Managing Clinical Practice: Creating Opportunities for Learning (Part 2 of 5)
(April 2001)

The following was excerpted from JHPIEGO's newly revised Clinical Training Skills manual. This is the second of five parts on managing clinical practice.

Planning includes designing a schedule that allows participants adequate time to work with clients, and developing assignments and other learning activities for participants to complete in order to provide a positive learning environment in the clinic.

Even the best planning is not always enough to ensure a successful clinical practice experience. In the classroom, the trainer is able to control the schedule and activities to a large extent. In the clinic, however, the trainer must always be alert to unplanned learning opportunities that may arise at any time, and be ready to modify the schedule accordingly.

Situation 1

You are the trainer for an IUD clinical skills course. Having completed the classroom portion, you are now in the clinic area supervising six participants. In the first 2 clinical days the number of clients has been adequate; all participants have been able to demonstrate competency in performing a pelvic examination. This is the third day, and according to your plan the participants should begin inserting IUDs with clients. Today, however, the weather has suddenly become cold and rainy. Only a few clients have come to the clinic, and no one has chosen the IUD as her contraceptive method. What do you do with the participants now that no clients are available?

Write your response on a piece of paper and then compare your response with the one found at the end of this section.

Planning for Learning

The trainer should develop a plan for each clinic day. Having previously visited the clinic(s) and worked with the staff, the trainer will be able to design a plan that addresses each clinic's specific situation. This plan will provide a daily focus that is consistent with the learning objectives, and it will help ensure that all required skills will be adequately addressed. When preparing the plan, the trainer should consider the following points.

• Clinical practice should progress from basic to more complex skills. In an IUD clinical skills course, for example, the participants should demonstrate competency with pelvic examination skills before they perform the IUD insertion procedure with clients. Many trainers have the participants practice their counseling skills before practicing more complex method provision skills such as Norplant(r) implants insertion. Progressing from basic to more complex skills allows participants to gain self-confidence as they demonstrate competency in the basic skills and ensures that participants provide safe and high quality care.

• More participants may be scheduled for training than can be accommodated comfortably in one area of the clinic at the same time. Generally, a specific clinic area can absorb three or four participants, at most, without affecting service delivery. If more participants are scheduled, the trainer should plan a rotation system that allows each participant to have equal time and opportunity in each clinic area. For example, two students can be assigned to the counseling area, two to the screening area and two to the procedure rooms, with others completing special assignments. They can change work areas every few hours, every day or every few days??whichever seems most appropriate.

It is important that the trainer share this information with the clinic staff members so they can support the participants' learning in each work area. Furthermore, the participants should understand that if they are to gain adequate experience to attain competency they will need to comply with the rotation schedule. 

Remember: Safe and efficient provision of services must be the highest priority for everyone working in the clinic, regardless of worker roles and responsibilities. This priority must not be compromised for the sake of learning.

• Some clinic experiences, such as screening for infrequently seen precautions and managing uncommon side effects, cannot always be planned. The trainer must be alert to identify appropriate clinical situations and distribute them equally among the participants. Before each day's practice, ask the clinic staff to notify the trainer of any clients who may be of particular interest so that participants can be assigned to work with them.
• In addition to daily practice of specific clinical skills, the trainer's plan should include other areas of focus such as infection prevention, clinic logistics or client flow. Although these topics may not be directly assessed with a checklist or other competency-based assessment tool, they play an important role in the provision of high quality family planning services. To make sure that participants give adequate attention to these topics, the trainer should design and develop activities that address each one, such as:

   

  • Observing the infection prevention practices used throughout the clinic. Which recommended practices are being used, and which are not? Are they being used consistently and correctly? Why or why not?
  • Reviewing clinic records for the past several months to identify the types of family planning clients seen. Additional information could be obtained (e.g., the most common complaints, which clients return according to method used, how long clients continue using the same method, reasons for method changes).
  • Taking an inventory of the storeroom to identify available contraceptives (e.g., the number in stock, expiration dates)as well as describing the system for procuring and storing commodities.
  • Drawing a map of the clinic and marking client flow through the clinic. The time spent at each "point" in the clinic (e.g., reception, history taking, physical exam) could also be noted.

  These activities can be used as the basis for discussions to improve the participants' understanding of the issues involved in the provision of high quality services. If appropriate, recommendations for improving the services provided in the clinic can be developed and given to the clinic staff.

