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Helping Our Students AND Preceptors Succeed
Doctor Frank J. Tornetta
Memorial Lecture
Contact Information
• John O’Donnell
– jod01@pitt.edu
• Michael Kost
– kostmike@einstein.edu
Our Discussion Plan
• The stakes – Why CRNA preceptors and SRNAs should care
• The teaching-learning environment – Today’s perioperative environment
• Parallel priorities – Safe patient care combined with student success
• A review of educational best practices – Moving from theoretical principles to practical
principles
Learning Objectives
• Describe current processes in preparing preceptors and statements for their roles
• Review environmental and situational factors that determine an effective teaching/learning environment
• Analyze trigger videos and clinical vignettes to identify problems and potential solutions
• Reiterate practical applications to the clinical area
Developing Agreement
• Are all NAPs and their students alike?
• What is the main job of a preceptor?
• How to individualize to students?
• Are SRNAs truly adult learners?
• How do patient care priorities impact clinical precepting?
Ex: Student vs. Preceptor Expectations Medication Preparation
Why is Precepting Challenging?
• Stressors of student role
• Stressors of the faculty role
• Production pressure
• Complex patients
• Mismatch of student level to case/situation
• Remediation student
Importance of Preceptor Education
and Preparation for the Role
How Do We Align Expectations
Focus: Precepting Best-Practices
• Interactive learning
• Review of educational best practices for clinical precepting
• Mostly expert consensus, from other professions or taken out of the simulation world
– Ex: Loading (Power/load, cognitive load), feedback, pre-brief/debrief, reflective learning, novice to expert development process
• Provide practical approaches/techniques to improve the teaching-learning environment
Baseline Video Group Discussion
3 Key Precepting Skills (among others)
for signs of stress, anxiety, overload and ‘gaps’ Observation
• This will allow you to intervene when students become overloaded
• Often useful to identify a task or function they CAN do
Expectations and objectives clearly Communication
• This will reduce SRNA confusion about what is expected and….
• Set the stage for deeper understanding of their performance
Coaching, prompting and cueing Use of
Techniques
• Being mindful about which techniques are most effective for students at different levels of ability is critical
• For example: more novice students or those under stress may require that you use more direct instruction as compared to more advanced students
Careful Preceptor Observation
Identifying & Closing ‘Gaps’
Performed well
Performed well
Performed poorly
Performed poorly
Feels good
Feels bad
Feels bad
Feels good
GAP
CRNA Preceptor:
Observation of performance SRNA:
Perception of performance
Knowledge
Skill
Behavioral
14 Adapted from: Phrampus P.E. and O’Donnell J.M. ‘Debriefing: Using a Structured and Supported Approach’ in The Science and Art of Health Care Simulation (Ed.) Levine A.L., Bryson E.O., DeMaria S., Schwartz A.D. Springer and Springer (2013)
Common Precepting Techniques
• Active instruction- do – Coaching
• Directing, instructing and training …..aim to achieve some goal or develop a specific skill
– Prompting • Well….what was our plan?
– Cueing (more experienced) • Giving more subtle clues- verbal non-
verbal that are designed to trigger an action
• Passive instruction- show
– Modeling- demonstrating effective behaviors that you want students to emulate
Directly Instruct
Facilitation
Importance of Preceptor Use of
Educational Best Practices
17
Personalized experience
Making didactic information come to life
Transfer of knowledge and skill
Serving as a positive role model
Video 1 Group Discussion
Video 1: Effective Planning Practical Application
• Educational Time Out (ETO) – Pre-briefing
– Occurs at the beginning of the day BEFORE beginning of the first case or a few minutes prior to the case
Easton A., O’Donnell J.M., Morrison S., Lutz C. Development of an Online, Evidence-based CRNA Preceptor Training Tutorial (CPiTT): A Quality Improvement Project. AANA Journal. (in press- scheduled for publication Summer 2018)
Prebrief Assess SRNA Level and Experience
Prebrief
Prebrief
“This is my fourth day in the O.R.”
Prebrief Plan and set achievable goals…
• “Just want to let you know that you will be receiving an unsatisfactory clinical evaluation on one of your students. Really has to work on room turnover and anticipating events in the O.R…”
Patricia Benner Stages of Clinical Competence
Dreyfus Model of Skill Acquisition
• Stuart Dreyfus
– Mathematician and systems analyst
• Hubert Dreyfus – Philosopher
• Developed a model of skill acquisition based on the study of chess players and airline pilots.
• Benner applied it to nursing practice Dreyfus, S. & Dreyfus, H. (1980). A five stage model of the
mental activities involved in directed skill acquisition. Unpublished report supported by the Air Force Office of Scientific Research (AFSC), USAF. University of California at Berkley.
The 5 Levels of Nursing Practice
NOVICE ADVANCED BEGINNER
COMPETENT
PROFICIENT EXPERT
27
The Expert Practitioner
“Experts are always made, not born.”
