Lesson 1: Student Learningin the Clinical Goals

Setting •Learning for understanding

•Recognizing relationships
The Three Roles of the
BaccalaureateGeneralist Nurse (AACN, 2008) How to Learn
-Provider of direct and indirect care •Learning how to learn as opposed to learning
-Designer, manager, coordinator of care information
-Member of a profession •Three ways to take in information
•In a way that it is meaningless to us,
The Most Predictive Indicators of Learning •In a misleading way, and
Outcomes •In a way that leads us to important
•Three environmental factors knowledge through which we can
●​ Interaction among students acquire knowledge and insight (Paul &
●​ Interaction between students and faculty Elder, 2011)
(Astin, 1991) •Discover and process new information in new
●​ -Interaction between and among students ways
and staff nurses, and other facility staff •Discover models and resources that work best
for you
Barriers to Learning
Barriers to Learning in the Clinical Setting Adult Learners
•High student to faculty ratios •Adult learners are capable decision makers
•Increasing patient acuity whoneed to be active participants in the learning
•Student anxiety process.
•Faculty concerns about patient safety •Interactive Learning
•Limited number of clinical sites •Adult learners construct knowledge by
•Lack of variety of patients linkingconcepts together in meaningful ways
based on former learning and life experiences.
Anxiety and Learning
•Unsure of faculty expectations How People Learn
•Classroom instructor vs. •Four primary processes
•Clinical instructor •Wanting to learn: motivation
Unsure of staff nurses expectations •Learning by doing: trial and error
•Instructors vs. •Learning from feedback: others'
•Staff nurses comments;seeing the results
•The climate of the environment affects learning. •Digesting: making sense of what has
•Clarify expectations beenlearned (Race, 1994)
•Create a learning environment where students
can thrive How do you learn best?
•Acknowledge anxiety and explore why it •How do you learn new concepts?
exists •How do you learn about caring for a patient with
•Be open and approachable an unfamiliar diagnosis?
•How are you learning about the clinical instructor
When and How People Learn role?
Learning •How do you function/adapt when you are
•Experts' abilities to think and solve problems reassigned to another unit?
depend strongly on a rich body of knowledge
about subject matter. (Bransford, et al., 2004)" Learning Styles
•Learning is the process whereby knowledge is •Students have different methods of learning.
created through the transformation of •IDEAL: develop activities and materials that draw
experience." (Kolb, 1984) on abilities from each student.
•Application and usefulness of information is
increased by understanding detailed information
about the system's operation. (Kolb, 1984)
Application of Knowledge to Practice •IWhat would happen if I did this?
•What should students be addressing in clinical? •I What is there to know?
•Must we supervise skill performance every time? •IHow is this relevant?
•Are we valuing the thinking work when •IWhy is this relevant?
focusedon skills?
Team Learning
Critical Thinking •Create a realistic learning situation.
•More than one patient
Cognitive skills •Follow and assist an RN with a full load
•Information seeking •Manage a care team.
•Discriminating •Pair an advanced and beginner student.
•Analyzing •Interprofessional clinical learning: pair with
•Transforming knowledge OT/PT/dietitian, etc. (Hendricks, 2014)
•Predicting •Explore new strategies to facilitate learning.
•Applying standards
•Logical reasoning Learning Activities - Pick a Card
•Create questions that would be relevant to any
Affective skills clinical.
•Perseverance •Distribute question cards to students in
•Open-mindedness advance so they will know how the activity works.
•Flexibility •During post conference or other time, students
•Confidence pick a card and respond. (Hendricks, 2014)
•Creativity
•Reflection Stacking Clinical Activity
•Intuition •Create a practice patient assignment.
•Inquisitiveness •Create a list of 4-5 patients on the unit.
•Intellectual integrity •Have the students create a plan for
•Contextual awareness delegation: tasks/why.
•Perspective •Have some things that can interfere with
their plan: how would they change the
Clinical Reasoning plan?
•Critical Thinking leads to… •When would an activity like this make sense?
•Clinical Reasoning which
•"requires practical ability to discern the Practices for ClinicalEducators
relevance of the evidence behind general Strengths and Weaknesses of
scientific and technical knowledge and FacultyTeaching Performance - Wolf, et al.,
how it applies to a particular 2004
patient"(Benner, et al., p.4).
•"is determining the best course of action Strengths
to take based on what is known or what •Being a knowledgeable and štrategic teacher
can be hypothesized from clinical data" •Creating a positive learning environment
•Demonştrating professionalism
Reasoning Skills to Improve Patient Outcomes •Demonstrating positive personal traits
•Thinking is clarified when reasoning skills are •Displaying scholarly traits
used to figure out: •Being supportive
•What is wrong
•What is right Weaknesses
•What could have caused the problem •Providing poor delivery of content
•Thinking through: •Acting disorganized Being inaccessible
•Different options •Displaying weak teaching škill
•Weighing each option •Being dishonorable
•Exhibiting unprofessionalbehavior
Questions from Learners •Displaying negative personal traits
 •Why was it important to intervene?
Best practices for clinical faculty •How did I determine the priorities?
•Communicate high expectations •What would I do differently in the future, after
•Provide feedback reflecting on this situation?
•Be a coach •We are all learning!
•Facilitate reflection
•Increases self-awareness
• Reflection is critical for learning, decision
making process, feelings, values, etc.
•Reflective activities

