Preceptor Tips

This topic involves everyone’s favorite topic: Documentation! A recent publication in the Athletic Training Education Journal (@ATEJ_NATA) by Neil et al. (2019) explored the frequency in which preceptors have AT students participate in medical documentation. While 82.3% of preceptors who participated in the study provided documentation experiences for their students, it is concerning that 17.7% provided no documentation experience at all (Neil et al., 2019). As health care providers, we must document and maintain accurate medical records for optimal patient care and communication among health care providers. Research in AT shows that while ATs value documentation, it is time-consuming and therefore does not always get done or is not done to the standard that it should be (Welch Bacon et al., 2017). Students should be integrated into all aspects of patient care at their clinical sites. I know that many of you may document in the morning or evening when the students are not around, however, it is an extremely valuable experience to have them involved in the documentation processes in your facilities. It does not matter if it is pen and paper documentation or the fanciest electronic medical record system. At the end of the day, documentation should hold the same pertinent medical information. By integrating the student into the documentation process, you are providing a great avenue for establishing an educational partnership.

Here are a few snippets from the article (Neil et al., 2019):

• “Many shared that they were active facilitators of the learning, specifically assisting with feedback and revision through the process of documentation. They also described progressive opportunities, where students at different stages of their education were provided more autonomy to document patient care. These preceptors were engaging the athletic training students in experiential learning to facilitate competence (p. 187).”

• “Previous research identified that 10% to 15% of assigned clinical experiences are unengaged waiting time. Rather than having athletic training students fill unengaged waiting time with extra managerial tasks, such as cleaning the facility or restocking supplies, preceptors should consider allocating unengaged time for guided learning and experiences with medical documentation (p. 187).”

• “Simply allowing students to perform a task once will not allow them to improve on their skills and abilities. Instead, preceptors should provide opportunity and feedback that transitions an athletic training student from interdependence to independence…. Because medical documentation requires a cosignature of the supervising AT, it is possible that this kind of activity can be done with independence, but also complemented with feedback and consultation (p. 187).”

• “In order to have effective mentoring and role modeling, the role of preceptor is one that requires time, dedication, and altruism. Respondents indicated that additional time is required to provide the athletic training student with a quality clinical experience… In terms of medical documentation, students should be given opportunities to complete medical documentation after patient encounters… Because medical documentation does not involve any direct risk of harm to the patient, preceptors can allow autonomy with supervision and mentorship occurring as a result of cosigning the record. By being near and available for the athletic training student, the preceptor is able to address any questions or concerns that may arise while completing the medical documentation. We advise that preceptors allow students to first practice and work through any complications they may have with medical documentation, followed by the preceptor immediately reviewing the document with the student and providing feedback (p. 188).”

Examples

• • Let the students take ownership of documentation for all of their patient interactions. Any patient interaction that day must be documentation before the conclusion of the day. Afterwards, you can review their documentation and start off their next day of clinical experience with a constructive conversation about their documentation skills.

  • Ask the student to observe you conducting a patient evaluation. Afterwards, have them write an evaluation note based on their observations of your evaluation. This also helps them with their observation skills and tests their knowledge.

  • You can review the NATA's Best Practices Guidelines for Documentation here. Ask the students to review and come up with an action plan to adopt the recommendations in your facilities. In both cases, you can review the student’s documentation and then provide meaningful feedback on information that they did or did not include.

Documentation might not be your favorite part of the job, but it has to be done. Integrating the students can provide a new opportunity for learning and mentoring. What kind of experiences do you provide related to documentation for the students you supervise? I would love to hear your thoughts about this. Please share with me via e-mail or post on the discussion board on the Preceptor Resource Page. If you are interested in writing a monthly tip, please reach out to Taylor.

References

Neil, E. R., Welch Bacon, C. E., Nottingham, S. L., Kasamatsu, T. M., & Eberman, L. E. (2019). Preceptors’ frequency and supervision of athletic training students’ medical documentation during clinical education. Athletic Training Education Journal, 14(3), 182-190. https://doi.org/10.4085/1403182

Welch Bacon, C. E., Eppelheimer, B. L., Kasamatsu, T. M., Lam, K. C., & Nottingham, S. L. (2017). Athletic trainers’ perceptions of and barriers to patient care documentation: A report from the Athletic Training Practice-Based Research Network. Journal of Athletic Training, 52(7), 667-675. https://doi.org/10.4085/1062-6050-52.3.15

Many of you may be familiar with MedBridge and the various continuing education activities that they provide. I received an e-mail the other day about an article they posted regarding being a rookie physical therapist. I think the points that they bring up are great and can really translate to the development of our students. Gourlay and Plisky (2019) disused their initial fear of failure even though that had heard that they should embrace failure. They had feelings of not feeling good enough and that they were letting their patients down. I have heard this from students, and it can be difficult to help a student see their strengths when they are so focused on their weaknesses. They also noted that the feeling never really went away, even as they progressed through their career. Gourlay and Plisky (2019) formulated three pieces of advice that they wish they would have been told.

