Pursuing Precepting Excellence:

Evolving Educational Paradigms and the Changing Landscape of Clinical Education

Jane Houston, DNP, CNM, FACNMIrma Jordan, DNP. APRN, FNP/PMHNP-BC, FAANP

Anna Louiso, DNP, APRN, FNP-BC

Disclosures/Conflicts

The presenters have no financial disclosures or actual/potential conflict of interest in relation to this presentation.

Objectives

At the conclusion of this presentation the audience will be able to:1. Discuss how the role of the preceptor has evolved with

changing educational paradigms2. Identify what should be the expectations of the

preceptor in relation to the University3. Provide strategies to address clinical time constraints

while precepting students4. Examine strategies to address clinical time constraints

while precepting students5. Explain commonalities of the struggling student

Changing educational paradigms

The role of the preceptor has evolved with changing educational paradigms • The millennial student • Distance education and brick and mortar

schools

The millennial student

Features of younger graduate learner can include:• Positive and confident• Seek structure but without impeding their freedom• Multitasking is a way of life• Expect to always be connected• Learning is like Nintendo, not logic• Intolerant of delays

Millennial students

Need clear expectations and regular feedback• Often perform significantly better• Develop better judgment• Learn faster than students who do not receive regular feedback

Students like feedback, and often identify it as one of the most important characteristics of a good preceptor

Feedback is described as comments that:• Let the student know what they have done well• Let the student know what they need to improve• Let the student plot a course of action

Millennial students

• Identify the purpose of feedback: to help the student midwife or practitioner learn what it is that he/she is expected to be able to know and do (be specific)

• Identify strengths first before moving on to areas for improvement: sandwich method

• Describe behaviors the student needs to change or develop back up comments with specific evidence and observations

• Prioritize the feedback by focusing on areas that are most important first

Millennial students

• Provide feedback on a routine basis• Make sure the feedback has been clearly understood: have

student summarize feedback and plan• Avoid sending mixed messages• Be honest in all of your feedback• Be sure you have the evidence needed

ReferencesAbrams, J., von Frank, V. (2014). The multigenerational workplace. Thousand Oaks, CA: Corwin.

Cennamo, L., Gardner, D. (2008). Generational differences in work values, outcomes and person-organisation values fit. Journal of Managerial Psychology, 23, 891-906.

Chou, S. Y. (2012). Millennials in the workplace: A conceptual analysis of Millennials’ leadership and followership styles. International Journal of Human Resource Studies, 2, 71-83

France, A., Roberts, S. (2015). The problem of social generations: A critique of the new emerging orthodoxy in youth studies. Journal of Youth Studies, 18, 215-230.

Helve, H., Evans, K. (2013). Youth and work transitions in changing social landscapes. London, England: The Tufnell Press.

Kivinen, O., Nurmi, J. (2014). Labour market relevance of European master education: From university enrolment to professional employment in 12 countries. European Journal of Education, 49, 558-574.

Krahn, H. J., Galambos, N. L. (2014). Work values and beliefs of “Generation X” and “Generation Y.” Journal of YouthStudies, 17, 92-112.

Twenge, J. M., Campbell, S. M. (2012). Who are the Millennials? Empirical evidence for generational differences in work values, attitudes and personality. In Managing the new workforce. International perspectives on the millennial generation, 1-19.

S. T., Schweitzer, L. (Eds.), Managing the new workforce: International perspectives on the Millennial generation (pp. 1-19). Cheltenham, UK: Edward Elgar.

Distance education vs brick & mortar schools

Similarities• Provision of excellent graduate programs in Midwifery, Women’s

Health and NP healthcareDifferences• Delivery of material can be in person, traditional community

environment of staff, faculty and students

All types can include mixed presentation types• Live• Recorded• Virtual

Building community at FNUAt Frontier Nursing University, each student: • Attends campus for 2 one week programs• Has an assigned Regional clinical faculty• Close bond over 1 to 2 years• Live site visit(s) with evaluations• Google Hangouts• Community building initiatives, Sage and

Student engagement, state meetings, case days

References

Advanogy.com (2015). Learning-styles-online.com. Retrieved September 13, 2018 from http://www.learning-styles-online.com

D'Amore, A., Santhamma J., & Mitchell, E. (2012).Learning styles of first-year undergraduate nursing and midwifery students: A cross-sectional survey utilising the Kolb Learning Style Inventory.Nurse Education Today 32 (5), 506-515.

