Lecture 1 - Concepts in Clinical Learning and Education

2015‐02‐10
Concepts in
Education &
Clinical
Learning
Lecturer, BScN, MN
©2014 – The Hospital for Sick Children, Toronto, Canada. All Rights
Reserved. Used under a limited licensing agreement.
Learning Objectives
At the end of this session, the learner will be able to:
 Apply the principles of adult learning theory to enhance
teaching
 Critically appraise and utilize teaching strategies useful in
the classroom and clinical environments
 Describe simulation based learning
 Outline the difference between Teacher & Facilitator
 Outline the difference between Feedback & Debriefing
 Develop experience and expertise in teaching others using
a variety of teaching approaches
 Develop an understanding of evaluation
© 2014 ‐ The Hospital for Sick Children,
Toronto, Canada. All Rights Reserved.
Day 1
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Agenda
 Let’s get thinking!
 Adult learning principles
 Break
 Teaching strategies
 Putting it into action
 Debrief
The Learner
What kind of learner are you?
 Think of the time when you were learning a new
sport or skill?
 How do you learn new recipes?
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Adult Learning Principles
Adult Learner
Characteristics
What do we know about adult learners?
Adults…
• arrive with a set of previous life experiences and
“frames”
• have ingrained personality traits, and relationship
patterns, which drive their actions
• become more self‐directed and autonomous as they
mature
• like their learning to be problem centered and
meaningful to their life situation (are practical)
• learn best when they can immediately apply what they
have learned
• are goal oriented
• need to be shown respect
(Fanning & Gaba, 2007)
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Enabling Learning
The best way to motivate adult learners is
to enhance their reasons for learning and
to decrease their barriers.
Basic Principles of Adult Learning
Control
Previous
Experience
Relevance
&
Usefulness
Supportive
Climate
Learning Styles
(Kolb 1984; Honey & Mumford, 1986)
Doing Watching
Active Experimentation Reflective Observation
Feeling Accommodator Diverger

