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Where to teach clinical skills

Traditionally, clinical teaching occurred in hospital wards, GP surgeries, outpatient settings and operating theatres. During the past 20 years, clinical skills centres, laboratories and, more recently, simulation centres with high-fidelity simulation have been introduced. While traditional clinical settings have never been the ideal teaching and learning environments, they are becoming increasingly more difficult to use as service demands stretch goodwill and reduce opportunity. However, workplace-based learning is vital for the acquisition of a comprehensive range of clinical skills that can be used in a variety of complex situations.

Teaching and learning opportunities on wards

Traditional ward teaching usually takes one of the following formats:

  • incorporation of teaching into business rounds
  • the planned examination skills session
  • opportunistic teaching and learning that occurs when dealing with acutely unwell patients.

The business round
Teaching on true business rounds can be unfair on patients, junior colleagues and nursing staff. Useful methods of improving the learning experience include the following.

  • Setting some learning goals prior to the round, e.g. students writing in the patient notes, or presenting the data, ECGs or radiographs on given patients, on or after the round (see below).
  • Asking one of the students to act as a scribe. Then when inspiration hits, prompted by data, signs or symptoms, the scribe is asked to write down your questions. These are then addressed in a follow-up session after the round. This gives time for students to go away and read around areas of weakness, and also avoids humiliating the students in front of the assembled round. As one student put it, ‘This way, only the teacher and my peers get to see how stupid I really am’.
  • More senior students can be asked to take on a given role within the round, giving much-needed experience and insight into the roles and responsibilities they will be expected to fulfill when they graduate.
  • The ‘paper round’ – students present cases in a classroom setting (case-based learning, CBL). All ‘additional’ paperwork, e.g. results of investigations, drug charts, fluid charts, TTAs and death certificates (where appropriate), need to be copied by the students and brought to the round. Any clinical history, examination and investigation findings, pharmacotherapy or procedures may then be used to promote discussion and generate questions. Students should be encouraged to annotate charts to help pre-empt any questions you may generate.

The planned clinical examination session
Small groups of students (two to six) are taken to the bedside, an ‘expert’ demonstrates the skills and then observes the students’ performance of the skill. The main mistake teachers make during such planned sessions is using the patient as a chalk board, lecturing the students while ignoring the wonderful resource that is the patient and their clinical history and signs. These sessions must follow the simple philosophy of making the most of the patient .

Opportunistic teaching and learning
By definition, opportunistic teaching and learning is unpredictable but can be maximised by setting learning outcomes or educational objectives, pre-planning and reflection on important generic and specific educational issues that may arise.

Thinking point

Thinking about these traditional models of ward teaching, how could you update them to suit the environment of the 21st-century ward and help both teacher and learner?

 

See ‘Teaching and learning at the bedside‘ on the Explore around this topic page and the Facilitating learning in the workplace module for more ideas about ward-based teaching.

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