St. John’s Medical College, Bangalore, India.

2

Acknowledgements We would sincerely like to place on record the many people who have supported this effort to adapt and modify material, directly and indirectly, in the course of developing this Mentorship Workshop material.

Dr. Prem Pais, Dean, St. John’s Medical College, Bangalore, Karnataka, India

Dr. Swarna Rekha Bhat and Our Team, Department of Medical Education, St. John’s Medical College, Bangalore, Karnataka, India

Dr. Sandy Gove, WHO, Geneva

Dr. McHarry Kirsty, WHO, Geneva

Dr. Po-Lin Chan, WHO, India

Dr. Karthikeyan K, WHO-India

Dr. Moses Christian, St. John’s Research Institute, Bangalore, India.

Our Families for putting up with our travels and work – Celine and Rhea; Maria and Tarun; Our Parents

St. John’s Medical College, Bangalore, India. 2012

3

Preface For many years now, we at St. John’s have been supporting by training health care providers in the delivery of chronic care and treatment primarily HIV related using a mentorship model. In addition, faculty on our staff have played active roles as Clinical Mentors in districts of Karnataka State as well as in Africa while on sabbaticals. These experiences and trainings that we developed and adapted formed the basis of our present Mentoring Workshop design. The content of this Mentoring Skills Participants Workbook is based on the “WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings”, WHO, Geneva, 2006. We have used the insights, information, and many perceptive quotations from “WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings” to develop this practical guide. This revision of the material includes additional advice, strategies, and resources for mentors that can help them work more effectively as mentors. Incorporated were elements of Teaching Learning based on our work as a Department of Medical Education where we have periodically conducted Faculty Development Workshop material for our own institution as well as for regional medical college faculty being a Medical Council of India’s (MCI) Nodal Centre for Medical Education in South India. This Faculty Development Model was also what we ‘exported’ to our partners in Africa, the University of Nairobi, Kenya. The Mentoring Skill Workshop material produced has both components of Mentoring and Clinical Teaching-Learning to strengthen the training and build competencies. We do hope all mentors, past, present and future, enjoy this attempt to strengthen Clinical Mentorship Programs. We are happy to share this material with all requesting only to recognize the work whenever used or adapted. Dr. John Stephen, MD DNB, Professor of Dermatology and Medical Education Dr. Sanjiv Lewin, MD DNB, Professor of Pediatrics, Clinical Ethics and Medical Education For The Department of Medical Education St. John’s Medical College Bangalore, Karnataka, India 560034 (js.stephen@gmail.com; drlewin@gmail.com) Date: 8 January 2012

4

5

1 Introduction 7

2 Clinical mentoring: Definition, purpose & relevance 8

3 Essentials of mentoring 13

4 Principles of Adult Learning 15

5 Mentoring skills 19

a Attending skills

b Listening skills

c Observational skills

d Appropriate use of names

e Speaking skills

f Responding skills

g Exploring skills (explore what is not clear; clarifying questions)

h Giving feedback

i Summarising skills

j Problem solving skills

k Evaluation skills

l Planning skills

m challenging and confronting (conflict management)

6 Approaches and tools

a Learning objectives, their domains 36

b Domain directed T-L Method selection 38

c One on One Learning 39

o One minute perceptorship 42

o Modelling 43

o TOSBA 43

7 Annexures

1. Rapport Building 48

2. Seven Pedagogical Strategies 50

Contents

6

7

Introduct

This Participants Workbook is designed for the training of medical college teachers in a core set of basic skills necessary for mentoring. This includes two training modules which address the range of skills needed to be a good clinical mentor. The first module addresses the psychological preparation to be a good clinical mentor, emphasizing the conceptual, personal, process and communication sets of skills that are central to the mentorship process. The second module addresses the models and modes of mentorship focusing on the methodologies related to bed side teaching.

