Geriatric Tricks of the Trade for Teaching at the

Bedside Barbara Resnick, PhD, CRNP, FAAN, FAANP

The Advantages of Bedside Teaching

• "Learning is nothing but discovery that something is possible: To teach means to show a person that something is possible"

• Frederick Perls, Gestalt Therapy Verbatim

Teaching at the Bedside

• One of the tangible benefits of teaching is the chance to stimulate students' critical thinking and also demonstrate these skills.

• Critical thinkers – engage in productive and positive intellectual activities; – view their thinking as a process rather than an outcome; – vary their applications of critical thinking according to

the context of the clinical situation; and – feel comfortable with the emotive as well as rational

elements of the critical thinking process.

– ????TASK VERSUS OUTCOME!

Teaching at the Bedside

• The elements of critical thinking in a clinical context includes: – identifying and challenging

student assumptions; – understanding the importance

of the particular clinical situation to the thinking;

– exploring and imagining alternatives; and

– engaging in reflective skepticism.

Teaching at the Bedside

•Agree on the ground rules

• Ground rules are both practical (punctuality, dress, access to patient records) and philosophical (respect for patients and colleagues, confidentiality, consent, openness to different points of view).

• Make sure that the learner knows how much time you will be able to spend in observing, teaching, and giving

• Clear expectations set for the day

Teaching at the Bedside

• Ask for her/his thoughts…no matter the situation …before immediately moving into action - that is where the best learning/understanding takes place.

• Dialogue during the course of the busy day to clarify and validate existing knowledge or to gain new insights.

• At the end of the clinical day, take a few minutes to reflect on what happened, why it happened, what you liked about the day and the student's performance as well as what each of you could have done differently to improve the outcomes of the practice.

Teaching at the Bedside

• Challenges of clinical teaching• x Time pressures• x Competing demands—clinical (especially when

needs of patients• and students conflict); administrative; research• x Increasing numbers of students• x Clinical environment not “teaching friendly”

(grabbing private area)• x Rewards and recognition for teachers and

students want the A-OKAY approach!

Teaching at the Bedside

• Common problems with clinical teaching

• x TOOO much passive observation rather than active participation of learners

• x Inadequate supervision and provision of feedback

• x Little opportunity for reflection and discussion• x “Teaching by humiliation”

– Power over versus power with– Stress a learning together mode

Teaching at the Bedside • How to use questions• x Restrict use of closed questions to establishing facts

or baseline• knowledge (What? When? How many?)• x Use open or clarifying/probing questions in all other

circumstances• (What are the options? What if?)• x Allow adequate time for students to give a response

—don’t speak• too soon• x Follow a poor answer with another question-ask the

same thing three ways!• x Resist the temptation to answer learners’ questions

—GIVE HOMEWORK AND FOLLOW UP

Teaching at the Bedside

• How to give effective explanations

• x Focus on non-verbal cues to get sense of what they know

• x Give information in “bite size” chunks

• x ask student to summarize their experiences

Teaching at the Bedside

• FOLLOW….Sir William Osler’s dictum that “it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself”.

Teaching at the Bedside

Give feedback•Learners value feedback highly, and valid feedback is based on observation. •Deal with observable behaviors and be practical, timely, and concrete…. And in private.

Making it Happen: It is all in a Day

• Know your student ….– Attitudes toward aging – Prior aging experience– What can they handle?

A Self-efficacy Approach

• Social cognitive theory…– Self-efficacy– Outcome expectations• Performance• Verbal encouragement• Role modeling• PHYSIOLOGICAL FEEDBACK-angst/sweating/increased

heart rate…fear versus feel good, feel proud

Determine What they Need

• Carefully consider clinical experience and exposure– What are their clinical strengths and weaknesses• Do they need to learn more about heart murmurs; afib;

gyn problems; infections?

– Match patient to student provider – vice versa• What do they want to learn and how can you excite

them?• Clinically in geriatrics we have it all-things you can’t see

elsewhere

Set Them Free

• Give the student a list of patients to see, write up and report back– Let them do this alone and TELL them why!• Give them the freedom to make mistakes alone-tell

them this is why you are not supervising them.• Let them know clearly the expectation

– Present the case orally– Write up the note in draft– Let them know you plan to discuss this and when

Nonstop model the behavior

• While it is hard …remember you are constantly being observed by the student and must:– Be on best behavior• Model the kind of care you feel should be provided• Address and acknowledge when you cut corners• Share your own mistakes as you make them

Even on busy days…model and show what you want them to know

Model the Joy, Fun, Excitement of Geriatrics • This is not setting

specific it is spirit specific– Greenhouse effect

or not!– Make your

environment one that exudes positive aging

At The Bedside

• At the end of your day….review findings with the student– Go back to the patient– Confirm what the note says….is there a murmur

for real? Is there REALLY no edema? Let the student see and feel it.

– Share exciting clinical findings – things they won’t see elsewhere (tumors, murmurs, palpable thyroids, livers etc)

DO NOT…..at all costs….correct the student in front of the patient.

At all costs…make it a feel good, successful experience

Become A Novice

• As you model….remember to put on your novice hat– Avoid skipping steps that may be skipped as an

expert or ARTICULATE what they are.– Acknowledge your own shortcuts

Do NOT Settle

• Note writing– A note is a reflection of the students’

knowledge/NP practice– A note is a reflection of YOU, YOUR program and

YOUR University.– I take a zero tolerance approach…with LOVE• Write, rewrite and rewrite again• NO books, blackberries or Iphones

Challenge with Love

• Ask and expect– Pharmacology– Lab questions• Expect the answer without books• Repeat the questions on another patient in another

way and on another day• Have the student share their learning with others in

class-via sharing the case or providing the didactic background they have reviewed.• Give homework and check answers

Review Progress

• If it is one day experience…at the end of the day review progress or lack there of.

• If it is a full semester at mid and semester end review: – Where you were– Where you are– Where you are going– What you need– What you need to do to get there

Handling the Tears

• Women cry– Nursing students are used to being expert nurses

in all clinical situations.– I start my experiences with them letting them

know I have been practicing as an NP for over 30 years.

– I share with them that I make mistakes every day.……..they still cry if everything isn’t perfect.

Handling the Tears

• I mostly ignore them….and keep on going – Criticisms with love and support– Acknowledging of course the good and great

before the issues and concerns

Dealing with the Defensive Student

• My biggest challenge– Acknowledge this coping mechanism– Discuss it• MOVE ON TO LEARNING!• GIVE UP

Like Child Care and Clinical Work

• TAKE A BREAK WHEN YOU KNOW YOU NEED IT– We are human– We get tired– We get cranky– We drink too much coffee– END THE DAY but do not model negative care

behaviors….• Do not dress a patient• Do not get short with a patient or nurse

Share Gero Opportunities

• Nonstop and throughout the programs plant the seeds of gero opportunities– Subacute– LTC– AL– Specialty work

My Three Favorite Sayings….

• If I didn’t care I wouldn’t bother…..• It is what it is ….• You don’t lose anything by giving it away…..

Along Those Lines

• Make sure to include a combination of– Challenging cases for

learning– Easy successful cases

for confidence building

Make Sure to Have Fun!