• Inevitably there will be times when few or no clients are in the clinic. The trainer should have additional activities ready for the participants, such as those described above. Case studies and role plays are also very useful at such times. Even without clients, learning must continue. Taking extended breaks or leaving the clinic site early are not acceptable options.

Situation 2

It is the second day of clinical practice in a Norplant implants clinical skills course. The four participants you are supervising have many questions about how to manage the side effects of Norplant implants, but no clients with problems have come into the clinic. You and the participants are about to have an extended post?clinical practice meeting about recommended infection prevention practices as observed in the clinic. At this time, a client arrives complaining of heavy prolonged vaginal bleeding since her implants were inserted 6 months ago. You had planned to discuss this and other side effects and their management at tomorrow's post-clinical meeting. What do you, as the trainer, do in this situation?

Write your response on a piece of paper and then compare your response with the one found at the end of this section.

In the Clinic

As has been mentioned, planning alone is not sufficient to guarantee a successful clinical practice. A clinical trainer can use several key strategies in the clinic to increase the likelihood of success.

• The trainer must actively monitor the skills, noting what skills are practiced and how often each participant is able to practice them, so that each participant has adequate opportunities to develop competency. A participant who demonstrates competency in no-scalpel vasectomy (NSV), for example, should not be assigned additional NSV clients until all the other participants have also achieved competency. Only then can competent participants be given additional opportunities to perform NSV and move towards proficiency. 

Remember: The goal of mastery learning is to give every participant the opportunity to achieve competency by the end of the course. The trainer is responsible for meeting this goal.

• It is essential that the trainer be flexible and constantly alert to learning opportunities as they arise in the clinic. The trainer needs to know how the clinic is set up, how it functions, and what the client profile is. The trainer also needs to have a good working relationship with the staff. This relationship is most easily established during precourse visit(s) made by the trainer. The trainer will need to rely on the staff's cooperation in notifying her/him of unique or unusual clients and in allowing participants to provide services to these clients. The participants should also be encouraged to watch for relevant learning opportunities in the clinic. 
• When learning opportunities are identified, the trainer may decide which of the participants, and how many, will be assigned to a particular client. The trainer and participants should remember that clinical experiences need to be shared equally. Therefore, the participant who identifies a case may not be assigned to it if this participant has had a similar case before. It is not appropriate to subject the client to a procedure (e.g., pelvic examination) multiple times simply to give all participants an opportunity to practice a skill. 
• To take advantage of opportunities as they occur, the trainer may need to modify the plan for the day and subsequent days. These modifications should, however, be undertaken with as little disruption as possible to the logical flow of activities. Participants should be notified of any changes as soon as possible so that they can be well prepared for each clinical day.
• All participants will rarely have the opportunity to work with all types of clients. The clinical trainer will need to supplement, with case studies and role plays, the work done with clients. The trainer should identify important but uncommon experiences and prepare activities in advance. Actual cases seen in the clinic may also serve as the basis for such activities. These can then be used during clinical sessions to expand the participants' range of experiences.

Situation 1 Response

Prior preparation is vital at a time like this. You should already have prepared a number of activities, including case studies, role plays and other assignments that can be used when there are no clients. You should then gather the participants in a place where they will not interfere with clinic routines and get them started on an activity. If you have nothing prepared, you will need to come up with something QUICKLY! Participants must not stand around doing nothing, nor should they go home early because you, the trainer, are unprepared. Situations like this occur in almost every clinical practice, so it is very important that you think ahead and be prepared to offer alternative activities. Once you have them prepared these kinds of supplementary activities, you can use them again and again with different groups of participants.

Situation 2 Response

Now is not the time to keep to the planned schedule! Not only is the management of Norplant implants side effects of interest to the participants, it is uncommon to see these clients in the clinic. You should take advantage of this opportunity to have participants work with this client. It probably will not be possible for all four participants to interact with her, because you risk overwhelming her. You will have to decide which two participants will have this experience. You should note who had this practice, so that the next time a client comes in with this problem, different participants can be given the opportunity to work with her. You should supervise the client-participant interaction. Afterwards, during the post?clinical meeting, the two participants should share their experience with the others, and discuss alternative ways of helping this client. It is probably a good idea to switch the more detailed discussion of side effects and their management that was planned for the next day with today's infection prevention discussion, which can be postponed until tomorrow.

For more information about conducting a clinical skills course, contact Rick Sullivan.

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