The objectives:

By the end of the training, participants will:

Understand the role of mentorship

Understand the aims of mentorship

Understand the defining characteristics of mentorship

Understand the models of mentorship and modes of mentorship

Understand the sets of skills central to mentorship

Have learned and practiced communication and facilitation skills

1. Introduction

8

What is Mentoring? Mentoring is a reciprocal relationship between an experienced, highly regarded, empathetic person (the mentor) and a less experienced junior faculty/student member (the mentee) aimed at fostering the professional and personal development of the junior faculty /student member.

The term “mentor” has a long history rooted in Greek mythology. During the Trojan war, King Odysseus left Telemachus, his son and heir to the throne in the care of his friend, Mentor. Odysseus entrusted Mentor with the role of tutor and guide for young Telemachus. Mentor fulfilled a complex role, combining a number of different functions, teacher, guide, advisor, supporter, and advocate. Fundamentally, he served to foster and promote Telemachus’ ongoing development. We derive our current understanding of mentorship and its role from these early roots. The term “mentor” has more than twenty different definitions in the literature and there is no consensus on any operational definition. However, certain basic elements of mentoring relationships can be generally agreed upon. A mentoring relationship is personal in nature, long lasting, and it involves direct interaction. It furthermore involves emotional and psychological support, direct assistance with career and professional development and role-modeling. It is reciprocal, where both the mentor and the mentee derive emotional and tangible benefits but emphasizes the mentor’s greater experience, influence and achievement within a particular field. The overall goal is to enhance and facilitate the professional and personal development of medical students.

Purpose & Relevance Mentorship has been applied in a range of contexts, industry and commerce, health and human service professions, politics and education. Based on the context, there are several different definitions of mentoring in literature. In the context of undergraduate medical/nursing education, mentoring has 3 essential purposes:

2. Clinical Mentoring: Definition Purpose & Relevance

Continuing education

Professional development

Personal support

9

Continuing education: Mentoring should be seen as part of the continuum of education required to create competent doctors and nurses.

The need and purpose of mentoring in many ways correlates with

Fink's five principles of good course design:

1. Challenges students to HIGHER LEVEL LEARNING. All courses require some "lower level" learning, i.e., comprehending and remembering basic information and concepts. But many courses never get beyond this. Examples of "higher level learning" include problem solving, decision making, critical thinking, and creative thinking.

2. Uses ACTIVE FORMS OF LEARNING. Some learning will be "passive", i.e., reading and listening. But "higher level learning," almost by definition, requires active learning. One learns to solve problems by solving problems; one learns to think critically by thinking critically; etc.

3. Gives FREQUENT and IMMEDIATE FEEDBACK to students on the quality of their learning. Higher level learning and active learning require frequent and immediate feedback for students to know whether they are "doing it" correctly. "Frequent" means weekly or daily; feedback consisting of "two mid-terms and a final" is not sufficient. "Immediate" means during the same class if possible, or at the next class session.

4. Uses a STRUCTURED SEQUENCE OF DIFFERENT LEARNING ACTIVITIES. Any course needs a variety of forms of learning (e.g., lectures, discussions, small groups, writing, etc.), both to support different kinds of learning goals and different learning styles. But these various learning activities also need to be structured in a sequence such that earlier classes lay the foundation for complex and higher level learning tasks in later classes.

5. Has a FAIR SYSTEM FOR ASSESSING AND GRADING STUDENTS. Even when students feel they are learning something significant, they are unhappy if their grade does not reflect this. The grading system should be objective, reliable, based on learning, flexible, and communicated in writing.

Finks five principles A "good course" is one which meets the following five criteria: Challenges students to

higher level learning Uses active forms of learning Gives frequent and

immediate feedback Uses a structured sequence

of different learning activities

Has a fair system for assessing participants

Creative thinking

Critical thinking

Decision making

Problem solving

Understanding concepts

Remembering basic information

Comprehending

Classroom based lectures

Clinical mentoring (bedside)

10

Personal support: The term ‘support’ is often used in relation to the wider aspects of learner support, which may include study skills, IT skills and library services, including the provision of academic or personal support given to individual students, trainees or groups by clinical teachers.

