Teaching Clinical Skills

Dr/ Mahmoud Abdel-Aleem

Objectives

• What do we teach students ?

• Clinical Skill learning: definition and phases.

• Differences between academic and clinical teacher.

• Preparing learning tools.

• Clinical practice sites.

• Conducting a skill session.

Skill: A task or group of tasks performed to a specific level of competency or proficiency which often use motor functions and typically require the manipulation of instruments and equipment. (e.g., IUD insertion or Norplant ® implants removal). Some skills, however, such as counseling, are knowledge- and attitude-based.

knowledge vs. skills

• Knowledge: to know and process information. Teaching by lectures, tutorials etc.

• Psychomotor skills: to do.

Teaching by practice and feedback

• Attitude embedded in the skill teaching

What do we teach students ?

As: Knowledge: to know and process information. Teaching by lectures, tutorials.

Bs: Psychomotor skills: to do. Teaching by practice and feedback

Cs: Attitude embedded in the skill teaching

Teaching skills

Assessment drives learning “Story starts by: what do we need the student to do”

1. An appropriate assessment for clinical skills needs be incorporated.

2. All the specified skills in a curriculum need to be delivered with adequate chance for each student to practice.

3. You cannot provide teaching, feedback or evaluation on something you don’t observe and measure.

Types of Clinical Skills

• Communication

• Physical Examination

– Observation

– Palpation

– Auscultation

• Procedural

• Reasoning

• All students should have the same opportunity to experience and learn the competencies they require for clinical practice.

• The content of each session should be defined beforehand by a Curriculum Planning Group.

• The content of each session should be integrated to the theoretical course currently being studied.

Why we teach skills?

Accuracy of Diagnosis

Clinical Diagnosis

others

Diagnostic imaging and correct diagnosis

Diagnostic Imaging only

Despite this !!!!

• 49% never observed taking a history.

• 46% never observed doing focused PE.

• 20% never observed doing a complete PE by either faculty or residents.

“Howley and Wilson, Academic Medicine, 2004”

PRINCIPLES & PHASES

Clinical skill teaching

Skill learning

• Activity aids learning

• Repetition and practice aid learning

• Small steps aid learning

• Reinforcement aids learning

Principles of Teaching skills

SkillActivity

Dissection

Visualization

Verbalization

Practice

Reinforcement

Mastery &

Autonomy

Phases of skill learning

Acquisition

Competency

Proficiency

Acquisition

• The initial phase in learning a new clinical skill.

• One or more practice sessions are needed for learning how to perform the required steps and the sequence (if necessary) in which they should be performed.

• Assistance and coaching are necessary to achieve correct performance of the skill or activity.

Competency

• The intermediate phase in learning a new clinical skill.

• The participant can perform the required steps in the proper sequence.

• The student may not progress from step to step efficiently.

Proficiency

• The final phase in learning a new clinical skill.

• The participant efficiently and precisely performs the steps in the proper sequence (if necessary).

Components of teaching a skill

• Simple

• Practical

• Consistent

• Skill lab

• Outpatient clinic

• Case presentation

• Ward round

• Willingness

• Behavior

• Attitude

• Proficiency

• Management

Clinical coach

Student

SkillTool &

Site

Skill lab1. Clients are not harmed or inconvenienced if a mistake is

made.

2. The demonstration or practice can be stopped at any time.

3. Several participants can practice simultaneously.

4. Difficult tasks can be practiced repeatedly.

5. Practice is not limited to a site or a time.

6. Practice of a sequence of steps or skill can be repeated at any time and as often as needed.

7. Clinical training is possible even when client caseload is low.

8. Training time is reduced.

Conditions for skill lab

1- Sufficient models are available.

2- The model is positioned as if it were a client.

3- Conditions (e.g., instruments, infection prevention practices) replicate the real situation.

4- The model is treated gently and with the same respect given an actual client.

HOW TO BE A CREATOR

Competency-based learning

• Educational programs designed to ensure that students attain pre-specified levels of competence in a given field or training activity.

• Emphasis is on achievement or specified objectives

• Versus: time-based learning OR traditional classroom learning.

Competency-Based Learning Tools

• Dissection: Presents the individual steps of a skill in a standardized way.

• Steps + Sequence: teach the correct steps and the correct sequence of steps for performing a skill.

• Objective measurement: measure students’ progress in learning as they gain confidence in the skill.

Examples of Tools

• Learning guides

• Decision trees

• Flowcharts

• Algorithms

• Posters

• Charts

How to design an learning tool?

• Identify the steps or tasks. How to know the steps ?

• Place steps in the correct sequence.

• Identify standards or minimum levels of performance (rating scales).

• Directions.

• Field test the instrument.

How to know the steps?

1. Identify a group of healthcare providers who are proficient in performing the skill.

2. Observe several of the healthcare providers as they perform the skill. Record each step that each healthcare provider performs.

3. Develop an initial list of steps.4. Discuss the skill with the same group of healthcare

providers.5. Test the initial list of steps.6. Test the final standard way of performing the skill.

How to use a learning tool?