Specific clinical learning techniques

•Encourage independent discovery
•Facilitate active participation
•Encourage questioning and thinking through
the question.
•How will this question help the patient?
•How will this question help the student?
•Who should answer the question?

Encourage Students to
•Practice critical thinking and clinical
reasoningintentionally.
•Develop reflective practice.
•Reflect on their learning experiences.
•Study to understand and apply, not to memorize.

Reflection is critical
"In all classrooms, even in the hard sciences,
professors use stories, usually in the form of
anecdotes,to illustrate points, to elucidate
information that may beabstract. Story, especially
personal story, is one of the most powerful ways
to educate (p. 56)."

Reflection Activities
•Ask questions that help students analyze the
story for what they learned about caring for the
patient but also about themselves. They must
reflect on and think about their day, their personal
story.
• Why did they make the decisions they did?
•Why was it important to intervene?
•How did I determine the priorities?
•What would I do differently in the future, after
reflecting on this situation?

Personal Reflection
•Ask questions of yourself that help you to
analyze your personal "teaching stories."
•You must reflect on your day and your story. Ask
yourself some of the same questions.
•Why did I make the decisions I made?
Lesson 2: Customer Service in the •NRC Picker
Ambulatory Setting •Clinic Pulse Surveys

University of Missouri Health Care Clinic Press Ganey

System •28 Questions
•51 Outpatient Clinics-Primary Care and Specialty •Some Questions not Relevant
Care •Low Response Rates
•600,000 Clinic Visits Annually •Timeliness of Results
•400+ Physicians-Mix of Full and Part Time •User Friendly
Faculty •CG-CAHPS
•585 Clinic Staff
•Clinics Reviewable by Centers for Medicare and NRC Picker
Medicaid Services (CMS) and The Joint •Guaranteed Response Rate
Commission Web-based
•Clinic Management Model Requires •Timely Results
Collaboration between Hospitals, School of •Custom Reports
Medicine, and University Physicians Practice Plan •Stoplight Reporting
•Sample Action Steps for each Question
Customer Service in UMHC Clinics •Shared Action Planning
•History as a Teacher
•Who Owns Customer Service? Clinic Pulse Survey
•Getting Organized •Simple and Brief-2 Questions
•Buy-In •Timely Results-ARC
•Voice of the Customer •High Response Rate
•Rapid Action Planning
Why Focus On Customer Service? •Inexpensive
•Competition
•Revenue and Finance The Good, The Bad, and The Ugly
•CG-CAHPS •Examples of Less Than Desirable Practices
•Reputation/Marketing •Examples of "Works in Progress"
•Most Important..."It's the Right Thing to Do" •Examples of Great Successes

