Geriatric Tricks of the Trade
for Teaching at the Bedside
Barbara Resnick, PhD, CRNP, FAAN, FAANP
The Advantages of Bedside Teaching
• "Learning is nothing but discovery that
something is possible: To teach means
to show a person that something is
possible"
• Frederick Perls, Gestalt Therapy Verbatim
Teaching at the Bedside
• One of the tangible benefits of teaching is the chance
to stimulate students' critical thinking and also
demonstrate these skills.
• Critical thinkers
– engage in productive and positive intellectual activities;
– view their thinking as a process rather than an outcome;
– vary their applications of critical thinking according to the
context of the clinical situation; and
– feel comfortable with the emotive as well as rational
elements of the critical thinking process.
– ????TASK VERSUS OUTCOME!
Teaching at the Bedside
• The elements of critical thinking
in a clinical context includes:
– identifying and challenging
student assumptions;
– understanding the importance of
the particular clinical situation to
the thinking;
– exploring and imagining
alternatives; and
– engaging in reflective skepticism.
Teaching at the Bedside
• Agree on the ground rules
• Ground rules are both practical (punctuality, dress,
access to patient records) and philosophical (respect
for patients and colleagues, confidentiality, consent,
openness to different points of view).
• Make sure that the learner knows how much time you
will be able to spend in observing, teaching, and giving
• Clear expectations set for the day
Teaching at the Bedside
• Ask for her/his thoughts…no matter the situation
…before immediately moving into action - that is
where the best learning/understanding takes place.
• Dialogue during the course of the busy day to clarify
and validate existing knowledge or to gain new
insights.
• At the end of the clinical day, take a few minutes to
reflect on what happened, why it happened, what you
liked about the day and the student's performance as
well as what each of you could have done differently to
improve the outcomes of the practice.
Teaching at the Bedside
• Challenges of clinical teaching
• x Time pressures
• x Competing demands—clinical (especially when needs
of patients
• and students conflict); administrative; research
• x Increasing numbers of students
• x Clinical environment not “teaching friendly” (grabbing
private area)
• x Rewards and recognition for teachers and students
want the A-OKAY approach!
Teaching at the Bedside
• Common problems with clinical
teaching
• x TOOO much passive observation rather than active
participation of learners
• x Inadequate supervision and provision of feedback
• x Little opportunity for reflection and discussion
• x “Teaching by humiliation”
– Power over versus power with
– Stress a learning together mode
Teaching at the Bedside
• How to use questions
• x Restrict use of closed questions to establishing facts or
baseline
• knowledge (What? When? How many?)
• x Use open or clarifying/probing questions in all other
circumstances
• (What are the options? What if?)
• x Allow adequate time for students to give a response—don’t
speak
• too soon
• x Follow a poor answer with another question-ask the same
thing three ways!
• x Resist the temptation to answer learners’ questions—GIVE
HOMEWORK AND FOLLOW UP
Teaching at the Bedside
• How to give effective
explanations
• x Focus on non-verbal cues to get
sense of what they know
• x Give information in “bite size”
chunks
• x ask student to summarize their
experiences
Teaching at the Bedside
• FOLLOW….Sir William Osler’s dictum that
“it is a safe rule to have no teaching
without a patient for a text, and the best
teaching is that taught by the patient
himself”.
Teaching at the Bedside
Give feedback
• Learners value feedback highly, and valid
feedback is based on observation.
• Deal with observable behaviors and be
practical, timely, and concrete…. And in
private.
Making it Happen: It is all in a Day
• Know your student ….
– Attitudes toward aging
– Prior aging experience
– What can they handle?
A Self-efficacy Approach
• Social cognitive theory…
– Self-efficacy
– Outcome expectations
•
•
•
•
Performance
Verbal encouragement
Role modeling
PHYSIOLOGICAL FEEDBACK-angst/sweating/increased
heart rate…fear versus feel good, feel proud
Determine What they Need
• Carefully consider clinical experience and
exposure
– What are their clinical strengths and weaknesses
• Do they need to learn more about heart murmurs; afib;
gyn problems; infections?
– Match patient to student provider – vice versa
• What do they want to learn and how can you excite
them?
• Clinically in geriatrics we have it all-things you can’t see
elsewhere
Set Them Free
• Give the student a list of patients to see, write
up and report back
– Let them do this alone and TELL them why!
• Give them the freedom to make mistakes alone-tell
them this is why you are not supervising them.
• Let them know clearly the expectation
– Present the case orally
– Write up the note in draft
– Let them know you plan to discuss this and when
Nonstop model the behavior
• While it is hard …remember you are
constantly being observed by the student and
must:
– Be on best behavior
• Model the kind of care you feel should be provided
• Address and acknowledge when you cut corners
• Share your own mistakes as you make them
Even on busy
days…model and show
what you
want them to know
Model the Joy, Fun, Excitement of
Geriatrics
• This is not setting
specific it is spirit
specific
– Greenhouse effect
or not!
– Make your
environment one
that exudes
positive aging
At The Bedside
• At the end of your day….review findings with
the student
– Go back to the patient
– Confirm what the note says….is there a murmur
for real? Is there REALLY no edema? Let the
student see and feel it.
– Share exciting clinical findings – things they won’t
see elsewhere (tumors, murmurs, palpable
thyroids, livers etc)
DO NOT…..at all costs….correct the student in front
of the patient.
At all costs…make it a feel good, successful experience
Become A Novice
• As you model….remember to put on your
novice hat
– Avoid skipping steps that may be skipped as an
expert or ARTICULATE what they are.
– Acknowledge your own shortcuts
Do NOT Settle
• Note writing
– A note is a reflection of the students’
knowledge/NP practice
– A note is a reflection of YOU, YOUR program and
YOUR University.
– I take a zero tolerance approach…with LOVE
• Write, rewrite and rewrite again
• NO books, blackberries or Iphones
Challenge with Love
• Ask and expect
– Pharmacology
– Lab questions
• Expect the answer without books
• Repeat the questions on another patient in another
way and on another day
• Have the student share their learning with others in
class-via sharing the case or providing the didactic
background they have reviewed.
• Give homework and check answers
Review Progress
• If it is one day experience…at the end of the
day review progress or lack there of.
• If it is a full semester at mid and semester end
review:
– Where you were
– Where you are
– Where you are going
– What you need
– What you need to do to get there
Handling the Tears
• Women cry
– Nursing students are used to being expert nurses
in all clinical situations.
– I start my experiences with them letting them
know I have been practicing as an NP for over 30
years.
– I share with them that I make mistakes every day.
……..they still cry if everything isn’t perfect.
Handling the Tears
• I mostly ignore them….and keep on going
– Criticisms with love and support
– Acknowledging of course the good and great
before the issues and concerns
Dealing with the Defensive Student
• My biggest challenge
– Acknowledge this coping mechanism
– Discuss it
• MOVE ON TO LEARNING!
• GIVE UP
Like Child Care and Clinical Work
• TAKE A BREAK WHEN YOU KNOW YOU NEED IT
– We are human
– We get tired
– We get cranky
– We drink too much coffee
– END THE DAY but do not model negative care
behaviors….
• Do not dress a patient
• Do not get short with a patient or nurse
Share Gero Opportunities
• Nonstop and throughout the programs plant
the seeds of gero opportunities
– Subacute
– LTC
– AL
– Specialty work
My Three Favorite Sayings….
• If I didn’t care I wouldn’t bother…..
• It is what it is ….
• You don’t lose anything by giving it away…..
Along Those Lines
• Make sure to include
a combination of
– Challenging cases for
learning
– Easy successful cases
for confidence
building
Make Sure to Have Fun!