• Coach-student: Students can follow the steps in the learning tool while a teacher or other students demonstrate a skill.

• Student-student: During classroom sessions, pairs of students can work together.

• Student-students: Students who are confident in a skill can use the learning tool to observe each other and give each other feedback.

HOW TO BE A COACH

Conduction of a Practical Session

How to be an effective coach?

• Be prepared! - do read information on the content of the proposed clinical skills session before arriving.

• Arrive in good time to check that all equipment required is present and that you know how to use it.

• Try to become familiar with those learning outcomes of the curriculum which can particularly be illustrated by your clinical skills session.

• View any demonstration videos by yourself in advance and check other resource material referred to.

• Make a checklist of what you think are the key points you should get across in the session.

• Observe a senior colleague facilitating a small group clinical skills session. If you are unsure about taking a session this will help you get started.

• For the group discussion ensure every one sits in a circle so that no one is obscured.

• Don’t let any one person dominate the discussion. Encourage quieter members to contribute.

• When questions arise do not supply the answers yourself. Encourage the group to contribute the answers or to decide on ways to research them independently.

• When observing performance, emphasise that the student should relate to their colleague or simulated patient as they would to a real patient.

• Also look out for things like: Was the patient’s consent gained before starting? Did the student explain what he/she was going to do?

• Did the student show consideration for the “patient’s” feelings?

• Personal behavior:

1. Patient and supportive

2. Providing praise and positive reinforcement

3. Maintaining self-esteem and correcting participant errors.

4. Listening and observing.

A PRACTICAL SESSION

Conduction of a Practical Session

Introduce

&

Demonstrate

Practice

&

Feedback

Assess

A) Introduce• Prepare yourself well AND always be available during the session

• Set up the practice area.

• Review the skill with the students.– Describe what the skill is and why the skill is important.

– When it should be used.

– The steps involved in performing the skill.

• In case of large numbers: – Divide the students into small groups.

– Use student-student Or student-students approach.

Demonstrate

• It is not enough to just show students WHAT you do You must also show them HOW.

• Follow the list of steps.

• Use the necessary tool for the skill– Use slides or a videotape.– Perform a role play in which a student simulates a

patient.– Use anatomic models to demonstrate a skill.– Demonstrate the skill with simulated or real patients.

B) Practice“Whole-Part-Whole Approach”

• Demonstrate the whole procedure from start to end.

• Isolate or break down the procedure or activity into parts and allow practice of the individual parts of the procedure.

• Demonstrate the whole procedure again and then allow students to practice it from start to end.

Do’s

• Always demonstrate the skills correctly.

• Use equipment and materials correctly.

• Interact with the students.

• Use a learning tool for complicated skills.

Feedback “to student”

1. Be timely – give your feedback soon after the event.

2. Be encouraging “initially positive and ending positive”.

3. Avoid embarrassment.

4. Be specific.

5. Do not criticize.

6. Take responsibility for your own feedback. Speak for yourself, not for others.

7. Convey positive feedback by facial expression and tone of voice rather than words.

8. Give students an opportunity to respond to the feedback, while you actively listen during this response.

9. Highlight any other aspects which could be improved but which the student did not initially identify.

10. Ask in what ways they could improve the ‘less well’ stages.

Examples of feedbacks

• I was pleased to see that you asked each mother with a child older than 6 months what foods she was using to complement breastfeeding.

• When you inserted the speculum, you did not tell the patient what to expect. I saw her tense up making it difficult for you to open the speculum and painful for the patient. If you tell the patient what you plan to do ahead of time, it will help her relax and make the experience more pleasant for everyone.

• I think that I am speaking on behalf of everyone here when I say you really could have been better.

• Do you really expect to pass the exam doing the skill like this

• You seem to have a problem performing manual skills. You need to work on it.

• Do you like to have an instrument inserted inside you without being told. I don’t.

C) Assess

• Assess and re-practice.

WHO CAN ASSESS ?

– Coach.

– Peer assessment.

– Self-assessment.

What if no feedback??

• A waste of precious time

• Mistakes going uncorrected

• Correct performance not reinforced

• False sense of competence

• Self-validation and defensiveness

Summary: 5-step approach

• Step 1: overview.

• Step 2: silent demonstration.

• Step 3: narrative demonstration.

• Step 4: Students talk about the skill.

• Step 5: The students perform the skill.

How can the coach ask the player during practical session?

• Use both closed and open questions.

• Ask factual questions, beginning with what, where, or when, that obtain information and begin discussion.

• Ask broadening questions that assess additional knowledge.

•

Failure to teach clinical skill !!!

• Learner Trait Ability.

• Inadequate/Inappropriate Task Description and/or Demonstration.

• Imprinting of Previous Incorrect or Obsolete Performance.

• Improper Correction/Reinforcement.

• Affective Factors.

• Inaccurate Learner Perception of Performance

For Large Numbers

• Divide the students into small groups.

• Identify other persons, such as tutors or more senior students, who could assist.

• Ask students to work in pairs or groups of three and take turns practicing, observing, and giving feedback to each other.