The ART OFClinical Teaching

The ART OF Clinical Teaching

by

Randa Mamdoh Gad Allah2nd Term of Doctorate

Under Supervision of

Prof. Dr. Kamelia Fouad

Prof. of Medical Surgical Nursing Faculty of Nursing

Ain- Shams University

2010

OUTLINES Introduction Definition of the teaching-learning process Definition of clinical teaching Purpose of teaching Goals of teaching. Levels of teaching

Cognitive Affective (attitude) Psychomotor (skills or clinical teaching)

Main components of the clinical teaching Teacher (clinical teacher) Student (leaner) Clinical teaching setting

Clinical teaching environment Course (skills or procedure that will be learning)

Clinical teaching cycle

Preparatory theory Laboratory Briefing Clinical practice Debriefing Follow-up evaluation

Clinical teaching type (format)

Bedside teaching

Definition.

Objectives.

Technique.

Clinical teaching methods

Role play

Definition Purpose Types of role play Advantages Disadvantages

Demonstration and redemonstration

Strategies to improve clinical teaching

Definition

Purpose Advantages Disadvantages

THE ART OF CLINICAL TEACHING

OBJECTIVES :

Upon completion of this session, the participants will be able to :

Define the term of teaching

Define the term of the teaching-learning process

Identify purposes of teaching

Discuss levels of teaching

Define the term of clinical teaching

Mention main components of the clinical teaching

Discuss clinical teaching cycle

Apply microskills for clinical teaching

Enumerate factors affecting on clinical teaching

Discuss clinical teaching type

List methods of clinical teaching

Enumerate advantages and disadvantages of each methods

Identify strategies to improve clinical teaching

OBJECTIVES : cot…

THE ART OF CLINICAL TEACHING

IntroductionEffective clinical learning is a major objective in preparing professional nurses for the health care services.

The shift of nursing education into tertiary institutions provides new opportunities for planned clinical programs and new challenges for teachers and researchers.

Definition of teaching-learning process

The teaching-learning process is a human

transaction involving the teacher, learner and

learning group in a set of dynamic

interrelationships.

Clinical teaching

Is an interaction between teacher and student under

the teacher responsibility in order to bring about

expected change in student knowledge, skills and

attitudes and preparing students to integrate

previously acquired basic science information with

performance-oriented skills and competencies

associated with the diagnosis, treatment, and care of

patients.

Clinical teaching

Is defined as acting and interacting with

students and and other health professionals in

setting where people are in need of health care

to promote both the maximum learning of the

students and the maximum health of clients.

propose of clinical teaching Facilitate learning.

Help student to acquire, retain and be able to use

knowledge.

Help student to understand, analyze, evaluate and

achieve skills.

Help student to establish new habits.

Help student to develop attitudes.

Goals Of Clinical Teaching

Skill acquisition.

Integration of theory and practice.

Application of problem solving skills.

Development of interpersonal skills.

Socialization of formal and informal norms of the

profession.

Exposure to the socio political health care arena

Provides the students with the opportunity to

translate basic theoretical knowledge into

practice.

Levels of teaching

Cognitive …….acquiring information.

Affective ….. incorporating values, feelings and

beliefs

Psychomotor ….. learning motor skills through

Controlled neuromuscular movements through

practice. -.

Main components of the clinical teaching

Teacher (clinical teacher)

Student (learner)

Clinical teaching setting

Clinical teaching environment

Course skills or procedure that will be learning

A) Clinical teacher Clinical teacher must combine the skills of theoretician

and clinician. Integrate theory and practice:

Responsibilities of clinical instructor

• Expectation about students previous knowledge

• and ability and the level of outcome.

• Finding space for clinical experience.

• Determining objectives for clinical experience.

• Diagnosing individual students learning needs,

• planning, clinical rotation and schedules.

• Selecting learning experiences.

• Demonstrating professional skills.

• Communicating with agency staff.

• Evaluating learning experiences.

• Providing and facilitating student learning.

• Choosing of course content and assessment.

Responsibilities of the clinical supervisorsManager: planning and organizing.

Instructor: demonstrating, presenting ideas,

questioning and guiding problem-solving.

Observer: systematically viewing and recording

accurate data on performance of student in clinical

setting.

Feedback: to assess student progress.

Evaluator: making sound judgments about the level

of students development

Teachers behaviors reported by nursing students in a clinical setting.

a)Behaviors helpful to learning (positive learning behavior).

b)Behaviors which hinder learning (negative learning behavior).

