Teaching the Senior Student - Ryerson

Teaching the Senior Student

Elizabeth AllemangClinical Education Coordinator

Loreto FreireExperiential Learning Coordinator

│Spring 2019

Content

slide #

3 MEP clinical curriculum and the senior year

6 C&C clinical objectives and learning to lead

9 Common learning and teaching challenges

11 Teaching tips and learning strategies

28 Feedback, evaluation and competency standards

37 Building effective student-preceptor relationships

43 When challenges arise

48 Placement structure, workload and planning

53 Ryerson MEP and university resources

2

MEP clinical curriculum

NC16+ weeks

3rd IP Year24 weeks

MNP 12+ weeks

Clerkship 12+ weeks

C&C11+ weeks

Normal conditionsVariations of normal conditions

Atypical conditions Abnormal conditions Professional issues

Kn

ow

led

ge

Skill

s

Basic midwifery skillsManagement of normal

IP collaborationFill in NC skills for senior yearAdvanced clinical skills intensives

Management of atypicalLearn to lead careConsolidate normal skillsAssist with emergency management

Management of abnormalLead careEmergency management with assistance

Entry level care under supervisionEmergency management with minimal assistance

3

Senior year overview

Complications &

Consultation

Maternal & Newborn

PathologyClerkship

Academic learning

• Atypical conditions

• Weekly PBL tutorials

• 2 papers/2 exams

• Abnormal conditions

• Weekly PBL tutors

• 2 papers/2 exams

• Professional issues

• Bi-weekly tutorials

• 2 comprehensive exams

Clinical learning

• Learning to lead care

• Consolidate normal

• Integrate aytpical

• Assist with emergencies

• Confident to lead care

• Consolidate atypical

• Integrate abnormal

• Initiate emergency care

• Entry level care under

supervision

• Final consolidation and

refinement

Placement length • 11 weeks + 4 days • 12 weeks + 3 days • 12 weeks + 3 days

Birth numbers• ≥ 12 primary

• ≥ 6 seconds

• ≥ 12 primary

• ≥ 6 seconds

• ≥ 12 primary

• ≥ 8 seconds

Expanded role• 1 routine postnatal visit

after day 3, before 6 weeks

• 2 routine postnatal visits


• Hospital birth: 1 of 2

midwives

• 3 routine postnatal visits


• Hospital/OOH birth: 1 of 2

midwives

4

5

C&C clinical placement objectives

A student who is Satisfactory in C&C:

• Displays an expanding base of knowledge about maternal and newborn conditions in situations outside of normal where consultation is required

• Demonstrates primary care responsibility in the provision of midwifery care

• Seeks advice and consultation from the supervising midwife as needed

• Demonstrates clinical decision making skills in normal situations with confidence and in situations outside of normal where consultation is required with minimal assistance

• Routinely initiates the planning of care and debriefs with preceptor

• Conducts prenatal and postnatal visits in normal situations with confidence and in situations outside of normal where consultation is required with minimal preceptor supervision

6

C&C clinical placement objectives

• Responds to pages and phone calls appropriately and provides clear information/direction to clients

• Manages normal labour and birth, including third stage, with confidence

• Manages labour and birth in situations requiring consultation with minimal assistance

• Identifies the need for intervention and/or consultation and participates in consultations with preceptor supervision

• Recognizes emergency situations and initiates care with preceptor assistance

• Establishes effective, professional relationships with clients, midwives, administrative staff, student midwives and other health professionals

7

Consolidating ‘normal’ knowledge and skills

Gaps identified with learning plan

Understanding components of MRP role

Learning knowledge and skills to manage ‘atypical’ conditions

Learning to communicate and lead care with assistance and prompts

Shifting from task orientated approach to seeing ‘big picture’

Understands MRP role

Moves from task oriented approach to big picture

Takes increasing responsibility as lead provider

Initiates communication about assessments and plans with decreasing prompts

Makes assessments and plans for normal conditions with confidence and for atypical conditions with decreasing assistance and prompts

Organizes and follows up care with minimal assistance

Uses systematic approaches

Leads care for normal and variations of normal with confidence and independence

Initiates communication about assessments and plans with minimal prompts

Leads care in atypical situations with minimal preceptor assistance and prompting

Able to assist in emergencies

Basic midwifery skills well consolidated

Plan for simulation or consolidation of skills with limited clinical opportunity, e.g. IVs, suturing, NRP, emergencies