Godfrey, P. (2009). Characteristics of successful and unsuccessful technical college students in online and face-to-face mathematics classes. Retrieved September, 2018 from http://www.public.iastate.edu/~laanan/ACTER/2010/manuscripts/CharacteristicsofSuccessfulandUnsuccessful_Final.pdf

Jackson, A., Gaudet, L., McDaniel, L., & Brammer, D. (2011).Curriculum integration: The use of technology to support learning. Journal of College Teaching & Learning (TLC).Retrieved from http://cluteinstitute.com/ojs/index.php/TLC/article/view/1127

Kolb, A. and Kolb. D. Experiential learning theory. Encyclopedia of the Sciences of Learning (2012): 1215-1219.

Lu, H. & Ming‐Jen, C The impact of individual differences on e‐learning system satisfaction: A contingency approach. British Journal of Educational Technology 41.2 (2010): 307-323.

What will they expect of you?

What might you expect from them?

Anna Louiso DNP, APRN, FNP-BC

Expectations in Relation to the University

Expectations

Faculty Involvement

Paperwork

Communication

What should I expect?

It can be a rewarding and enjoyable experience for both you and the

student!

ACNM Survey--2014Factors That Influence Midwives to Serve

as Preceptors

● Top motivating factor--commitment to the profession

● Top barrier--need to maintain high patient volume

Role expectations--faculty● Coordinates placement of student with

site/preceptor● Communicates with preceptor● Coordinates clinical site visit● Communicates student’s progress with

appropriate members of University● Maintains responsibility for final evaluation

and clinical course grades

ACNM, 2018

Role expectations--Student

● Arrange Schedule● Develop personal learning objectives● Address course objectives● Observe policies of site● Confer with preceptor and faculty● Come prepared each day● Evaluate faculty, course, and preceptor

ACNM, 2018

Role expectations--Preceptor● Orient student to site● Identify learning needs of students● Set goals with student ● Provide feedback● Plan learning experiences● Consult with faculty● Participate in ongoing evaluation of

student, including final evaluation of clinical performance

ACNM, 2018

Precursors of Success● Know expectations of the University● Have access to course objectives and/or

syllabus● Be aware of hour requirement and time

frame● Expect of student:

○ Be prepared each day-mentally and physically

○ Professional behavior○ Be willing to supplement clinic time with

learning behaviours

Preparation and Planning

Meet with faculty● By phone or in person● Share a bit about yourself

○ Professional experience○ Teaching styles

● Ask for any specific expectations● Discuss methods of communication

Preparation and PlanningSet up a pre-clinical meeting with student

● Learn about student:○ professional background and interests○ learning patterns, skills learned○ strengths and weaknesses

● Discuss:○ Your teaching style○ Office routines○ Patient population○ Expectations (dress code, charting, etc).

●

PaperworkShould not take a ton of your time!

● Evaluation of core competencies● Verify student hours and cases● Positive/negative feedback● Completed daily, weekly, or per

term/semester

PaperworkCore Competencies for Basic Midwifery

Practice

● Fundamental knowledge, skills, and behaviors expected of a new nurse midwife

● Serve as guidelines for educators, students, and policymakers

ACNM, 2012

Paperwork

AMCB certification

○ 9 precepting hours = 1 contact hour

○ Up to 10 contact hours or 90 preceptor hours per recertification period

AMCB , 2018

Communication: Feedback

What is feedback?

● Specific and non-judgemental● Compares performance with standard● Intended to improve performance● Bidirectional● Effective feedback is key to student learning

experience

CommunicationCommunicating with faculty

● You should have means of contact during all office hours. Phone number, email.

