Geriatric Tricks of the Trade for Teaching at the Bedside

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Geriatric Tricks of the Trade for Teaching at the
Bedside

• Barbara Resnick, PhD, CRNP, FAAN, FAANP

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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

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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!

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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.

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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

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Teaching at the Bedside

• Ask for her/his thoughtsno 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.

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Teaching at the Bedside

• Challenges of clinical teaching
• x Time pressures
• x Competing demandsclinical (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!

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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

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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
  responsedont speak
• too soon
• x Follow a poor answer with another question-ask
  the same thing three ways!
• x Resist the temptation to answer learners
  questionsGIVE HOMEWORK AND FOLLOW UP

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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

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Teaching at the Bedside

• FOLLOW.Sir William Oslers 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.

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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.

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Making it Happen It is all in a Day

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

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A Self-efficacy Approach

• Social cognitive theory
• Self-efficacy
• Outcome expectations
• Performance
• Verbal encouragement
• Role modeling
• PHYSIOLOGICAL FEEDBACK-angst/sweating/increased
  heart ratefear versus feel good, feel proud

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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 cant see elsewhere

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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

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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

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Even on busy daysmodel and show what you want
them to know
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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

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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
  wont see elsewhere (tumors, murmurs, palpable
  thyroids, livers etc)

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DO NOT..at all costs.correct the student in
front of the patient. At all costsmake it a
feel good, successful experience
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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

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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 approachwith LOVE
• Write, rewrite and rewrite again
• NO books, blackberries or Iphones

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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

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Review Progress

• If it is one day experienceat 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

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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 isnt perfect.

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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

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Dealing with the Defensive Student

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

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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

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Share Gero Opportunities

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

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My Three Favorite Sayings.

• If I didnt care I wouldnt bother..
• It is what it is .
• You dont lose anything by giving it away..

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Along Those Lines

• Make sure to include a combination of
• Challenging cases for learning
• Easy successful cases for confidence building

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Make Sure to Have Fun!