Clinical Skill Learning and Teaching - Essay Example

Clinical Skill Teaching Plan Introduction Teaching in a clinical setting is much different from teaching in a room. The major challenge is everything that a student learns in a nursing school in theory; they have to apply it in the clinic. There is no room for theory only. One thing that adds to the complexity of the teaching methodology is Clinical settings dictate the teaching approach. My practice setting involves only five students in a clinical setting with mannequins. The procedure is the Lumbar Puncture and involves a lot of practice before it can done on real human. The students are expected to learn theory if this procedure as well as the process. It is obvious that for such a sensitive procedure, my students have the basics of clinical studies covered. The most common way of classifying students is to use the visual, auditory and kinesthetic way, otherwise known as the VAK model (Utley, 2010). This model establishes a learner’s preferred mode for learning and processing new information. The VAK model was introduced in the 1920s by the likes of Keller, Orthon, Fernald, Stillman, Gillingham and Montessori (Dreeben-Irimia, 2010). In addition to the VAK model Gaberson and Oermann (2010) add more tools to expand the teaching strategies by including olfactory and emotionally experimental methods that help children who don’t benefit a great deal from didactic methods, learn. Although there are three main categories for students (refer to the VAK model) however, within the visual class Ryan at al. (2011) further divide the class into two subclasses; the ‘verbal visual’ and the ‘spatial visual’. The verbal visual students are those that best learn when the information is ‘written down’. The spatial visual students prefer solely the marvel of the visual; graphs, charts, diagrams etc. Such learners are generally good with faces and have good sense of direction (Hill & Howlett, 2012). Auditory students perform really well in brainstorming sessions. It is almost a ideal way to absorb, process and take part in the creative process (Spencer & Vavra, 2009). These learners can be taught better when the same idea is rephrased in several different ways (Lauwers & Swisher, 2010). The whole idea behind using the VAK model is not to isolate students based on their preferred teaching styles. It is a mere recognition that some students prefer one method over another while learning. In real practice, the VAK model is more popular with the more vulnerable exceptional learners (Zhang et al., 2012). The teacher can affirm if a student prefers visual learning by asking simple questions. If the student tries to remember things by either looking straight or upwards (can be both to the left or right side), he/she is a visual learner (Martin & Loomis, 2012). The point of the VAK model is not to divide students into sections within the clinical study arrangement, so that one has an LCD screen to ‘see’ the study while the others have their headphones on and listening to the instructions. The purpose of the VAK model is to make the group go through all the procedures that are targeted for each student’s preferred method (Willingham, 2009); an auditory learner will see the charts and graphs but will also get the listening part to stimulate the natural learning proclivity. A multisensory approach lets all students learn regardless of their personally favourite modals. This gives a synergistic effect to the strongest learning mode (Hiskes, 2011). So the theory gets validation from the fact that even if a students doesn’t learn anything other than his/her favourite learning mode, but the other student will. And that student might be his/her partner in a group and the necessary social interaction for learning gets completed when the multisensory approach is used; learning is a social activity (Ingleby et al., 2011). In addition to the benefits of the VAK model, there is a more recent model known as the VARK model that incorporates ‘read/write’ modality (Kruse, 2009). Despite the preference for a certain modality, the fact remains the deciding factor on how much portion of the teaching will be auditory, visual or kinesthetic, that a human brain absorbs 70%-90% of the information through visuals (Vasquez et al., 2010). Interpersonal learners respond to social interactions and relationships (Kelly, 2011). The kinesthetic learner is advised to use muscle memory for learning (Bradshaw & Lowesntein, 2011); they need to scribble a piece of information more than one time to incorporate it. For an auditory learner, the same process will be followed; registration of preferred learning methodology. In practice, more emphasis will be given to the tonality and the choice of words while explaining a concept. For instance, a common nursing practice is to measure the blood pressure of a patient. To teach an auditory learner, I would use words that convey the message with clarity. The use of tonality will also help an auditory learner as it will help