Core Components of Customer Service Patient Expectations in Clinics

•Leadership •The Visit Through the Eyes of the Patient
•Service Goals and Expectations •Greeting and Welcome
•Responsibility and Accountability •Wait Times-Waiting Room and Exam Room
•Communication •Provider Encounter
•Education •Clinic Environment
•Service Recovery •Technology
•Reinforce Behaviors
•Measure Satisfaction Speaking of Technology...
•Action Planning •Phones and Phone Management
•Smart Phones
Education and Training •Email
•Ritz Carleton Model •Social Media
•Patient and Family Centered Care (PFCC) •Telemedicine
•Clinic Front Desk Training •EMR/HIE
•Interpret Survey Results
•Action Planning-It Takes a Team Patient Portals
•Book Clinic Appointments 24/7
Measurement Tools •View Previous Appointments
•Clinic Free-For-All Surveys •View Lab Results
•Press Ganey Survey-Pluses and Minuses •View Medical Record
•Communicate with Provider
•Receive Appointment Reminders Patient Experience - Our Journey
•Prescription Refill Requests
•Patient Education Material

Strategies For Customer Service to

Improve Patient Satisfaction
•Communication with Patients
•Staff Training and Engagement
•Physician Training
•Other Tools

Communication With Patients

•Appointment Delays-Be Honest and Timely
•Reminders
•Cancellations/Rescheduling
Clinic Pulse Surveys
•Utilize Wait Time
•Question 1: Based on today's visit, I would
•No Surprises-Don't "Blindside" Patients
recommend this practice to family and friends.
•Patients Care about their Care
Options: Strongly Disagree, Disagree, Neutral,
Agree, Strongly Agree
Staff Training and Engagement
•Question 2: What, if anything, could have been
•Patient Satisfaction-Incorporate into
improved today? Options: No Problems,
Performance Evals
Scheduling Appt., Check In/Arrival Process, Care
•Phone "Scripting"
Provider, Lab/X-Ray/Other Service, Nurse, Wait
Phone Etiquette-"Smile over the phone"
Time, Comfort/Cleanliness, Check-out Process
•5/10 Rule
•Survey Period-11/05/12-11/09/12 (5 working
•Body Language
days)
•Manage Up
•Response: 35% of all patients seen completed
•Appropriate Attire and Appearance
survey
•Partner with the Patient
•Be a Resource
Clinic Pulse Surveys
•Mean Score for Q1 for 3517 responses: 4.4
Physician Training
(5=Strongly Agree)
•Review Clinic Schedules/Appointment Access
•Q2 Results:
•Distribute and Review Physician-Specific Patient
No Problems=2946
Satisfaction Scores
Scheduling=64
•PFCC for Physicians-Mandatory
1.No Problems=2946
•Incorporate Patient Satisfaction into Incentive
2.Scheduling=64
Plans
3. Check In/Arrival=87
4. Care Provider=36
Other Tools
5. Lab/X-Ray/Other=23
•Communication Boards in Clinics
6. Nurse=22
•Share Best Practice in Clinic Staff Meetings
7. Wait Time=351
•Do Follow-Up Phone Calls
8. Comfort/Cleanliness=52
•Review Clinic Space for Best Workflow
9. Check-out=36
•Clinic Environment-Art, PCs, Clean, and Safe
•Stand Behind Your "Brand"
•Rounding For Outcomes
•Innovate

Results
•NRC Picker
•Pulse Surveys
Lesson 3: Teaching in the Ambulatory Setting Figure 1 Model Schedule

Goals
•To identify and improve upon existing skills in
ambulatory education
•To identify key factors which improve efficiency
and effectiveness in ambulatory education

Objectives
•Identify key differences between teaching in the
ambulatory v inpatient setting
•Understand the importance of student orientation
•Understand teaching tasks involved in
case-based teaching, observation, and modeling
•Understand the ways to integrate teaching with Traditional Schedule
patient care
•To identify the process of credible feedback

Keys to clinical teaching

•Demonstrate enthusiasm
•Give meaningful (“authentic")
responsibility
•Possess credible clinical skills

