Effectively Teaching Students with Challenging Professional Behaviors During Clinical Education

1. Successfully Teaching Students Who Exhibit Challenging Professional BehaviorsDuring Clinical Education

2. Lynn English, PT, MSEd, DPTKara Lee, PT, DPT, NCS University of Kentucky Doctor of Physical Therapy Program

3. Objectives At the conclusion of this session, the learner will be able to: Identify some typical “challenging professional behaviors”. Propose options for documenting these behaviors objectively.

4. Objectives (2) Give examples of specific and well-considered communication and conflict management skills to work effectively with these students. Plan for a solution to meet the needs of the instructor and learner as possible.

5. And a Final and Difficult Objective • Sustain unconditional positive regard for the individual (keeping emotions and biases at bay).

6. Challenging Professional Behaviors I Have Known • Inability to accurately self-assess abilities. • Lack of commitment to learning/responsibility… especially in certain clinical settings. • Lack of ability to communicate effectively...congruent with situational needs.

7. Challenging Professional Behaviors (2) • Resistance to feedback from the clinical instructors. • Lack of critical thinking/problem solving skills.

8. Proposed Teaching Strategies Use careful and early observation of the student's performance. Prepare to use an organized approach to documenting behaviors of students who are exhibiting challenging behaviors.

9. Teaching Strategies (2) Consider early contact with the DCE/ACCE regarding the student’s level of performance in the clinical setting- either to seek help or make recommendations.

10. Teaching Strategies (3) Carefully select learning experiences Plan for/adapt clinical situations to enhance teaching Communicate clearly and often - with ample listening.

11. First Steps with Any Student • Observe and note the student’s level of learning • (Hayes, Huber, Rogers, Sanders)

12. Stages of Learning • Exposure: Student is a novice • Acquisition: Student can participate in planning and evaluating learning experiences. • Integration: Student can take most of the responsibility for planning, implementing and evaluating learning experiences.

13. Identifying Challenges What is the problem??? Not meeting expectations for • safe and effective practice • a level of independence appropriate for your facility • a level of competence consistent with the student’s educational preparation

14. Performance different than expected? Alteration of your teaching plan may be necessary: • The student may require smaller steps in the progression of learning experiences to meet the behavioral objectives.

15. Accurate Identification of Student Behaviors Study: Diagnosis of Student Professional Behaviors (Hayes, Huber, Rogers, Sanders; Jette, Bertoni, Coots, et al)) Behaviors deemed as questionable by supervising CIs were either: • Cognitive: • Inadequate knowledge and skills • Noncognitive • Poor communication • Unprofessional behaviors

16. This Study Concluded • Most unacceptable student behaviors were noncognitive, but cognitive behaviors were addressed more often. • Students who did not receive feedback were unlikely to change. • If behaviors changed, the experience was more successful. • CIs used cognitive behaviors more often to recommend a negative outcome.

17. Teaching Strategies: Looking carefully at where the problem lies Is it a cognitive issue? (Underlying knowledge) Is it a psychomotor issue? (Manual skills awkward or lacking) Is it affective? (Communication, interpersonal) Example:A student could perform well in the cognitive domain and lower than expected in the affective domain.

18. Tools to Help Document Develop a portfolio of examples to help the student: Formative Evaluation Instruments • Weekly Planning Form- sets goals and documents achievement or residual needs • Anecdotal Record • Professional Behaviors Assessment (Kontney, May, Iglarsh; May, Morgan, Lemke et al) • Clinical Performance Instrument

19. Student Self-Assessment • Important to determine how perceptions match--- or not. • Same tools may be completed by the student: • Weekly Planning form with self- assessment component • Professional Behaviors self-assessment • Clinical Habits Inventory Test

20. Comparing Reality to Expectation Compare student performance with facility expectations/objectives. Compare student performance with academic objectives. Look at student previous clinical experience

21. Once the comparison is complete… Again…you may choose to communicate with the academic program and contact the ACCE/DCE. With your formative evaluation you can provide a more detailed picture of the student's performance.