Concrete (activist) (reflector)
Experience
Thinking Converger Assimilator

Abstract
Conceptualization
(pragmatist) (theorist)
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Kolb’s Learning Styles
 Accommodators (activists) – rely on intuition and
prefer hands on learning
 Assimilators (theorists) – prefer readings and
lectures, interested in theories and abstract thinking
 Convergers (pragmatists) – like to find practical uses
for ideas and theories, need clear objectives with a
logical sequence to activities
 Divergers (reflectors) – prefer to watch rather than
do, enjoy innovative activities, discussions and
generating ideas
The Learner in the Clinical Setting
 Identifies own learning
needs
 Seeks out learning
opportunities
 Recognizes own
limitations
 Accountable for safety &
quality care
 Professional in
interactions with staff &
patients
Challenges & Limitations
 Suitability of the content to a particular style
 Physical space available for teaching
 Available resources
 Number of participants
 You often don’t know the learner’s preferred
learning style
 Learning styles differ amongst participants
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Activity ‐ Adult Learning Principles
 You are Hilina’s instructor and you are about to
teach her how to do surgical gowning and gloving.
Given that Hilina is an adult learner, apply what you
have learned about general principles of adult
learning to this case.
 What do you need to consider in preparation for
teaching Hilina?
Activity ‐ Learning Styles
 You are Hilina’s instructor and you are about to
teach her how to perform surgical gloving and
gowning.
 How would you teach Hilina if her learning style is:
1. Accommodator (Activist)
2. Assimilator (Theorist)
3. Converger (Pragmatist)
4. Diverger (Reflector)
The Educator
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Let’s Get Thinking!
My personal teaching philosophy
 What does “great
teaching” mean?
 What does it look like
(describe what you would
see)or feel like when real
learning is taking place?
a) What is the teacher
doing?
b)What are the learners
doing and saying?
c) What is the learning
environment like?
Activity – Teachers vs. Facilitatators
Groups of 5, 5 minutes to talk about….
 What are the differences between Teachers &
Facilitators?
Pick a representative to report back.
Teacher Facilitator
Leader
Consultant Coach
Guide
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Teacher vs. Facilitator
 Facilitation: bringing out and focusing on the
wisdom of the group or individual, often as
something new is created or a problem is solved
(Hogan, 2002)
 Teaching: conveying knowledge and giving
information to students
Teacher Facilitator
Content Expert Guides process to
learning
Presents Provides right
Information questions
Provides the right
answer
Facilitator Competencies
 Create a positive learning climate
 Adapt teaching to what participants know and how
they learn
 Focus on learning objectives
 Facilitates learning by encouraging participation
 Employs a variety of teaching tools and techniques
 Ensures learning outcomes
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Teaching Strategies
You the Educator
 What strategies have you used that have gotten
students excited?
 How does your perspective on the students
influence your teaching?
Create a Positive Learning Environment
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SMART Objectives
S Specific
M Measurable
A Achievable
R Realistic
T Timely
Teaching Methods & Learning Styles
Intuiting Feeling
•Practice •Personal Experience
•Apply concepts •Role plays
•Simulations •Group exercises
Strive for
Diversity
Thinking Sensing
•Reading •Lectures
•Questioning •Discussion
•Independent activities •Problem solving
Teaching Strategies
Exchange
Action Observation
Reflection Simulation
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Strategies in the classroom
 Lectures
 Discussion
 Demonstrations
 Case studies
 Videos
 Visual aids
 Small group work
 Role plays
How do these surgeons do with teaching?
Challenges in Education
 Students don’t understand content
 Students who don’t want to be there
 Unable to answer questions posed by learners
 Classroom dynamics
 Diversity in the classroom
 Difficult Participant Behaviour
 Giving feedback
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Methods of Evaluation of Students
 What are some methods of evaluation?
 What are some limitations of these methods?
Evaluation Methods
 Reflection
 OSCEs
 Pre/post tests
 Clinical Observation
 Content evaluation
 Progress evaluation
 Facilitator evaluation
Putting it in action!
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5 Minute Presentation
 Tomorrow you will each present a 5 minute
presentation (you will be timed)
 Your presentation will have 1 objective that should
be stated at the beginning
 You will choose a topic
Applying what we’ve learned!
Presentation Assignment
 Later in the course you will deliver a presentation to the
rest of the class
 Part of your evaluation in this assignment will be on the
groups use of interactive teaching strategies and
simulation based learning
 You will also complete a self‐reflection on the
presentation:
◦ What went well?
◦ What are some of the challenges you encountered?
◦ What would you have done differently?
Day 2
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Agenda
 5 min presentation
 Break
 Break
 Debrief
5 Minute Presentation
Clinical Preceptorship
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Let’s Get Thinking!
 Take a moment to remember a good teacher in
the clinical setting– someone you knew recently
or long ago.
 Share with the group: In your opinion, what
were the personal characteristics that made
him/her a good teacher?
The Preceptor Role
 Role Model
 Coach
 Facilitator
 Advocate
 Evaluator
 Safety net/Protector
 Socialization Agent
Effective Preceptors
Interpersonal Qualities Professional Qualities Personal Qualities