Inpatient vs ambulatory education

• Team learning
• Advanced preparation
Orientation and setting expectations
• Educational intimacy
•Understand the student's background and
• Number of examiners
personal goals and objectives
Time/patient pressures
•Explain your vision of the student's role
• Speed of evaluations
•Your teaching and evaluation style
•About the practice
Teaching in the Ambulatory Setting
•Create a positive learning environment
NO
•In depth lectures
Priming the trainee
•Seminars
•Chart review
•Formal educational sessions
•One minute summary of patients hx and areas of
•Extensive discussion
focus
•Allow more efficient use of student/patient time
•Efficient and effective ambulatory care teaching
requires that both the student and preceptor
Overall Curricular Goals Moving the student
accept the limitations of the outpatient setting.
along the curriculum
•Extensive discussions of differential diagnosis,
pathophysiology and psychosocial problems are
not possible nor necessarily desirable

Planning
•Scheduling
•Orienting
•Priming
Teaching Strategies •Provides for brief discussion of learning points
1. The "one-minute" preceptor after observation
2. Modeling
3. The "two-minute"observation Overview of student-patientpreceptor
encounter
Teaching Strategies The One-Minute •Orient student to each patient encounter
Preceptor - Brief overview to each patient encounter
1. Get a commitment - Recommendations for time and extent of
2. Probe for supporting evidence exam to perform
3. Teach general rules --Take each encounter to a •Student sees patient independently
learning point •Student presents in front of patient
4. Provide feedback --Positive --Corrective •One minute preceptor
•Student can demonstrate part of PE, preceptor
Presentation in front of patient can model certain skills
•Saves time
•Reinforces the student's role Tasks a student may be able to do
• Reassures the patient "Service-based education"
Caution student to alert you beforehand if • Patient counseling
sensitive HX/PE info present or if they are • Charting/dictating
considering a potentially serious Dx • Lab/x-ray retrieval .
• Follow-up phone calls
Pitfalls in clinical case based teaching • Looking up articles/info (eg Medline)
• Taking over the case .
• Inappropriate lectures LEVELS OF FEEDBACK Level 1: Daily
• Insufficient "wait time" 3 Feedback
-​ -5 second wait to answer your question
• Preprogrammed answers
-​ What do you think is going on? Could it be
gastritis?
•Rapid reward
-​ Effectively ends the student's thinking
process
•Pushing past ability
-​ Persisting in carrying the student beyond
their understanding of what is being asked Characteristics of Credible Feedback
• Formative
Teaching Strategies Two Minute Observation -Based upon direct observation
•Explain the purpose of the observation -Accurately reflects goals mutually understood
• Explains how the observation will occur -Reliably occurs (expected)
•Informs patient of what will take place -Development of plan for improvement
•Observes without interrupting - Well timed
•Leaves room without disrupting the student - Allows time for improvement
•Provides feedback
•Agenda for future learning Diagnosing the learner

Teaching Strategies Modeling with trainees

•Determine the student's relevant knowledge
•Identify what the student should learn
•Provide guidelines of what the student should do
during the observation
•Includes student in discussions and examination
of patient
Other opportunities for feedback • Reads deeply and shares new learning with
•Case based presentation others
-​ Diagnosing the learner while diagnosing • Defining important questions to research
patient • Takes drive, insight, skill, maturity, and
•Two-minute observations confidence
-​ HX, PE, Technical procedures,
Educating/Informing patients
-​ Written record
-​ Professional attributes

RIME Evaluation Framework

RIME Evaluation Framework Reporter

•Accurately gather and communicate clinical facts
•Requires basic skill and knowledge of what to
look for
•Recognizes normal v abnormal
•Confidence to identify and label new problems
•Consistency in "bedside" skills, sense of
responsibility
•These skills must be mastered to pass

RIME Evaluation Framework Interpreter

•Prioritize among problems identified in patients
•Offers differential diagnosis (at least three)
•Follow-up of tests and their interpretations
•Selecting clinical findings which support possible
Dxs and applying test results to specific patients
•Transitions from "bystander" to active participant
in patient care