Learning to lead – sample C&Cpathway

Entry to C&C

Midterm C&C

Final C&C

8

Common learning challenges

Skill/knowledge/experience gaps entering placement

Adapting to new practice environment

Managing/balancing primary care responsibilities

Communicating assessments and care plans, i.e. thinking out loud

Learning to lead care without prompting

Being systematic

Responsible and consistent follow up

Time management

Structured time for debriefing and teaching

Establishing effective/trusting student-preceptor relationship

9

Common teaching challenges

Handing over clinical care and decision making, especially for newer

preceptors still developing competence and confidence

Integrating student into senior level care with clients

Feeling confident in assessment of student’s level of competency

Comfort with indirect supervision

Providing difficult feedback

Understanding MEP competency expectations

Assisting the struggling student

Lack of familiarity with MEP curriculum and expectations if non-MEP grad

10

General teaching tips

Break skills and responsibilities into ‘chunks’ or building blocks

Mentor/teach a systematic approach to skills and clinical thinking

Recognize a plan is the outcome and assist students to build a care plan

Role model reflective practice and encourage students to self reflect on

the care they provide

Assist student to understand if at or above appropriate level

Assist student to recognize gaps and when to go back to theory and skills

basics, e.g. Leopold’s manouevres for abdominal palpation

11

‘Chunking’ skills

Break down skills into discrete components

Assists with transparency of skills and staged skill development

Assess where student is at in mastering components and where learning need starts

Have the student take on one step at a time and gradually add other components with increasing competency and consolidation

Expand to encompass the full skill or role

Suitable for clinical skills and clinical responsibilities, e.g. first call, primary care role

Supports systematic approach

Assists with feedback and evaluation

12

Mentorship

Mentoring is an effective teaching strategy

What you do and say has a powerful impact

Plays a significant role in learning to make clinical decisions and care plans

Explain why you do what you do, i.e. evidence, protocol, standards, etc.

Ask the student to provide a rationale for their recommendations or actions

13

Reflective practice

Reflective practice is an effective teaching strategy

Contributes to constructive analysis of care for improvement

Do self reflection first and ask student to self reflect before critiquing care of the others

Share rationale for your clinical actions or improvements

Explore context for you or others that may contribute to care provided

Clarify safety and evidence based practice vs style

Models professionalism, critical generosity and humility

14

Safety, best practice vs style

Distinguish safety vs best practice vs style

Clarify style differences in what student is seeing or being taught with co-preceptors

Be transparent about your style preferences

Consider if you can ‘tolerate’ style difference in student’s practice

15

Using structured approaches

Chart review

• Preceptor mentors student to do thorough yet efficient chart review followed by student supervision with constructive feedback

Making care plans

• Student does thorough 36 week chart review for primary clients, prepare admission history notes and writes anticipatory plan of care for labour

Giving concise reports

• Student presents concise report of client history and plan of care for a prenatal visit, starts visit, provides concise report to preceptor for what has been completed, assessment and plan of care prior to asking preceptor to step in and what priorities are for preceptor attendance at visit

16

Using structured approaches

Communicating assessments and care plans

• Student does initial assessment at labour, prepares report for preceptor with short term (1 hour) and long term (4 hour) plan of care

• Every hour, student updates short term and reviews 4 hour plan and reformulates as needed

• At the end of 4 hours, the student formulates a new 4 hour plan, reports hourly to preceptor and any revision to 4 hour plan

Immediate postpartum roles and responsibilities

• Student prepares list of immediate postpartum responsibilities for primary and second midwife

• After birth, student reviews list and assesses priorities

• Provides a concise report of roles and responsibilities and recommended priorities for preceptor feedback, revises as needed, implements plan

17

Using scripts*

‘First words and actions’ for the student to use when seeing conditions

Supports student-led communication

Facilitates student-preceptor conversation with client present

Allows for preceptor ‘correction’ in front of client

PPH e.g. – I am seeing more blood than we usually see. I recommend 10 IU oxytocin IM. [Preceptor] do you agree?

FHR e.g. – The baby’s heart rate is slow. I would like to change your position and reassess. [Preceptor] do you agree?

*Thanks to Jennifer Gardiner, The Midwives Clinic of East York-Don Mills

18

Using tools

Sample tools:

Primary care – Seeing the big picture of midwifery care

Developing care plans – Making care plans using ASOAPER

Communicating assessments and plans – ‘Traffic light’ model

Communicating plans and rationale – Using 3 questions

Preceptor pause – Rule of 3s

19

Seeing the Big Picture of Midwifery Care

This simple model breaks down midwifery

care into discrete components. It helps the

student to understand the midwife’s role

and responsibilities. Details for each area

of responsibility can be added (see

reverse). Illustrated as a series of balls

balanced around the central concept of

midwifery care, this model provides a

visual cue for students learning to multi-

task and prioritize the elements of

midwifery care. It is adaptable to clinical

learners at all levels, including the

struggling student. It provides a framework

for clinical teaching and for feedback and

evaluation. The areas shaded in green are

the focus of learning in the senior year.