Professional development: The responsibility for development must always lie with the individual, but the active support of a wise colleague, in the role of a mentor, can be extremely helpful at particular times, for example in the early stages of a career or in times of change.

The Difference between “Teaching” and “Mentoring” NO TEACHER MENTOR

1 A teacher often tells you important information. A mentor provides the opportunity for you to discover the information.

2 A teacher tells you to read a book; then tests you on your retention of the facts.

A mentor reads a book with you; then discusses how that book changed you both.

3 A teacher understands his/her job to be that of educating.

A mentor understands his/her job to be that of inspiring the students to educate themselves.

4 Syllabi can be planned The teaching moment will occur in some fashion every time the mentor and the student interact

5 There is limitation in the amount of time that can be given to the student

There is no limitation in the amount of time that can be given to the student… it is more generous

6 A teacher imparts the same information to each student equally.

A mentor observes each student and makes suggestions based on their individual needs, passions, or skill levels.

11

Activity 2.1: Self-assessment questionnaire for use by clinical mentors in training Instruction: Read each statement and tick the option A or B which most accurately describes you or your response. Follow the scoring and interpretation guide below after completing the exercise. This will help provide some insights into your skills and approach that will influence your work as a mentor. You are doing this privately.

A B

1. People probably see me as… a soft touch hard nosed

2. I like my days to be… spontaneous planned

3. When it comes to holidays, most organizations need... fewer more

4. When I evaluate people, my decisions are based on… mercy justice

5. My approach to planning my personal activities is… easygoing orderly

6. Most people generally see me as a person who is… formal casual

7. When it comes to social situations, I tend to… hold back get involved

8. I like to spend my leisure times in ways that are fairly… unplanned routine

9. I believe that leaders should be more concerned about people’s… rights feelings

10. When I encounter people in need of help, I’m more likely to… avoid assist

11. When I am in a group, I usually follow lead

12. Most people see me as being… private open

13. My friends know that I am… gentle firm

14. If I were in a group of strangers, people would see me as a … listener leader

15. When it comes to expressing my feelings, most people see me as… reserved comfortable

16. When people I depend on make mistakes, I am typically… patient impatient

17. When I eat out, I generally order food that… sounds unique I know I like

18. In general I prefer… the theatre parties

19. In a conflict when anger is involved, my emotional fuse is… long short

20. In an emergency situation, I would most likely be… calm anxious

21. I prefer to express myself to others in ways that are… indirect direct

22. I am likely to be ruled by… emotion logic

23. In new and unfamiliar situations, I am usually… carefree careful

24. In a festive social situation I am usually… passive active

25. When I am wrongfully accused of something, my first response is to listen defend

26. In situations where I lose or get disappointed, I become… sad mad/angry

27. Dealing with someone in tears is… awkward easy

28. Most people see me as… an optimist a pessimist

29. People think of me as… uncritical critical

30. If people were asked to make a choice, they would say I was… too quiet too loud

31. At the end of a long party, I usually feel… exhausted energised

32. When I work on projects, I am best at getting them… started completed

33. I believe people should approach their work with… dedication inspiration

34. If I made a social blunder, I would be… embarrassed amused

35. When faced with a major change, I get… excited concerned

36. People are likely to see me as… stern warm

37. After a tough day I like to unwind… alone with others

38. Change is most often my… friend enemy

39. My work and social like… are separate often overlap

12

Scoring and Interpretation There are three subscales on this self-assessment exercise. Count up how many As and Bs you have for each of the following three sub-scales by counting your ticks for A and B.

