JHPIEGO TrainerNews™ |
Managing Clinical Practice: The Trainer
as Coach (Part 5 of 5)
(August 2001)
The following was excerpted from JHPIEGO's newly revised Clinical Training Skills manual. This is the fifth of five parts on managing clinical practice.
Situation
You are coaching a participant who is inserting an IUD with a client. The client is aware that the "service provider" is learning a new skill and she appears somewhat nervous, but has agreed to have the insertion done by the participant. The participant performs the first steps of the insertion procedure correctly, but has some difficulty applying the tenaculum to the cervix. What would you do? How would you interact with her? What would you do if the participant, after inserting the speculum, forgot to swab the cervix before continuing with the procedure? What would you do if the participant had difficulty using the withdrawal technique for IUD insertion and began pushing the IUD inserter tube to release the IUD in the uterus?
Write your responses on a piece of paper and then compare your responses with the ones found at the end of this article.
The Trainer as Coach
One of the most difficult tasks for the trainer, and one with which even experienced trainers struggle, is to be a good coach and provide feedback in the clinic setting. No matter how comfortable a trainer may be in giving feedback in the classroom or while working with models, the situation changes in the clinic. The clients, staff and other participants are nearby and the clinic services need to keep flowing smoothly and efficiently. The trainer often feels pressured to keep things moving because the client does not want to wait a long time for services and the trainer needs to be available to all the participants. Spending "too much time" with any one client or participant has an impact on everyone.
Feedback Sessions
The feedback sessions before and after practice are often skipped in an effort to save time. These sessions, however, are very important for the continued development of the participant's skills. Without adequate feedback and coaching, the participant may take longer to achieve competency, and end up using the "saved" time later. Keep in mind that by this time the participant has already demonstrated competency on a model and should not need extensive feedback. To minimize disruption of services, the pre- and post-practice feedback sessions can take place in just a few minutes in a location away from the client care areas.
The structure of the feedback session is essentially the same regardless of whether the session takes place before or after practice, and whether it is for a participant's performance with models or with clients.
- The participant should first identify personal strengths and the areas where improvement is needed.
- Next, the trainer should provide specific, descriptive feedback that includes suggestions of not only what, but how, to improve.
- Finally, the participant and the trainer should agree on what will be the focus of the practice session, including how they will interact while they are with the client. For example, they may agree that if the trainer places a hand on the participant's shoulder, it is a signal to stop and wait for further instructions.
The feedback session before practice should be given before entering the room to work with the client. The feedback session after practice can be delayed until the client's care has been completed and the client is ready to leave the clinic. The trainer should try not to delay it much longer than this (e.g., until the end of the day). Feedback is always more effective when given as soon after the procedure as possible. Giving it soon after the procedure will also allow the participant to use the feedback with the next client for whom services are provided, if appropriate.
Feedback During the Procedure
Be sure the client knows that the participant, although already a service provider, is also a learner. Reassure the client that the participant has had extensive practice and mastered the skill on models. The client should expect to hear the trainer talk to the participant, for example, encouraging the participant to "tent" the skin further during Norplant® implants insertion, and that it does not mean that something is wrong. Finally, the client should clearly understand that the trainer is a proficient service provider and is there to ensure that the procedure is completed safely and without delay.
Positive Feedback
Positive feedback is often easy to give and can be provided in the presence of the client. Trainers often think that hearing feedback, even positive feedback, will disturb the client. Many clients, however, find it comforting to hear the service provider being given positive feedback.
- Keep the feedback restrained and low-key; overly exuberant praise can be as worrisome to the client as hearing negative comments. Too much praise may cause the client to wonder, "What is being hidden?" "Why is it so surprising that this person is doing a good job?"
- Positive feedback can be conveyed by facial expression and tone of voice rather than words, and still be highly effective.
At the same time, the absence of feedback of any kind can be disturbing to the participant. By this phase of skill development the participant is expected to do a good job even with the first client, and is accustomed to hearing positive comments. Therefore, in order to maintain the participant's confidence, it is still important to give positive feedback.