Sensitive Competent Enthusiastic
Respectful Confident Honest
Interested Creative Cheerful
Accessible Stimulating Considerate
Supportive Skilled Calm
Open Relaxed Warm
Concerned Flexible
Burns, C., Beauchesne, M., Ryan‐Krause, P. & Sawin, K. (2006)
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Clinical Preceptoring
Critical Thinking
“If the learner is in constant fear and state
of anxiety, they are unable to think
critically or to think at all .”
(Myrick & Yonge, 2011)
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Preceptors Help Learners Develop
Knowledge
Skill
Judgment
Developing Clinical Judgment
Levels of Cognitive Activity Examples
Questions
Evaluation Making a judgment using a Can you evaluate each goal of the treatment plan? Is
standard or criteria it being met?
Is the plan sufficient to ensure the prevention of
future asthma attacks?
Synthesis Combining ideas and How do you plan to educate this client regarding the
knowledge into a new plan proper use of their medication?
Analysis Breaking an idea into What are the implications of the abnormal blood gas
component parts for results?
analysis and to draw What is the family’s understanding of the triggers of
conclusions asthma attacks?
Application Solving problems in new How would you use these blood gas results in
situations planning the care of the patient? How would you
prepare this medication for administration to a child?
Comprehension Showing understanding of Why is it important to check blood gases?
the essential meaning Describe how Ventolin works?
Knowledge Remembering previously What is a normal range for arterial blood gases?
learned material or What is Ventolin prescribed for?
information
How do these surgeons do with teaching
in the clinical setting?
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Road Map for Precepting.
Getting Off to a Good Start
 Review program objectives & individual learning goals
 Discuss expectations (yours and theirs)
 Explore past experiences
 Make a plan (start with basic skills, evaluate knowledge, skill
and judgment and move forward)
 Return to beginning (as needed)
◦ How can I help them move forward?
◦ Do they need extra time to work on a competency or exposure to a
skill?
◦ Do you need to go over the theory
◦ Do they need practice?
Getting Off to a Good Start
 Help the learner fit within the team, clarify the roles &
responsibilities of interprofessional team members
 Focus on commonly occurring diagnoses, treatments and
technical skills
 Help the learner understand routines and common practices
 Progress at a rate of the learner abilities
 Assist the learner to think and make effective clinical
judgments as a results of experiences you set forth
 Work on effective communication & documentation
(Ullrich S. & Haffer, A. 2009)
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Challenges for Clinical Preceptors
 Patience with variation in learning styles, pace of learning
& progress
 Unrealistic expectations
 Difficulty in distinguishing “need to know” vs. “nice to
know”
 Lack of confidence in own ability to precept & evaluate
 Attributing learner problems or lack of progress to lack in
ability of themselves to precept
 Supervising procedures vs. Helping the learner see the big
picture, develop clinical reasoning and gain transferable
skills (teacher vs. facilitatator)
 Letting go while ensuring patient safety
Red Flags in Learners
 Not asking questions
 Lack of awareness re: their own limitations
 Lack of preparation & effort
 Inability to follow instructions
 Lack of motivation
 Lack of confidence or overconfidence
 Attitude & professionalism issues
 Poor communication & interpersonal skills
Evaluation of the Learner
Evaluation is a judgment whether objectives and criteria
for the experience have been met & competencies
achieved
 Based on evaluation tools, observation, anecdotal
notes, learner self‐evaluation
 Based on standards and guidelines, not your
preferences
Your final evaluation of the learner should never come as
a surprise to anyone!
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Share one thing that you have learned
today that you will apply to your
practice as a clinical preceptor?
Simulation Based Learning
Challenge values
& attitudes
Review principles
Investigate
of
causes of error
pathophysiology
Enhance clinical
Examine nursing Case reasoning/critical
thinking &
care
Studies Facilitate Self
Learning
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What is Simulation?
A teaching technique to replace real
experiences with guided experiences,
often engaging in nature, that replicate
aspects of the real world
(Maran, N.J. & G)
Objectives Facilitation Debriefing
• SMART • Practical • Reflection