Sub – scale A B High scores: 8 and above in the B column Low scores: 5 and below in the B column

Sociability (13 items):

1, 4, 7, 10, 13, 16, 19, 22, 25, 28, 31, 34, 37

Dominance (13 items):

2, 5, 8, 11, 14, 17, 20, 23, 26, 29, 32, 35, 38

Openness (13 items):

3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33, 36, 39

Interpreting your profile

Sociability: Mentors with a high sociability profile will find it easier to build rapport, express and share feeling and have open dialogue with mentees. High sociability mentors will however need to be concerned with avoiding a domineering role in the process of mentoring. Low sociability mentors will tend to display a reserve making them somewhat unapproachable. These mentors will need to concentrate on making a focused effort to facilitate mentees to be open and to communicate freely with the mentor.

Dominance: Mentors with a high dominance profile will have difficulty with control issues and sharing power in the mentorship relationship. This is important given the understanding of mentorship based in a partnership relationship characterised by shared power. High dominance mentors will need to focus on active listening and be aware of and avoid dominating discussions. Low dominance mentors should consider developing their leadership role in the relationship in order to create a secure, developmental and learning environment for the mentee.

Openness High openness mentors who easily share feelings and thoughts need to consider the effects of this on less confident mentees. High levels of openness may be intimidating for some mentees. Low openness mentors may have difficulty making appropriate emotional and interpersonal connections with the mentee and this may impede the creation of a positive learning environment in which mentees can take risks, experiment and learn through autonomous actions. These mentors will need to address their cautious interpersonal style especially in the early phase of the mentor – mentee relationship.

13

Mentoring is “the process whereby an experienced, highly regarded, empathetic person (the mentor), guides another individual (the mentee) in the development and re-examination of their own ideas, learning and personal and professional development”1. Clinical mentors are experienced clinician-trainers who provide case review, problem solving, quality assurance and continuing education in the context of an ongoing personal relationship. There are 5 essential steps in mentoring:

1. Building relationships 2. Identifying strengths and gaps 3. Responsive coaching and modeling 4. Advocacy for work environment (patient and provider) 5. Giving feedback

Build Relationships (also check Annexure 2 on rapport building)

Establishment of a trusting and receptive relationship between the mentor and mentee(s) is the foundation for an effective mentoring experience. This component is ongoing over the course of the mentorship, as the relationship continues to evolve and grow. What are the qualities of an effective mentor? What strategies do mentors use to engage and connect with mentees? These questions are at the heart of all mentoring relationships. Some Mentor-mentee relationships do well while others come apart. Studies have shown that the key reasons had to do with the expectations and approach of the mentor. Most of the mentors in the relationships that failed had a belief that they should, and could, “reform” their mentee. These mentors, even at the very beginning, spent at least some of their time together pushing the mentee to change. Almost all the mentors in the successful relationships believed that their role was to support the mentee, to help him or her grow and develop. They saw themselves as a friend2.

1 Standing Committee on Postgraduate Medical and Dental Education in the United States of America 2 K.V., & Styles, M.B. (1995). Building Relationships with Youth in Program Settings: A Study of Big Brothers/Big Sisters.

Philadelphia: Public/Private Ventures. Available online at http://www.ppv.org/ppv/publications/assets/ 41_publication.pdf

3. Essentials of Mentoring

14

What are the qualities of a mentor for good relationship building? The important features of successful mentors’ attitudes and styles are:

1. Be friendly and approachable 2. Have realistic goals and expectations. 3. Give your mentee voice and choice in deciding on activities. 4. Be positive. 5. Listen. 6. Respect the trust your mentee places in you. 7. Remember that your relationship is with the mentee, not your employee, not his employee 8. Remember that you are responsible for building the relationship.

Identifying strengths and gaps This component involves observation and assessment of existing systems, practices, and policies to identify strengths and areas for improvement. This manual describes a number of tools that can help with this assessment phase. This observation assessment allows the Mentor to identify strengths and weaknesses (gaps). These identified strengths and gaps give direction to the Mentor’s to reinforce strengths and assist Mentees work out solutions to existing gaps in their abilities to deliver quality care.

Responsive coaching and modeling Mentors must demonstrate proper techniques and model good practices. During mentoring, this means examining patients along with the mentee; using appropriate, systemic examination techniques with gloves when appropriate; and hand washing. Mentorship is as much about setting a good example as it is about directly intervening to improve mentee practice.

