The Educational Role of Senior Hospital Staff

Fig. 14.1

Development of Competence
Experts, recognised by colleagues for being at the top of their field, may appear to be unconsciously competent (UC), but develop their high level of performance by remaining conscious of their performance and reflect on what they have done, how well they did it and whether they should take a different approach next time. They do this when working in challenging cases or when an error was made, but even when there are no problems, they still ask “Could I have done this better?” The addition of a fifth stage, termed “reflective competence” to the standard model of developing competence reminds us we need to regularly slow down and review our competence, and it is through this we continue to improve and perform at a higher level [15, 16, 18].
The translation of these concepts to what kind of learning environment you establish is that by engendering a culture of reflection and reinforcing it through teaching, learners are much more likely to gain knowledge and skills and take responsibility for the learning themselves [19]. As the teacher, the following are important aspects of deliberate practice you are responsible for [20];
  • Define outcomes (or use University or College set outcomes, or job description) , which are important to focus on in your setting.
  • Ensure learners have the opportunity to repeat tasks and improve.
  • Provide learners with good supervision and feedback.
It is up to the learner to reflect on performance, remain motivated and put in the effort and plan so time is used optimally.
A simple approach to establishing the educational program for students, trainees or new health professionals based with you from a few weeks to many months, is shown in Fig.14.2 [2]. This similarly applies to new staff who have a probationary period and who are expected to come with skills and learn new ones. You start with understanding and then defining for your specific setting, the learning outcomes; secondly, you facilitate the learning experience; and finally, provide feedback aiming to help learners improve or assess to determine their competence. The rest of this Chapter will use this framework to explore each area in depth.
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Fig. 14.2

Learning cycle. (Modified from Lake [2]

Phase 1: Defining Outcomes and Planning

Senior staff often think at the last moment about what they can teach and students are often asked “what do you want to learn about today” (not uncommonly leading to an awkward silence). We less often consider what a learner should leave the attachment knowing or be capable of doing, be it over 2 weeks or 12 months. As a teacher, you will receive the guidebooks for the clinical rotation, from the University for your students, the hospital for prevocational trainees and Colleges for specialist trainees, and job descriptions for new staff, outlining expected learning outcomes, learning activities and assessment or performance expected [21]. Often lengthy and complicated , these need to be turned into something manageable for yourself and useful for learners, which can provide guidance on a week to week basis but ensure comprehensive coverage on a term basis [21, 22].
Learning outcomes are explicit statements that refer to what a learner needs to know or be able to do at a given point in time.
Frequently based around clinical competence (knowledge and procedural skills), communication and professional skills , they are to guide the learning and are linked to assessment [21]. To tackle outcomes by aiming to tick each one off, makes for an impossible task for the teacher. The beauty of learning in the clinical environment is that multiple outcomes are fully integrated in activities or skills we use on a daily basis; such as talking to patients and colleagues, making a diagnosis or choosing a treatment . By encouraging activities that include multiple clinical, communication and professional outcomes, such as clerking patients, and then ensuring presentation to you and others is combined with discussion of a range of issues (not just the diagnosis), guidance to further learning and importantly provision of feedback on the learners performance, we can feel comfortable as to the breadth of learning. Ideally this is supplemented by highlighting difficult or complex topics in tutorials or grabbed moments during work.
Although as noted stated outcomes are often extensive and learning around a patient very integrated, so it is useful to personalise the outcomes and activities for your own setting, knowing what conditions are common, opportunities the practice provides, degree of supervision required and extent of risk if learners are unsupervised and your personal style. A suggested step by step approach to develop your own Plan is outlined below, with examples as to how outcomes can link to learning activities and how they may differ for a student or a senior trainee (Table 14.1).
Table 14.1

Linking Outcomes and Learning Activities
Outcomes: what it is hoped is learnt
Learning activities: how they will go about learning
Clinical competence—SURGICAL WARD
Physiotherapy student
Take a history, perform an examination and formulate a post-operative mobilisation plan for a patient undergoing abdominal surgery
Clerk patients, write in notes, present to supervisor
Ensure they seek out common scenarios (emergency and elective surgery, elderly
Vocational medical trainee
Manage an acutely deteriorating patient in the inter-operative period
Simulation training
Observation and discussion during assisting with increased responsibility matching competence
Communication—PAEDIATRIC EMERGENCY DEPARTMENT
Medical student
Obtain informed consent for a common minor procedures (such as IV cannulation
You role model with student observation and reflection
Practice under supervision
Role play
Trainee administrative officer
Demonstrate effective verbal communication skills and styles with hospital staff
Role modelling and observation with discussion during supervised placement, with increasing responsibility matching competence
Seek feedback from other staff on performance
Professionalism—GENERAL MEDICAL TEAM
Nursing student
Describe and explain the principles of multidisciplinary care
Role modelling, student observation, reflection and discussion
Attachment to another professional and reflection on observations
Required attendance at weekly multidisciplinary meeting
Vocational trainee
Recognise, display and discuss ethical behaviour in clinical practice
Discussion around critical incidents
Discussion on specific scenarios (referrals, treatment decisions in incompetent patients
1.

