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Hearing Journal:
doi: 10.1097/01.HJ.0000399910.54648.f6
Part 2 in a Four-Part Series

Becoming a better preceptor: The clinic as classroom

Newman, Craig W. PhD; Sandridge, Sharon A. PhD; Lesner, Sharon A. PhD

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Craig W. Newman, PhD, and Sharon A. Sandridge, PhD, are members of the Head and Neck Institute at the Cleveland Clinic. Sharon A. Lesner, PhD, is a part of the School of Speech-Language Pathology and Audiology at the University of Akron.

Learning does not take place in a vacuum, or even in just a classroom. If it did, our students would never acquire the skills they need to enter practice. One of the best models is using day-to-day clinical sessions around direct patient care, expanding on traditional classroom instruction and using the clinic as a classroom. The clinical learning opportunities you offer students at your clinical site help crystallize and bring to life the academic knowledge and theory gained in the classroom, giving them hands-on practice in applying it to patient care.

We covered the fundamentals of precepting in the first part of this series, focusing on the appropriate and preferred use of clinical education terminology, the multiple roles of the preceptor, the challenges and rewards associated with the precepting process, and the usefulness and necessity of a collaborative clinical education partnership involving the preceptor, student and university (HJ 2011;64[5]:20; bit.ly/HJpreceptor).

A host of issues must be considered before accepting students in your clinic, and preceptors must know how to apply an experiential learning model in clinical teaching, how to use interactive teaching triads, and how to develop and incorporate learning opportunities into your daily clinical practice.

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REFLECTING ON THE PAST

Examining personal experiences

A helpful first step in preparing yourself to become a successful preceptor is to reflect on your own past experiences while you were a student clinician. Ask yourself:

* What qualities did my best preceptors possess?

* What qualities did my worst preceptors have?

* What characteristics about the clinical environment made learning effective and efficient for me, and which ones did not?

Identifying the characteristics we want to foster—and the ones we do not—will help you cultivate the skills you need to become an effective preceptor. Perhaps you appreciated how a supervisor created an environment for you to find answers to questions in a nonintimidating and nonthreatening manner. Perhaps you appreciated how your preceptor instructed you in a quiet manner that did not embarrass you in front of the patient. We can all improve by analyzing our previous preceptors' positive traits and avoiding those characteristics that had a negative impact on us.

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Motivation

Simply having good intentions is not enough to facilitate successful precepting for you and your student. Consider your motivation for accepting the precepting role. What is it about precepting that appeals to you?

Zachary suggested that discovering your core motivation is like peeling back the layers of an onion—the more layers you peel, the more you find underneath.1 The degree of your self awareness and candidness in evaluating your motivation will be reflective of the layers you peel and what you learn from the process. (Table 1.) And don't just engage in this exercise once; revisit it regularly.

Table 1
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Readiness

Equally important in your self-awareness process is determining if there are any potential barriers in your clinical setting that might impede the student's clinical development. Ask yourself:

* What elements are in place to facilitate accepting students?

* What elements are not yet in place but could easily be implemented? Do any elements pose significant barriers?

* If multiple clinicians work in your practice, have they agreed to take on students? Who will serve as preceptors? Does everyone understand the obligations associated with precepting?

Table 2 will help you evaluate your readiness as a preceptor.

Table 2
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TEACHING IN THE CLINICAL SETTING

The clinical teaching environment is probably the most complex teaching environment within which anyone is asked to function.2

Whether a sound booth, sensory device, fitting and counseling room, or evoked potential or balance function lab, every clinical environment offers teaching moments for you and learning opportunities for your student. In essence, the clinical setting is your classroom.” It's where students focus on real patient issues in a professional practice. In fact, the clinical setting is the only teaching environment in which skill sets such as history-taking, behavioral and electrophysiologic assessment, audiologic management, clinical reasoning and decision-making, empathy, and professionalism can be integrated by the student.

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Experiential Learning

Tell me and I will forget.

Show me and I may remember.

Involve me and I will understand. - –Confucius, 450 BC

Learners who take an active role in their own learning learn more. If we expect our students to master clinical skills and make appropriate diagnostic and management decisions, then we need to give them opportunities to practice audiology by engaging them with direct, hands-on meaningful experiences.