Midwifery Education Program • 350 Victoria St Toronto ON Canada M5B 2K3 • www.ryerson.ca/midwifery/20

• Mentor/assist the student to identify and learn

the components of midwifery care

• Have the student be responsible for those

components where skilled and confident

• Add one new or challenging component at a

time until each one is mastered and integrated

• Set discrete goals with the student and a long

term plan to be responsible for all components

• Develop a multistep, gradual process for the

student to multitask all components at their

expected level of competency

• Use this model for student self-reflection and

to provide feedback re: progress for each

component and overall

• Reformulate goals and expectations for the

struggling student to build from their level of

skill and confidence, identify priorities and

make a staged learning plan

Elizabeth Allemang RM Associate Professor • Vicki Van Wagner RM Associate Professor • Spencer Sawyer SM

Using the Big Picture learning tool

21

Making Care Plans Using A-SOAP-ER

This expanded SOAP model provides a

visual cue that care plans are built on a

series of steps or building blocks. It

guides the student to use a systematic

approach and provides a tool for

preceptors to mentor clinical thinking.

Anticipation is added to guide students

to think ahead and consider a range of

options based on potential outcomes.

It assists the student to be better

prepared to act rather than react,

especially in the unpredictable, fast-

paced environment of intrapartum

care. Evaluate and reformulate are

added to remind the student to assess

the effectiveness of the care plan and

modify as needed.


Using the A-SOAP-ER learning tool

• Assist the student to understand the discrete components for making clinical decisions and care

plans and the importance of making a differential diagnosis before a likely diagnosis

• Assist the student to understand when to use this or another standardized tool like CHAT or

SBAR

• Assist the student to develop anticipation skills. Ask what findings they expect prior to making

an assessment and what actions may be needed with each potential finding

• When asking the student ‘What is your plan?’, remember a plan is an outcome that is built on a

series of steps

• Mentor how to sequentially move through each step to come to a likely diagnosis and plan

• Have the student demonstrate each step in a particular clinical situation, verbally or in writing

• Encourage the student to consistently and systematically use a step-by-step approach until

confident and competent

• Assist the student to develop reflective practice skills. Do case review and ask if the outcome

could have been anticipated and if so, when in the care. Ask what could have been done

differently and if the plan needed to be reformulated, when and how. What will the student do

differently another time

Elizabeth Allemang RM Associate Professor • Vicki Van Wagner RM Associate Professor • Spencer Sawyer SM23

Communicating Assessments and Plans

This model provides a structured

pathway that encourages the student

to communicate their assessments

and plans. The script provides an

‘easy’ starting point beginning with

observation. The simple framework

organizes assessments and actions

into three categories and the

management plan flows directly from

the assessment. It allows for staged

entry into clinical decision making as

the student’s learning progresses from

normal, to atypical to abnormal. Using

this tool helps to facilitate preceptor

‘correction’ in the clinical setting.


• Encourage the student to use the

pathway in common situations to

develop confidence

• Encourage the student to use the

pathway systematically

• Have the student follow the script

and state their responses aloud

• The symbol of a traffic light links the

assessment to an appropriate plan

• Use the pathway if prompting is

needed, e.g. What are you seeing?

What are the parameters for normal

(or abnormal) for the situation? If

atypical, what would increased

surveillance look like?

Elizabeth Allemang RM Associate Professor • Vicki Van Wagner RM Associate Professor • Spencer Sawyer SM

Using the Communication learning tool

‘Traffic Light’ model: Green = proceed Yellow = caution Red = action

25

Communicating plans and rationales –using 3 questions*

Assist/encourage the student to use the following 3 questions to provide their plan and rationale:

What?

Why?

Why now?

