Teaching Procedural Skills
UCSF Faculty Development Workshop
January 21, 2014
Diane Sliwka, MD
Kirsten Greene, MD
Darren Fiore, MD
Workshop Objectives
• Develop a process for teaching a procedure.
• Describe how the theory of deliberate practice
guides the steps for teaching a procedure.
• Practice providing feedback that will enhance
performance.
• Analyze obstacles to the teaching of procedures.
Small Group Activity 1
Goal: How would you teach someone to make an
easy origami heart (procedure)?
-4 groups
-Practice making a heart
-Identify steps for teaching a procedure
-Present steps to large group
http://www.origami-instructions.com/easy-origamiheart.html
Deliberate Practice
• All practice is not equal
• Practice makes permanent
• Deliberate practice makes perfect
• Unproductive (mindless) practice vs.
• Deliberate (mindful) practice
Deliberate Practice
• K. Anders Ericsson
• Expertise: more to do with how one practices
than with performing a skill many times
• Repetitive, goal-directed practice
• Targeted feedback
• Reflection on performance
DIRECT
Practice
Goals
Targeted
Feedback
Observed
Performance
ALLOWS FOR
Framework for Teaching A Procedure
• Identify a skill
• Problem Identification
• Know your learner
• Needs Assessment
• Define specific goals
• Goals and Objectives
• Devise an exercise
• Educational Strategies
• Practice the skill
• Implementation
• Provide feedback
• Evaluation
Steps of Procedural Teaching
• Preparation
• Task analysis
• Conceptualization
• Visualization
• Verbalization
• Guided deliberate practice with feedback
Small Group Activity 2
Goal: Learn and teach a complex origami heart
(procedure) .
-2 groups practice blossom heart
-2 groups practice beating heart
-Work in pairs to teach each other your heart
-Self-assessment of teaching
http://www.origami-instructions.com/easy-origamiheart.html
Feedback
Feedback
• Be respectful and sensitive
• Be specific
• Temporally close to event
• Optimal Losada ratio reinforcing: corrective
5.6:1
ARTful Feedback
• Ask
• Respond
• Tell
Feedback
• What do you think you would like to KEEP
doing? (reinforce)
• What do you think you would like to STOP
doing? (correct)
• What do you think you would like to START
doing? (next steps)
Feedback
• What did you do well?
• What do you think did not go well?
• What do you want to work on next time?
What is hard about teaching procedures?
Patience
• Give the learner a set period of TIME
• Give the learner a set number of TRIALS
• Give the learner a set number of STEPS
Communication
•
•
•
•
Give clear directions
Don’t scare the patient
Don’t scare the learner
Use similes, think creatively about how to
describe things
Safety
• Do not teach a procedure you can’t do yourself
• Do not let the learner get into trouble you can’t
bail them out of
• Choose the correct level of learner for your OWN
experience level
• Choose the correct patient for your OWN
experience level
Challenging Scenario 1
Chris is a surgery intern who has been having a hard
year. His evaluations haven’t been good on any
rotation this year. Faculty report that he is lazy, has
poor technical skills, lacks time management, and still
can’t prioritize what is important vs. what is trivial.
You know that he has gotten a lot of negative
feedback this year. He seems demoralized and less
responsive when attendings point out errors
compared to a few months ago. Today you are
supervising him placing a central line. In the past, he
has had trouble with this according to your
colleagues although you have never worked with
him. What is your approach?
Challenging Scenario 2
You are supervising a resident doing a lumbar
puncture for his 3rd time. He has been attempting
to get the LP for ~20 minutes, and has not been
successful despite your attempts to give
suggestions. The patient is awake and is becoming
increasingly anxious, expressing concerns about
how long the procedure is taking. The patient asks
whether the resident knows what he’s doing. What
do you do as the supervising physician?
Challenging Scenario 3
A new nurse has been training for about 4 weeks to
place PICC lines. Her teacher is an experienced
PICC nurse. The trainee observed her teacher for a
week and has had supervised practice for 3 weeks.
She has been successful nearly 80% of the time, but
doesn’t know why she’s not yet at 100%. She
seems to find and access the vein easily, but
sometimes has difficulty using a guide wire and
manipulating the equipment. How might her
teacher approach this situation?
Summary
• Teaching a procedure takes time and involves
helping learner: prepare, analyze the task,
understand, observe, verbalize the steps, then
practice with feedback.
• Deliberate practice is repetitive and goaldirected with targeted feedback and reflection.
• Procedural teaching parallels the steps of
curriculum development.
• Feedback is critical to improve performance.