Advocacy for work environment (patient and provider) This component relates to technical assistance in support of systems-level changes. Mentors work with colleagues and the management to enhance the development of infrastructure, systems, and approaches that can support the delivery of comprehensive care. For example, mentors might provide technical assistance in support of proper flow of patients at the facility, advocate for provision of privacy for patients during examination, or help to promote a multidisciplinary approach to care. In relation to mentoring students, the mentor may be called upon to advocate for special postings, leave for attending conferences, research funding,…etc.

Feedback It is the ability to learn from mistakes that makes us competent health care providers. Mentoring relationships can play an important role in facilitating the feedback loop – helping the mentees to reflect on their learning and mistakes and to develop and become more competent health care providers.

15

The six principles of adult learning (Knowles)

1. Adults are internally motivated and self-directed

2. Adults bring life experiences and knowledge to learning experiences

3. Adults are goal oriented 4. Adults are relevancy oriented 5. Adults are practical 6. Adult learners like to be respected

Part of being an effective instructor involves

understanding how adults learn best. Compared to

children, adults have special needs and requirements as

learners. Andragogy (adult learning) is a theory,

pioneered by Malcom Knowles, that holds a set of

assumptions about how adults learn. This section will

describe these principles and how they can be applied to

improve the effectiveness of teaching-learning sessions.

1. Adults are internally motivated and self-directed Adult learners resist learning when they feel others are imposing information, ideas or actions on them. Your role is to facilitate a students'/participants’ movement toward more self-directed and responsible learning as well as to foster the student's internal motivation to learn. For learning to occur, adults have to do things. They must get involved and work at tasks and exercises. They learn by doing and making mistakes and then discovering solutions for themselves. Adults want to be consulted and listened to. Although trainers need to give direction at times, this should be the exception rather than the rule. As clinical educator you can: Set up a graded learning program that moves from more to less structure, from less to more

responsibility and from more to less direct supervision, at an appropriate pace that is challenging yet not overloading for the student.

Show interest in the student's thoughts and opinions. Actively and carefully listen to any questions asked.

Lead the student toward inquiry before supplying them with too many facts. Provide regular constructive and specific feedback (both positive and negative), Review goals and acknowledge goal completion Encourage use of resources such as library, journals, internet and other department resources. Set projects or tasks for the student that reflects their interests and which they must complete

and "tick off" over the course of the placement. For example: to provide an in-service on topic of choice; to present a case-study based on one of their clients; to design a client educational handout; or to lead a client group activity session.

2. Adults bring life experiences and knowledge to learning experiences Adults like to be given opportunity to use their existing foundation of knowledge and experiences gained from life experience, and apply it to their new learning experiences. As a clinical educator you can: Adults want to test what they learn with what they already know. Encourage them to answer

questions from their own experience. Don’t just present information as truth… Use people’s different experiences to encourage

questioning and discussion so that they can arrive at the truth for themselves.

4. Principles of Adult Learning

16

Assist them to draw on those experiences when problem-solving, reflecting and applying clinical reasoning processes.

Facilitate reflective learning opportunities which can also assist the student to examine existing biases or habits based on life experiences and "move them toward a new understanding of information presented”.

3. Adults are goal oriented Adult students become ready to learn when "they experience a need to learn it …. in order to cope more satisfyingly with real-life tasks or problems" (Knowles, 1980). Your role is to:

o Facilitate a student's readiness for problem-based learning and o Increase the student's awareness of the need for the knowledge or skill presented.

As educator, you can: Provide meaningful learning experiences that are clearly linked to personal, client and fieldwork

goals as well as assessment and future life goals. Provide real case-studies as a basis from which to learn about the theory and implications of

relevance. Ask questions that motivate reflection, inquiry and further research.

