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Precepting Students & Residents:Exploring Teaching and Learning
Deanna Kania, PharmD, BCPS, BCACPAmy Hyduk, PharmD, MBA, BCPS
Both, Dr. Kania and Dr. Hyduk have no actual or
potential conflicts of interest in relation to this program or
presentation
Identify opportunities to make site-based learning interesting and interactive for preceptors, students and/or residents
Discuss strategies and unique ways for student learning to improve patient care and experience
Review different student scenarios to gain comfort and appropriate feedback techniques
Objectives
The Preceptor Role
“Modeling the Way”
Introduce to culture & values of the profession
Demonstrating the multidisciplinary team approach to patient care
Instilling knowledge
Coaching, facilitating, reinforcing behaviors & skills
“It is the preceptor who sets the tone of the training program. He accomplishes this by what he does personally, by what he stands for, by the contributions he makes to the profession, by his actions and by his sense of values.”
Am J Hosp Pharm 1967;24:192-203.
Preceptorship
Preceptorship
Preceptors
Manage
LearningStyles
Preceptor
Teaching Styles
Communi-cationStyles
Expectations
Personal Attribute
s
Learning TaxonomiesCognitive Domain(Problem-solving)
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Evaluate self, evaluate work of others according to objective criteria
Create something new
Select pertinent data on which to base a decision
Use method, theory or principle to solve a new problem
Understand meaning & intent of material; Can restate & describe importance in own words
Recall or recognize ideas or material
The Learning Pyramid
Guide for Instruction by Preceptors.
www.ashp.org
Preceptor’s Role
Facilitating
Coaching
Modeling
Direct Instruction
• Provides some instruction – not the main focus• Readings, guideline review, discussions
Direct Instruction
• Show learner what you would do• Think out loud• Timing is key – prioritization
Modeling
• Working together or separately – dependent on time of year & learner’s progress
• Learner explains back their thought processCoaching
• Working more independently• Later in rotation / learning experience
Facilitating
Preceptor’s Role
Avoid giving “lectures”• Some level of instruction needed, but shouldn’t be
the main focus• Often used as a crutch to cover desired material• Need self-directed learning
Assign readings
Review practice guidelines, protocols w/learner
Guided discussions w/questions & interactive learning techniques to assess understanding
Explain or show “how to” do something
Direct Instruction
Learner observes preceptor
Preceptor “thinks out loud” with learner
Show the “how to’s” in practice
Academics vs. practice examples
Utilize w/patient encounter• Point out controversial issues• Explain rationale• Enhance problem-solving skills in a practice environment
Meet w/learner after the encounter to discuss other points
Modeling
Preceptor begins to take “back seat”
Learner displays a previously modeled task or skill
Learner explains their thought process to preceptor
Preceptor coaches learner before the activity
Preceptor provides “how to” tips for unique scenarios not yet encountered
Preceptor provides timely & specific positive & negative constructive feedback after the activity
Coaching
Preceptor offers an opportunity for learner to practice on their own where appropriate• Develop own clinical decisions• Apply learned problem-solving skills• Perform self-evaluation process
Preceptor assigns learner more complex tasks/patients as learner progresses
Facilitating
The Learning Pyramid
Resident assumes
TPN dosing Service
Resident writes TPN w/preceptor observing;
Resident explains to preceptor his/her recs
Write TPN on patient w/resident observing, explain thought process, resident observes
preceptor communicate w/RN, MD & RD
Review reading materials on nutrition support w/resident, discuss protocol, demonstrate how
to collect lab data in IT systemGuide for Instruction by
Preceptors. www.ashp.org
Preceptor’s Role
Facilitating
Coaching
Modeling
Direct Instruction
The Learning Pyramid
Student provides anticoag
education to pts on own
Student & preceptor review consult for
anticoag education, review pt chart, student
performs teaching to pt while preceptor observes, preceptor
provides feedback after
Preceptor & student review consult for anticoag education, review pt chart, preceptor explains how s/he will tailor education to pt, preceptor teaches pt while student observes
