1. EDUCATION EXCHANGE — Lauren P. Hunter, CNM, MS
THE CIRCLE OF SAFETY: A TOOL FOR CLINICAL PRECEPTORS
Helen Varney Burst, CNM, MSN, DHL(HON), FACNM
ABSTRACT
The Circle of Safety is a tool for all clinical faculty, regardless
of profession and regardless of locale. Applying principles of
teaching-learning, the Circle of Safety was originally devel-
oped by the author for use by clinical preceptors in nurse-
midwifery education. Its purpose is to provide a structure that
removes a major obstacle to learning and facilitates student
efforts to learn in accord with an individual’s pattern of
learning. J Midwifery Womens Health 2000;45:408–10
© 2000 by the American College of Nurse-Midwives.
The Circle of Safety*† is a concept that provides a
method for setting up clinical experiences that avoid
some of the common pitfalls in clinical teaching and
facilitate student efforts to learn. It is grounded in basic
teaching-learning philosophy that includes the beliefs
that:
1. Each student has an individual pattern of learning.
2. Adult learners can identify what facilitates their learn-
ing.
3. Learning takes place by removing obstacles to learn-
ing.
4. Clinical learning occurs best when the preceptor
creates an environment as free from obstacles as
possible.
5. Learning occurs best when reinforced.
6. Learning occurs best when it takes place in an
environment of shared responsibility and mutual re-
spect.
The context for the Circle of Safety is the clinical
learning environment, wherever that may be: hospital,
home, birth center, clinic, office. The patient, of course,
is the recipient of the care and the common focus of both
the teacher and the student. Taking care of patients
should be a shared experience of the faculty member and
the student, with each contributing the expertise that
individual has to the situation. This involves true col-
leagueship between the faculty member and the student
with both caring for one patient. The balance of who does
what changes over time, with the extent of that change
dependent on the changing clinical situation and on the
progress of the student within the education program.
The student does what s/he can do, and the preceptor
does the rest—teaching, role-modeling, and mentoring in
the process. In this way, the joy of clinical practice is
communicated and shared.
The Circle of Safety is a teaching method of the utmost
importance because it is a basic “how to” for working
clinically with students. Benefits of using the Circle of
Safety include that it:
1. Recognizes and respects the different way individual
faculty members practice and do procedures
2. Keeps students from having to mentally catalogue
how each faculty member does something
3. Frees the student from wasting energy that could be
better spent in learning
4. Facilitates and reinforces learning
The principle underlying the Circle of Safety is that of
consistency between and among faculty in their ap-
proach to and expectations of students. Note the empha-
sis on just what consistency the faculty should have.
Students want faculty to be consistent in clinical practice.
This is an understandable but not realistic expectation on
the part of students. It would be easier for students if
faculty all did everything the same way and if there was
only one way of doing something. However, faculty do
not all do everything the same way, and there is often
more than one way to do something.
The Circle of Safety is designed as an approach that
will keep students from having to mentally compute what
each faculty member does and adjusting what they do
accordingly. Such mental gyrations waste energy better
spent in learning. Furthermore, if the student is con-
stantly adjusting to each preceptor’s method of doing
something, then the student is rarely getting reinforce-
ment experience in a method of his or her own choosing
and development.
Thus, the consistency that can be expected from
faculty is not in practice but in expectations of and
approach to students. The consistency in expectations of
students is explicitly defined in the clinical objectives as
Address correspondence to Helen Varney Burst, Yale University School
of Nursing, 100 Church Street South, P.O. Box 9740, New Haven, CT
06536.
* The Circle of Safety is applicable to all clinical professions. Examples
in this article are those from the profession of midwifery.
† This teaching method was developed nearly 30 years ago by the author
in conjunction with the initial application of mastery learning principles to
a nurse-midwifery curriculum (1).
408 Journal of Midwifery & Women’s Health • Vol. 45, No. 5, September/October 2000
© 2000 by the American College of Nurse-Midwives 1526-9523/00/$20.00 • PII S1526-9523(00)00052-0
Issued by Elsevier Science Inc.

2. specified within the midwifery management process
(2,3). The consistency in approach is reflected in the
Circle of Safety.
As shown in Figure 1, the perimeter of the Circle of
Safety is the Faculty Boundary of Safety. This has two
meanings. The first meaning refers to the personal
boundary of safe practice that every practitioner has. This
boundary is made up of the limits of practice. The factors
determining the limits of practice, as identified by Ernes-
tine Wiedenbach (4), are the following:
1. Legislative limits imposed by state statute, rules and
regulations
2. Institutional policy
3. Professional limits imposed by the professional orga-
nization
4. Personal limits
A practitioner’s boundary of safe practice varies with
different institutions and with different patient situations.
Personal limits change and generally expand with expe-
rience. The boundary of safe practice for a new graduate
is much more circumscribed than for someone with
several years of experience. A practitioner’s boundary of
safe practice has a fluctuant quality and is in a constant
state of expansion and contraction. This is illustrated by
the arrows pointing to smaller and larger circles from the
Faculty Boundary of Safety.