1. “You won’t be perfect, but you will see progress.”- We let our students know that we do not expect perfection, but we do expect progress. Every opportunity is a learning experience. We learn in both our successes and missteps. Gourlay and Plisky (2019) argued that if you learn from a failure, then it actually was not a failure.

   1. • Action Step- Weekly Reflections: Our students now participate in weekly discussion boards with their peers to discuss their clinical experience from the previous week. The aim of this assignment was to allow them to reflect on their experiences but also learn from each other. They have participated in one reflection so far, and I am really happy to see their enthusiasm in their participation. Gourlay and Plisky (2019) recommend asking the following questions: What were my big wins? In which areas did I need help? What can I do to make the next week better?

2. "You’ll want to be an expert, but you will continue to learn.”- There is no need to pretend that we know the answer to everything. Gourlay and Plisky (2019) stated that developing expertise is a process, not a destination. I would agree with that, as we are all working towards bettering ourselves and developing our clinician expertise. Those feelings of inadequacy should be the precursor for improvement (Gourlay & Plisky, 2019). Joe Maddon is quoted as saying “If you become a comfortable person, I think that subtracts growth from the equation. I think if you remain somewhat uncomfortable, you’ll continue to grow. You don’t become stagnant. You don’t become complacent, set in your ways.”

   1. • Action Step- Continued Learning Written Plan: Our students write goals at the beginning of each clinical experience. Those who write down their goals are 42% more likely to achieve their goals (Dr. Gail Matthews). Students should consistency re-visit these goals to see how they are progressing towards achieving the goal that they set for themselves. It is the preceptor’s responsibility to help the student set a plan and integrate ways that the student can develop during their clinical experience. It is also important to share with the students what your goals are and how you work towards your goals. Give them examples of your successes and missteps.

3. “You’ll want to do it on your own, but you’ll need guidance.”- We want students to progress to independent clinical practice, however, even once certified, they need to develop relationships with mentors and colleagues. Most of us do not want others to see use struggle or know when we are not good at something, but being vulnerable provides you an opportunity to seek guidance (Gourlay & Plisky, 2019).

   1. • Action Step- Identifying clinical and professional guidance: Students see preceptors as mentors. Some relationships last throughout a career, and some last throughout a clinical experience. However, both are opportunities to help guide and develop the student. Gourlay and Plisky (2019) encouraged students and young professionals to identify someone or something that will always make them reach for more and help them get there.

During our end of the year banquet last year, our speaker talked about the power of the word yet. Students need to embrace that they are not always there, yet. They should embrace what they do not know, yet. We need to be okay with that, as long as they are working towards bettering themselves. How do you help students embrace the yet? I would love to hear about the various ways that you do this. Please share with me via e-mail or post on the discussion board on the Preceptor Resource Page.

Developing Clinical Reasoning: It’s a SNAPP(S)!

As we continue our focus on metacognition, I wanted to bring attention to a tool that can be implemented into your preceptor practice. SNAPPS is a learner-centered teaching approach that can easily be integrated into athletic training clinical education. In this process, the student takes on an active role where the preceptor service as the facilitator (PAEA, 2017). The student has the opportunity to discuss beyond just the facts and focuses on their clinical reasoning (PAEA, 2017). It is most effective for “communicating patient findings and expressing clinical reasoning in a time-efficient manner while allowing the [preceptor] to remain fully engaged in the patient care” (Heinerichs, Vela, & Drouin, 2013, p. 363). Heinerichs et al. (2017) found that the SNAPPS process was effective with athletic training students and allowed students an opportunity to express their clinical reasoning skills. The chart below explains the SNAPPS process.

I am sure many of you utilize this process in one way, but I encourage you to implement this with the students at your clinical site. Depending on where they are in the curriculum, they may only be able to participate in certain parts of the process. Regardless, it is still an opportunity for learning. I have provided additional resources on this topic in the references. I would love to continue the conversation on this topic. Please let me know if you would like to discuss or post your comments on the discussion board.