*Thanks to Sandy Knight, Niagara Midwifery Practice

26

Preceptor ‘pause’ – rule of 3s

Students will not make decisions or take action as quickly as preceptors - it can feel uncomfortable to wait for the student to formulate a plan or take the initiative needed

Some preceptors use the ‘rule of 3s’ to help them give the student more time before they prompt or take over

For example you could give the student:

• 3 seconds in shoulder dystocia or other emergency

• 3 minutes in with increased postpartum bleeding that does require immediate response

• 3 hours to identify the need to arrange a non urgent consult

• 3 weeks or even months to follow up an issue identified in history taking that is non urgent

26

Student feedback about feedback

Students report anxiety of feedback due to:

• Feeling ‘watched’ and being evaluated

• Preceptor-student power dynamic and preceptor responsibility to evaluate

• Working with multiple preceptors with different expectation and styles

• Critical vs constructive feedback for learning

• Lack of positive feedback

• Lack of structured opportunities for feedback

• Timing and place of feedback, e.g. being critiqued in front of clients, other care providers

27

Contextualizing feedback and evaluation

Preceptor responsibility for evaluation contributes to (real and perceived) power imbalance in student-preceptor relationship

Expect your student is far more anxious than you perceive

Even students who are excelling need to know where they are meeting expectations

Knowing where they are doing well provides a ‘safety net’ for students to hear and integrate feedback and evaluation

Students integrate more feedback if they are not afraid they are failing

Students who are struggling need to know where they are doing well as well as areas for improvement and benefit from a team approach with clear expectations

28

Effective feedback and evaluation

Role model reflective practice

Role model professionalism re: feedback

Debrief regularly

Provide written feedback

Coordinate feedback from other preceptors

Be timely and specific

Be positive, transparent and constructive

Focus on learning rather than performance

Be open and straightforward about challenges and how to work together to address them

29

More on feedback and evaluation

Use MEP materials (course clinical evaluation form, MEP Guide to Teaching, Learning and Assessment) to set expectations and goals

Tell students what they are doing well and what needs to be improved

Don’t isolate yourself with your student if things are not going well

Get input and support from practice members, experienced preceptors

Get help early from the tutor

Request additional faculty support as needed, e.g. Course Coordinator

If a student is not at the level they should be, make a clear and active plan to remediate with tutor assistance

30

Feedback and evaluation strategies

Checklist feedback forms – student or preceptor led (see ‘Guide’)

Reflective feedback, e.g. 1 thing did well, 1 thing to be improved, 1 thing to review or look up

Informal debriefing ‘on the fly’

Structured/regular debriefing times

31

Evaluation meetings

Opportunity to model professional behavior

Book in a timely and cooperative way, cancel only for births

Be on time and treat the evaluation as a formal meeting

Follow MEP policy for evaluation procedure, i.e. preceptor and student complete form independently, meet together to review, then meet with tutor to report

Evaluate at appropriate level and be clear about learning needs to be addressed

Too high expectations is not fair, but failure to fail is not kind to the student

Tutor can assist preceptor and student with grading

32

Grading

Midterm – Satisfactory or Unsatisfactory

Final – Satisfactory, Unsatisfactory, Provisional Satisfactory

Provisional Satisfactory – 4 week remedial placement with objectives and goals, suitable for discrete ‘gaps’

Placement extension – up to 4 weeks if learning opportunities have been limited

33

Clinical competency standards

Clinical course objectives and competencies defined in clinical evaluation forms

• Care management skills• Assessment skills• Communication skills• Clinical skills• Pharmacology skills• Professional skills

Levels of competency and teaching suggestions defined in MEP Guide to Teaching, Learning and Assessment

• Introductory• Intermediate• Entry to practice

34

https://www.ryerson.ca/midwifery/Placements/Preceptor-Events-and-Resources/

Clinical course benchmarks

Provide a baseline for what is needed to achieve a Satisfactory grade

Developed as guideline by Ryerson faculty for faculty to support appropriate grading

Developed for midwifery clinical courses and pre-clinical midwifery skills course to support grading

Developed for midterm and final evaluations

35

Effective student-preceptor relationships

Coordinate with co-preceptor(s) re: clinical workload, student priorities and feedback/evaluation

Mentor and assist student to prioritize clinical responsibilities to meet MEP workload standards

Support students to prioritize academic work

Foster an environment for open dialogue

Make structured time for debriefing/check in

Ask for feedback about your teaching

Use ‘Ask-Connect-Reflect’ cards to facilitate communication between preceptors and students (next slides)

36

Preventing and minimizing problems

Create an environment that welcomes students to raise concerns

Identify issues early

Take a problem solving approach

Ideally resolved by student and preceptor speaking directly with one another

Tutor is first point of contact within the MEP

Identify a person other than preceptor who student can go to within the practice if needed, ‘Teaching Practice Coordinator’

Be aware of power dynamics

See MEP template protocol for preceptor-student communication

37

Giving and receiving feedback

38

39

40

41

When learning challenges arise

Identify issues early

Notify tutor and seek assistance ASAP

Document your feedback and evaluation in relation to competency expectations

Set goals and depersonalize – use the Guide to Teaching, Learning and Assessment and clinical evaluation form