differentiate one thing from the other. When talking about high blood pressure, the sound of the instructor will automatically go at a high pitch. The student will tie to procedure of what to do in case of high blood pressure with the high pitched voice of the instructor. The same will be done for procedure tied with the ‘low’ blood pressure. The tonality and the word choices will affect the deliverance of the message. I would also urge to have the auditory type of student(s) to have a small voice recorder. Many cell phones have those built in. Recording instructor’s lectures as well as their own thoughts will help them recall the process. Studdy et al. (1994) proposes an integrated teaching model, which makes sense as the nursing practitioner, there will be all kinds of students that will require coaching in clinical practices. A five stage teaching model (Studdy et al., 1994) would best serve me in my teaching; Step one: exposing to a new experience that packs a skill This is demonstrated as a part of real time procedure. The skill becomes part of an experience. The student can absorb more information this way as they are not focusing on the skill in isolation. Step two: Exploration and Elaboration The concept of understanding something is productive when the learner can tie the concepts into their pre-existing memory. They need to have some basics of the new skill in order to acquire it. For instance, a math student doesn’t learn integration before having the basic knowledge of addition and subtraction. Exploration and elaboration is where the instructor can explain the same concept using different analogies. Generally this turns into a discussion with the student so that the student can confirm that they have truly grasped the new skill. Step three: Experiment Students need to practice the skill acquired by performing it. This is generally done under the supervision of the instructor; the students experiment with the concept while the instructor is observing, correcting and giving feedback. It is the ‘’indoor practice’ for students or the ‘hands on training’. Step four: Evaluation This step is also performed in the form of a discussion. The instructor is evaluating while students try to explain what their needs are regarding the experiment. Here the instructor can assess which student needs more training but more importantly, the instructor assesses what exactly a particular student requires in order to master the skill. Step five: Skill acquisition During the learning process, the student moves in and out of the learning cycle many times (Studdy et al., 1994). Once the loop is complete the student needs to frequently check with the new acquired skill to make sure that it is permanent. Theory Theory and practice are complementary; learning one without the other is only half the battle won. Having a sound base in clinical theories can help students a lot. The case with clinical teaching is the same with every other knowledge field; it keeps changing. There has been so much advancement in the field of medical science that it is almost impossible to learn everything in medical school (Hugget, 2010). Understanding the learning theories can boost the learning process of students manifolds. For instance some of the theories that are helpful (for my particular teaching methodology) include (Hugget, 2010); Active learning It is a proactive approach for every type of student. Passively taking in information lacks the critical analysis on the students’ part. Interacting with the material is mandatory for learning any skill. This works for both auditory and visual learners. Self-directed learning This learning theory is more proactive. Here the learners decide the goals as well as the procedures of learning. This gives ample control over what is taught and how it is taught. The learners also have a significant control on assessment task. They determine how they would like to be assessed. This theory must not be confused for giving too much control to the learners. The learners determine the course, the pattern to some degree, it doesn’t give them a free hand to do whatever they feel like. It is a win-win situation as students cannot complain about the teaching or assessment methodology later. Surface learning Although this form of learning has its place in the teaching-learning curve however for a clinical setting, this will be strongly discouraged in my class. Surface learning is another name for ‘cramming’, memorizing without reflecting. My class is in a clinical setting. The graduates will need to make decisions based on what they have learnt in the class. If they don’t reflect on it in the class, how will they make sound judgements in their medical practice? Scaffolding Just like the training wheels of a bicycle, this is a form of assistance provided to the students while they experiment in the clinical setting. My teaching methodology incorporates this aspect of learning. Later on the assistance will be removed to help students practice independent judgements. Learning