Sue Murphy (biography and disclosures)
What I did before:
An ongoing problem with student supervision in the clinical setting is managing the expectations of Clinical supervisors. Frequently, clinical supervisors are clinicians with many years of experience in their specialty, who have not been practicing at “entry level” for some time. The expectations of these supervisors of novice, entry level students is often way above what students can be expected to master in a limited time frame on a clinical placement, leading to frustration on the part of both learners and supervisors. I had previously attempted to address this in supervisor workshops by outlining the curriculum, setting out written “expectations” for students at each level, and by explaining that students were at a novice level and would never become experts.
What changed my teaching practice:
Despite my explanations and wise nods from attendees at the workshops, I continued to get calls from “frustrated” clinicians and students, and to have to deal with unrealistic clinical supervisor expectations. Particularly troubling was when the supervisor expectations were reflected in the student evaluations with low marks and comments on how the student was at too basic a level by the end of the placement, an observation which did not seem valid when I actually looked at how the student had performed. Obviously a didactic approach was not working, so I decided to tackle this issue using an experiential approach, putting the supervisor into the role of the student.
What I do now:
Using Kolb’s experiential learning cycle as a framework, I incorporated concrete experience, active experimentation, and reflective observation into two experiential exercises into the workshop, with the aim of getting clinicians to actually experience how it feels to be a student. In the first exercise, the workshop participants (clinician supervisors) are asked to pair up with another clinician who works in a completely different area of specialty (for example, a clinician from critical care may be paired up with a clinician from community health). The only information the clinicians know about each other is the name and type of environment where they work. Each clinician is then asked to assume that they will be the spending the next month working in the unfamiliar clinical area, and are asked to write learning objectives for themselves for the coming month. A distinct look of alarm usually ensues, as clinicians usually find this extremely challenging: they know little about the area to which they have been “assigned”, do not know what skills will be the most important or what a typical caseload may look like, do not fully understand their professional roles in that environment, and have little idea as to what other team members may be present. Does this sound like the first day of a clinical rotation? The parallels are easy to draw, giving clinicians concrete experience of what it feels like to be a student coming onto an unfamiliar area and being asked to identify learning needs on arrival. Having drafted their objectives, they then share these with their partner and, following discussion, reflect on how these should be reframed to make the best possible learning experience.
This exercise is followed by a role play where clinicians role play the part of a student who is having issues at a placement site. The roles the clinicians play incorporate typical personal student issues such as financial hardship, family / relationship issues, stress, as well as issues prevalent in the clinical setting such as fear of failure, negative sequalae from previous placements, and issues with supervisor relationship. The supervisor role (played by another clinician) is unaware of these issues and is asked to deal with a perceived performance problem. A third clinician acts as observer and reflects back their observations to the role play participants following the exercise. These role plays are often ranked as being the most helpful part of the workshop (despite initial resistance and some performance anxiety – which just adds to the experience!), with participants frequently commenting on how unnerving it is to be in the student role.
References and/or Additional reading:
Beard, C., & Wilson, J. P. (2006). Experiential Learning: A Handbook of Best Practice for Educators and Trainers (Chapter 2) (London, GB, Kogan Page).
Fowler, J. (2008) Experiential learning and its facilitation, Nurse Education Today. 28 (4), p427-433.
Kolb, D.A. (1984) Experiential Learning (Englewood Cliffs, NJ, Prentice-Press).
Kreber, C. (2001) Learning Experientially through Case Studies? A Conceptual Analysis. Teaching in higher education. 6 (2) p 217-228.
Loading ...Request from editor for author comment: Has this reduced the number of mismatched evaluations or frustrated supervisor academic reviews. If the evaluation has not yet happened, then perhaps a comment that it will be captured to confirm the effectiveness of changing the workshop. Could we ask Sue if she has noted any changes?”
Author’s response: I think it would be hard to link the # of mismatched evaluations to exactly this intervention, as there are so many variables in each set of placements, and not all supervisors take the workshop. I have (anecdotally, not through a formal process) noticed less calls and questions from supervisors about the level of performance the student is expected to attain. It also tends to be quite an “aha” moment during the workshop and generates significant discussion amongst peers on supervisor expectations, which is always useful as it tends to standardize supervisor expectations.
Has the author sought any specific feedback from attendees to see if they gave more “fair” evaluations after the workshops, or did the evaluators feel they just needed to set lower expectations and “mark softer”? Has there been any look into how evaluators might implement some of this in their own teaching (aside from having a greater empathy toward junior trainees, do they now actively seek out some of the parameters and issues they saw in the workshop?).
I would love to evaluate some of this, but as you say, it is a very hard thing to measure given the variability in clinical experience, student, preceptor and other factors affecting placements. My “gut feel” is that they set more realistic objectives, having experienced the student role; also that they are more able to understand the students point of view or perspective, and have more realistic expectations. But measuring this concretely has so far eluded me!!
Is there any thought as to how to implement this in a practical setting? For example, I teach on the CTU at VGH, and aside from the first day meetup with students and briefly discussing my expectations of them and asking them what rotations they’ve done, their career goals and their day 1 anxieties, I see nothing from UBC undergrad regarding this, and the mid-term and final evaluations on one45 certainly don’t really encourage a more thoughtful approach.
I would love to chat further about this. My feel is that there may be something which could be incorporated into a busy clinical setting which is a derivative of this approach, or which could be woven into the clinical rotation. I agree that this point is worth further brainstorming.
Even orientating statements at the start of the rotation would be helpful, like:
“A 3rd year student entering an internal medicine rotation will have covered xxx, yyy, zzz modules in didactic and small group sessions, but has not yet had direct clinical responsibility in looking after inpatients. They have had xxx instruction in history taking and physical examination skills, but no specific training in writing (inpatient/outpatient) orders and prescriptions…”
We have what we call a “shopping list” which is basically this. It outlines what skills have been covered in class and / or in Lab settings, and supervisors love it as it is a lot more specific and detailed than the course outlines, and in an easy to read format.
Or, even better would be if the student fills out a form with these areas listed as blanks, plus an area about anxieties/personal areas of interest/weakness and career goals, and hands them to the preceptor on day 1 (or even better, before) the rotation.
We have a template we use for this also – it is taken from the “preceptor education program” (am not sure if you are familiar with this). The program is at http://www.preceptor.ca
Come to think of it, I may just make this form myself and hand it to my students on day 1 and ask them to return them to me the next day (privately)…there — my teaching may have already been changed!