Start with the Learning Outcomes
 
2.

Choose outcomes covering areas which are a core part of your practice and therefore able to be met (Taking a history on inpatient ward; obtaining informed consent in a surgical day ward, assessing home safety, organising financial reports).
 
3.

Highlight or add your own outcomes, by considering what is special about your environment that you think is important to learn (breaking bad news in an Oncology ward).
 
4.

Relate the chosen learning outcomes to learning activities that are possible and manageable in your environment [1, 5, 23, 24]. Consider;
a.

Who else can teach, supervise and give feedback? (share the load, involve other professions).
 
b.

What resources are on hand to assist learning (e.g. on-line, simulation).
 
c.

What activities will you organise? (tutorials, case reviews, learning on ward rounds or in theatre).
 
d.

How can they learn by themselves? (Set guidelines for using unallocated time).
 
 
5.

Consider when you will observe and give feedback.
 
6.

Do you need to assess for competence? (As set by Universities, Hospitals and Colleges) [11].
 
7.

Make all this explicit to the trainee/student at an orientation meeting.
 
The key principles behind well written outcomes, are that they are SAM;
Specific Worded clearly so they know what is to be achieved (“take a history”) and at what level (“patients with common conditions”).
Achievable How long will it take to reach the set standard (is the term long enough)? Are there sufficient cases and opportunity to practise? Do they have the basic skills to tackle the outcomes (passed basic surgical skills course prior to attempting an appendectomy)?
Measurable The learner (through reflection) and you (by assessing) can determine if competence has been reached (i.e. 80 % of cannula in first time).
Even with extensive experience and learning, gaps may still be significant. These need to be identified, through regular review of the outcomes by both the learners and supervisor and supervisor reflection on whether performance is matching the expected outcomes for that learner.

Phase 2: Facilitating Learning: Providing Opportunities to Repeat Tasks and Improve

Familiarity with expected outcomes provides you with the guidance as to what needs to be learnt. The previous section also touched on how learning can be encouraged, for example through learners interacting with patients and discussion encourages reflection on important topics. However, when it is busy, things often fall apart. For students, the complaint is often they feel in the way, and have no real role. Under stress, junior or new staff tend to focus on tasks and or mainly learn how to survive. Therefore you need a range of strategies to ensure learner engagement which will push learners out of their comfort zone, while allowing you to cope with the workload and still provide safe patient care [1, 3, 5, 23, 24, 25]. Much has been written about this area, including frameworks for couching a teaching session [25]. Important tips are to avoid trying to cover too much, ensuring the topic and questions are pitched at the correct level and, use questions to explore what learners do NOT understand (rather than reinforcing what they do know) [25, 26, 27] and provide guidance at the end to what further reading they should do or resources they should look at. Table 14.2 provides a range of practical ideas for different settings .
Table 14.2

Educational strategies for clinical teachers
Setting
Opportunities
Ward rounds
Evidence shows patients like being involved in teaching and learning as long as they are asked permission, treated with respect, have their answers questions. They are a good source of feedback for learners
Make the student write in the patient notes and provide feedback on their efforts
Allocate each patient depending on their problem and who knows them to someone (you, junior medical staff, student) and that person should lead the patient interaction (greetings, introductions, questions, examination, explanations). Check understanding before entering and let students know you are there as a backup. Afterwards, all provide feedback on the interaction (ensure your performance is also critiqued). Students are terrified but love the experience and sometimes are better than the doctors! Valuable learning points, in particular around communication and professional behaviour, are often raised for the doctors
Involve everyone in discussion around the problems, diagnosis or management by getting those more senior to answer student’s questions. Rather than ask Learners questions (which tends to test what they do know), ask what they do not understand about a case [25]
Teaching moments—on each patient grab a few minutes to reinforce a specific point, check understanding and recommend further reading (Avoid trying to cover too much
Use SNAPPS, [26, 27] show to increase clinical reasoning, as a guide to the interaction around a patient’s problem;
Learner S

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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on The Educational Role of Senior Hospital Staff
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