RIME Evaluation Framework Manager

•Deciding when action needs to be taken
•Propose and select among at least three
diagnostic and therapeutic options for the patient
•Take into account particular patient's
circumstances and preferences
•Requires more confidence, knowledge, and
judgment

RIME Evaluation Framework Educator

• Mastery of the basics .
• Self-directed learning
Lesson 4: Small Group Teaching in a Clinical Choose teaching techniques that will promote
Setting the learning objectives
(Lecture ≠ critical thinking)
Small Group Clinical Teaching
• Teaching goals and objectives Teacher-centered learning VS
• Types of clinical teaching . Student-centered learning
• Your role in creating the learning environment
and motivating students Student-centered learning promotes
• Student evaluation development of:
• Critical thinking
Goal of Clinical Teaching • Independent, lifelong learning
Produce competent veterinarians who are critical • Communication skills
thinkers and can function independently • Teamwork skills

Determining Learning Objectives Teaching Opportunities in the Clinic

•Preparation for entry-level practice • Rounds
•Consider your course in the context of the whole -Topic rounds
curriculum -Case rounds
•What has been covered previously? •One-on-one over cases
-​ Hold the students accountable •Daily interactions
•Cannot "cover" all content in your area - Role modeling
•What is relevant to the goal of entry-level
competency? Topic Rounds vs Case Rounds
•Identify key content in your discipline • Topic rounds .
•Focus on application of knowledge - Good way to consistently address specific
•Focus on the overarching competencies content in each rotation
- History-taking Physical examination skills -Can become a teacher-centered lecture
-Identifying problems, DDx list • Case rounds
-Dx work-up, interpretation -Patient a vehicle for exploring many different
- Formulating treatment plans aspects of case management - relevant
-Communications with clients, staff -Easier to promote application of knowledge
•Promote critical thinking, decision-making -Housekeeping vs teaching rounds
•Instill the behavior of lifelong learning
•Facilitate the transition to being the doctor Rounds
- Active involvement •Avoid telling them everything in the book but
-Accept responsibility share your clinical expertise
-Create opportunities for students to be the doctor •Discuss alternative case management strategies
and decision-making
Define Expectations •Discuss financial/business aspects
•Don't assume that students know what you -​ Critical to success in practice
expect •Encourage active discussion
•Clearly articulate your expectations
- Behavior, attire Learning Environment
- Preparation Participation •The learning environment has a profound effect
- Procedural protocols on student learning
-What to do in case of illness, personal problem •Learning environments that are positive and
•Communicate the learning objectives to the supportive promote learning
students •Your attitude and behavior have a profound
•Help the students set realistic expectations effect on the learning environment and student
•Involve the students--ask them what their goals motivation
are for the rotation
The Ideal Learning Environment
• Safe
• Low stress Avoid Bias
• Encouraging • Try not to let pre-conceived perceptions about a
• Fun particular student's abilities or performance affect
• Allows practice your expectations of that student
• Accessible • Each rotation should start with a clean slate
• Allows mistakes—low risk
Provides immediate feedback Challenge your students…
...but show them how to succeed
Create a safe learning environment Students need to believe the goals are attainable
• Clearly articulate expectations
• Be consistent
• Be fair
• Be understanding when appropriate
-​ Allow extension on medical records when
no sleep due to emergency
• Encourage questions
• Encourage students to take risks
-Cheerleader-"You can do it!"
- Protect patients from serious mistakes
• Encourage teamwork
Maintaining standards is critical
Foster teamwork • Set high standards
We are on the same team with the same goal We • Clearly articulate your expectations
want them to succeed • Be consistent in enforcing standards

