western immigrant women have an increased prevalence of severe maternal morbidity and higher risks of maternal death, stillbirth and infant death. Suboptimal care is a contributing factor to these ethnic disparities, and thus the provision of appropriate antenatal care services is pivotal to reducing these disparities and challenges to public health. Yet, little is known about the targeted interventions which have been developed to reduce these inequities in reproductive health. The MAMAACT intervention, which included a training course for midwives, a leaflet and a mobile application, as well as additional visit time, was developed and tested at a maternity ward to increase responses to pregnancy warning signs among midwives and non-Western immigrant women. AIM: To explore the feasibility and acceptability of the MAMAACT intervention among midwives and identify factors affecting midwives' delivery of the intervention. METHODS: Eight mini-group interviews with midwives (n = 18) were undertaken. Systematic text condensation was used to analyse data. RESULTS: Three main categories were identified, which were 'Challenges of working with non-Western immigrant women', 'Attitudes towards and use of the leaflet and mobile application', and 'Organisational factors affecting the use of the MAMAACT intervention'. CONCLUSIONS: The MAMAACT intervention was found to be feasible as well as acceptable among midwives. Women turning to relatives for pregnancy-related advice, time constraints during midwifery visits, incomplete clinical records and lack of professional interpreter assistance impacted midwives' delivery of the MAMAACT intervention. Midwives displayed a readiness for the MAMAACT intervention; however, there is a need to further examine how contextual factors may impact the use of the intervention in antenatal care. TRIAL REGISTRATION: ClinicalTrials.gov, Retrospective Registration (07/2/2020), registration number NCT04261400.

Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty.

As the demographics in the United States continue to change, nurses must deliver care to patients from diverse cultural backgrounds. Cultural humility is a lifelong process of self-reflection which is also defined by that individual. It allows an individual to be open to other people's identities, which is core to the nursing standard of providing holistic care. Embracing and incorporating cultural humility is essential for creating a comprehensive and individualized plan of care. One of the ways to achieve cultural humility in nursing is to train future faculty to become agents of cultural humility. This also helps to create a pipeline of nurses who have respect and empathy for the patients they serve. The aims of this paper include: 1) define cultural humility and its importance to healthcare professionals; 2) explore the intrapersonal, interpersonal, and system levels of cultural humility; 3) provide insight on how to promote cultural humility; 4) reflect on best practices across a variety of healthcare disciplines; and 5) provide suggestions for practice.

Incorporating an Equity Agenda into Health Professions Education and Training to Build a More Representative Workforce.

Efforts to achieve health equity goals in the United States require the recruitment, retention, and graduation of an increasingly diverse student body of aspiring health professionals. Improving access to health care providers who are culturally congruent with the populations served is a related ethical priority that has the potential to improve the health inequities faced by communities of color and others in the United States. Midwifery education program administrators and faculty have responded to this need by acknowledging that creation of a more representative midwifery workforce starts with midwifery education. The Equity Agenda Guideline, related conceptual model, and website resources were developed for the purpose of supporting health professions educators and institutions who recognize a need for change and are seeking answers about how to train and graduate more health care providers from communities that are currently underrepresented. Using a systems approach to outline the transformative multilevel changes required, these resources offer a roadmap for how to address the underlying problems of racism and other differentisms that have limited the growth and diversification of the health and helping professions. This article addresses how health education programs interested in making an impact on this complex and persistent problem can adopt or adapt the Equity Agenda Guideline, originally developed for midwifery education programs in the United States.

The influence of yarning circles: A cultural safety professional development program for midwives.

BACKGROUND: A university educated, First Peoples health workforce is paramount to improving health outcomes for Australia's First Peoples. However, a significant gap exists between the academic success of First Peoples and non-Indigenous students. The facilitation of culturally safe learning and teaching environments by academics is essential to closing this gap. There is little research on midwifery academics' understanding of Cultural Safety and the translation of this understanding in learning and teaching. OBJECTIVES: To explore the influence of yarning circles within a professional development program to enhance midwifery academics' awareness of Cultural Safety. METHODS: A six-month staff development program which consisted of two workshops and a series of yarning circles was offered to all midwifery academics. Eight participants agreed to be interviewed after completion of the program. Interviews were transcribed verbatim, read and re-read, and analysed using a six staged thematic analysis process. RESULTS: Six key themes centred on participants' Sense of Belonging, Sense of Safety, Sense Knowing, Sense of Support, Sense of Difference, and Sense of Challenge were identified. These concepts were supportive of participants' developing awareness of Cultural Safety. CONCLUSION: Yarning circles can encourage midwifery academics' awareness of Cultural Safety. Awareness is the first step towards becoming culturally safe. Yarning provided a safe and supportive space for challenging discussions and reflective learning about racism, white privilege, and difference. Midwifery academics described steps they could take to promote Cultural Safety in the classroom.

