Manage Clinical Practice

IntroductionIntroduction What challenges do you face when students are working in the clinical area to practice their skills? Is the facility appropriate? Do the staff welcome your students?

ObjectivesObjectives Select and prepare clinical instructors and staff Coordinate clinical practice Conduct clinical practice sessions Monitor students’ progress

Clinical Practice Team Students Teacher Clinical instructor Staff members working in the clinic

Selecting Clinical Instructors Time available and a desire to work with students Proficient healthcare delivery skills that are consistent with what is being taught Excellent interpersonal communication skills Organizational skills Teaching skills

Strengthening Clinical Instructors Clinical knowledge and skills are up-to-date and consistent with what is being taught Teaching skills, such as demonstrating with models, coaching, providing feedback, and performing assessments, that they will need in working with students

Preparing Clinical Instructors and Staff #1 Meet to communicate objectives and requirements for the clinical rotation and discuss any questions Inform the clinical instructors of the students’ abilities and learning needs

Preparing Clinical Instructors and Staff #2 Inform the clinical instructors and staff about to give feedback on student performance (provide them with the checklists, forms, feedback reports) Clinical practice carried out in communities and homes requires making sure students and any staff are fully aware of expectations

Coordinate Teaching #1 Work closely with all members of the team Meet with clinical instructors in advance to discuss student placement, preparation of the staff and communications with students Share copies of the syllabus with the clinical instructors and staff

Coordinate Teaching #2 Give the clinical instructors or staff copies of the student performance report Discuss plans for student assessment including sharing copies of the checklists and a summary of the skills they will be responsible for observing

Student Responsibilities #1 Review any assigned readings or checklists Attend and actively participate in all clinical practice visits Take an active role in learning and communicate questions and concerns to the clinical instructor or teacher Obtain comprehensive and targeted health histories Conduct physical examinations

Student Responsibilities #2 Present findings clearly and concisely Observe demonstrations of skills and perform skills Select and interpret screening and diagnostic laboratory tests in collaboration with the clinical instructor Co-manage patients with complex health problems

Student Responsibilities #3 Educate and counsel patients and families Coordinate and communicate patient management with the clinical instructor Document findings and experiences in an organized, thorough manner Evaluate clinical practice experience

Responsibilities of Teachers, Clinical Instructors and Staff #1 Maintain up-to-date healthcare delivery skills Review teaching materials or tools Review learning objectives for clinical practice Ensure that the necessary logistics have been arranged Orient clinical staff and any others involved in teaching to the learning objectives and the expected tasks

Responsibilities of Teachers, Clinical Instructors and Staff #2 Communicate with other teachers or clinical instructors Orient students to each new clinical site, with the assistance of a staff member Ensure that students and clinical instructors or staff members have the tools (checklists, logbooks) Review learning objectives with the students and clinical staff

Responsibilities of Teachers, Clinical Instructors and Staff #3 Select appropriate patients based on the learning objectives for the session or rotation Demonstrate skills for students Observe students as they practice, and provide frequent feedback on performance Assist students, clinical staff, and other teaching assistants with any difficulties

Responsibilities of Teachers, Clinical Instructors and Staff #4 Sign and review the logbook Plan with the students for additional experiences Assess and report on students’ performance Monitor students’ progress throughout the clinical practice experience, and report results to other teachers or clinical instructors responsible for the session or rotation

Use Objectives to Plan Review the learning objectives to assist in planning appropriate clinical practice activities Determine which objectives can be met in the outpatient department and which in the inpatient ward. External clinics, communities, and home visits are other sites used in clinical practice activities.

The Outpatient Department #1 First point of contact for most patients, so most appropriate place to practice interviewing and interpersonal and counseling skills as well as clinical skills Best place to develop an initial care plan and to teach patients how to implement the plan at home

The Outpatient Department #2 The outpatient department also is an excellent interim step between simulated practice and working with very sick patients in the inpatient ward. The manual lists some objectives that can be met in the outpatient setting. Can you think of others?

The Inpatient Ward In inpatient settings, patients are usually seriously ill, and have already started a care plan and specific treatments. Inpatient wards are a good place to teach patient management, practice healthcare delivery skills, and demonstrate management of rarely seen conditions.

Examples of Inpatient Ward Skills #1 Assess clinical status Perform specific clinical interventions such as administering an intravenous solution Document information on the patient’s plan of care, treatment, and changes in condition

Examples of Inpatient Ward Skills #2 Communicate clearly with clinical staff and family (as appropriate) the findings about a patient Review diagnostic test results and apply them to the patient’s condition

Examples of External Clinics and Home Visit Skills Assessment of environmental hazards Group and individual education skills Communication skills History-taking skills Infant and postpartum visit assessment skills

Structure Clinical Practice Sessions #1 Move from basic to more complex skills. Move students from observation to direct work with patients. Structure activities to allow for the most interaction with patients.