Make learning FUN! Refrain from giving students the answers

Engage the students! •Give students the opportunity to figure out the
answers themselves
Respect students' time •Encourage students to become independent
•Follow through with time commitments learners
-​ Rounds start at 8:15 a.m.
• Make discussions relevant Questioning can bе an effective teaching tool
•Be cognizant of students' other responsibilities •Give students the time to answer
-​ Fatigue •Avoid embarrassing or belittling students
-​ Time of day •Know when to stop questioning
-​ Offer to help
Challenges to Clinical Teaching
Show that you care • Limited control over schedule
•Show genuine concern for each student and • Caseload unpredictable
he/she will put forth greater effort • Emergencies
• Treat students as individuals • Client demands
• Be compassionate • Dependence on others
•Respect your students
•Treat each student fairly and equally Challenges to Clinical Teaching
•Invite questions •Multiple groups of students with differing needs
•Listen to student feedback -Veterinary students (some with different
educational backgrounds)
Mutual trust is critical in the student-teacher -Interns
relationship. -Residents
Treat your weakest student as you treat your •Concurrent demands on your time
best student -​ Meetings, lectures, labs

Expect them to succeed!

Try to protect some time every day when 3 Keys to Motivating Students to Learn
teaching is the priority • Enthusiasm
• Show you care
Student Evaluation • Encouragement
Evaluation methods drive the learning
process Match the evaluation process to the Clinical Teaching Y
learning objectives •You can have a profound effect on the learning
experience
Provide Feedback •Respect students and empower them to be the
•Timely doctor
•Specific, concrete examples -​ Include students in case discussions
•Provide appropriate positive feedback -​ Minimize busy-work
•Be honest •Encourage critical thinking and independent
•Specific suggestions for improvement decision-making

Effective feedback builds students' The Continuum

confidence
•Improperly delivered feedback can destroy
students' selfconfidence
•Too much feedback can be overwhelming

Giving feedback in the group setting

•Treat all students equally
•Do not embarrass students
•Provide compliments as well as suggestions for
improvement
•Feedback should be constructive rather than
punitive
•Admit your mistakes

Importance of Feedback
•Feedback drives learning
•Give feedback on non-technical skills as well as
technical skills and knowledge
•Students need to know how they are perceived
•We need to help students learn how to
accurately self-asses

Documentation
•Clinical grading is largely subjective
•Document in writing feedback that you provide to
students, particularly if student is failing
-​ Helpful to student
-​ Evidence to defend grade appeal
• Warn students of unsatisfactory performance
with sufficient time for them to improve

What are my responsibilities as a teacher?

•Be prepared
•Be organized
•Be accurate
•Be a positive role model .
•Provide feedback
Lesson 5:Teaching in the Inpatient Setting •Get to the bedside!

Characteristics of Good Teachers Give Feedback

•Enthusiastic • Let your team know what they are doing well
•Ask Questions and where they can improve
•Nonthreatening •Feedback is absolutely crucial for improvement
•Promote self learning
•Recognize the needs of the learner Pitfalls in Clinical Teaching
•Knowledgable • Taking over the patient
• Inappropriate lecturing
Inpatient vs Ambulatory Education • Insufficient "wait time" on questions
•Team Learning • Leading questions
•Time for Advanced Preparation -"Could this be a PE?"
•Number of Learners • Pushing Past Ability
•Less time/patient pressures
•Speed of evaluations Teacher Reasoning and Action
•Educational intimacy • Diagnose the Patient
• Diagnose the Learner
Orient Your Team 1. Get a commitment
•Outline Expectations 2. Probe for evidence
•Assess their needs • Teach
•Organize the month Teach general rules. Provide
•Assign responsibilities feedback. Correct mistakes.
•Explain your teaching and evaluation
Style

Role Model
•Be professional
•Have a good attitude
•Be on time
•Pitch in/lead from the front
•Treat everyone with respect

Create a Good Learning Environment

•Show enthusiasm
•Involve your learners
•Be friendly
•Be consistent
•Ask questions in a non-threatening way

Put Forth an Effort

•Take the time to teach!
•Give assignments when things are busy
•Get to the bedside

Teach What You Know/ What the learners

need
•Students need to know how to present, how to
write orders, how to examine patients, how to
read EKGs, how to replace K+, where the
bathroom is, etc.
•Recognize that different levels of learners will
benefit from the same discussion