Presentation Transcript

1. The Art and Science of Precepting Gail M. Whitelaw, Ph.D. The Ohio State University whitelaw.1@osu.edu
2. Ideas for the session List the key “players” and factors in developing a precepting relationship Describe principles of adult learning and how these impact the clinical teaching/learning process Assess their skills and motivation toward precepting and how these factors influence the precepting process Discuss key components of mentoring and how these concepts influence the clinical education process Provide specific feedback in the precepting process Discuss a process for addressing challenging situations in precepting Understand “requirements” for precepting
3. Most importantly… Provide tools for precepting Stimulate thinking on the topic Later in the presentation, we will talk about adult learning…will ask that if you have your computer, smart phone, or iPad with you, you “play along”
4. Precepting overview
5. The clinic as the classroom: one-to-one teaching One of the most powerful ways of “influencing students” Creating opportunities for active learning in authentic clincail settings Opportunities for modeling professional (and perhaps personal) attributes (Gordon, 2003)
6. Preceptors serve as “gatekeepers” of the profession because they are responsible for training the next generation of professionals, while balancing their commitment to patients. Additionally, a preceptor is responsible to deem whether the abilities of students are “passable” for entry into the profession; those who are not ready do not proceed to professional practice.Rao & DeRuiter (2012)
7. However, good precepting is broader than being “just” a gatekeeper. It a foundation for a profession, part of our “corporate" culture
8. Patient outcomes can be improved in the precepting process
9. Supervision vs. Precepting A transformation or merely antics with semantics?
10. Supervision Historically, the focus was supervision, defined as “critical watching and directing” Supervisor was required to have a specific certificate, a specified number of years of expereience, oversee the clinical experience, often by providing a specified number of hours in specified areas, and required to observe during a specified number of times/amount of time Prescribed role and expectations Focus on “clinical training” Learning may be classified as “passive” Whitelaw (2012); Newman, Sandridge, and Lesner (2011)
11. Precepting Focus on the development of broad-based critical thinking skills required for the profession of audiology Development of knowledge and skill as guided by the preceptor, which is defined as “expert or specialist who gives practical experience” Predicated on active learning Preceptors have a broader role than supervision, one-on-one learning in the triad of student-preceptor-patient
12. Mentor Counselor who can advocate and support in the professional setting Not usually assigned, such as a preceptor, however a preceptor may also be a mentor Facilitates growth and learning Example: American Board of Audiology “Meet and Greet” at AudiologyNOW Newman, et al, 2011; Rall & Brunner, 2006
13. Clinical placements Recommended terminology (Newman et al, 2011) Internship: Clinical training opportunities provided at the University, such as a University hearing clinic Rotations: Short term clinical training experiences which may be a semester in length; still involved in taking coursework Externships: long-term clinical training experiences that occur outside the University; reserved for what is often called “the 4th year” All under direction of University Avoid terms of practicum, fellowship, etc.
14. Collaborative model (from Newman et al, 2011) The focus is on the patient
15. Relationship with the University “Triangulated model”: Student, University, Preceptor Critical features Expectation Communication Formalized relationship: Contract or affiliation agreement
16. Challenges for preceptors in the triad model Being asked to provide clinical education with no formal “authority” from the University “Virtue is it’s own reward”…what’s in it for the preceptor? Perception that their input is not heard, valued, appreciated Knowing that the University will support the preceptor in decisions and provide help/support when issues arise Lack of training, clear direction, or expectation
17. Challenges for Universities in the triad model Having no formal “authority” over the preceptor…not an employee Finding ways to reward preceptors Assuring that the input of the preceptors are heard and respected Lack of training, clear direction, or expectation: No calibration of precepting skills Addressing the myth that “bad” students are intentionally sent to sites…letting someone else deal with the problem The truth is that the University “vetting” process is not flawless
18. Frank discussion between University and preceptor Discussions should happen prior to establishing affiliation agreements (Newman et al, 2011) Acknowledge “at least” two perspectives Clinical placement site is focused on patient care and service provision University is focused on developing clinical education options that enhance the ability to ensure competence of graduates My own example from last week: Many sites have learned this from “trial and error”
19. Challenges for students in the triad model Imbalance of power Fearful of providing feedback to preceptors or the University regarding their experience Lack of clear direction or expectation Student serves two different roles in clinical setting: Learner and provider of audiology services (Newman et al, 2011) They are a student first and foremost
20. Challenges to patient care Time and money Informed consent Risk (will discuss the “unsafe student” later in the presentation) Relationship building Many others
21. Generational influences This has ALWAYS been true Has been a focus of studies more recently so more data to address this “They are not like us” Understanding generational perspectives can be a strength Technology benefits: Two of our current 4th years… iPad use in patient care New audiometer