Indigenizing and Decolonizing the Teaching of Psychology: Reflections on the Role of the Non-Indigenous Ally.

Canada's 2015 Truth and Reconciliation Commission published 94 Calls to Action including direction to post-secondary institutions "to integrate Indigenous knowledge and teaching methods into classrooms" as well as to "build student capacity for intercultural understanding, empathy, and mutual respect." In response, Canadian universities have rushed to "Indigenize" and are now competing to hire Indigenous faculty, from a limited pool of applicants. However, it is missing the true spirit of reconciliation for non-Indigenous faculty to continue with the status quo while assigning the sole responsibility of Indigenizing curriculum to these new hires. How can non-Indigenous psychology professors change their teaching to ensure that all students acquire an appreciation of traditional Indigenous knowledge about holistic health and healing practices, as well as an understanding of Canada's history of racist colonization practices and its intergenerational effects? Community psychologists, particularly those who have established relationships with Indigenous communities, have an important role to play. In this article, I survey the existing literature on Indigenizing and decolonizing psychological curriculum and share ways in which I have integrated Indigenous content into my psychology courses. I also reflect upon the successes, questions, and ongoing challenges that have emerged as I worked in collaboration with first Anisinaabek First Nations and then Mi'kmaw/L'nu First Nations.

Cultural empathy in midwifery students: Assessment of an education program.

BACKGROUND: The ability of midwives to provide empathic care that is culturally appropriate is critical for women to feel accepted by the midwives who support them. Australia is a culturally diverse society, yet there is evidence of poorer maternity outcomes for some women and infants, related to their cultural background. OBJECTIVES: This study's objective was to evaluate the effectiveness of an education program for student midwives. The program was intended to increase the cultural empathy of future midwives, to help ensure greater cultural safety and optimal maternity outcomes across all sections of Australian society. DESIGN: This quantitative study compared pre- and post-intervention measures of students' empathy. SETTING: The health faculty of a large urban university in Australia. PARTICIPANTS: Fifty-five students from all three years of an undergraduate midwifery program participated. METHODS: The study examined students' scores on the Jefferson Scale of Empathy for health profession students, measured before and immediately after the education program, and again after four weeks. RESULTS: The midwifery students had a high mean baseline score on the empathy scale. Scores increased significantly after the education program. Students with lower pre-test scores recorded significantly greater increases in their empathy levels than those who were more empathic initially. Empathy scores declined one month after the program, but remained higher than baseline levels. CONCLUSIONS: Several studies have explored empathy levels amongst current and future health professionals. However, few studies of health professional students have evaluated the impact of specific education interventions addressing cultural empathy. This study found that midwifery students tended to have higher empathy scores than students in other health disciplines. The education workshop further increased participants' scores.

Engagement in an Online Cultural Competency Training.

OBJECTIVES: Engagement with online cultural competency training has not been well studied. We examined knowledge, attitudes, and skills differences among medical students, physicians, and other professionals in an online cultural competency education program. METHODS: A total of 1745 participants completed up to four online modules aimed at exploring stereotype, bias, diet, and religion among African American patients with hypertension. We examined knowledge, attitudes, and self-reported skills with 17 multiple-choice questions embedded in the 4 modules. Participants received comparative responses with their peers. RESULTS: Between 75% and 84% of participants knew the definition of stereotype and <50% knew the definition of bias (47% students, 36% physicians, 33% others, P < 0.001). Most responded that minorities perceive bias (98%-100%) and believe that evidence exists showing that bias affects decision making (62%-69%). Although most perceive that religious and spiritual beliefs affect reaction to illness often (78% students, 68% physicians, 79% others, P < 0.001), few would ask about religious beliefs during a typical encounter (13% students, 16% physicians, 30% others, P < 0.001). CONCLUSIONS: All of the participants struggled to define bias; however, most agreed that minorities perceive bias in the care they receive. We examined usage and interaction with the online content as a dimension of engagement.