● Bidirectional● Contact should be timely if there are

issues● Meet privately during site visit

ReferencesThe American College of Nurse-Midwives. (n.d.). Clinical placement responsibilities. Retrieved September 16, 2018 from http://midwife.org/clinical-placemengt-responsibilities

The American College of Nurse-Midwives. (n.d.). Resources for preceptors: special situations. Retrieved September 16, 2018 from http://midwife.org/index.asp?bid=1032

American Midwifery Certification Board (n.d.) Continuing Education Policy. Retrieved September 16, 2018 from https://www.amcbmidwife.org/certificate-maintenance-program/continuing-education-policy

APRN precepting: Providing the tools for successful clinical education experiences (March 11, 2018). Retrieved from https://www.napnap.org/sites/default/files/userfiles/Conferences/2018SpeakerHandouts/211%20HEUER.pdf

ReferencesBarker, E.R .& Pittman O. (2010). Becoming a super preceptor: A practical guide to preceptorship in today’s clinical climate. Journal of the American Academy of Nurse Practitioners, 22 144-149. doi:10.1111/j.1745-7599.2009.00487.x

Brooks, M.V. & Niederhauser, V.P. ( 2009). Preceptor expectations and issues with nurse practitioner clinical rotations. Journal of the American Academy of Nurse Practitioners, 22: 573-579. doi: 10.1111/j.1745-7599.2010.00560.x

Burns, C., Beauchesne, M., RyanKrause, P., Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical teaching. Journal of Pediatric Health Care, doi:10.1016/j.pedhc.2005.10.012

Core competencies for basic midwifery practice (2012). Retrieved from http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000050/Core%20Comptencies%20Dec%202012.pdf

ReferencesGermano, E., Schorn, M.N., Phillippi, J.C. & Schuiling, K. (2014). Factors that influence midwives to serve as preceptors: An American College of Nurse-Midwives survey. Journal of Midwifery & Women’s Health, 59:167-175. doi:10.1111/jmwh.1

Krause, S.A. (2016). Precepting challenge: Helping the student attain the affective skills of a good midwife. Journal of Midwifery & Women’s Health, 61:S37-S46. doi:10.1111/jmwh.12517

Myers, K. & Chou, C. (2016). Collaborative and bidirectional feedback between students and clinical preceptors: Promoting effective communication skills on health care teams. Journal of Midwifery & Women’s Health, 61: S22-S27.

Zeidenstein, L. (2014). Columbia University School of Nursing preceptor module. Retrieved from http://nursing.columbia.edu/sites/default/files/documents/clinical_preceptor_module_2014-15.pdf

One minute preceptor Clinical flow management

Anna Louiso, DNP, APRN, FNP-BC

Strategies to address clinical time constraints while precepting students

Barriers to Precepting

● Need to meet patient volume/students slow us down● Competition from other students● Midwives want to provide direct care● Midwives need a break from teaching● Previous poor experience with student● Midwives feel unprepared to teach● Patients not accepting students● Staff unsupportive of students● Difficult communication with instructor

Germano et al, 2014

Reducing Complexity is Key!

Dispelling myths

● Productivity

● Length of your day

● Stress

Day One

● Make sure staff is aware of student

● Give brief tour and intro to staff

● Introducing student to patient ○ patient specifically chosen○ student has fresh eyes, knows latest and greatest

Specifics for new students

Little experience but mountains of enthusiasm!

● Selectively choose patients● Quality, not quantity● Slow is OK● Learn skills in a sequence● Follow behind all vaginal exams at first

New students

● When student can’t chart in EMR○ Use a SOAP note form

● CMS documentation guidelines○ Physical presence of billing provider○ Documentation limitations

● index card for questions○ address at lunch or end of day

Intermediate students

Focus: Become more systematic

● Help student prioritize what is important● Help student develop systematic

approach● Quality over quantity, but start working on

time● Encourage creative problem

Advanced students

Everything's coming together

● Increased independence● Student takes lead● Time management● Wrap up skill acquisition

Acute/Inpatient setting

Intrapartum: Meshing of Art and Science

● Orient student to setting● Create a climate of safety● Students feel more vulnerable

Effective time saving strategies

One Minute Preceptor

● Originally developed by Kay Gordon and Barbara Meyer, Department of Family Medicine, University of Washington School of Medicine in 1992

● Widely adopted● Has been shown to improve precepting

behaviors

One Minute Preceptor

5 microskills

● Get a commitment● Probe for supporting evidence● Teach general rules● Give positive feedback● Correct mistakes

Five microskills

Get a commitment

● What do you think is going on?● What do you want to do?● Resist the urge to take over the case.