Kolb's classic experiential learning cycle3 fosters our understanding of how the learning process works, and has application for preceptors teaching clinical audiology skills. (Figure 1.)

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The cycle involves four learning stages. Concrete Experience entails performing clinical activity such as puretone threshold testing, and will be passed after gaining a full understanding of the process and expected outcome. After that, the student proceeds to the Reflection Observation phase where they watch, internalize, and review their actions and outcomes. Next in the process is Abstract Conceptualization, in which the student begins to distill and assimilate information into general rules from which new clinical decision-making strategies can be drawn. In the Active Experimentation stage of the cycle, the newly acquired clinical knowledge can be tested so that future occurrences of the experience can be modified and improved.4–5

You can assist your student's movement through the cycle by asking probing questions about the clinical encounter that encourage reflection, conceptualization, and integration of new knowledge and clinical decision-making skills. It is important to challenge the student with deliberate, thoughtful questions throughout the learning cycle so he can apply his newly acquired clinical knowledge to other experiences as they arise.

The experiential learning cycle is driven by the notion that clinical experiences should be tied to reflections by the student with feedback from the preceptor. This interaction promotes thinking, discussion, cognitive processing, and addressing emotions related to the clinical experience itself. The process complements other adult learning theories that will be covered in detail in the next installment of this series. Specific techniques for asking the right questions and providing appropriate feedback will be discussed in the final article.

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INTERACTIVE TEACHING TRIADS

Allow the student to participate in patient management to a degree appropriate for his or her level of clinical experience and training.

Clinical education is simply transferring the abilities, ideas, and beliefs from the preceptor to the student through direct interaction with patients.6 But the process is more complex, with the interplay among the clinician, student, and patient focusing on promoting optimal patient care. Several variations of this triad of student, clinician, and patient are possible, each influencing the learning process and outcome of the given clinical learning experience.

These triads are useful in all aspects of clinical teaching and direct patient care, whether it is taking a case history or performing a diagnostic battery. Four different triads are available for these interactions, providing students with different types of learning opportunities as they gain clinical skills and independence.7 (Figure 2.)

Figure 2
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* Triad A: Initially, students are passive observers of the clinical encounter, with the interaction exclusively between the patient and the clinician (indicated by the solid arrow). The student watches as the clinician models appropriate professional behavior. The student should record certain aspects of the encounter to discuss with the preceptor after the appointment. This also gives the preceptor an opportunity to ask questions consistent with the student's competency level. He can ask, for example, “If the patient reported X, Y, and Z symptoms, what would you have expected to see on the audiogram?”

* Triad B: The student now begins to be involved in providing patient care by working directly with the preceptor. The student may obtain the case history, for example, with the preceptor supplementing the information as needed. As the student gains confidence and competency in his clinical skills, the preceptor takes less of a role but continues to be an active member of the team providing direct clinical care.

* Triad C: Once the student's skills develop and he becomes more independent, the roles reverse—the student assumes the role of service provider and the preceptor assumes the role of observer. It is important to note that the preceptor remains a presence in the clinical encounter, offering additional input when needed but allows the student to manage the case.

* Triad D: This teaching triad promotes independence for the student; the patient in essence becomes the student's patient with minimal guidance from the preceptor. The preceptor and student consult before the session to verify that an appropriate clinical plan is in place and again after the patient visit to review the outcome and recommendations. To develop the student's independence, however, the preceptor needs to stay out of the patient's sight. If it is not possible to observe from another room, the preceptor should stand behind the patient and offer comments or information only when the student is unsuccessful or unsatisfactory in his comments.

It is important that preceptors foster and promote students' progress across the teaching triads. As supervisors, our ultimate goal is to train fully independent and competent clinicians. If we fail to give students independent learning opportunities, we will have failed to reach our goal. At some point in your student's clinical training, you must trust his judgment, and allow him to manage the cases with minimal control by you. Remember, though, that current Center for Medicare and Medicaid Services regulations require the preceptor to be present throughout the entire diagnostic evaluation when the patient has Medicare coverage.

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CREATING CLINICAL LEARNING

The learning opportunities we establish for our students are dependent on three main considerations: what we want to teach (content including skills, attitudes, and values); who we are teaching (stage of student's development); and level of competence at each stage of development.8

Clinical education can take many forms, and is not a straightforward process, and it will pose a number of challenges when integrating students into your clinical practice. (Figure 3.)