Reflections on Nursing Educational Advancement Within Diverse and Evolving National Cultural Contexts.

As the development of nursing education becomes increasingly internationalized, it is tempting to focus on universal aspects of the discipline rather than explicitly emphasizing the distinct national cultures and contexts within which our profession and its educational styles and approaches have evolved. Capitalizing on an opportunity for comparative critical reflection on the relevant political, economic and social histories that have underpinned the development of nursing education in China, Brazil and Canada - three countries united by shared values about equity and access to health services - we sought to deconstruct the manner in which these forces have shaped the national differences in the way we conceptualize and deliver nursing education. On this basis, we examined the implications for the advancement of nursing education within each national context, recognizing the fundamental relevance of indepth critical reflection for optimizing nursing's advocacy capacity within each of our national health care and policy systems.

Atención del parto y del puerperio inmediato con pertinencia intercultural / Care of childbirth and immediate puerperium

PROPÓSITO: Explorar los factores que influyen en la aplicación de la interculturalidad con respecto a la atención del parto y puerperio inmediato en personal médico y paramédico, comadronas y usuarias del Centro de Urgencias Médicas (CUM) de Tecpán, Chimaltenango, abril-mayo 2017. MATERIAL Y MÉTODOS: Estudio cualitativo con diseño etnográfico. Se realizaron entrevistas en profundidad al personal de salud y usuarias del CUM y grupos focales con comadronas. Se evaluó la infraestructura de las salas de parto y posparto. RESULTADOS: En el personal médico y paramédico se evidenciaron saberes limitados acerca de la pertinencia cultural, descrita en las Normas de Atención con Pertinencia Cultural. Se contó con el 65% de los elementos de infraestructura y equipo de la sala de partos culturalmente adecuada. Las comadronas percibieron una atención deficiente y refirieron poco interés y capacitación del personal del servicio de salud. Las usuarias opinaron que existe una buena relación con el personal de salud, sin embargo no se les brindó una atención con adecuación cultural. CONCLUSIONES: Los factores que influyen en la implementación de las prácticas interculturales son de índole económica principalmente, además de aspectos estructurales, organizaciones y socioculturales.

PURPOSE: To explore the factors that influence the implementation of interculturality in regards to care during childbirth and the immediate postpartum period, in medical and paramedical staff, traditional midwives and patients of the Center of Medical Urgencies (CUM), Tecpán, Chimaltenango, April-May 2017. MATERIALS AND METHODS: Qualitative study with an ethnographic design. In-depth interviews with medical staff and patients of the CUM were carried out in addition to focal groups with traditional midwives. The infrastructure of the birthing room and postpartum ward were evaluated. RESULTS: CONCLUSIONS: The medical and paramedical staff showed limited awareness of cultural pertinence, as described in the Norms of Attention with Cultural Pertinence. The birthing room satisfies 65% of the criteria of infrastructure and equipment of a culturally pertinent birthing room. The traditional midwives perceived deficient patient care and identified a lack of interest and training of the health staff. The patients experienced a good relationship with the health staff, but declared a lack of cultural adequacy in the attention. The factors that influence in the implementation of intercultural practices are principally of economic nature, in addition to structural, organizational and sociocultural aspects.

Pilot Testing an Intervention on Cultural Safety and Indigenous Health in a Canadian Occupational Therapy Curriculum.

First-year Canadian occupational therapy students (n=27) rated their knowledge of and cultural/emotional responses to cultural safety and Indigenous health prior to and following an educational intervention led by a trained Indigenous educator. At post-intervention, students were also asked to comment on their learning experience. Pilot data of 40% of the class were analyzed using nonparametric approaches proposed by Koller and colleagues; qualitative data were explored using conventional methods. The majority of participant ratings reflected a perceived increase in knowledge and cultural/emotional responses, indicative of positive change following intervention. Student comments about their learning were in keeping with the positive findings. Although our sample size was small and our study examined perceived knowledge acquisition, preliminary results were consistent with related literature.

Impact of a continuing professional development intervention on midwifery academics' awareness of cultural safety.