Five Microskills

Probe for supporting evidence

● Allows preceptor to determine knowledge base

● Preceptor can assess clinical reasoning skills

Five Microskills

Teach general rules/pearls

● “Typically there are two main treatment options”

● “Important factors to consider are…...

Five Microskills

Reinforce what was done right

● “You did a really good job of prioritizing the problem list”

● “You were conscious of the patient’s financial stiuation”

Five Microskills

Correct mistakes

● Identify gaps or omissions● Avoid negative comments● Identify next learning steps● Engage student to identify own gaps in

knowledge

Scheduling Strategies

Table 3. Scheduling Strategies for Precepting

● Focused half days● Focused observation● Wave scheduling● Appointment modification

Barker & Pittman, 2008

Scheduling Strategies

Focused Half Day

● Good for new student● Less intimidating● In-depth experience

Scheduling Strategies

Focused Observation

● Good for beginning student● Preceptor is role model● Provides material for student reflection

Scheduling Strategies

Wave Scheduling

● Requires change in scheduling method● Eliminates backup of patients● Best for intermediate to advanced

students

Scheduling Strategies

Appointment Modification

● Allows for catch up time● Reduces productivity● Allowed by some sites

ReferencesThe American College of Nurse-Midwives. (n.d.). Clinical placement responsibilities. Retrieved September 16, 2018 from http://midwife.org/clinical-placemengt-responsibilities

The American College of Nurse-Midwives. (n.d.). Resources for preceptors: special situations. Retrieved September 16, 2018 from http://midwife.org/index.asp?bid=1032

APRN precepting: Providing the tools for successful clinical education experiences (March 11, 2018). Retrieved from https://www.napnap.org/sites/default/files/userfiles/Conferences/2018SpeakerHandouts/211%20HEUER.pdf

Barker, E.R .& Pittman O. (2010). Becoming a super preceptor: A practical guide to preceptorship in today’s clinical climate. Journal of the American Academy of Nurse Practitioners, 22 144-149. doi:10.1111/j.1745-7599.2009.00487.x

ReferencesBurns, C., Beauchesne, M., RyanKrause, P., Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical teaching. Journal of Pediatric Health Care, doi:10.1016/j.pedhc.2005.10.012

Germano, E., Schorn, M.N., Phillippi, J.C. & Schuiling, K. (2014). Factors that influence midwives to serve as preceptors: An American College of Nurse-Midwives survey. Journal of Midwifery & Women’s Health, 59:167-175. doi:10.1111/jmwh.12175

Krause, S.A. (2016). Precepting challenge: Helping the student attain the affective skills of a good midwife. Journal of Midwifery & Women’s Health, 61:S37-S46. doi:10.1111/jmwh.12517

Neher, J.O., Gordon, K.A., Meyer, B. & Stevens, N. (1992). A five-step "microskills" model of clinical teaching. Journal of the American Board of Family Practice 5:419-24.

ReferencesNeher, J.O. & Stevens, N.G. (2003) The one minute preceptor: shaping the teaching conversation. Family Medicine 35(6) 391-3.

Zeidenstein, L. (2014). Columbia University School of Nursing preceptor module. Retrieved from http://nursing.columbia.edu/sites/default/files/documents/clinical_preceptor_module_2014-15.pdf

Critical thinking skills in student learners

Developing the clinical grasp Use of Socratic Questions: “Paper-Clip” Remediation guidance

Developing the clinical grasp

Critical thinking underlies independent and interdependent decision making. Include:

• Questioning• Analysis• Synthesis• Interpretation• Inference• Inductive and deductive reasoning• Intuition• Application• Creativity

AACN (2016)

Use of Socratic questionsCompetency-based education requires that students:

• Develop a deeper understanding of course material– Necessitates new modes of content delivery and incorporation of new

thought processes.

Socrates observed:• Students often lost their ability to justify their own preconceived thoughts

and beliefs after a series of specific, targeted questions. • Through appropriate and repeated questioning, students eventually

developed self-generated knowledge and the ability to regulate their own thoughts.