• Bloom’s Experience • Analysis
Taxonomy • Role Play, • Exploring &
• Outcomes Case study Closing
• Generating Performance
Observations Gap
Glavin, 2011
Offers learners the opportunity to go through active
participation with subsequent analysis of, and
reflection on the experience aiming to facilitate
incorporation of changes in practice.
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Before During
Facilitators in Simulation After‐Debrief
Pre‐learning Listen attentively Allow learners to
(didactic, reading, reflect and discuss
etc)
Clear objectives Minimize verbal Reinforce learner
feedback contributions
Set expectations Determine need for
assistance
Frame how
simulation/role play
will run
Day 3
Agenda
 Break
 Debrief
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Agenda
Debriefing & Feedback
Reflecting on your own practices
1. How are you currently providing feedback to
students?
2. What is the nature of the feedback?
3. How do your students generally respond to your
feedback?
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Debriefing Directive Feedback
 A conversation between  Is intended to acknowledge
two or more people in the student’s progressions
which participants analyze toward learning outcomes.
their actions and reflect on Good feedback is also
the role of thought constructive and points
processes, psychomotor students in the way in
skills, and emotional states which they can improve.
to improve or sustain
performance in the future
Let’s Debate
 Group 1: will work together to present a case for:
Debriefing as the best way to provide feedback to
students. In your presentation list at least 5
advantages to debriefing with learners.
 Group 2 will work together to present a case for:
Directive Feedback as the best way to provide
feedback to students. In your presentation list at
least 5 advantages to feedback with learners.
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Is this feedback or debriefing?
This report is better than your last one.
You've made it clear you think we should
recycle water sachets. What would make it
even better is more facts about what
would happen if we did recycle.
I noticed you chose to write your
report on recycling. I thought it was
interesting that you brought in many
examples of what would happen if we
didn’t recycle. Help me understand
how you decided to focus on effects
of not recycling?
Is this feedback or debriefing?
When the patient started to become
unstable I see that you did an
assessment first before calling for help.
Next time you must call for help first to
get resources in the room to help the
patient.
When the patient started to become
unstable I noticed that you did an
assessment first before calling for
help. Help me understand how you
decided that?
Purposes of Debriefing Discussion
1. Development of problem‐solving skills, critical
thinking, and clinical judgement skills
2. Debriefing of clinical experiences and following
simulations
3. Development of cooperative learning and group
process skills
4. Assessment of own learning
5. Development of oral communication skills
(Gaberson & Oermann, 2014)
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Judgmental
Non‐Judgmental
Debriefing with Good
Judgment
The Judgmental Approach
 My goals
◦ Get you to the right thing; avoid the wrong thing
◦ Occasionally make you feel bad
 I think
◦ I know what went wrong; “I have the answer”
◦ I have to get you to see it the way I do
 How I do this
◦ State the judgment and the solution
Debriefing with Good Judgment
 To help sustain or improve performance
 DOES share observations, opinions based on
expertise
 I want to maintain a good relationship with the you
 Withholds judgment and gently lets the learner find
the answer for themselves.
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Appreciative Enquiry
Activity – Appreciative Enquiry
Your perioperative nursing student has come to you asking if
you can watch her scrub and set up for an emergency
laparotomy case. You observe her scrub, gown, and glove
with no difficulty. As she is setting up the sterile table a fly
comes into the room and lands on the corner of the table.
Both you and the student notice the fly, but nobody else in
the room does.
 What questions can you ask to help the preceptee
develop clinical judgment?
Activity ‐ Appreciative Enquiry
 Your student is circulating in a general surgery case.
The patient has been very unstable and she seems
unsure of what to do.
 What questions can you ask to help the preceptee
develop clinical judgment?
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Appreciative Enquiry
Debriefing Model
Advocacy Inquiry Model
Advocacy: My perspective
‐Use the first person “I”
‐Make my perspective clear
“I observed…..”
“I am concerned/please because
Inquiry: to find the learner’s perspective
‐Short, open‐ended questions/statements, eg:
“I wonder how you see it…
“I wonder what happened…
“What was on your mind at that time…
Identify Gaps Determine Frames
Identify
Determine Frame
Performance Gap
Reasoning about a
Objective data Question
concern or appreciation
I liked that… How do you see it?
I noticed…
I thought that was: I was wondering
I see / saw that…
•interesting what your thoughts
I hear / heard you •fascinating are?
say… I was thinking…

