That classroom teaching is sometimes called “protected” teaching sheds a contrasting light on clinical teaching. There are so many more factors impacting clinical teaching and those factors shift and change much more so than any classroom. These conditions lead to a dynamic and exciting learning environment, certainly, but one that can be unpredictable as well and can lead to “learning outcomes [that are] intentional or unintentional, positive or negative.” (Jarski, Kulig, & Olson, 1990).
With planning and reflection, clinical teachers can learn to use the dynamism of their learning environments to the advantage of their students. The real world clinical setting lets students watch master clinicians in action. It allows them to take the theoretical knowledge they’ve gained from their classroom learning and put it into practice, setting them on the road to becoming master clinicians themselves.
The role of a clinical teacher is certainly complex, but this guide is designed to break the complexity down to help you prepare, and then in the Styles section, help you find comfortable ways of performing those roles.
The first step is to identify each of the smaller roles that are wrapped up in clinical teaching:
- Clinician - the expert, sage, and upholder of professional standards
- Teacher - helps students move from inexperienced to knowledgeable, by identifying students’ needs, providing instruction and opportunities for experience, and encouraging them to reflect on what they’ve learned
- Supervisor - assesses students’ progress, provide feedback, and evaluate performance
Whether you are aware of them or not, you most likely have preferences in the methods and means you use to teach. This is known as your teaching style. Your style can be based on quite a few things: your personality, the ways in which you were taught, your learning style, and more.
Regardless of where your style came from, it can be very helpful to become more aware of the preferences that make up your style. Awareness can help you communicate better with your students, choose learning activities that fit your style of teaching, and help you identify areas of discomfort that may need some attention.
A study involving eight programs across the U.S., asked physical therapy students who had recently completed at least one clinical rotation to rate behaviors of their clinical instructors based on what they found most helpful (Jarski, Kulig, & Olson, 1990). The following is the top ten most helpful behaviors of clinical instructors.
- Takes time for discussion and questions
- Answers questions clearly
- Provides constructive feedback
- Provides students with opportunities to practice both technical and problem solving skills
- Is willingly accessible to students
- Discusses practical applications of knowledge and skills
- Shares his or her knowledge and experience
- Creates practice opportunities for students
- Asks questions that stimulate problem solving
- Deals with students in a friendly, outgoing manner
The best tip for successfully incorporating students into your daily practice is to plan ahead.
Manage your interactions with your students right from the start by planning a thorough orientation.
Help your student feel more comfortable and simply more aware of how things work in your clinic. Create an orientation checklist to make sure you stay on track and cover everything you need to, but remember that the orientation does not need to take place all at one time or even first thing. Schedule time for orientation throughout the student’s first days working with you. By interspersing those times with shadowing in the clinic, the student will undoubtedly get more insight into the content of the orientation and be able to ask good questions.
Finally, consider conducting exit interviews with students, asking them for feedback about the orientation process.
Next, let your patients know they may be working with students before they get into the examination room. You may even want to put up a sign in the reception area with a picture of the student. You will also want to include information letting patients know they may opt out of being seen by the student before they come face to face with him or her.
Staff and Colleagues
Ask staff and colleagues to participate in teaching. If possible, let students meet with someone from every department that affects and is affected by the work they will be doing, from reception to the laboratory to billing. Not only will they get information from the trenches, but it takes some of the burden off of you to be the only source of knowledge for the student.
Likewise, ask your colleagues to let you know if they would be willing to have your student accompany them on particularly interesting cases or look in on some of the more unusual procedures and situations if they arise.
Planning Learning Time
There are a two things you will want to think about before a student enters your clinic.
Planning for content
Realizing that working with patients can be unpredictable in nature, it can help to focus on those topics, issues, and experiences that you know recur regularly. That way, even if you can’t predict when they’ll occur, you’ll still be ready to teach them when they do.
It may not be realistic to hand pick each and every patient your student sees, but some thought about whether a student would benefit from seeing new, follow-up, or walk-in patients or some combination can help you plan for the student’s experience.
Balancing patients and students
Take some tips from the Des Moines University Survival Guide for managing clinical teaching minute to minute.
- Every student does not need to see every patient
- The student does not need to perform every part of the examination or history taking
- Incorporate the patient into the teaching; don’t save teaching for between patients
- However, in-depth discussions should be set aside for down time
- You aren’t the only teacher. Encourage your student take part in other educational opportunities offered by your clinic.