• True knowledge is not the acquisition of facts, but self-generated knowledge

• Socrates claimed he never taught his students anything

“PAPER CLIP”Questions regarding

PrecisionAccuracyPerspective EquityRelevanceComplexity LogicIntuitionPerspicuity

Paper Clip (continued)• Getting students to clarify their thinking and explore the origin of their thinking

e.g., 'Why do you say that?', 'Could you explain further?'• Challenging students about assumptions

e.g., 'Is this always the case?', 'Why do you think that this assumption holds here?'

• Providing evidence as a basis for arguments

e.g., 'Why do you say that?', 'Is there reason to doubt this evidence?'

• Discovering alternative viewpoints and perspectives and conflicts between contentions

e.g., 'What is the counter-argument?', 'Can/did anyone see this another way?'

• Exploring implications and consequences

e.g., 'But if...happened, what else would result?', 'How does...affect...?'

• Questioning the question

e.g., 'Why do you think that I asked that question?', 'Why was that question important?', 'Which of your questions turned out to be the most useful?'

Remediation guidance

• Approximately 30% of all NP and midwifery students can struggle both academically and clinically at various times

• Have to acknowledge that students may not be “on” 100% of the time

Remediation guidanceAssessment of non-academic qualities• Motivation• Professionalism• Responsibility

Successful performance in the clinic is predicted by:• Strong communication skills• Self- and social awareness• Self-control• Moral reasoning

Remediation guidance• Early involvement of university/academic faculty is key when issues

are identified• Preceptors initially try to “solve” student clinical problems in a

vacuum• May need specialized learning tools and faculty assistance to

promote success

Tools at Frontier Nursing University

• Embedded in the community- close relationships• Evaluation tools based on national competencies• Learning tools- student directed• Performance plans- faculty directed

ReferencesA brief history of the idea of critical thinking. The Critical Thinking Community; http://www.criticalthinking.org/pages/a-brief-history-of-the-idea-of-critical-thinking/408. Accessed September 19, 2018.

Paul R, Elder L. The Art of Socratic Questioning. Dilton Beach, CA: The Foundation for Critical Thinking; 2007.

Hart Research Associates, on behalf of the Association of American Colleges and Universities. It takes more than a major: employer priorities for college learning and student success. Liberal Education. 2013; 99(2)

Zou L, King A, Soman S, et al. Medical students’ preferences in radiology education: a comparison between the Socratic and didactic methods utilizing PowerPoint features in radiology education. AcadRadiol.2011;18(2):253–6.

Tofade T, Elsner J, Haines S. Best practice strategies for effective use of questions as a teaching tool. Am J Pharm Educ. 2013;77(7)

Sandahl SS. Collaborative testing as a learning strategy in nursing education. Nurse EducPerspect.2010;31(3):142–7.

Wald HS, Borkan JM, Taylor JS, et al. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing. Acad Med. 2012;87(3):41–50.

Chan ZC. Exploring creativity and critical thinking in traditional and innovative problem-based learning groups. J ClinNurs. 2013;22(15-16):2298–307.

Houston...We have a problem

Irma Jordan, DNP, APRN, FNP/PMHNP-BC, FAANP

What to do when a student is not meeting expectations?

Objectives

At the conclusion of this presentation the audience will be able to:1. Manage the challenging student2. Define unprofessional behavior3. Identify of causes of incivility

The Problem: Student struggling to meet expectations

● These students require closer supervision● More time consuming● May need to be taught specific skills● Preceptors feel ill equipped to handle these

students

Identify the problem

● Cognitive--Easiest to identify and remediate!○ Unprepared for clinical

■ Lacking critical thinking skills■ Inattentive■ Gaps in basic clinical knowledge

● Personal--Difficult to identify and address○ Integrity○ Respect for others○ Responsiveness and sensitivity to patients○ Accountability○ Mental health issues

Feedback vs Evaluation● Feedback

○ Communicates Information○ Focuses on what was done○ Identifies potential consequences of action

● Evaluation○ Judgement of the student’s performance in comparison to clinical

goals

Types of feedback and evaluation

● Formative Feedback○ Provide frequently

● Summative Feedback (Evaluation)○ Provided at specific points (halfway/end of experience)