Structure Clinical Practice Sessions #2 Plan a rotation system so that students do not overwhelm one area. Prepare activities that students can do when there are no appropriate patients at the clinical practice site.

Outpatient Teaching Approaches Apprentice Team member Supervisor Let’s take a look at each of these approaches

ApprenticeApprentice Students function as healthcare providers while the clinical instructor or assigned staff member closely observes and intervenes when appropriate. Slows patient flow but does provide excellent practice opportunities.

Team Member Students function as a member of the team and see patients individually or in pairs in a separate room and then report their findings and recommended plan of care. This gives students a more independent experience but takes more of the patient’s time.

SupervisorSupervisor Students are assigned to several different rooms, and a clinical instructor or other designated staff member moves back and forth among the rooms providing feedback and supervision. This method allows students a great deal of independence, but does not allow for much direct supervision.

Inpatient Teaching Approaches Patient-centered teaching Ward rounds Let’s take a look at these approaches

Patient-Centered Teaching Student is assigned one or more patients to follow. Student works under supervision of staff and is responsible for the patient’s care. Student will present the patient during rounds, assist in the care plan, and communicate with staff about the patient’s condition.

Ward Rounds Ward rounds may be used for either observation or interaction. Care must be taken during ward rounds to protect the patient’s privacy and to avoid talking as if the patient were an object. It is better to discuss the patient in a private location away from the bedside.

Ward Rounds - Observation The students join rounds as an observer. The healthcare provider managing the patient’s care will report the patient’s presenting complaint, initial findings and treatment, laboratory and other diagnostic results and interpretation, current condition, and future plans.

Ward Rounds - Interaction During ward rounds, the students are asked questions about the patient’s condition and are expected to respond. Several of the students may have been asked to prepare to present the patient to the group.

Positive Feedback Positive feedback is often easy to give and can be provided in the presence of the patient. Keep the feedback simple and relaxed; too much feedback may alarm the patient. At the same time, the absence of feedback of any kind can be disturbing to the student.

Constructive Feedback Constructive feedback is difficult to give, but particularly when a patient is present. It is important to keep such feedback low-key and restrained. Avoid embarrassing the student and try and save constructive feedback until the students are gathered away from the patients.

Constructive Feedback Techniques #1 Often a look or hand gesture (e.g., a touch on the shoulder) can be as effective as words and less of a concern to the patient. In a quiet, direct manner, you can make simple suggestions to facilitate the procedure, for example, “You might find it easier to insert the speculum if you use gentle downward pressure.”

Constructive Feedback Techniques #2 To help a student avoid making a mistake during a procedure, ask a question about the procedure itself. Sometimes, even though they have had extensive practice on models, students make mistakes that can potentially harm the patient, so you must be prepared to step in and take over the procedure.

Cover Before the Clinical Practice Session #1 The learning objectives for that day or the clinical session Any necessary scheduling changes Students’ tasks for that day or session, including the work assignments and rotation schedule if applicable Assignments to be completed that day or that session

Cover Before the Clinical Practice Session #2 The topic for the post-session meeting, so the students can prepare cases or look for experiences to share Questions related to the session or from previous sessions Discussion about how feedback will be provided in the clinical setting

During the Clinical Practice Session #1 Check in periodically with clinical instructors and staff Coordinate any planned learning activities Observe student-patient interaction Continue to facilitate skill development (demonstrate, provide feedback)

During the Clinical Practice Session #2 Ask if students have been assessed on any of the skills in their logbook Assess student skills or ask staff to do this Create a positive learning environment by having a friendly and helpful manner

Protect Patient’s Rights Inform the patient of the role of each person involved and make sure that a licensed provider is always present Obtain the patient’s permission before having students observe, assist with, or perform any procedures Respect the right to bodily privacy Strictly observe the confidentiality

After the Clinical Practice Session #1 Review the learning objectives and assess students’ progress toward meeting them Present cases seen that day, particularly those that were interesting, unusual, or difficult Provide an opportunity for students to ask questions

After the Clinical Practice Session #2 Ask students questions about cases or their care plans Tell students about the logistics of future clinical practice sessions

Monitor Students’ Progress Logbooks (also called a casebook) as seen in Samples 9-1 and 9-2 Student performance reports Field notebooks (often used during community or home visits)

SummarySummary Let’s review the information contained in the job aid on Page What questions do you have about managing clinical practice? How will you plan and manage clinical practice for your students?