What were you
I was worried / concerned... thinking at the
I had the impression that… time?
It seemed to me that…
Help me
understand how
Eppich W, ChengA; Modified after you decided that?
PAEDSIM Debriefing Script
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Let’s Practice! Turn these questions into
Advocacy Inquiry statements.
Questions Advocacy Inquiry Model
1.
1. Did you feel like you and the
other team members handled
sharing the workload as well
as you might have?
2. Do you think that short time 2.
frame was enough?
3. Did it occur to you to call for
help?
4. Why wouldn’t you double 3.
check your medication?
5. How do you think that went?
Closing Performance Gap Summarize
Clarify Understanding
Closing Performance Gaps
of Frame
Combine Performance Close Performance
Summarize
Gap with Frame Gap
So what I’m hearing is How will impact your What are the main
that [insert performance performance next take home
gap here] was related to time? messages?
[insert frame here]…
What did you
How would you do learn?
If I understand correctly, things differently?
you are saying that [insert The key learning
performance gap here] How will your train of points are…
was due to [insert frame thought change the
here]… next time you
encounter a similar
Eppich W, ChengA;
situation? Modified after PAEDSIM
Debriefing Script
Let’s Practice! Closing the Performance Gap
1. I did not know I was 1.
supposed to give the
patient oxygen.
2. I thought the doctor
wanted me to give the 2.
medication not just draw
up the medication.
3. I did not want to ask for 3.
help because I thought I
was supposed to do
everything myself.
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Clinical Debriefing
Clinical Debriefing ‐ Questions
Effective Feedback
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Types of Feedback
Formative
Summative
On the Spot (Ongoing Formal Feedback)
Midterm &Final
(Informal Assessment
Feedback) (Formal Feedback)
Feedback
Formal Feedback Model
(Formative & Summative)
Collaboratively
Develop an
Get the Give Your Summarize Action Plan
Learner’s Views & Key Learning
Views Impact Points
Set Timeline to
Re‐evaluate
Explore
Barriers
(Adapted from Ulrich, 2012)
Providing Feedback
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Let’s Practice ‐ Feedback
 Your student is very strong clinically. However, you
have noticed that once the patient is asleep he
makes inappropriate comments about the patient
and their family in front of the surgical team.
 When he engages with the patient and the family he
acts professionally.
 How would you provide feedback about this to the
student?
Key Points re: Feedback
1. Think about the purpose of your feedback & its
value for the learner
2. Consider time and place (well‐timed & private)
3. Be specific
4. Focus on behaviors that you have observed
5. Consider the amount of feedback that the learner
can absorb; not on how much you might like to give
6. Check the learner’s understanding
7. Explore with the learner how their behavior can to
be modified to further improve performance
8. Be supportive & respectful
Feedback skills take time and practice to develop!
Activity: Let’s Rephrase
1. You really need to work on your documentation
2. You have an attitude!
3. Why did you talk to the nursing aid that way?
4. That was a truly insensitive thing to say to the patient. Why do
you always interrupt? And by the way, you were late again this
morning!
5. You might have done that sterile set up well but it took too
long. Did you notice that the patient was desaturating?
6. Everything is going on well. You are making good progress.
7. You are very shy
8. Because you did poorly the last time you did a patient
assessment, I need make sure you don’t mess it up this time
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Activity – Feedback &
Debriefing Stations
Evaluation
Evaluation of Education
 Why it is important?
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Four Levels of Evaluation
Satisfaction: Did they like it?
Learning Outcomes: Did they learn it?