-Ericsson, Prietula, & Cokely
29
Novice 10,000 hours Expert
I. Novice
The Novice SRNA
Characteristic
The SRNA has the theoretical knowledge
of anesthesia from their didactic study but little
practical application
CRNA Preceptor Role
Discuss your expectations for the SRNA and his/her
responsibilities before beginning patient care
Read the care plan and discuss it with the
SRNA while imparting any knowledge you have about the case
32
I. Novice Expectations
• SRNA
– No experience
– Should not be expected to ‘perform’
– Behavior in the clinical area is inflexible and limited
I. Novice Expectations
• CRNA Preceptor
– Understands not ‘all’ didactic course work initiated
– Observation days are utilized by some programs
• 2 to 3 days early in program
– Initial clinical assignments
• Assign ‘routine, reasonable’ clinical cases
• If possible, assure student has case assignment prior to clinical day
– Extremely stressful
• SRNA does ‘not know what they do not know’
I. Novice Expectations
Video 2 Group Discussion
Video 2: Effective Evaluation Practical Application
Forms of Student Evaluation
Formative Summative Responsibility of CRNA preceptor or
anesthesiologist Responsibility of the Clinical Coordinator
Critiques the SRNAs performance for the day
Reflects the SRNA’s performance at the end of a rotation
Verbal feedback should be offered to SRNA when possible
Clinical coordinators should review with the SRNA if possible
Unsatisfactory performance should be discussed with SRNA and documented on
the daily evaluation
Clinical Coordinator should be made aware
Unsatisfactory performance should be discussed with the SRNA’s advisor
44
Effective Evaluation
Timely
Non Judgmental
Private
Objective
SRNA Expectations
• Preceptor has working knowledge of:
– Principles of adult education and adult learning
– Learning styles
– Planning and implementing learning experiences
– Principles of providing objective clinical evaluations and providing constructive feedback
– Resources to problem solve
Ideal Characteristics
• Overall, they agree that critical requirements of the effective clinical preceptor include:
– Sound interpersonal skills
– Able to provide timely feedback
– Are clinically competent
– Function as good role models
– Encourage mutual respect C. Kelly (2006) Student’s perceptions of effective clinical
teaching revisited. Nurse Education Today, 27, 885-892.
Practical Approaches to Evaluation
• Production/Patient Care Pressures
• Practical and easy to use approaches – Plus - Delta
– One minute preceptor
– Newspaper review
– GAS
Plus/Delta
What did you do effectively?
What would you
do next time?
One Minute Preceptor
• Described by Neher, Gordon, Meyer and Stevens in 1992
• Beneficial when ‘teaching moments’ are very short.
• Effectiveness evaluated in several studies
– (Aagaard, Teherani & Irby 2004)
One Minute Preceptor
Plus/Delta
‘End of the Day Newspaper Review Technique’
• End of the day review that focuses on: • Learning goals achieved
• Clinical tasks accomplished
• Student perception of clinical day
• What worked
• What did not work
• Identification of ‘clinical corrections’ for next clinical day
Plus/Delta
GAS Tool
Goal: Listen to the SRNA to understand what they think & how they feel
GA
THER
25%
Actions: Have the SRNA fill out this portion of the evaluation form. Review this portion of the evaluation with the SRNA
Sample Questions: How do you feel the clinical day went? Were your goals achieved?
GAS Tool
Goal : Facilitate the SRNA reflection on & analysis of their actions
AN
ALY
ZE
50%
Actions: You complete this portion of the evaluation – include narrative about things that stuck out in your mind during the clinical day.
Report observations (correct & incorrect steps)
Reveal the SRNA’s thinking processes
Reflect on performance
Sample Questions: “Tell me more about…”
“What were you thinking when…”
“I understand, however, tell me about “X” aspect of the case…”
“Let’s refocus… what’s important is not who is right but what is right for the patient…”
GAS Tool
Goal: Facilitate identification & review of lessons learned
SUM
MA
RIZ
E
25%
Actions: The SRNA identifies positive aspects of his/her performance along with areas of improvement
Summary of comments or statements
Sample Questions: “List two actions or events that you felt were effective or well done”
“Describe two areas that you think you need to work on…”
Summary: Using the GAS Model
Gather: Student impression
Analyze: Base on goals/ case detail
Summarize: Went well/ Need for improvement
Preceptor
Preceptor & Student
Student
Video 3 Group Discussion
Video 3: The ‘Safe’ Learning Environment
• Assignments match the clinical objectives
• Environment is viewed as ‘safe for learning’
• Student feel comfortable and ‘free to ask questions’
Objective Evaluation
• Objective assessment of
– Basic knowledge application
– Assessment skills
– Technical skills attainment
– Time management
– Critical thinking
– Communication
Safe = Factual
Safe = Fair
Family
Educational
Rights and
Privacy Act (FERPA)
64
Privacy of Student Education Records
SRNA Clinical Evaluation Forms
http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html
Safe = Legal
Video 4 Group Discussion
Video 4: Practical Application
CRNA’s and Clinical Sites are Program Partners
Student as Consumer
SRNA = Our Consumer
Health Care Benefits Pharmacy Benefits Meals
Tuition and Fees
NAPs
Clinical Sites
Students
Academic Institution
CRNA Perspective
• What is the ROI for having students?
– Service
– Professional rewards- teaching, satisfaction
– Recruiting opportunities
– Exposure to the latest thing
Achieving Balance
FINAL COMMENTS/DISCUSSION
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