● Ways to give feedback○ Directive○ Elaborative

The important elements of giving feedback

• Timing -planned in advance-and in private• Permit the student to self-assess the event• Deliver focused and concise feedback• Means of Delivery (oral vs. written)• Discuss specific examples -be non-judgemental and • Focus on what needs to be changed• Develop a plan of action

What gets in the way?Student:• Defensive student• Previous feedback has been generic and students perceives this as

positive• Fear of negative consequences for both preceptor and student

Preceptor:• Poor documentation of prior behavior • Unclear outcome goals or a clinical rotation• Unclear guidance from the University

Institutional• Ambiguity of outcome goals or a clinical rotation• Process unclear for initiating remediation

• Who to notify• Who leads the remediation

Using SOAP to give feedbackSubjective: Detect a problem based on a subjective impression

• Preceptors should trust their impression• If in doubt observe and document• Early identification of difficulties

Objective: Gather and document objective data• More than one context and as many direct observations as possible• Provide informal discussion before taking further steps

Assessment: differential diagnosis of problem• The “differential” should include cognitive and personal• Start with the difficulty that is causing the most problem

Plan: Targeted remediation• Firm up the diagnosis of the problem• If at all possible the preceptor making the diagnosis should be

involved in remediation• Integrate remediation into the student's regular clinic activities.

Civility is the Common Thread

Professionalism

Respect

Civility

Positive Communication

Inclusivity

Causes of Student Incivility

Meeting Deadlines

Concerns about grades

Demanding

workloads

Juggling work, school and family responsibilities

Anxiety/Stress over new role

Examples of incivility● Eye rolling● Sarcastic comments (verbal

or electronic)● Dominating conversation● Arriving late/leaving early/no

show for clinic● Being unprepared for clinic● Taking personal phone calls

in clinic● Demanding tone● Refusal to accept

constructive feedback

Communication with the challenging student

• Check your emotions at the door• Focus (and listen) on your student and what

they are saying• Watch body language

• Inconsistent language• Negative body language

● Expect professional behaviors and professional dress○ Let the student know your expectations at the outset of the

experience○ Identify poor professional behavior or boundary breaches early

and communicate expectations for change● Early communication of problems to both student and faculty

○ Document your concerns in writing ● A failing student will often have limited insight or lack of personal

awareness ● Patient safety is a primary concern If you don’t think the student is

safe, let the faculty know immediately ● Trust your judgment

Managing the Challenging Student

Tips for dealing with difficult students● Express empathy

○ Communication by the preceptor is from a position of power but respect

○ Recognizes that the behavior that needs to be changed can be changed only by the student.

● Develop discrepancy○ Motivation to change occurs when the discrepancy between where

they are and where they want to be is clear. T● Avoid arguing

○ Arguing only makes them more resistant. ● Roll with resistance

○ Don’t meet it head on. ○ Invite the student to think about the problem differently.

The process of improving a situation… Remediation

• Enlist university faculty in developing a remediation plan • Assist the student in development of their remediation

plan• Specific examples of areas needing improvement• Specific actions leading to improvement• Timeline for re-evaluation of the student

ReferencesBoileau, E., St-Onge, C., & Audétat, M.-C. (2017). Is there a way for clinical teachers to assist struggling learners? A synthetic review of the literature. Advances in Medical Education and Practice, 8, 89–97. http://doi.org/10.2147/AMEP.S123410

Ebbeling, J. & Van Brunt, B. (2010). Faculty Focus: https://www.facultyfocus.com/articles/effective-classroom-management/four-tips-for-dealing-with-difficult-students/

Katz, NT (2006). The Effective Preceptor Series is a Project of the Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC); Crofton, MD.

Lazarus, J (2016). Precepting 101: Teaching Strategies and Tips for Success for Preceptors. Journal of Midwifery & Women’s Health. American College of Nurse-Midwives (61/1).

Stewart, J.G and Denisco, S.M (2015). Role Development for the Nurse Practitioner. Jones and Bartlett Learning, Burlington, MA

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5260943/

Breakout Session

Two student scenarios- group work

a. Identification of problemb. Steps to resolvec. Discussion

Group work

First scenario- the unsure, timid student in busy clinical setting, student is easily overwhelmedSecond scenario- student is not meeting clinical objectives, does not accept constructive feedback well, is very experienced in the RN role

Wrap Up

Question & Answer

Thank you for coming!