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One of the most common reasons clinicians do not work with students is time. Clinical teaching occurs in the context of a busy clinical setting where time is at a premium. You may feel that there is too little time to teach because you have many patients to see, with little to no time between patients. If your day is too busy, it may be more meaningful to have the student revert to the observer (Triad A). The experience can continue to be a teaching opportunity by spending a few minutes at the end of the day to discuss the session.

Providing teaching moments in a busy, time-pressed clinical setting is not only possible but very doable—it just may require some thought and creative planning. The “one-minute preceptor” approach offers a teaching technique that can be used easily with your student.9 This strategy has five steps or “microskills” you want to accomplish when discussing a clinical case with your student. (Table 3.)

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Another challenge in working with students is the mismatch between the needs of the student and the patient. The student's level of expertise may not be consistent with the services needed by the patient. A second-year student, for instance, may not know how to reprogram hearing aids to address a patient's complaints, but there are learning opportunities in each diagnostic and treatment case, regardless of student skill level or patient complexity, through one-on-one discussion and role modeling.

And learning is not limited to the clinical setting and direct patient contact. Other activities can be implemented to help students achieve the learning objectives for your rotation, and a number of options can enhance the learning experience outside the clinic for students. (Table 4.) While this list is geared more toward fourth-year students, many of these activities can be modified for younger students. A few examples that are appropriate for all students include:

Table 4
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* Preceptors should encourage students to research a specific disorder or syndrome presented by a patient and compile that information into a notebook. Because the student was involved with the case, the information has greater relevance than reviewing abstract case studies from a textbook or journal article. Including the resulting audiometric and otologic findings in the notebook permits review of that particular disorder or syndrome, reinforcing the learning process. Of course, all identifying information needs to be removed from clinical documentation to preserve patient confidentiality and comply with HIPAA regulations.

* Preceptors can also instruct students to develop a series of grand rounds that they present to the staff. This activity promotes performing literature searches, organizing material, and developing presentation style. Topics can include increasing knowledge base (e.g., anatomy, physiology, diseases, syndromes), debating different practice management processes (available speech assessment tools, verification and validation methods), or developing best practice clinical documents.

Many activities or learning opportunities occur outside direct patient care that will not only enhance student skills and knowledge but may be beneficial to the staff as well.

Working with students in the clinical setting may be challenging, but preparation and creativity can make precepting rewarding and beneficial for the student, preceptor, patient, and practice.

In the September and November issues of The Hearing Journal, we will take a closer look at adult learning theory and the issues involved in the evaluation process.

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REFERENCES

1. Zachary LJ: The mentor's guide: facilitating effective learning relationships. San Francisco: Jossey-Bass, A Wiley Company, 2000.

2. Kleffner JH: Becoming an effective preceptor. Available online: www.utexas.edu/pharmacy/general/experiential/practitioner/becoming.pdf, 2010. Retrieved: May 18, 2011.

3. Kolb DA: Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall, 1984.

4. Atherton JS: The experiential learing cycle. Available online: http://learningandteaching.info/learning/experience.htm; 2009. Accessed May 18, 2011.

5. Neill J: Experiential learning cycles. Available online: http://wilderdom.com/experiential/elc/ExperientialLearningCycle.htm; 2010. Accessed May 18, 2011.

6. DeClute J, Ladyshewsky R: Enhancing clinical competence using a collaborative clinical education model. Phys Ther 1993;73(10):683–689.

7. Spencer J: ABC of learning and teaching in medicine: learning and teaching in the clinical environment. BMJ 2003;326(7389):591–594.

8. White C, Manfred L, Bowen J, Leamon M et al.: Instructional methods and strategies. Guidebook for Clnical Directors (3rd ed). Available online: http://familymed.uthscsa.edu/ACE/chapter5.htm. Accessed May 18, 2011.

9. Neher JO, Gordon KC, Meyer B, Stevens N: A five-step “microskills” model of clinical teaching. J Am Board Fam Pract 1992;5(4):19–24.

© 2011 Lippincott Williams & Wilkins, Inc.

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