Summarize the history and physical examination findings (briefly if applicable)

• • Obtain a history, performs a physical evaluation, and presents the summaries of the findings to the preceptor. Students should be able to highlight key pieces of information during this discussion.

Narrow the differential diagnoses

• • Provides two to three possibilities of what the diagnoses could be.

Analyze the differential diagnoses

• • Discusses the possibilities and analyzes the evaluation to support or refute the differential diagnoses. This should be a process that occurs out loud and in front of the preceptor.

Probe the preceptor with questions and express uncertainties

• • Discusses areas of confusions and asks questions of the preceptor. This helps the preceptor to evaluate the student’s knowledge base as well as their clinical reasoning. This can also stimulate additional conversation about the pathology, clinical pearls, etc.

Plan management for patient care

• • Discusses the patient care plan and outline next steps. The student should justify their plan and utilize the preceptor’s input when needed.

Select a case related problem for self-directed learning

• • Identified a learning issue related to the encounter. This may stimulate more conversation around the pathology or evaluate. Stunted should follow up with learning and share new learning with preceptor at agreed upon time (next day, next time at clinical, etc.).

Adapted from PAEA (2017) and Heinerichs et al. (2013)

References

Barrett, J. L., Denegar, C. R., & Mazerolle, S. M. (2018). Challenges facing new educators: Expanding teaching strategies for clinical reasoning and evidence-based medicine. Athletic Training Education Journal, 13(4), 359-366. https://doi.org/10.4085/1304359

Carr, L. L. (2015, March 31). The SNAPPS clinical learning-teaching model. Retrieved from https://facultyedsolutions.org/the-snapps-clinical-learning-teaching-model/

Heinerichs, S., Vela, L. I., & Drouin, J. M. (2013). A learner-centered technique and clinical reasoning, reflection, and case presentation attribute in athletic training students. Journal of Athletic Training, 48(3), 362-371. https://doi.org/10.4085/1062-6050-48.2.17

Physician Assistant Education Association. (2017, February). SNAPPS: A six-step learner-centered approach to clinical education. Retrieved from https://paeaonline.org/wp-content/uploads/2017/02/SNAPPS.pdf

Meckel, M. (n. d.). How to implement SNAPPS into clinical education. Retrieved from https://cdn.ymaws.com/www.ohiochc.org/resource/resmgr/webinars/10.30.18_SNAPPS_FINAL_pp_for.pdf

The Reflective Zombie

Happy Halloween! I know it is not yet November, but I could not help myself by sending out such a timely topic. I have recently read de la Croix and Veen’s (2018) article titled, The Reflective Zombie: Problematizing the Conceptual Framework of Reflection in Medical Education. de la Croix and Veen (2018) defined the reflective zombie as a student who “displays all the outer trains of reflection, without having actually reflected” (p. 1). As part of the Clinical Courses (KIN 220, 330, and 440) students are required to submit their end of the rotation reflective journal. There are several questions to help guide their reflection. Students vary in how much they write and how deeply they reflect. But what is their focus? Is it just to complete the assignment or is it to help them “develop into curious, emotionally intelligent, and critically reflective practitioners” (de la Croix & Veen, 2018, p. 1). Reflection should be challenging because it urges us to evaluate experiences and ourselves and should always lead to changes in behavior (de la Croix & Veen, 2018).

Grading and evaluating reflection is even more difficult! How do we do decide if it is enough? Did the student actually reflect in a meaningful way? There are a lot of scales and checklists we can go through, but is that the best way to reflect? de La Croix and Veen (2018) stated that “mandatory reflective products can lead to a learning environment in which it is more advantageous for students to demonstrate behaviors that fit the expectations of ‘reflecting’ than it is to invest in an authentic search for meaning” (p. 3). This is where the term Reflective Zombie comes from. Students go through the motions of reflection rather meaningfully reflect, which can help them develop skills and attitudes towards reflection that will aid in their development as students. It is also the hope that the reflective skills will translate into the professional clinical practice, as we know that reflection should not stop after schooling.

de la Croix and Veen (2018) offer some solutions to the Reflective Zombie. The first is to embrace diversity in the reflective process. Not all students reflect best through a journal or completing a checklist. While the proposed reflection methods are lofty, we can still take some of the ideas and implement into our current reflective practices. They suggest that students create their own learning objectives, and based on their preferences, they can reflect on those objectives. Currently, our students write goals for their clinical experience. They should be reflecting on their goals at the end of the term and see how they have accomplished a goal that they have set or how they have worked towards it. Just because a goal has not been met, does not mean the student or preceptor failed. Some goals take more than 10 weeks to actually accomplish, and that is okay. It is about progress, not perfection.

