PRECEPTORS MICROSKILL

The microskills provide a simple framework for daily teaching during patient care. This strategy was developed from a combination of educational theory and practical experience. Addresses problems that arise during teaching session To use the MicroSkills, Listen for a cue

Microskill 1: Set Expectation

Cue: Beginning a new educational experience The general discussion with the students about goals and expectations for the entire rotation sets the stage for adult learning to occur with each patient encounter Designed to optimize the "reporting back" encounter between learner and preceptor Example: Welcome. So, what do you hope to learn during this rotation? "Meet me back here in 15 minutes and present today's problem list and differential for this patient "The diagnosis is pretty clear. Review all the results with the patient, discuss the treatment options and let me know in about 30 minutes what you think will work the best for her".

Microskill 2: Get a Commitment The learner should be encouraged to make a commitment to a diagnosis, work-up, or therapeutic plan Cue: After presenting the facts of a case, the learner either stops to wait for response or asks guidance on how to proceed. In either case, the learner does not offer an opinion on the data presented. The preceptor ask the learner to state what s/he thinks about the issue presented by the data. Asking learners how they interpret the data is the first step in diagnosing their learning needs. Difficulty or unwillingness of the learner to make a commitment could be due to: incomplete or contradictory data, knowledge gaps, fear of making a mistake, fear of you. The learner must feel safe enough to risk a commitment even if it is wrong. Examples "What do you think is going on with this patient?" "What other types of information do you feel are needed?" "What would you like to accomplish in this visit?" "Why do you think the patient has been non-compliant?" What other diagnoses would you consider in this setting? What laboratory tests do you think we should get? How do you think we should treat this patient? Based on the history you obtained, what parts of the physical should we focus on?

Microskill 3: Probe For Supporting Evidence Aims to encourage the learner to "think out loud", sharing with the preceptor his/her rationale for the commitment they have just made to diagnosis, treatment, or other aspects of the patients problem. Cue: When discussing a case, the learner has committed him/herself on the problem presented and looks to you to either confirm the opinion or suggest an alternative. Ask the learner for the evidence that he/she feels supports his/her opinion. Learners reveal their reasoning, factual knowledge and gaps in understanding. Examples "What were the major findings that led to your conclusion?" "What are the key features of this case?" "What questions are arising in your mind What points from the history and exam support the diagnosis of _____? Of these two diagnoses, which do you think is more likely, and why?

What factors in the history and physical support your diagnosis? Why would you choose that particular medication? Why do you feel it is important to do that part of the physical in this situation? Microskill 4: Reinforce Good Performance Effective reinforcement must be specific and professional, not just vague praise. Learners may not be sure what is correct,unless reinforced, competencies may be established Cue: The learner has handled a situation in a very effective manner that resulted in helping the preceptor, patients, or other colleagues. Take the first chance to comment on the specific good work and the effect it had. Actions that are positively reinforced are highly likely to be repeated Examples "Obviously you considered the patients finances in your selection of a drug. Your sensitivity to this will certainly contribute to improving his compliance." You identified poor nutritional status in your assessment, and addressed it in your plan. That is important to wound healing. You obtained blood cultures before the first dose of antibiotics. Thats important because failure to identify the pathogen can lead to incorrect therapy. Your diagnosis of `probable pneumonia' was well supported by your history and physical. You clearly integrated the patient's history and your physical findings in making that assessment.

Microskill 5: Correct Mistkakes Cue: The learners work has demonstrated mistakes (omissions, distortions, or misunderstandings) that have or will have an impact on the patients care, the teams functioning, or the learners own effectiveness. As soon after the mistake as possible, find an appropriate time and place to discuss what was wrong and how to avoid or correct the error in the future. Allow the learner a chance to critique his/her performance first. Mistakes left uncorrected will be repeated The correction must be specific and focused on the professional content. Tone of voice and body language are almost as important as the choice of words to convey that the preceptor are coaching them to better performance through learning from mistakes. Examples "You may be right that this childs symptoms are probably due to a viral upper respiratory infection. But you cant be sure it isnt otitis media unless youve examined the ears." "That drug is often a good first choice for this condition, but she is also taking warfarin (or has an elevated creatinine) and the interaction would be dangerous." In your presentation you mentioned a temperature in your history but did not tell me the vitals signs when you began your physical exam. Following standard patterns in your presentations and note will help avoid omissions and will improve your communication of medical information.