Demonstrating willingness to answer questions and explain. Being interested in students and respectful to them. Encouraging. Informing of progress. Displaying a sense of humor. Pleasant voice. Available when needed. Appropriate amount of supervision. Displaying confidence in themselves and in the students.

a)Behaviors helpful to learning (positive learning behavior)

b) Behaviors which hinder learning (negative learning behavior)

• Threat.

• Being sarcastic.

• Acting in superior manner.

• Be letting students.

• Correcting them in front of others.

Clinical teacher’s qualities

• Willingness to admit to errors.• Enthusiasm.

• Cheerfulness.. • Control of anger.

• Honesty. • Sense of humor.

• Calmness. • Lack of annoying mannerisms.

• Patience. • Neat appearance.

• Flexibility. • Good communication skills.

B) Learners (students) Learners progress though four levels of sophistication

as they learn new skills (personnel journal, 2005).

Teachers must be aware of the level of sophistication at which a learner is currently functioning and match

their teaching to that level.

The four levels of understanding through which learners pas in becoming competent practitioners

of a skill are:

Level .1. unconsciously incompetentLevel .2. consciously incompetent Level .3. consciously competentLevel .4. unconsciously competent

Most learners start at Level 1, where they do not even know what they do not know.

Most teachers are at level 4, where they can “do it in their sleep.

For example: In teaching student, who is unconsciously incompetent how to draw a venous blood specimen

…….

the teacher would first make the learner aware of the: *Technique’s existence .

*The equipment required . *The indications and contraindications .

The learner would then know that he does not know and be Consciously incompetent.

Proper demonstration and practice on models,

fellow learners and patients would allow the learner

to see and perform the procedure correctly, albeit

with hesitation and anxiety, and thus become

Consciously competent.

Hundreds of correct performance later, the learner would be Unconsciously competent.

Introductory phase (“See One”): State the objective of the skill teaching about what to be done, and the specific performance that is expected at the conclusion of the teaching. “The purpose of this session is to teach you how to perform a venipuncture for the obtaining of laboratory blood specimens, and I expect you to perform one veinpuncture satisfactorily at the conclusion of the session.”

Explain the rationale and importance of the skill. “Venipuncture is a common procedure done in

hospitals and offices, and you will be frequently as medical students to obtain blood for various laboratory tests.”

In moving from level 1 to level 4, the learner moves through three phases:

Present a description of the necessary equipment and materials and an overview of the skill’s basic sequential steps.

“The equipment necessary to perform a venipuncture is shown here… The first step is to select a site of venous access, such as the antecubital fossa…”

Explain how each sequential step is done.

“The next step is to apply a tourniquet on the upper arm, using this rubber strap or a blood pressure cuff inflated to a pressure between the diastolic and systolic pressure.

Demonstrate the entire skill, using the technique of either backward chaining or

forward lengthening. “The last step, which I’m performing

now, is to apply an absorbent gauze or cotton ball to the site and flex the

elbow so as to achieve hemostasis.”

N.B.: The learner has now progressed to level 2, consciously incompetent, and can proceed to the practice phase.

Practice phase (“Do One”):

Give specific instructions on what to practice and how. I’d like you to begin by choosing a partner, laying out your equipment, and demonstrating to me the vein you will be using for this venipuncture.

Observe and practice closely and give frequent brief promptings about how the learner is doing. “The arm should be more extended and the tourniquet a bit tighter.” Provide generous quantities of feedback generated by the learner, his peers and the instructor (in that order). “Tell me how you think you did in explaining to the patient what you were about to do.”

Allow a period of independent practice time. I’ll be out of the room for about 15 minutes and want each of you to perform a complete venipuncture by the time I get back.”

Certify each student on the entire skill. “Over the next two days, each of you should come and get me to watch you do an entire venipuncture.”

N.B.: The student has now progressed to level 3, consciously competent, and can move on to the perfecting phase.

Perfecting phase (“Do One More”) Provide precision practice under realistic stress

situations. “During the next four weeks of your clerkship, I want you to perform 10 venipunctures needed by your ward team.”

Prompt and give feedback only rarely. “The last three venipunctures you did seemed to go quite well. I noticed this time that you seemed a bit unsteady in collecting the second tube of blood.”

N.B.: The student has now progressed to level 4, unconsciously competent, and is able to “teach one.”

Clinical teaching setting Definition:

Is the setting in which the various aspects of clinical learning take place.

Is the setting which the students can apply the principles of nursing to the client, so develop competence in nursing practice.

Clinical teaching setting:

The college laboratory:

Prepared to simulate real clinical settings, appropriatefor gaining competence in managing parts of the total

practice role.

Clinical laboratory:

In which student, teacher and patient interaction occur.

Characteristics of a satisfactory clinical teaching setting:

Commitment by heath authority to:

Provision of good health care.

Meeting requirements of clinical experience.