22. Confronting the Issues

23. Meeting to discuss progress • Earlier is better if you have identified specific issues. • May be before midterm- at the end of a week, or as needed. • Bring documentation to clearly describe…

24. Using Specialized Communication Skills(Patterson, Grenny, et al; Albardiaz; Welch) • Maintain an environment for open discussion • Identify the problem to all parties-succinctly • Be open to suggestions, alternatives, ideas, and compromise • Keep the environment non­threatening • Use "cooling-off periods" • PRACTICE…and build in PAUSES

25. Using Specialized Communication Skills (2) • Manage defensiveness (yours and students’) Rehearse…Being aware of sensitive areas • Separating the facts from your impressions • Considering your own role and contributions • Using a positive approach to work with the individual’s strengths • Conveying clear messages and limits

26. Using Specialized Communication Skills (3) • Focus on the behavior, not the person • Focus on professional requirements not being met • Work to establish mutually acceptable goal(s) to all involved parties • Be prepared to have a third party present, when needed, especially in difficult discussion

27. Communicating a Negotiated Plan • Promote collegiality through disclosure and shared responsibility • Focus on completion of the task • Identify the tasks and each person’s responsibilities/roles • Use collegiality to define roles, not to place each person on the same level • Work together as colleagues, respecting each other’s roles to complete a task

28. Summarize the Discussion • Keep communication open to help each person understand perception of roles and responsibilities • Problem presentation • Problem resolution • Interpersonal dimension • PAUSE and LISTEN…critical

29. Using Specialized Communication Skills (6) • Support the discussion with documentation- either previous or current • Weekly Planning Form • Anecdotal Record • Professional Behaviors Assessment

30. Once the Discussion is Completed • Moving forward in the teaching/learning environment:

31. Give Special Attention To The Learning Environment • Possibilities after discussion: • Alter the pace of teaching/expectations • Give repeated similar experiences • Refer to the established goals. • Clearly maintain expectations of professional behavior.

32. Give Special Attention To The Learning Environment (2) • Maintain unconditional positive regard • Keep an open mind for explanations/motivations • Focus on the behavior, not the person • Develop ways to work together

33. If there are serious problems: One possible outcome: Learning contract

34. Learning Contract University of Kentucky Physical Therapy The clinical learning objectives included in this document reflect the results of midterm CPI comments and a phone conversation with ……, clinical instructor at …….. and ………., University of Kentucky Physical Therapy student Class of …... The course is ……… Clinical Internship , The purpose of defining specific performance statements is to clarify the expectations of performance during the remainder of the clinical experience.

35. I understand that I must incorporate these suggestions into my daily activities. Failure to successfully meet these objectives by DATE… may result in a requirement of further clinical internship time. I understand that emphasis on these objectives should in no way be construed to mean that the remainder of the goals and objectives for this experience are less important, or that successful completion of the remaining objectives is not required for successful completion of this experience.

36. Happy Endings • Stories from the field…

37. References • Anderson LW, Krathwohl Dr, Airasian PW. et al (Ed). A taxonomy for learning, teaching and assessing: a revision of Bloom’s taxonomy of education objectives( Abridged edition). New York, NY: Addison Wesley Longman Inc; 2001. • American Physical Therapy Association. Physical Therapy Clinical Performance Instruments. Alexandria, VA: American Physical Therapy Association 2006. • Hayes KW, Huber G, Rogers J, Banders B. Behaviors that cause clinical instructors to question the clinical competence of physical therapy students. Phys Ther. 1999; 79:653-671.

38. References(2) • Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When the Stakes Are High. New York: McGraw Hill; 2012. • Shea ML, Boyum PG, Spanke MM. Health Occupations Clinical Teacher Education Series for Secondary and Post Secondary Educators. Urbana, IL: Department of Vocational and Technical Education, University of Illinois at Urbana-Champaign, 1985.

39. Your stories/questions???