The second recommendation is the let the students reflect on the reflection process itself (de al Croix & Veen, 2018). Reflection should be a shared process and not just a means to a grade. The authors suggest providing an opportunity for creativity in the reflective process. The student should guide the way that they reflect to best fit their preferences for reflection. While we are not there yet, your conversations with the student on reflection should look different for each student. Ask them their views on their reflection are and how they believe they best reflect in a meaningful way. de la Croix and Veen (2018) recommended that we must “create conditions that foster reflection, rather than trying to teach directly ‘how to reflect’” (p. 4). Students must experience meaningful reflection to help them develop this habit.

The final recommendation is to investigate the practice of reflection in research. de la Croix and Veen (2018) stated that we must describe how reflection is taking place rather than focus on what counts as “good reflection” (p. 5). I hope that we will see more of this information to come in medical and athletic training education research in the future. Hmm, sounds like a possible doctoral project idea.

We know that reflection is an important practice, and it is essential that students develop strong reflective attitudes and processes to aid in their development. However, we need to take it one-step further. We need to find an opportunity for the students to reflect in meaningful ways to them. Share with them how you reflect, whether it is daily, at the end of the season, or end of the year. How have you developed a meaningful reflection process? Share with them things that have worked for you as well as things that have not. While I have provided a brief overview of the major concepts of the article, I highly recommend reading the full version. You can find free access to the article in the reference below. I would love to continue the conversation on this topic. Please let me know if you would like to discuss.

References

de la Croix, A., & Veen, M. (2018). The reflective zombie: Problematizing the conceptual framework of reflection in medical education. Perspectives on Medical Education. https://doi.org/10.1007/s40037-018-0479-9

Illusion of Fluency

Desai, McCray, and Todd (2018) discussed the "illusion of fluency" in a recent Faculty Focus blog post. I thought this was a very timely post. The illusion of fluency centers on the misjudging of the depth of what one knows. They also refer to it as a false belief of mastery of a concept or area. They focus on the last five minutes of class and how to disrupt this illusion, but I think that we can translate this to the end of a day or week of clinical experience.

At the end of a day, take a moment to talk to and connect to with the student. I am sure a lot of this is happening already, but Desai et al. (2018) provided some useful tools to guide this conversation. The end of the Class Wrapper can easily be used in clinical education. Ask the student the following three questions: the most understand concept/topic, the concept/topic that needs more clarity, and the most confusing concept/topic.

For example, a student may say that they really understand the evaluation process of a lateral ankle sprain based on the evaluation they performed or witnessed you performing that day. They may want more clarity on the diagnostic accuracy of the anterior drawer of the ankle test, and they were most confused by physician referral process for the patient who was four days post-concussion. This provides you great insight for specific areas to provide supplemental information or to stimulate a conversation in that moment or the next day of clinicians. If you were trying this for the first time, I would recommend letting the student know that at the end of the day, you would be asking them those specific questions. This will help them reflect in the moment.

The One Minute Paper is another way to stimulate reflection of the day’s learning. Fulbright (2018) discussed having the students write for one minute after being given an open-ended question. It is up to you if you would like to have them write it down or not, but I believe that the questions Fulbright (2018) shares would stimulate great conversation. Examples of questions include:

• • • The clearest point of today’s clinical experience was...

    • The muddiest point of today’s clinical experience (or something that confused me or I want clarified) was...

    • How did I prepare for the clinical experience today?

    • What did I like best that helped me learn?

    • What do I wish that had been discussed during today’s clinical experience?

Reflection is a very important opportunity to grow as a student, health care provider, and human being. Not all students are innately strong at this. It is one of our many responsibilities as educators and preceptors to help students appreciate growth and understand how effective self-reflection correlates to growth. I often see students focusing solely on the “negatives” or the areas for improvement instead of celebrating their success and taking pride in their growth. Hopefully, this opportunity for self-reflection will empower the student to take ownership of their learning and to be an active rather than passive participant. It is not an easy challenge for us, but I hope that this resource provides you with another tool to help with self-reflection and metacognition. I would love to continue the conversation on this topic. Please let me know if you would like to discuss.