Providing adequate teaching and supervision by appropriately

qualified staff.

Providing opportunities for continuing professional education.

Making adequate financial provision for maintenance of standards.

Successful partnership between education and service.

Training area must offer a good climate for learning.

There should be a nursing-education center equipped to

enable students and teacher to learn and work together.

The number of teaching staff provides an acceptable

teacher-student ratio.

Clinical teaching environment:

The environment also impact the ability to learn. One of the nurses major tasks is to manipulate environmental conditions to facilitate learning.

Ideal environment for learning is a room that is:

Well light,

Has good ventilation,

Appropriate furniture,

A comfortable temperature.

Course (skills or procedure that will be learned)

For example:

In teaching a student, how to draw a venous blood

specimen, the teacher would first make the learner aware

of the technique's existence, the equipment required and

the indications and contraindications.

Clinical teaching cycle

Preparatory theorya

Clinical practice

Follow-up evaluation

Laboratory

Debriefing Briefing

The step 1 is :

Clinical learning cycle begins with the major principles

And concepts thought in the theoretical program.

Motor skills have an essential part in the

procedural knowledge which is knowledge about

how to do things.

Preparatory Theory

The step 2 is:

Learning in the laboratory provides learner with near

real experience using equipments, Materials,

procedures, situations that will be found in the actual

clinical practice sitting.

Laboratory

Purpose of the laboratory learning includes assisting students to:

Understand, test and use major concepts from the

theoretical program for application to clinical practice.

Develop skills, practical, intellectual and attitudinal as a

preparation for the care of clients.

Discover principles and develop insights through practical

exercise which aim to apply basic sciences to nursing

practice.

Increasing motivation for learning in the lab.

Making the demonstration relevant:

Drawing on students’ interests and past

experiences.

Challenging their possible achievement.

Including ways students can feel

personally involved and rewarded.

Building expectancy: Building confidence.

Emphasizing positive expectancies.

Making criteria for successful performance clear.

Increasing opportunities for experiencing success.

Facilitating satisfaction:

Rewarding interesting practice performance.

Provide unexpected rewards.

Briefing The step 3 :

Preparing students for clinical practice

Purposes of the briefing session To provide direction for learning for the day.

To recognize the scope and limitations of the nurse’s

role.

To reinforce “process” learning, for example,

problem-solving, application of knowledge, and use of

judgment.

The Step 4

Learning through clinical practice

A clinical area is a social setting with its own norms, values and group phenomena help the student undergoes the process of socialization into nursing.

Clinical sitting is regarded as the reality aspect of nursing education.

Clinical Practice

Debriefing The step 5 is:Debriefing and reflecting on practice.

Debriefing can also address accountability for the

standard of the student’s and your own

performance.

•Feed back is given to the students on practice to be

corrected and improvement to be implemented.

• Is a follow-up and of the student’s performance to

see whether clinical objectives had been met.

This the final step 6 :

Evaluation is described as continuous process

based on criteria cooperatively developed that is

concerned with measurement of the learners

performance.

Follow up and Evaluation

There are four fundamental objectives of any bedside teaching interaction Base all teaching on data generated by or about the

patient.

Conduct bedside rounds with respect for the

patient’s comfort and dignity.

Use bedside teaching particularly for teaching psychomotor skills.

Use every opportunity in bedside teaching to provide feedback to learners.

Clinical teaching type (format)

Bed side teaching

In essentially all cases, teaching should focus on History.

Physical examination findings.

Psychomotor skills being taught.

Should be used as an opportunity to

demonstrate appropriate methods of patient

interaction and consideration for the

psychosocial aspects of patient care.

the skills include the usual diagnostic and

therapeutic procedures , also include physical

examination skills and medical problem

solving skills. Evaluation by the teacher of the learner Giving of

feedback,

both positive and negative, a critical

part of the bedside teacher’s job.

Feedback has both formative and summative purposes,

and both have value at the bedside.

Clinical teaching methods

• Role play.

• Demonstration and return demonstration.

Role Play

Definition :

• Role play is a creative teaching strategy that

allows the person to learn new behaviors and

problem solve.

• Role playing is an exercise in which the

students act the parts of different people and

so begin to experience some of the feelings of

these people.

Role play is a teaching strategy is a problem

solving technique in which students are asked to

act out a role, one that they would not be normally

be in.

Role playing in practice asks students to act as

they would imagine the person would in order to

increase the class’ understanding of that role or the

problem presented.

Purposes of role play • Role play an excellent technique for diagnosis of readiness.

• A good technique for teaching ideas and attitudes.

• Role-playing learns how to interact with different clients in a variety of situation.

• Provides a kind of behavioral and mental rehearsal.