Corrective Feedback
Corrective feedback is difficult to give under any circumstances, but particularly when a client is present. It is important to keep such feedback low-key and restrained. The following are some techniques that will make it easier to give corrective feedback:
- Often a look or hand gesture (e.g., a touch on the shoulder) can be as effective as words and less worrisome to the client.
- Simple suggestions to facilitate the procedure can be made in a quiet, direct manner, for example, "You might find it easier to manipulate the tenaculum if you use your middle finger and thumb, rather than your first finger and thumb." Do not go into lengthy explanations of why you are making the suggestion or offering an observation. Save that for the post-practice feedback session.
- To help a participant avoid making a mistake, the trainer can calmly ask a simple, straightforward question about the procedure itself. If a step in a procedure is about to be missed, for example, asking the participant to name the next step before doing anything further could help avoid an error. This is not the time to ask hypothetical questions about potential side effects and complications because this may distract the participant and alarm the client.
- Sometimes, even though they have had extensive practice on models, participants make mistakes that can potentially harm the client. In these instances, the trainer must be prepared to step in and take over the procedure at a moment's notice. This should be done calmly and with complete control to avoid unnecessarily alarming the client.
The best approach to providing corrective feedback is to minimize, or even eliminate, the need for it by conducting effective practice sessions in the classroom. If participants become truly competent on models, there will not be much need for corrective feedback in the clinic except in unusual situations.
Situation Responses
You should let the participant know what she is doing well while she is performing the procedure. A few brief comments such as "nice job," or "well done," said in a moderate tone are adequate. This is not necessary for every step in the procedure, but enough to let the participant know that she is doing well. When the participant gets to a step where there is a problem, such as in this case of applying the tenaculum to the cervix, you may want to make a few calm, supportive statements indicating how to overcome the difficulty. Some examples include: "Try holding the tenaculum with your thumb and middle finger," or "Turn the tenaculum over; that may make it easier." Again, these should be said in a calm, straightforward manner. Do not let the participant struggle for very long before you offer advice. If she continues to have trouble, be prepared to step in and take over. Although this is not a life-threatening step for the client, it is uncomfortable, and you do not want to prolong the procedure. After the insertion is complete and the client is on her way out of the clinic, find a quiet place to spend a few minutes providing feedback to the participant, including more detailed information on what her problems were and ways to overcome them.
If the step is an important one, as in the second example (forgetting to swab the cervix), as soon as you realize that the participant is about to make an error, you need to intervene. In this case, as soon as it is clear that the participant is going to apply the tenaculum without cleaning the cervix, you might ask her to wait and consider the next step carefully. A hand on the shoulder may also convey the message to stop, and think before proceeding. If the participant is unable to identify that she is skipping a step, tell her what to do. Again, this should be done in a calm, direct manner in such a way that it does not prolong the procedure.
The third example, pushing the IUD inserter tube into the uterus, is a potentially dangerous or even life-threatening mistake. Use the same approach as above: stopping the participant, having her think for a minute, and so on. But if she is not able to identify the problem and correct it, you must step in and finish the procedure to ensure the client's safety.
Summary
During the clinical practice, the trainer is responsible for ensuring that all participants have adequate opportunities for practicing with clients so that by the end of the clinical experience they are competent in the required skills. The trainer must prepare for the clinical practice by becoming familiar with the clinic site and the staff who work there, and by developing a logical plan for skill practice and activities to complement and support those skills. This includes being prepared with activities that will fill gaps between clinical experiences and keep the participants continually involved in learning activities. Most important, the trainer must be constantly alert to what is going on in the clinic in order to identify potential learning opportunities, even when they are not consistent with what was planned for that day. The trainer must supervise all activities performed by the participants or delegate some of the responsibilities to clinic staff. And finally, the trainer must continue to provide both positive and corrective feedback to participants in the clinic to ensure the continued development of skills.
For more information about conducting a clinical skills course, contact Rick Sullivan.