22. Generational influences (for more info, see Rall and Brunner, 2006; Newman et al 2011b) Current students are generally “millennials” (born after 1980) Incredible number of positives Tend to ask “why do I need to know this”—not always meant as disrespectful Want to understand relevance of the information One consistent issue is that as a group, then tend to “expect” positive feedback What has been referred to as “everybody gets a trophy” syndrome Preceptors need to find ways to give specific feedback and to always assure to separate person from behavior
23. The “science” of precepting
24. All professions that use a “one-on-one” teaching model face similar questions and challenges Audiology is not unique
25. Evidence based precepting Strongest models from medicine and nursing at this point
26. Common sense: It all starts with expectations Research consistently states that the greatest number of precepting issues are reportedly related to lack of clear understanding of expectation, lack of clear communication of expectations, or mixed signals The issue of thinking everything is fine and finding out after the fact that it’s not
27. Expectations for audiology (Newman et al, 2003) Students should arrive at the externship site with a solid theoretical foundation as well as clinical experiences in at least the basics of audiologic diagnostics and treatment Nascent skills and attitudes should be developing and ready for refinement
28. Expectations for audiology The 10,000 hour expert! The competency ladder: Unconscious incompetent Conscious incompetent Conscious competent Unconscious competent
29. Principles of adult learning
30. Considerations in Adult Learning Active not passive Focus on KSA’s (Knowledge, Skills, and Attitudes) Enhances critical thinking skills skills There is research evidence to indicate that the most effective approach for adult learner is to use demonstration, have the learner practice, then teach someone else The classic “see one, do one, teach one” is actually evidence based
31. Andragogy: adult learning Autonomy Problem-solving Preceptor and student learn together Positive climate for learning Consider Tier I, consider the PASC exam, consider feedback from adult learners Polleverywhere
32. Knowles principles of adult learning Adults are self-directed Experience is a rich resource Adults learn effectively through discussion or problem-solving Learning should be based on “life application”; adults want to know why they are learning something Adults are competency based learners in that they wish to apply new knowledge and skills to immediate circumstances
33. Bloom’s Taxonomy of Learning Helps to look at specific levels and skills Complexity of skills increases; suggests that skills must be mastered prior to moving on to the next level Cognitive domain, psychomotor domain, affective domain Terrific guidance for adult learners Two audiology related articles on this: Newman et al 2011b and Bruggeman, 2006
34. Relationship between existing knowledge and new knowledge How to active existing knowledge “I’ve never heard this before” Bloom’s taxonomy helps to shape understanding this
35. Goals Develop ability of critical reflection Develop desire for lifelong learning Commitment to professionalism (specific to audiology, for example)
36. Preceptor as facilitator Adult learning theory indicates that preceptors are actually best in the role of facilitator Some guidance on facilitating: Decrease learner’s dependency on preceptor over time Help learner understand how to use their resources Assist learning to increase their independence and take greater responsibility for their own learning Learner should formulate their own learning objectives Opportunity for carrying out learning plan should be made available to the learner
37. Preceptor as facilitator Some guidance on facilitating: Use self-reflective types of assessment Student must be involved in their own goal setting, etc. Establish a physical and psychological climate that supports learning A climate of “humanness”
38. What interferes with adult learning? Anxiety Focus on the grade “History”: Low self-esteem, lack of confidence, fear of ridicule or failure Attitude: I know it all, why do I need to listen/try/learn this?
39. Common issues in clinical teaching Lack of objectives and expectations being communicated Focus on factual recall rather than application for problem-solving Clinical teaching “pitched” at wrong level (often too high) Passive participation rather than active learning Teaching by “humiliation” Lack of respect for patient privacy/dignity…they are not a guinea pig Lack of congruence/continuity in the curriculum Spencer, (2003)
40. Ultimately… Adults are responsible for their own learning Why this matters to you as a preceptor: You can’t learn it for them; mistake I’ve made You can provide opportunities, goals, coaching, encouragement Trying multiple approaches may be beneficial
41. Motivation for precepting
42. Considerations Exploring preceptor motivations Self-awareness and self-reflection If any of the answers start with “having an ax to grind”, “going to show them”, or “I was treated like this so this is how I’ll treat students”, not likely to be a successful endeavor Recognizing that many GREAT audiologists are not great clinical educators Much of precepting has a basis in human resource management—a great way to learn but must understand this going in (and more complicated, since in most cases, the student is NOT an employee of the site)
43. The “fondly remembered” preceptor “What qualities did my best preceptors possess?” “What qualities did my less than stellar preceptors possess?” What characteristics about clinicial environments I have been in provide the best opportunity to learn? Do you precept like you were precepted?
44. Other considerations What elements are in place to facilitate accepting students? Are there elements not in place that could be easily implemented? Are there significant barriers? If there are multiple preceptors at the same site, how will the student rotate among them?
