Part 5: Tips and Strategies for Success

B. Including Your Patients

“Getting Past The Door” With Patients

The preceptor must determine how patients will be introduced to the idea of student participation in their care. It is important that all staff members of the practice meet the student and know when the student is there. The attitude the staff displays toward the student is key to the patient's perception of the student, as demonstrated by these contrasting introductions:

1. The student nurse-midwife/nurse practitioner will see you today, do you mind? You're having a pelvic today.
2. The nurse-midwife/nurse practitioner is working with a student. She will be with us for a few months. Would you be willing to see her before you see the nurse-midwife/nurse practitioner? You can talk with her about the pelvic exam. The nurse practitioner/nurse-midwife will review everything with her/him and be present for the exam.

Some sites have a written informed consent mechanism for patients who will participate in clinical education. Other sites post a picture and/or a biography of the student in the waiting room to give patients a chance to “get to know” the student. Whatever approach the preceptor uses, an attitude of inclusion of the patient in a valuable process, of openness about what to expect, of the patient's right to decline, and of confidence in the student helps patients feel valued and safe in the process.

Staying on Time

Not all days are created equal. Sometimes preceptors will be unable to stay on time, no matter what is done. Though students are not with preceptors to lighten their clinical burden, they do not need to make it harder. How the student and the preceptor work together is key to providing education and care at the same time.

Observation

When the student starts working with the preceptor, both will benefit from a period of observation while the preceptor gives care. This decreases the student's initial anxiety, allows both to become comfortable interpersonally and orients the student to the site and the preceptor role. Observation is also a great learning tool later in the clinical experience. Students observe and pick up things differently once they have had some experience and their anxiety level has decreased.

Adding Skills a Little at a Time

When the preceptor is ready to begin “hands-on” practice, it is best to start in one area (routine exams, for instance) or one or two skills at a time. The preceptor needs to use a directing style of precepting, and have the student focus on one aspect of care with each client. The preceptor may introduce several new skills each session this way, depending on the opportunities of the practice and patients present. As confidence is gained, the student will be able to complete several parts of an encounter. The following example describes one student's progression over a week, and the skill areas being developed.

Day 1: reviews charts, identifies difference between data, assessments, and plans (critical thinking); observes demonstration of a physical exam, pelvic exam technique, documentation of care, interview skills, education about good nutrition, selection of appropriate medication etc. (critical thinking)

Day 2: as above and returns demonstration of a physical exam; takes a diet history once (skill development); writes SOAP notes of two visits performed by the preceptor and observed by the student (critical thinking and professional behavior); suggests plan for diagnosis of UTI and options for treatment (critical thinking)

Day 3: continues to observe and performs delegated pieces of visits; because time “appears” in the schedule, assists to conduct pelvic exam portion of physical assessment (skill development); continues to SOAP short visits, and adds an interview of one problem visit; performs interval history for routine exams (critical thinking, professional behavior)

By selecting patients carefully, starting small, and limiting and discussing expectations, the preceptor and the student will be able to combine clinical education and practice, while keeping the needs of the patients primary. Both preceptors and students can keep a small notebook in which to record questions that come up while seeing patients. Questions and explanations should not slow down the preceptor's office schedule. Instead, find time during breaks, at lunch or during the post conference to answer questions. When clinical questions arise that neither the student nor the preceptor are sure about, the student can be assigned to research the question either immediately or before the next clinical session.

General Time Issues 

The student will not see all of the patients seen by the preceptor. Time must be provided for the student to look things up, to write client progress notes and the self-assessment form, and to observe roles of other members of the team (e.g. nutritionist, ultrasonographer, nurse educator, physician, and social worker). If the session is under intense time pressure, the student may just need to stand back until the preceptor brings things under control.

At every level of development, students have much to learn from observation. Watching the preceptor prioritize and juggle multiple simultaneous demands is a great opportunity for learning the clinical role. Students may convey anxiety about “getting their numbers,” or frustration with not getting enough “hands-on” experience at some times. This is normal. The preceptor must redirect the student to use the opportunities presented, reminding of the value of flexibility and reassuring that it is a transient situation. If managing time with a student is a persistent problem, the preceptor should seek the guidance of the RCC.

Though progress seems slow at the start, the pace of learning rapidly increases. Together, the preceptor and the student will make decisions about readiness for:

• Increasing independence of encounters
• Increasing complexity of situations
• Adding variety of types of encounters
• Care in the inpatient setting, if appropriate
• Learning with different preceptors

Preceptor decisions will be based on ongoing assessment of progress and skill. How the preceptor “frames” and communicates these assessments will be covered in the next section.

rev. 2/23/04

“Present education, provide options, and listen to them. Listen to women!” - Cindy Stewart, CNM and Mary Kay Miller, CNM, Lee OB/GYN Associates, Ft. Meyers, Florida

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