References

Desai, S., McCray, K., & Todd, C. L. (2018, October 8). Disrupting the illusion of fluency. Retrieved from https://www.facultyfocus.com/uncategorized/disrupting-illusions-of-fluency/?st=FFdaily;s=FF181008;utm_term=FF181008&utm_source=ActiveCampaign&utm_medium=email&utm_content=Disrupting+Illusions+of+Fluency&utm_campaign=FF181008

Fulbright, S. (2018, September 27). Three active learning strategies that push students beyond memorization. Retrieved from https://www.facultyfocus.com/articles/effective-teaching-strategies/three-active-learning-strategies-push-students-beyond-memorization/

Student Resilience

I find myself thinking about student resilience. I often ask myself, “was I like this as a student?”. There has been plenty of commentary on resilience of the Millennial and iGen Generations, but I appreciate Rosenbaum and Weatherford's (2017) focus of our own biases based on our experiences. I really like the questions of: "Do the greater presses that this generation face combined with being a more emotionally open and express group mean they are less resilient? Or, does it mean that they have less resilience in some areas but more in others?" (Rosenbaum & Weatherford, 2017, p. 91-92).

A recent article was published in the ATEJ by Crutcher, Moran, & Covassin (2018) about the relationship of social support and perceived stress and depression in AT Students. Their suggestions include helping students to cultivate and maintain social support networks. This includes people inside and outside of the AT program. An opportunity for conversation would to be to reflect on your own social support network and how you’ve cultivated it. How do you maintain your relationships with your social support network? What support do you look for? I would love to continue the conversation on this topic. Please let me know if you would like to discuss.

Below are several articles that could stimulation conversation with your students. I would love to hear about discussion points brought up in conversation. Happy Spring!

• • • Athletic Trainers’ Perceived Challenges Toward Comprehensive Concussion Management in the Secondary School Setting

    • Athletic Trainers’ Perceptions of and Barriers to Patient Care Documentation

    • The Effects of Post-exercise Cooling on Muscle Performance and Soreness Perception

    • Optimal Joint Positions for Manual Isometric Muscle Testing

    • Athletes’ Perception of Athletic Trainer Empathy: How Important Is It?

For the Summer 2017 Preceptor Training, we focused on the importance of effective feedback. At the 2018 GLATA Meeting, Dr. Kirk Armstrong presented on debriefing, in which he compared feedback and debriefing. Think of feedback as a one-way street, preceptor providing feedback to the student, whereas debriefing is a dialogue between two or more people to discuss the actions and thought process used during a particular situation in clinical experience. It provides an opportunity for critical self-reflection. This allows the student time to analyze their actions and reflect on the process to ultimately incorporating improved behaviors into clinical practice. Dr. Armstrong provided general debriefing questions that you can use with the AT students:

• • • How did you feel during the encounters?

    • What went well during the encounters?

    • What did not go well during the encounters?

    • What did you expect to happen during the encounter?

    • What did happen during the encounter?

    • What did you find helpful about engaging in this patient encounters?

    • How do you feel now that we had time to process and discuss the encounter further?

    • How will this impact your patient care in the future?

The 4 Quadrant Feedback Chart can be used to structure your debriefing at the end of each day of clinical experience. You can ask the student to complete the chart and be prepared to discuss it the next day, or you could pick one area to discuss at the end of each day or a number of encounters.

This month’s Preceptor Tip focuses on Visiting Team and Health Care Provider interactions. It is important to integrate the students into communication that you have with visiting teams, ATs, and other healthcare providers you work with. This can include e-mails that you send to ATs and schools coming to your setting for a meet or event or share treatment letters you send or receive, just as examples. Let them be part of the conversations you have with the visiting ATs or coaching staffs. The NATA posted a blog on this topic that may be of help in structuring your conversation with the students. It is also a great learning opportunity to include the students in conversations or opportunities that you have with other healthcare professionals. If your team physician is coming to campus, make sure to let the student know so they can experience your interaction with them. Maybe a patient is going to a clinic for their treatment and rehabilitation. Discuss with the student your conversations with the PT or HCP. You can have them write follow up notes (with your final approval) to physicians or other HCPs. Let them see some of the "behind the scene things” do you before they get there and after they leave. They can gain invaluable experience through these opportunities. The need to realize that that is a lot that you do when they are not there and that they will have to do those “things” when they are independently practicing. Each of your settings provides unique opportunities that the student may not realize.