45. To thine own self be true: Knowing yourself: The polar opposite student “The introvert” “Be just like me” Personality or leadership inventories Meyers-Briggs, for example
46. Preceptor education An issue in every field that uses a one-on-one precepting model Probably best models are medicine and nursing Research suggests that preceptor education is a critical feature in the foundation of clinical education However, over 70% of AuD programs indicate that they provide no preceptor education or training in a survey conducted by American Academy of Audiology (Roush, 2009)
47. Preceptor education A frequent request to the American Board of Audiology (ABA) is devleopment of precepting certificate Certificate vs. Certification: An important distinction Calibrating precepting/provide a foundation for education and training
48. What’s in it for the preceptor? What may motivate people to take on this role? Many intrinsic rewards Not many extrinsic rewards
49. TOOLS FOR PRECEPTING
50. Tools for precepting Should be efficient, promote mutual feedback, and provide the opportunity for modeling behaviors used in a “real-life” setting Universities may provide their own tools for evaluation, however often based on “summative” assessment (done at the end of specified time period) Tools that focus on “formative” assessment
51. A broader perspective on evaluation: How it can drive audiology education Essential! Focus on “quality improvement” Provides evidence on who well students’ learning objectives are being met Allows programs to assess curriculum (Morrison, 2003) Current issue in the profession of audiology: No standardized “check” points How a “national examination” is utilized by other professions and considerations for audiology
52. For formative assessment to happen… Need frequent opportunities for feedback; concern about how time consuming this may be Should capitalize on self-reflection, which in turn promotes active learning
53. Considerations in precepting Ask the student how comfortable they are with a specific skill: Watch you do it once, review it briefly, perform parts of it Sets expectation Things simple to the preceptor due to their 10,000 hours Students are processing a lot of new information at one time Difficult time separating critical from unimportant Focus on the wrong things Have student focus only on specific skill for a while, while preceptor completes rest of the assessment Pollack & Oshio (University of Washington School of Nursing)
54. Reflection and discussion Need to build in an opportunity for reflection and discussion every day Can be a simple “How did things to today” Can be a more detailed “What was the most challenging thing you encountered today and how did you handle it?”
55. For formative assessment to happen… Using a “SMART” perspective for feedback Specific Measureable Achievable Results-focused (focus on outcomes, not just doing) Time-bound Should impart “actionable” knowledge (Ida Institute: http://idainstitute.com )
56. The One-minute preceptor (Newman, et al. 2011a)
57. SUCCESS method (Teeter, 2005) (particularly useful for addressing a challenging student situation) See it early Understand the student’s perspective Clarify the situation with the student Contract with the student for success Evaluate the student’s progress regularly Sign the summary and look to the future
58. Reflective thinking Addresses “theory-practice” gaps Critical role of self-evaluation is noted consistently in precepting literature A number of tools for developing reflective thinking Reflective Journal tool available from Ida Institute Open ended Student can complete independently for feedback and share with preceptor Focus is NOT just on clinical skill but on clinical communication, which may be a more difficult area to assess
59. Audiology Counseling Growth Checklist (Clark, 2006) Self assessment Specific tool that can used for constructive dialogue
60. Standard/Simulated patients Another opportunity to bridge gap between practice and theory Students who participate in a standard/simulated patient model demonstrate better problem-solving skills, interviewing skills, and interpersonal skills as they provide clinical care compared to students who did not have this opportunity (Beshgetoor et al, 2007) Minimally used in audiology, to date (Whitelaw, 2012) Ida Institute tools
61. Successes and challenges in Precepting
62. Significant benefits Opportunities to teach and influence practice Increase the preceptor’s knowledge base Stimulate one’s own thinking Customize clinical approaches for clinical education and for the patient Stimulate one’s own crtical thinking skills Develop lifelong relationships, “grow” one’s own employees, meet some amazing people The “most productive” person I know!
63. Is there only one way to do it? Challenge your own thinking. “I recognize there are other ways to do this, however this is the method that is acceptable to me, and I would like you to do it this way while you are here” Open minded and can give a little,
64. The “challenging” student Comes with the territory The student who is challenged to meet the “technical standards” of the profession of audiology In the nursing literature, the term “unsafe student” is used Addresses the critical nature of this interaction Described as students “…whose level of clinical practice is questionable in the area of safety or to students with a marked deficits in knowledge and psychomotor skills, motivation, or interpersonal skills” (Luhanga, Yonge, Myrick, 2008) “An occurrence of a pattern of behavior involving acceptable risk” (as cited in Luhanga)
65. Unique situations Mental health issues Social pragmatic issues Can be addressed by the development of strong technical standards for the program, an understanding of accommodations under the Americans with Disabilities Act (ADA), and documentation!!! Can be addressed by addressing clinical education and educaitng University legal staff about the profession of audiology
66. The nature of the “helping profession” Not strong at conflict resolution: confrontation is an issue May want to “therapy-ize” the student Try to “save the day” Issues have to be addressed: If not, they take up time and organizational resources And, venting to others does not resolve the situation!