Make a learning plan with tutor assistance

Create an appropriate time frame for improvement

Facilitate clinical/simulation learning opportunities

42

When challenges are significant

Adjust expectations to where a struggling student is at rather than where they should be and assist them to progress from that point

Be transparent about learning needs (and document) and support remediation plan

Students may require more time, e.g. provisional placement, failure and repeat course

Students may be assigned to another preceptor or practice

43

Problem solving/conflict pathways

Developed following consultation with for preceptors, students and tutors and literature review on conflict in health professions education

Encourage direct communication and give both student and preceptor the option of seeking guidance from the tutor first

Guide tutors to make clear plans and be in frequent contact with students and preceptors when they experience problems or conflict

Seek to resolve issues within the placement but acknowledge that a tutor may recommend the student be relocated to a different placement if the conflict is not resolved

Students may take concerns directly to other offices in the university

44

45

46

Structuring an effective placement

Placement orientation, including preceptor/call model

Assign a coordinating preceptor

Plan appropriate clinical workload and experience with scope of practice considerations

Assist student to plan off call time and study time

Review student learning plan/needs and course competencies

Provide Active teaching/learning opportunities

Use ongoing and structured feedback mechanisms

Follow formal evaluation processes according to course standards

47

Common student placement challenges

Balancing clinical & academic responsibilities

On call models and multiple preceptors

Excessive workload – often clinic workload and seconds

Insufficient clinical experience – new MEP workload policies, scope of practice issues

Learning-teaching ‘fit’ with preceptor(s)

Managing stress and anxiety

Finding time for structured feedback, teaching and evaluation

Transitioning into lead role

48

Placement planning considerations

MEP policies related to clinical placements - see the Ryerson MEP Preceptor Policy Book

MEP birth number and clinical workload standards

Off call and study time

Preceptor caseload/call models

49


MEP workload policies

MEP Student Workload Report and Recommendations (2019):

• Average prenatal and postnatal visits per week: increased from 15 to 20

• Birth numbers: maximum planned birth numbers increased and minimum

number of primary births attended defined per course

• Time off call per month: 4 days away from the placement, not including

study day

• Study time: 24 hour off call ‘academic day’ Thurs 5pm-Fri 5pm

• Safety policy: off call time increased to 12 hours and clarified after 24 hours

awake

50

Academic study day variations

Variations to the study day may be requested by the preceptor and

approved by the tutor for all students and for students at risk of a shortfall

of attended births

Variations for all students:

• Start time of 24 hour study day may be delayed into late afternoon/early

evening on Thursday to accommodate routine clinic times needed to meet

prenatal/postnatal workload standard (requires advanced tutor approval)

• Student may attend birth up to 2359 on Thursday (student to notify tutor)

Variations for students at risk of birth shortfall (requires advanced tutor

approval)

• Student on soft call during study day and may miss one or more tutorial(s)

• Start/stop time of study day may be varied to stagger with other students in the

practice to maximize availability for student attendance at births

51

Policies/Resource Where to find

Ryerson Preceptor Policy Bookhttps://www.ryerson.ca/midwifery/Placements/Preceptor-Events-and-Resources/

Ryerson Policy & Information Handbook


MEP Policy and Information Handbook

Student can share access

Guide to Teaching, Learning & Assessment for Midwifery Preceptors and Student Midwives

http://www.ryerson.ca/content/dam/midwifery/students/Revised-and-Finalized-Guide-to-T-and-L-July-2013.pdf

Clinical evaluation form Student to share online form at onset of course

Student Guide to Professionalism https://www.ryerson.ca/midwifery/students/

MEP Equity Statement https://www.ryerson.ca/midwifery/about/equity/

MEP policies and resources

52



http://www.ryerson.ca/content/dam/midwifery/students/Revised-and-Finalized-Guide-to-T-and-L-July-2013.pdf

https://www.ryerson.ca/midwifery/students/

https://www.ryerson.ca/midwifery/about/equity/

Ryerson/MEP student services

Ryerson MEP• Student-faculty equity, diversity and inclusion (EDI) committee

• Indigenous student coordinator

• BIPOC student collective and mentorship program

• Student awards

Ryerson Student Services• Academic accommodation support office (AAS)

• Ryerson Aboriginal student services (RASS)

Faculty of Community Services • Personal counsellor

• Learning strategist

• English language specialist

• Student awards

53

For more information

Ryerson MEP Faculty Clinical Education Coordinator:

Elizabeth [email protected]

Ryerson MEP Experiential Learning Coordinator:

Loreto [email protected]

54

mailto:[email protected]

mailto:[email protected]

Documents

Teaching the Senior Student - Ryerson