environment The environment design plays a huge role in human behaviour. Classrooms and labs are designed with the design to make sure they positively effect the learning process. The learning process goes beyond the class and laboratory walls. Observers (instructors) can monitor students even outside the clinic, especially for values such as; honesty, professional values and respect. Simulation based learning Simulation based learning is not a very old concept. Gopee (2010) proposes that simulation based learning is a structured way of learning. The real world scenario is created within the clinic (classroom). Students benefit from this ‘hands on’ approach. Later, they can use the results from simulation in the real world as learning is productive. It is a fact that curriculum, the education and licensing boards have a significant say in determining the context of what medical students should learn (Hugget, 2010). But this should not be turned into an absolute restraint. Learners and instructors can help build a more self-directed learning environment. It is a fact that when medical students face a medical problem, they enjoy solving it on their own in a self-directed way (Hugget, 2010). They feel more comfortable approaching the solution of a problem ‘their way’. Discouraging such behaviour will effect students’ enthusiasm in facing a challenge. Feedback Feedback work both ways for the student as well as for the teachers. Nash (2009) proposes that instead of just giving a feedback like “that is correct James”, the teachers should delve into instructive feedback. For instance when the teacher asks a question and a student gives the correct answer, instead of uttering the obvious, the same comment can be followed by a little information that is relevant to that concept. Conclusion Regardless of the learning mode, a teacher must go through a multisensory approach so that every individual can learn from it in their own way. In a Lumbar Puncture demonstration, the instructor might ask the correct way of marking the spot for needle insertion. If the student gives the correct answer, the teacher can elaborate upon the sensitivity of the spinal cord through visual, auditory and with the aid of a model for kinesthetic demonstration. This way the student will learn additional information directly connected with the procedure but not covered in the session. This doesn’t increase the lecture time but it does increase the knowledge gained by the learner. Reference 1. Bradshaw, M. & Lowesntein, A. (2011) Innovative teaching strategies in nursing and related health professions. Sudbury: Jones & Bartlett Publishers. 2. Dreeben-Irimia, O. (2010). Patient education in rehabilitation. Sudbury: Jones & Bartlett Publishers. 3. Gaberson, K. B. & Oermann, M. H. (2010) Clinical teaching strategies in nursing. New York: Springer Publishing Company. 4. Gopee, N. (2010). Practice teaching in health care. London: SAGE Publication. 5. Hill, S. S. & Howlett, H. S. (2012). Success in practical/vocational nursing: from student to leader. River Port Lane: Elsevier Health Sciences. 6. Hiskes, D. G. (2011). Phonic pathways: Clear steps to easy reading and perfect spelling. San Francisco: John Wiley & Sons. 7. Hugget, K. N. (2010). An introduction to medical teaching. London: Springer. 8. Ingleby, E., Joyce, D. & Powell, S. (2011). Learning to teach in the lifelong learning sector. London: Continuum. 9. Kelly, P. (2011). Nursing leadership & management. Belmont: Cengage Learning. 10. Kruse, D. (2009). Thinking strategies for the inquiry classroom. Carlton South Vlc: Curriculum Press. 11. Lauwers, J. & Swisher, A. (2010). Counseling the nursing mother. Sudbury: Jones & Bartlett Publishers. 12. Martin, D. J. & Loomis, K. S. (2012). Building teachers: A constructive approach to introducing education. Belmont: Cengage Learning. 13. Nash, R. (2009) The active teacher: practical strategies for maximizing teacher effectiveness. London: Corwin Press. 14. Ryan, K., Cooper, J. M & Tauer, S. (2011). Teaching for student learning: Becoming a master teacher. Belmont: Cengage Learning. 15. Spencer, S. L. & Vavra, S. (2009). The perfect norm: how to teach differentially, assess effectively, and manage a classroom ethically in ways that are "brain-friendly" and culturally responsive. U.S.: IAP. 16. Study. S. J, Nicol. M. J, & Fox-Hiley. A, (1994). Teaching and Learning Clinical skills. Part, 2. Development of a Teaching Model and Schedule of Skills Development . Nurse Education Today. Vol, (14). Pp.186 to 193. 17. Utley, R. (2010). Theory and research for academic nurse educators: application to practice. Sudbury: Jones & Bartlett Learning. 18. Vasquez , J. A., Comer, M. W. & Troutman, F. (2010). Developing visual literacy in science. United States of America: NSTA Press. 