67. Additional challenges with the challenging student Emotionally draining for everyone involved Often involves legal and ethical considerations Clear policies are required to address this, however research suggests that there are often no clear policies or guidelines for clinical evaluation and a remediation process (Scanlan and colleagues, 2001).
68. All “difficult conversations” have a common structure Based on research from Harvard University Myth of tact and diplomacy makes having these conversations easier Even experienced preceptors, when confronting issues that are “simple” (student arrives late, not dressed appropriately), it’s still a difficult conversation. Delivering this type of information is like “throwing a hand grenade”; no matter how presented, still may cause damage
69. All “difficult conversations” have a common structure Great tool for addressing this: Stone, D., Patton,B., & Heen, S. (2010). Difficult conversations: How to discuss what matters most. New York: Penguin. Based on research from Harvard; described types of situations and approaches for addressing these situations
70. Additional tools Why don’t they do what they know they should do? Rational thinking vs. Emotion Heath, C. & Heath, D. (2010). Switch: How to change things when change is hard. New York: Broadway Books.
71. Summary of precepting Great opportunity and great challenge Need for formal preceptor education: part of an AuD program (may happen if/when we move toward audiometric assistants; some similar skills) Understand the expectations It’s all about the feedback Consider adult learning principles Self-reflection: that of the student and the preceptor
72. Questions for discussion What do you consider the most important criteria for precepting AuD students? What do you consider to be the biggest challenges to precepting? What would motivate a person to be a preceptor? How can this be supported? What is the best way to strengthen the student-preceptor-University triad?
73. Precepting discussion What are preceptor qualifications (e.g. years of experience, attitude, workplace, certification, etc.)? Are CCC's required to be a preceptor? How is or should be the University/preceptor/student triad structured? What motivates the preceptor to precept? What can the University do to provide support to preceptors? How should assessment occur? How should evaluation and feedback from students about preceptors and from preceptors about students be addressed? Specific case considerations? Student who needs accommodations, mismatch in preceptor-student personality/communication
74. References Behsgetoor, D & Wade, D. (2007). Use of actors as simulated patients in nutritional counseling. Journal of Nutritional Education Behavior. 39:101-102. Brueggeman, P.M. (2006) Applying Adult Learning Principles to Supervision. Seminars in Hearing, 27(2), 86-91 Clark, J.G. (2006). Audiology Counseling Growth Checklist. Seminars in Hearing. 27(2), 118-126. Gordon, J. (2003) ABE of learning and teaching in medicine: One to one teaching and feedback. British Medical Journal, 326 (9), 543-545. Luhanga, F., Yonge, O., &Myrick, F. (2008). Strategies for Precepting the Unsafe Student. Journal for Nurses in Staff Development. 26(5), 214-291.
75. References Morrison, J. (2003). ABC of learning and teaching in medicine: Evaluation. British Medical Journal, 326 (6), 385-387. Newman, C. W., Sandridge, S.A., & Lesner, S.A. (2011). Becoming a better preceptor: Part 1: The fundamentals. The Hearing Journal, 64 (5), 20-27. Newman, C. W., Sandridge, S.A., & Lesner, S.A. (2011a). Becoming a better preceptor: Part 2: The clinic as the classroom. The Hearing Journal, 64 (7), 12-18.
76. References Newman, C. W., Sandridge, S.A., & Lesner, S.A. (2011a). Becoming a better preceptor: Part 3: The adult learner. The Hearing Journal, 64 (9), 29-34. Rall, E. & Brunner, E. (2006). Mentoring in Audiology. Seminars in Hearing, 27 (2), 92-92. Rao, A. & DeRuiter, M. (2012). Ethical Considerations for Preceptors and Supervisors (p. 93-110). In T. Hamill (Ed). Ethics in Audiology (2nd Ed). Reston, VA: American Academy of Audiology. Roush, J. Doctoral Education in other health professions. Paper presented at Gold Standards Summit, 2009. Transforming Clinical Education in Audiology. January, 2009, Orlando, FL.
77. References Spencer, J. ABC of learning and teaching in medicine. Learning and teaching in the clinical environment. British Medical Journal, 326 (11), 591-594. Teeter, M.M. (2005). Formula for success: Addressing unsatisfactory clinical performance. Nurse Educator, 30(3), 91-92. Whitelaw, G. M. (2012). Expanding the toolbox for developing skills in auditory students: Using the Ida Tools in Precepting. Seminars in Hearing, 33(1), 78-86. Whitelaw, G.M. (2012). Leadership Challenges: Difficult Conversations. Perspectives on Administration and Supervision. ASHA Special Interest Group 11.