- Try different questioning styles to find your preferences, open up communication with students, and achieve learning objectives faster. One possibility is the One Minute Preceptor
You may also want to consider changing patient scheduling, perhaps having fewer patients early in the student’s time with you. Another possibility is using the Wave Scheduling System to help you manage the time between you, your student, and the patients.
Identify Learning Outcomes and Objectives
Next, identify what you want your students to learn. Whether you are teaching in a classroom or a clinic, there are goals you want your students to attain. Those broad goals are called learning outcomes, and when you break down those outcomes into measurable units, those are called learning objectives.
The learning objectives are the small steps that lead to the larger learning outcome. The more clear the learning objectives, the easier it is to choose experiences that will help students achieve the objectives and ultimately the outcomes as well. In fact, clear learning objectives can also help you identify the way in which you want to scaffold the experiences, or what are also known as the teaching methods.
As you are developing learning objectives, it can be very helpful to take a closer look at the clinical skills that are so crucial to your job. Even skills that feel as basic to the experienced clinician as taking vital signs or assessing range of motion actually involve quite a bit of clinical decision making. Students need to learn to:
- recognize when an action is called for
- recall the steps and sequence for the action
- carry out the action with efficiency and confidence
That would all be much easier if every situation was exactly the same. Because they are not, the student much also be able to
- monitor the patient’s reaction to the procedure
- compare those reactions to those that are considered typical
- appropriately adjust the actions, if necessary
(adapted from Handbook for clinical teaching, by Nancy T. Watts, New York: Churchill Livingstone, 1990)
By first breaking these tasks down and analyzing the clinical decisions that need to be made at each step along the way, you will be better prepared to teach them to your students.
Patients in Clinical Settings
In combination with the tips you can find above, prepare everyone involved in the experience:
Brief the Patient
- Who will be taking part in the examination (how many students, what and where they are studying, etc.) and how they will participate.
- The learning objectives (e.g. the student is learning to take medical histories), being as general or as specific as you think will help the patient understand
- How you, the student, and the patient will be interacting. Will you be in the exam room the entire time? Should the patient direct questions to you or the student?
- Relate any special instructions, including how to stop the teaching session at any time
- Remind the patient that students are bound by the same confidentiality rules as other clinicians
- Remind yourself of the steps and decisions involved in the most common procedures by doing a task analysis so that you are ready to make the most of situations as they arise.
- Check the clinical findings
- Check the students’ learning objectives to see which experiences may be most appropriate.
Brief the Students
- Provide ground rules. Are there topics that should not be discussed? Do you have advice for approaching sensitive topics?
- The learning objectives. Remind the student of the aim of the lesson.
- Discuss how students will participate and assign roles if appropriate. Will they be sharing the work with you, with other students?
- Review the patient chart and the reason for the patient’s visit.
Feedback - the moment to moment communications that let your students know what they are doing right and where they need to improve.
Feedback should be as specific as you can make it and focus on the behavior and the outcome, not on the student. By doing so, you’ll avoid miscommunication and having your student feel he or she has been attacked.
When critiquing, try to use phrasing that will lead the student to analyze the situations and the behaviors that may have lead to it.
Here’s an example of two different possible phrases that lead into a critical remark. The first focuses on the student and his lack of skill/knowledge, the second focuses on the result of that possible lack of skill/knowledge.
You don’t seem to know how to... vs. The patient appeared uncomfortable when you...
For more advice, take a look at Giving Effective Feedback (R-Scope)
In this situation, evaluation is the final assessment of what the student accomplished during his or her clinical rotation. It is a much more formal process than feedback and generally involves comparing the student’s progress to a set of established standards.
Because there is so much at stake, valuation can be stressful for both the student and the clinical teacher. Here are some tips to help reduce the stress (adapted from the University of Kansas’ Pearls for Preceptor Evaluations).
- Be prepared - read through the evaluation materials before the clinical rotation begins. You don’t want to come to evaluation time and learn that there are holes in what you know about your student’s skills.
- Similarly, keep notes. Think of it as a health record for your student that you can review during the final evaluation.
- Do not procrastinate. Even with notes, it will become increasingly difficult to accurately evaluate a student if you let too much time pass.
- Check for bias. Students who personally relate well to their clinical teachers tend to get higher marks, while those who hold different opinions, attitudes, or make a negative impression in general tend to score lower regardless of clinical skill.