BACKGROUND: Cultural safety in higher education learning and teaching environments is paramount to positive educational outcomes for Aboriginal and/or Torres Strait Islander (hereafter called First Peoples) students. There is a lack of research evaluating the impact of continuing professional development on midwifery academics' awareness of cultural safety. AIM: To implement and evaluate a continuing professional development intervention to improve midwifery academics' awareness of cultural safety in supporting First Peoples midwifery students success. METHODS: A pre-post intervention mixed methods design was used. Academics (n=13) teaching into a Bachelor of Midwifery program agreed to participate. The intervention consisted of two workshops and five yarning circles across a semester. Data included the Awareness of Cultural Safety Scale, self-assessment on cultural safety and perceptions of racism, evaluation of the intervention, participants' journal entries, and researcher's reflections. FINDINGS: Responses on the Awareness of Cultural Safety Scale revealed significant improvement in participants' awareness of cultural safety. There was an upward trend in self-assessment ratings. Participants reported high levels of satisfaction with the intervention or workshops and yarning circles. Participants' journal entries revealed themes willingness to participate and learn, confidence as well as anger and distress. CONCLUSION: Increased awareness of cultural safety can be transformative for midwifery academics. Workshops and yarning circles can support academics in moving beyond a 'sense of paralysis' and engage in challenging conversations to transform their learning and teaching and in turn foster a culturally safe learning and teaching environment for First Peoples midwifery students towards success.

Development of a First Peoples-led cultural capability measurement tool: A pilot study with midwifery students.

BACKGROUND: Midwives have a central role in closing the gap in health inequalities between Australias' First Peoples and other childbearing women. The Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) identifies five core cultural capabilities (respect, communication, safety and quality, reflection and advocacy) to foster culturally safe health care. AIM: To use a decolonising, First Peoples-led approach to develop and validate a tool to measure the development students' cultural capabilities. METHOD: A pre- post intervention design was used. Development of the Cultural Capability Measurement Tool followed a staged process which centred on First Peoples' knowledges. This process included: item generation, expert review; a pilot, test-retest; and psychometric testing (reliability, factor analysis and construct validity). All third year midwifery students (n=49) enrolled in a discrete First Peoples health course were invited to complete the survey pre and post course. FINDINGS: A response rate of 77.5% (n=38/49) pre-course and 30.6% (15/49) at post-course was achieved. The tool demonstrated good internal reliability (Cronbach alpha=.89-.91). Principal component analysis with varimax rotation produced a five-factor solution. A paired samples t-test revealed a significant increase from pre-course (mean 93.13, SD 11.84) to post-course scores (mean=100.53, SD 7.54) (t (14)=-2.79, p=.014). CONCLUSION: A First Peoples approach was critical to tool development and conceptual validity. The 22 item Cultural Capability measurement Tool reflected the core cultural capabilities of The Framework. The draft tool appears suitable for use with midwifery students.

A Journey Toward Cultural Competence: The Role of Researcher Reflexivity in Indigenous Research.

This article highlights the personal journey of reflective development that a non-Aboriginal White researcher and health professional underwent to be "fully positioned" in the everyday lives of a rural Australian Aboriginal community in Western Australia. The article explains the researcher's personal development in areas important to building respect, building relationships, and ensuring reciprocity while undertaking Aboriginal research. The researcher reports on the reflective evaluation of her worldview. Understanding that judgment is a natural tendency, the researcher used reflexivity as a tool to examine and contextualize her judgments, presumptions, and preconceptions, which positioned her to be open to differing viewpoints and actively explore alternate perspectives. The researcher explores her evolutionary understanding that cultural competence is not a destination but a continual journey, and she details her knowledge development regarding the Aboriginal research paradigm, which requires that all the learning, sharing, and growth taking place is reciprocal and engages all parties actively.

Incorporating Antiracism Coursework into a Cultural Competency Curriculum.

Creating a socially conscious educational environment is an imperative if health care practitioners are to have a significant impact on health inequities. The effects of practitioner bias, prejudice, and discrimination on health and health outcomes have been well documented in the literature. Individuals being trained to provide health care will be entering into an increasingly diverse world and must be equipped with the appropriate knowledge and skills in order to meet the needs of those seeking their care. Cultural competency training in medical education has evolved over the past 15 years since the Institute of Medicine's 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. As research on the effectiveness of this training has emerged, several authors have called for the integration of antiracism training into the cultural competency curriculum, but few have found effective ways of doing so. This article describes the approach of one midwifery program in order to inform clinical education programs across the spectrum of health care practitioners.