Review guidelines & education materials on anticoag & have interactive topic discussion, discuss various pt
teaching strategies, demonstrate how to document tchgGuide for Instruction by
Preceptors. www.ashp.org
Preceptor’s Role
Facilitating
Coaching
Modeling
Direct Instruction
Matching It All UpStages of Learning
Levels of Cognitive Learning
Appropriate Instructional Methods
Foundation Knowledge & Skills
Knowledge • Assigning readings• Reviewing protocols
Comprehension • Guided discussion• Teach back method
Practical Application
Application • Case presentation• Case-based
teaching• Simulation/role play• Practice-based
teaching
Analysis
Synthesis
Culminating Integration
Evaluation Guide for Instruction by Preceptors. www.ashp.org
Application & Synthesis Teaching Strategies
Create an environment where there is interaction
The ‘teacher’ should be present to “guide” the learning process• Must shift the responsibility for learning
toward the student• ‘Teachers’ should facilitate and serve as a
resource• Help your learners find the “joy” of learning
Teaching Strategies
Educational
traditionChange
Limited time
Learner group size &
resources
Teaching / Learning Barriers
See One – Do One – Teach One (SODOTO) Guided discovery• Use questions to evaluate knowledge
Role Play• Useful for motivational interviewing skills• Physician / pharmacist interactions
Teaching Strategies
Problem solving scenarios or simulations
Learner reflections
Afternoon of sharing• Personal stories• Unique case studies
Think Aloud
Teaching Strategies
Get a commitment• What do you think is going on?
Ask for evidence• What led you to that conclusion?
Teach
Reinforce what was done well
Correct mistakes• Next time, try this
One Minute Preceptor
J Am Board Fam Prac 1992;5:419-24
Summarize history and findings
Narrow the assessment of the problem to 2-3 possibilities
Analyze the assessment
Probe preceptor (ask any questions)
Plan for the patient
Select topic for self-study
SNAPPS Model for Patient Case Discussions
Acad Med 2003 Sep;78(9):893-8
Motivating Students / Residents
Motivating Learners
Give frequent, early, positive
feedback
Assign tasks that are
neither too easy nor too
difficult
Help learners find personal meaning and value in the
material
Create an atmosphere that is open and positive
Help learners feel that they
are valued
Identify the source of poor motivations
Intrinsic versus extrinsic motivation
Discuss behaviors that communicate elusive attitudes• Ex. tardiness = poor attitude
Motivation Challenges
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.J Am Pharm Assoc 2012;52(6):897-904
Criteria-based and specific
Listen to their self-assessment• Respect• Empathize/relate
Provide feedback with pos – neg – pos• Be honest
Provide specific examples
Attack the problem not the person
Focus on one or two points at a time
Effective Feedback Strategies
Effective Feedback Strategies
Learner identifies
area(s) for improvement
Learner identifies
specific steps to reach next
goal
Plan is reviewed and
modified
Know yourself as a preceptor
• What type of learner irritates you?
• What characteristics do you value most in
learners?
• What type of learner are you unsure how to
handle?
How to Prevent Problems
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015
Watch for warning signs• Missed deadlines• Lack of enthusiasm or engagement• Poor professionalism
Appearance Word choice/tone of voice Engagement
• Poor work ethic Late for rounds/clinic/pharmacy service Missing/late assignments Unprepared Insubordinate
• Knowledge base
How to Prevent Problems
Don’t ignore Don’t assume… Discuss and document
How to Prevent Problems
Fam Med 2000;32(4):232-4.
Diagnose the issue
• Knowledge/skill deficit Not taught Not understood Not prepared
• Attitude Doesn’t know what they don’t know Personality issues
• Professionalism
How to Prevent Problems
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015
Indications for Failing a Learner
Unsafe skill performances
Scrupulous activity
Not meeting rotation / facility
requirements
Poor knowledge
base
Poor communicati
on skills
Document everything!
Communicate• Allow learners to express perspective• Perception vs. reality• Be objective• Paint the picture for what success should look
like• Consider generational differences, stressors,
etc.
How to Handle Poor Learner Performance
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.J Am Pharm Assoc 2012;52(6):897-904.