The second meaning of the Faculty Boundary of
Safety refers to how constricted the preceptor chooses to
make this perimeter of safety for any individual student.
A more constrained boundary of safety may be placed on
inexperienced students during their initial clinical expe-
riences with such admonitions as not to do any procedure
or examination without the presence of the preceptor.
In the teaching-learning situation, the boundary of
safety is set by the faculty, not by the student. As shown
in Figure 1, the student is in the center of the Circle of
Safety during a clinical experience. Within the Faculty
Boundary of Safety, the student can practice and use
whatever methodology s/he wishes so that all energy is
directed toward learning. Such an idea accommodates the
individuality of the student. A student, however, cannot
insist that a faculty member go beyond that faculty
member’s personal boundary of safety. This becomes an
issue when the same clinical situation presents and the
first faculty member has a more expanded boundary of
safety as sometimes happens in “gray zone” areas. In
such cases, the faculty have two responsibilities regard-
ing the Faculty Boundary of Safety:
1. To respect each other’s variations in practice
2. To know and be able to clearly articulate what one’s
own personal limits of practice are and the rationale
for them
Within the Faculty Boundary of Safety, and in accord
with the patient and her preferences, the student can
perform a procedure and manage the care of the patient
the way s/he wants to. Common judgment calls in the
management of patient care include decision-making
about analgesia during labor and birth, fetal monitoring,
and whether to cut an episiotomy. Examples of proce-
dures involving variations among faculty include differ-
ent ways of inserting a speculum, placing local anesthe-
sia into the perineum, how to assist the baby’s head
during birth, and how or whether to support the mother’s
perineum during birth. The student has to be able to
present his or her rationale for what s/he plans to do and
that rationale has to be grounded in a sound theoretic and
patient-oriented base. This is in accord with the manage-
ment process that states that care “is supported by
explanations of valid rationale underlying the decisions
made. . . . ” (2).
It behooves the preceptor in the situation to clarify
with the student what s/he intends to do, preferably
beforehand. This is particularly true if the student has
learning goals for the day that include specific proce-
Helen Varney Burst has been an educator for more than 37 years,
directed three nurse-midwifery education programs (Mississippi, South
Carolina, and Yale), was co-originator of the mastery learning modular
curriculum design for nurse-midwifery, is the author of Varney’s
Midwifery, 3rd ed., and a co-author of Varney’s Pocket Midwife. She
received the ACNM Hattie Hemschemeyer Award in 1982, the 50th year
of nurse-midwifery education in the United States. She is currently a
Professor in the Yale University School of Nursing and teaches nurse-
midwifery and historical research.
FIGURE 1.
Circle of Safety.
Journal of Midwifery & Women’s Health • Vol. 45, No. 5, September/October 2000 409

3. dures that can be discussed during the pre-experience
conference. Judgment calls are discussed in the ongoing
clinical situation and depend on establishing a continuing
dialogue in which the student articulates his or her
thought process in relation to the steps of the manage-
ment process. Clinical preceptors need to remember that
the reasons for the concept of the Circle of Safety are:
1. To enable the student to concentrate on learning rather
than on computerizing faculty variations
2. To respect the student’s learning process, which, at
times, is the need to reinforce one method of doing
something and, at times, is the need to try other
methods
The need to reinforce one method of doing something or
to try other methods may vary with each student, and
each student may vary from one time to the next. This
does not mean that the individual preceptor never shares
his or her way of doing something. Of course preceptors
do this, complete with explanations of valid rationale for
why s/he does it a particular way. But, it is the student’s
free choice within the Circle of Safety to try somebody
else’s way.
The reality about the Circle of Safety is that it takes
committed effort to make it work as well in practice as it
does in theory. This means that it needs periodic rein-
forcement, especially with faculty members. Faculty
members often find it difficult to really believe that there
may be another way of doing something that is as good
as, if not better than, their way of doing it. In programs
in which the faculty subscribe to the Circle of Safety,
students should be encouraged to tell faculty what they
want to do and to remind them about the Circle of Safety.
The Circle of Safety also works better with more expe-
rienced, flexible clinician/teachers. It is difficult for a
relatively inexperienced clinician to be flexible. The
inexperienced clinician is often insecure, and an insecure
clinician tends to be inflexible. The Circle of Safety
demands the creativity and flexibility that comes from
comfort in clinical practice, the grace to acknowledge
legitimate differences in practice, and the willingness to
be a facilitator of the student’s efforts to learn as
determined by the individual student’s learning style
within the Faculty Boundary of Safety.
REFERENCES
1. Burst HV, Wheeler L, Christensen K. We hear you—keep talking. J
Nurse Midwifery 1973;18(2):9–13.
2. Varney H. Varney’s midwifery. 3rd ed. Boston: Jones & Bartlett
Publishers, 1997:25–6.
3. American College of Nurse-Midwives. The core competencies for
basic midwifery practice. Washington (DC): ACNM, 1997.
4. Wiedenbach E. Clinical nursing: a helping art. New York: Springer
Publishing Company, Inc., 1964:63–73.
410 Journal of Midwifery & Women’s Health • Vol. 45, No. 5, September/October 2000