Microskill 6: Teach General Rules Cue: The preceptor have ascertained from what the learner revealed that the case has teaching value (the preceptor know something about it which the learner needs or wants to know) Provide general rules, concepts or considerations, and target them to the learners level of understanding. Instruction is both more memorable and more transferable if it is offered as a general rule or a guiding metaphor. Examples Smokers are more likely than non-smokers to have chronic airflow limitation and abnormal inflammatory response of the lungs.yhis is one situation where you may need to broader your assessment.

Deciding whether a patient needs an antibiotic coverage is challenging. Fortunately, there are sonme criteria that have been tested which may further help the patient reverse pulmonary sufficiency "Patients with cystitis usually experience pain with urination, increased frequency and urgency of urination, and they may see blood in the urine. The urinalysis should show bacteria and white blood cells, and may also have some rbcs.

Microskill 7: Encourage Reflection and Integration Cue: Its the end of an educational experience debriefing on the days cases Encourage the learner to articulate what did not make sense or made me uneasy. Reflection reinforces learning and integration with previous knowledge and experience. Reorganize in memory what was learned Enhances learning and recall Examples What went well? How did things go today What caught your interest? Is the practice different from your interest?

Miss. Santos: BERNICE Student A: RONVIC Student B: KRIS

Scenario1: Fourth year nursing students started their first rotation on Medical Surgical Ward at St. Ann Hospital. Ms. Santos was their Clinical Instructor. Ms. Santos: Good Morning!! Im Miss Imee Santos, your clinical instructor for this weeks rotation. May I ask you, what do you hope to learn during this rotation? Student A: after this rotation I expect to learn and understand the case of our patient. Student B: To be able to provide specific nursing interventions based from the gathered data. Ms. Santos: Ok good. At the end of your rotation, you will be having a case presentation and I expect you to provide complete data. Now, I will assign each of you to your individual patient. Meet me back here in 30
minutes and present today's problem list of your assigned patient. Scenario2: After 30 minutes of history taking, students report back to their clinical instructor. And student A presented her patients case. Student A: My patient, Mr. X, a 67 yrs old man, with chief complaints of fever, cough and shortness of breath. He is known to be a smoker for almost 30 years and was diagnosed with mild COPD. He began getting sick about two days ago with what she thought was a cold but by yesterday she had more chest congestion and a temperature of 38. Yesterday his cough was productive of whitish sputum but by this AM it had become yellow to tan with streaks of blood. He noted chills this AM some increase in his wheezing but denies chest pain, except when he coughs. He is on Capoten and HCTZ for high blood pressure, and uses an albuterol inhaler and has been using this about every two hours since last evening. She has no allergies, got a flu shot this year and had the Pneumovax 2 years ago. On physical she is working hard at breathing with wheezes heard without a stethoscope. [Student pauses here waiting for your response] Ms. Santos: Based on the history you obtained, what parts of the physical should we focus on? Student A: According to my hx, we should focus on his breathing pattern

Ms. Santos: What laboratory tests do you think we should get? Student A: Chest X-Ray, sputum exam, ABG
3 Ms. Santos: What factors in the history and physical support your diagnosis?

Student A: He is known to be a smoker for almost 30 years. His cough was productive of whitish sputum but
by this AM it had become yellow to tan with streaks of blood

Ms. Santos: the diagnosis of `COPD' was well supported by your history and physical. You clearly integrated the patient's history and your physical findings in making that assessment. 5 Ms. Santos: You maybe right that Mr. X has COPD based on your history and physical exam. But you did not mention about the laboratory findings that would support the diagnosis 6 Ms. Santos: What will be your nursing intervention for this patient? Student A: Provide adequate oxygenation, maintain proper positioning, Ms. Santos: In patient with COPD, it is important to provide adequate oxygenation at 2-3LPM.___ Position patient in high fowler leaning forward, to facilitate breathing 7. Ms. Santos: ok. For the remaining hours of our duty, you stay at your patients bedside. 30 minutes before 3 pm, meet me back here in the station. How did things go today from your perspective? Student A: it was a good learning experience in my interaction with my patient. I was able to demonstrate well the proper intervention and improved my knowledge regarding the disease.