Use motivational interviewing techniques• “Do you mind if we discuss…”• “What I hear you saying is…”• “What I see happening is…”• “What would you like to see different about…”• “May I suggest trying…”• “Here are two suggestions…which would you like to
try…”• “Can I tell you what concerns me about…”
“A patient may be harmed if this continues…” “You may be let go from a position, if this doesn’t
change…”
Communicate
Sobell & Sobell. Motivational Interviewing Strategies and Techniques. 2008. http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf. Accessed March 2015.
How to Handle Poor Learner Performance
Be aware of FERPASeek opinions from
other staff members on-site
Ask for assistance from the College
Development an improvement / action
plan
Document Everythin
g
Work together with learner
Clear and measurable expectations / outcomes
Defined timeline for re-assessment of situation or incomplete assignments
Consequences if expectations / timeline is not met
Signed agreement by both learner and preceptor
Include Experiential office if support is needed
Improvement / Action Plans
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.J Am Pharm Assoc 2012;52(6):897-904.
Repeat the rotation• May recommend that this be done elsewhere• Colleges often place the learner with a faculty
member for a repeat rotation, but not always, so you may want to inquire
Repeat part of the rotation
Successfully perform a task that was identified as an area for improvement• Clinical skill• Presentation
Consider alternative career choices
Options for a Failing Learner
Learner Scenarios
You are precepting a learner early in their training on an outpatient rotation block, and it is his third day
You suggest that today would be a great day in hypertension clinic to work on blood pressure assessments
The preceptee replies, “I have done that a ton already and I’m comfortable with it and don’t need any practice.”
What are your concerns? How would you respond? What if this was late in their rotation year?
Case Scenario #1
Your preceptee is on her second week of a rotation She is doing very well on rounds Is completing all patient care activities Documents interventions thoroughly Types complete and excellent progress notes
You notice that she is very inquisitive and challenges you in many discussions, making you feel ‘uneasy’
You notice you are sometimes defensive and short w/ her
At times, she is also outspoken and demanding, even putting an attending physician on edge
How would you handle this situation?
Case Scenario #2
Your learner is on his last clinical rotation
He seems to be progressing well in the first week and is working independently
However, when you do your follow-up, you find Clinical mistakes are occurring All recommendations are not being reviewed w/ a
preceptor Non-patient care work is incomplete
How do you address this problem?
Case Scenario #3
Your learner’s self-evaluation is not consistent with your own at the mid-rotation evaluation He/she feels they are ‘on top of everything’ They display self-confidence despite a mostly lackluster
performance
You meet with them and provide clear documentation of errors and things they can improve upon
They are quite surprised to receive this less than positive feedback
You have heard from previous preceptors that this is a reoccurring problem
How would you handle this situation?
Case Scenario #4
Your preceptee is a stellar learner Excellent knowledge base Great recommendations You feel they could replace you
However, everyday for the first week, she is late to the rotation
She also has shown up late for meetings and has been behind on turning assignments in
You meet with her after week one and reiterate your expectations for timeliness
During week 2, she shows up late 3 of the 5 days and misses another deadline
How do you handle this situation?
Case Scenario #5
It is the April rotation and your preceptee has already signed on to work for community practice upon graduation
You are the preceptor for a critical care rotation
The student is uninterested in your patient population and does not see the value of the information they could obtain from your rotation
How do you handle this situation?
Case Scenario #6
You fail a student learner due to knowledge base deficits• You have multiple objective items documented about the
learner’s deficiencies
You refer the student to the experiential coordinator at the respective college for follow-up
Within 15 minutes, you receive a page from the learner’s mother who demands to know why you are failing her son and wants to know what she can do to fix the situation. She states that clearly you have done something wrong with her child.
How do you respond?
Case Scenario #7
Sweet learner who dresses professionally, is respectful, and is courteous and friendly towards patients
Within the first week, you notice she is struggling clinically• Not able to follow as many patients• Slow in looking up drug information questions • Unprepared in case/topic discussions• States incorrect pharmacy-related information
The learner is putting forth her best effort, is trying very hard, and has recognized that she is struggling
How do you handle this situation at the mid-point evaluation?
How do you handle this situation at the end of the rotation assuming you had a thorough mid-point review?
Case Scenario #8
Precepting Students & Residents:Exploring Teaching and Learning
Deanna Kania, PharmD, BCPS, [email protected]
Amy Hyduk, PharmD, MBA, [email protected]