Behaviour Change: Can they do it?
Impact/Results: Broader change
Examples, Financial impact
Organizational change
Improvements in health or
well‐being of patient/client
Take Home Messages
 Adult learners are different from children and
require a different approach
 Delivering education in an interactive manner with
varied strategies may be the best approach
 Providing guidance (preceptoring) in the clinical
setting can be challenging, however effective
preceptors are crucial to nursing education
The End!
 Any questions or comments?
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2015‐02‐10
Debrief
 What was most valuable to you?
 What did you enjoy the most?
 What would you have liked to cover that was not?
References
 Burns, C., Beauchesne, M., Ryan-Krause, P. & Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical
teaching. Journal of Pediatric Health Care, 20(3), 172-183 Retrieved April 3, 2008 from
http://www.medscape.com/viewarticle/532189_6
 Canadian Nurses Association (2004). Achieving Excellence in Professional Practice: A Guide to Preceptorship and
Mentorship. Ottawa, ON Retrieved Amy 2, 2014 from https://www.cna-
aiic.ca/~/media/cna/page%20content/pdf%20en/2013/07/26/11/04/achieving_excellence_2004_e.pdf
 Clark, D. (2000). Learning styles. Retrieved April 3, 2008 from http://www.nwlink.com/~donclark/hrd/styles.html
 Craig, J. & Page, G. (1981). The questioning skills of nursing instructors. Journal of Nursing Education, 20, 18-23.
 Cross, K.P. (1981). Adults as learners. Increasing participation and facilitating learning. San Francisco: Jossey-Bass
publishers.
 Gagerson, K. B., & Oermann, M. H. (2014). Clinical Teaching Strategies in Nursing. Springer: New York
 Luhanga, F.Yonge, O. & Myrick, F. (2008). Hallmarks of unsafe practice: What preceptors know. Journal of Nurses is Staff
Development, 24(6), 257-264
 Kertis, M. (2007). The one-minute preceptor: a five-step tool to improve clinical teaching. Journal for Nurses in Staff
Development, 23 (5), 238-242.
 Kolb, D. (1984). Experiencial learning. Experience as the Source of Learning and Development. Englewood Cliffs, NJ:
Prentice-Hall, Inc.
 Knowles, M. (1970). Andragogy: An emerging technology for adult learning. The modern practice of adult education:
angragogy versus pedagogy. New York, NY: Association Press.
References
 Miller, G. (1990). The assessment of clinical skills/competence/performance. Academic Medicine,
65 (9 Suppl), S63‐SS67
 Morrow, K.L. (1984). Preceptorship in nursing staff development. Aspen Systems Corp. Rockville.
 Myrick, F., & Yonge, O. (2005). Nursing preceptorship: Connecting practice and education.
Philadelphia: Lippincott Williams & Wilkins.
 Neher, J.O. Gordon, K.C., Meyer, B., & Stevens, N. (1992). A five‐step “microskills” model of clinical
teaching. The Journal of the American Board of Family Practice, 5 (4), 419‐424.
 Nursing Professional Development System. Retrieved on May 5, 2008 from
http://www.sickkids.ca/cfn_elearning.
 OHA/RNAO (2009). Health Care Education ‐ Level 1‐How To Design And Deliver Programs, Toronto :
Canada
 Ulrich, B. (2012). Mastering Precepting: A nurses handbook for success. Sigma Theta Tau
International: Indianopolis, IN.
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References
 Center for Medical Simulation (2012). Institute for
Medical Simulation Comprehensive Instructor
Workshop. Retrieved from www.
Harvardmedsim.org.
• Benner, P. Sutphen, M., Leonard, V., & Day, L.(2010).
Educating Nurses: A call for radical transformation.
Josey‐Bass A Wiley Imprint, U.S.A
THANK YOU
Break Time
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2015‐02‐10

Feeling Accommodator Diverger

Thinking Converger Assimilator

Interpersonal Qualities Professional Qualities Personal Qualities

Objectives Facilitation Debriefing

• SMART • Practical • Reflection

say… I was thinking…

 Clark, D. (2000). Learning styles. Retrieved April 3, 2008 from http://www.nwlink.com/~donclark/hrd/styles.html

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