• Role-playing is often constructive for clients with mental health problems or with chronic, irreversible disease.

• Role-playing is a good technique for developing verbal power.

• Through role play a person is taught the skills required and made more confident in carrying it out.

• Help learners see and understand a problem through the eyes of others.

•Role-playing allows students to experience a situation from more than one vantage point.

Advantages of role play • Add realism to training courses, which are of

necessary often theoretical.

• Provides a common basis for a group discussion.

• Are inexpensive to stage and prepare.

• Allow participants to experiment with various

types of behavior in a laboratory setting, where

mistakes can serve as a learning experience

without the risks of real life.

• Can be used in conjunction with the other

techniques.

• The exercise could be fairly simple to practice.

• Can address difficult topics and the affective

domain

• Can act out feelings without reprisals.

• Interesting and entertaining.

• Should not be used with groups of more than about 25 students to give chance for all students in the discussion at the end.

• Allow students to develop an understanding of others’ perspectives.

• Role playing has the potential for bridging the gap between understanding and feeling.

• Encourages students to work with others in analyzing situations and developing workable solutions.

• Provides students an opportunity to apply concepts they have learned in a rich, realistic environment.

• It encourages thinking and creativity and create the motivation.

• Students become more comfortable with expressing their opinions.

• Provides rapid feedback on the actions of participants.

Disadvantages of role play

• The teacher’s objective can be easily abused.

• Participants can be embarrassed personally and professionally.

•There is also a potential for psychological and

emotional damage if not handled with sensitivity,

care, and concern.

• May become repetitive.

•Are more time consuming than other methods of

training.

• Requires established trust and confidence of the

participants in the trainer.

•Students may fail to imitate the correct role.

• Participants may not take the activity seriously.

• Participants may be uncomfortable in their roles

and therefore are unable to develop the roles

sufficiently.

Demonstration and return demonstration

Definition of demonstration

Demonstration is a method by which the learner is shown by the teacher how to perform a particular skill.

Prior to giving a demonstration, learners should be informed of the purpose of the procedure, the sequential steps involved, the equipment being used and the actions expected to them.

Equipment should be tested beforehand to ensure that it is complete and in working order.

Definition of return demonstration

Return demonstration is a method by which the learner attempts to perform the skill with cues

from the teachers as needed.

Purpose of demonstration and return demonstration o REdemonstration is important for presenting and reinforcing information.o Enhancing recall. o To show the learner why certain things occur. o To show the learner how to perform certain psychomotor skills.

Advantages of demonstration and return demonstration

• Can serve to teach the scientific method.

• Usually high interest level.

• Reinforce theoretical aspects of a topic.

• Demonstrations are often be remembered for a long time.

• The student receive feedback about how well they are using the skill.

• Improving skills.

o Student interest is usually very high.

o The demonstration is often the only way of conveying the complex operations required in some skilled tasks.

o Effective in teaching psychomotor domain skills.

o Enhance cognitive and affective learning.

o Actively engage the leaner through stimulation of multiple visual, auditory and tactile senses.

Disadvantages of demonstration and return demonstration • Can be costly because of the necessity of keeping

the size of the group small and the need for

individual supervision during follow-up practices.

• Setting up demonstrations is very time consuming.

• Require special equipment.

• Outcomes can be unpredictable.

• Ineffective when used with large number of

students.

• A passive activity for learners, whose role is to

observe the teacher presenting an exact performance

of the required skill.

•Teacher presenting an exact performance of the

required skill.

Strategies to improve clinical teaching With a little bit of planning, it is possible to integrate

an enthusiastic student into your practice in an efficient manner.

Make a daily plan with your student.

Negotiate mini-goals for the day or half day.

Pick specific skills to practice or observe (i.e. conduct patient interviews).

Begin with skills the student has already learned. After observing the preceptor a few times, your student might conduct a medical history under your observation or alone and then make a presentation to you.

- Review your schedule.

Identify specific patients that may be best for

student learning.

Limit the number of patients the student sees

in a day.

- Let students do some patient teaching.

Once you’ve assessed your student’s knowledge

level, let him/her do some patient teaching. Have them go over pre-printed educational

handouts; educational for both student and patient.

- Students love the technical aspects of care

Let them assist in simple procedures (toenail removals, wart removals; draining).

- When everyone is comfortable, teach with the patient present

Listen to the student presentation in front of the patient. Encourage the patient to give feedback, too.

- Non-direct patient care tips

Let them look up a disease process that will likely

present or has presented in the clinic.

Let them learn how to fill out lab slips

- Set up time with willing colleagues who might have different practice styles than you or different

specialties: (OR, ER, OB).

THANK YOU