19. Willingham, D. T. (2009). Why dont students like school: a cognitive scientist answers questions about how the mind works and what it means for the classroom. San Francisco: John Wiley & Sons. 20. Zhang, L., Sternberg, R. J. & Rayner, S. (2012). Handbook of intellectual styles: Preferences in cognition, learning and thinking. New York: Springer Publishing Company. Appendix 1 by (Chislett, V., and Chapman, A., (2005). VAK Test VAK Learning Styles Self-Assessment Questionnaire Circle or tick the answer that most represents how you generally behave. (It’s best to complete the questionnaire before reading the accompanying explanation.) 1. When I operate new equipment I generally: a) read the instructions first b) listen to an explanation from someone who has used it before c) go ahead and have a go, I can figure it out as I use it 2. When I need directions for travelling I usually: a) look at a map b) ask for spoken directions c) follow my nose and maybe use a compass 3. When I cook a new dish, I like to: a) follow a written recipe b) call a friend for an explanation c) follow my instincts, testing as I cook 4. If I am teaching someone something new, I tend to: a) write instructions down for them b) give them a verbal explanation c) demonstrate first and then let them have a go 5. I tend to say: a) watch how I do it b) listen to me explain c) you have a go 6. During my free time I most enjoy: a) going to museums and galleries b) listening to music and talking to my friends c) playing sport or doing DIY 7. When I go shopping for clothes, I tend to: a) imagine what they would look like on b) discuss them with the shop staff c) try them on and test them out 8. When I am choosing a holiday I usually: a) read lots of brochures b) listen to recommendations from friends c) imagine what it would be like to be there 9. If I was buying a new car, I would: a) read reviews in newspapers and magazines b) discuss what I need with my friends c) test-drive lots of different types 10. When I am learning a new skill, I am most comfortable: a) watching what the teacher is doing b) talking through with the teacher exactly what I’m supposed to do c) giving it a try myself and work it out as I go 11. If I am choosing food off a menu, I tend to: a) imagine what the food will look like b) talk through the options in my head or with my partner c) imagine what the food will taste like 12. When I listen to a band, I can’t help: a) watching the band members and other people in the audience b) listening to the lyrics and the beats c) moving in time with the music 13. When I concentrate, I most often: a) focus on the words or the pictures in front of me b) discuss the problem and the possible solutions in my head c) move around a lot, fiddle with pens and pencils and touch things 14. I choose household furnishings because I like: a) their colours and how they look b) the descriptions the sales-people give me c) their textures and what it feels like to touch them 15. My first memory is of: a) looking at something b) being spoken to c) doing something 16. When I am anxious, I: a) visualise the worst-case scenarios b) talk over in my head what worries me most c) can’t sit still, fiddle and move around constantly 17. I feel especially connected to other people because of: a) how they look b) what they say to me c) how they make me feel 18. When I have to revise for an exam, I generally: a) write lots of revision notes and diagrams b) talk over my notes, alone or with other people c) imagine making the movement or creating the formula 19. If I am explaining to someone I tend to: a) show them what I mean b) explain to them in different ways until they understand c) encourage them to try and talk them through my idea as they do it 20. I really love: a) watching films, photography, looking at art or people watching b) listening to music, the radio or talking to friends c) taking part in sporting activities, eating fine foods and wines or dancing 21. Most of my free time is spent: a) watching television b) talking to friends c) doing physical activity or making things 22. When I first contact a new person, I usually: a) arrange a face to face meeting b) talk to them on the telephone c) try to get together whilst doing something else, such as an activity or a meal 23. I first notice how people: a) look and dress b) sound and speak c) stand and move 24. If I am angry, I tend to: a) keep replaying in my mind what it is that has upset me b) raise my voice and tell people how I feel c) stamp about, slam doors and physically demonstrate my anger 25. I find it easiest to remember: a) faces b) names c) things I have done 26. I think that you can tell if someone is lying if: a) they avoid looking at you b) their voices changes c) they give me funny vibes 27. When I meet an old friend: a) I say “it’s great to see you!” b) I say “it’s great to hear from you!” c) I give them a hug or a handshake 28. I remember things best by: a) writing notes or keeping printed details b) saying them aloud or repeating words and key points in my head c) doing and practising the activity or imagining it being done 29. If I have to complain about faulty goods, I am most comfortable: a) writing a letter b) complaining over the phone c) taking the item back to the store or posting it to head office 30. I tend to say: a) I see what you mean b) I hear what you are saying c) I know how you feel Now add up how many A’s, B’s and C’s you selected. A’s = B’s = C’s = If you chose mostly A’s you have a VISUAL learning style. If you choose mostly b’s AUDITORY learning style. If you choose mostly C’s KINESTHETIC learning style. Appendix 2 The lumbar puncture, or "LP", is a frequently performed procedure in emergency departments, neurology and radiology clinics and hospital wards. In the emergency department, LP can yield information that can rapidly differentiate benign from emergent conditions. In general, an LP may be done to: 1. analyse the cerebrospinal fluid (CSF) 2. measure the CSF pressure 3. access the intrathecal space for either drainage of CSF or injection of fluid or to administer medications into the intrathecal space 4. to perform myelography The most common emergency department indications for a LP include clinical suspicion of meningitis (bacterial, viral or fungal) or to rule out subarachnoid hemorrhage. Do not let LP (or CT scan) delay antibiotics and fluid resuscitation in patients with probable meningitis. In neurology clinics and other settings, LP is used to detect disorders with local immunoglobulin production in the CNS such as multiple sclerosis and SSPE, malignant infiltrates such as acute leukemia and lymphoma, and blockage of the spinal canal. Major contra-indications to lumbar puncture are: symptoms or signs of raised intracranial pressure. These include a decreased level of consciousness, localizing (focal) neurologic signs and papilledema. LP in patients with raised ICP may lead to uncal herniation and death, a severe bleeding diathesis or coagulation disorder or the patient is on anticoagulation therapy, infection at the planned site of the puncture When performed correctly, the LP procedure can be rapidly completed with little discomfort or risk to the patient. Using the sterile conditions recommended in this learning module, the introduction of infection by the LP procedure itself to the spinal cord would be extremely rare. A small chance of bleeding at the site exists. However "post-LP headache" is a relatively common occurrence (in up to even greater than 30% of patients depending on the LP needle type and caliber selected - see Preparation). This headache begins usually within hours to a few days after the LP procedure and is usually made worse with a positional change to the upright posture. The headache can be very severe and although the headache usually improves over time, the headache can last up to 3 weeks. A "blood patch" may be required to seal the hole in the lumbar meninges. Bed rest (although frequently recommended), whether prone or supine, immediately after LP does not prevent the headache. A non-postural headache after an LP is uncommon. If the onset is early, consider a puncture-induced meningitis and for those headaches of later onset consider a possible subdural effusion. A signed informed consent should be obtained from the patient or a substitute decision maker after explaining the risks and benefits of the procedure. The consent form should ideally be signed by the patient in the presence of a witness. This should include a discussion of the likelihood of "post-LP headache" and the small risk of bleeding or introducing infection. Lumbar Puncture Procedure The lumbar puncture, or "LP", is a frequently performed procedure in emergency departments, neurology and radiology clinics and hospital wards. In the emergency department, LP can yield information that can rapidly differentiate benign from emergent conditions. In general, an LP may be done to: 1. analyse the cerebrospinal fluid (CSF) 2. measure the CSF pressure 3. access the intrathecal space for either drainage of CSF or injection of fluid or to administer medications into the intrathecal space 4. to perform myelography The most common emergency department indications for a LP include clinical suspicion of meningitis (bacterial, viral or fungal) or to rule out subarachnoid hemorrhage. Patient Positioning Many patients may be too ill to sit upright for LP. The patient should be positioned in a left lateral (for a right handed physician) or right lateral position (for a left handed physician) for LP. The patient should curl into a fetal position, placing the lumbar spine in maximal flexion. It may help to support the upper arm to prevent the upper shoulder from rolling forward. This will in turn create the greatest interspinous distance (opens the gap) through which to access the intrathecal space. Needle Removal Replace the stylet fully into the spinal needle before withdrawing the needle. This will avoid aspiration of the lumbar nerve root and adjacent subarachnid tissue on withdrawal. Inform the patient that the procedure is finished and remove the needle in one smooth motion. Keep a gauze ready in the opposite hand to apply pressure on the puncture site for a short time. A band-aid is placed at the site. Read More