4. Adults are relevancy oriented Adult learners want to know the relevance of what they are learning to what they want to achieve. Adults prefer to focus on real life, immediate problems rather than on theoretical situations. Adults see learning as a means to an end, rather than an end in itself

As educator, you can: Provide useful information that is relevant to their needs. Adults would rather focus on current

issues, rather than material that may be useful in the distant future. Tell adults about the purpose and benefits of the session, and about the process you intend to

follow. That way they will know what’s in it for them. Summarize and review regularly so they can see that progress is being made. Ask the student to do some reflection … on for example

• What they expect to learn prior to the experience • What they learnt after the experience • How they might apply what they learnt in the future • How it will help them to meet their learning goals.

5. Adults are practical By interacting with real patients and their real life situations, students move from classroom and textbook mode to hands-on problem solving where they can recognize firsthand how their learning applies to life and the work context. As a clinical educator you can:

Clearly explain your clinical reasoning when making choices about assessments, interventions and when prioritising patient's clinical needs.

Be explicit about how what the student is learning is useful and applicable to the job and patient group you are working with.

Promote active participation by allowing students to try things rather than observe.

17

6. Adult learners like to be respected Respect can be demonstrated to your student by:

Taking interest Acknowledging the wealth of experiences that the student brings to the placement; Regarding them as a colleague who is equal in life experience Encouraging expression of ideas, reasoning and feedback at every opportunity.

In summary…

Treat adult learners with respect. Encourage discussion and participation. Rather than being the teacher with all the answers, try and be the facilitator who helps them to learn for themselves. Both you and they will then have a much more rewarding and enjoyable teaching-learning session.

18

Activity 4.1

The six principles of adult learning 1 Self-directed 2 Bring life experiences 3 Goal oriented 4 Relevancy oriented 5 Practical 6 To be respected

Discuss in your groups and identify: to which of the above principles does the below mentioned relate to.

1 Lead the student toward inquiry before supplying them with too many facts.

2 Provide real case-studies as a basis from which to learn

3 Encourage them to answer questions from their own experience

4 Encourage questioning and discussion

5 Tell adults about the purpose and benefits of the session, and about the process you intend to follow.

6 Increase the student's awareness of the need for the knowledge or skill presented

7 Encourage use of resources such as library, journals, internet and other department resources.

8 Promote active participation by allowing students to try things rather than observe.

9 Encouraging expression of ideas, reasoning and feedback at every opportunity

19

Mentoring: psychological, interpersonal, and communication skills Interpersonal communication skills are those skills which directly relate to initiating and maintaining effective and open communication between the mentor and mentee – they are the micro skills of listening and responding appropriately. These skills are used in a one-to-one session (face to face and over the telephone) and in group facilitation.

A. Attending skills Attending means being physically, intellectually and emotionally “present” in a mentoring session. These skills indicate to the mentee that the mentor is listening, is aware and is ready to interact. They show in a non-verbal way that the mentor is attentive and available. The acronym SOLER is often used to summarise these basic skills:

S stands for sit or stand squarely: this means facing the mentee so that they can see the mentor

and communicate openly. Sometimes a more “conversational” sitting or standing style is used where the mentor and the mentee sit or stand at right angles to each other while they talk. In a group mentoring session the mentor must face the group to convey openness and attentiveness and when appropriate turn his or her body to face a specific speaker.

O stand for open posture: this means not crossing arms or holding a folder/file in such a way

that it indicates a closed body, and possibly a closed or “switched off” mind. It can also refer to minimising barriers between mentor and mentee, such as a desk or bed. If mentoring a mentee next to a patient, try to stand next to each other.

L stands for leaning forward: this means leaning in to the mentee at appropriate times to

convey interest and concern. This should be used carefully so as not to intimidate a mentee too soon in an encounter. In addition, mentors must be mindful of body space differences in people from different backgrounds. Good observational skills will soon pick up what is an appropriate space.

E stands for eye contact: this means keeping natural eye contact to show the mentee that the

mentor is listening to what is being said. Eye contact in group sessions is vital to focus in on a specific participant and to notice what is going on in the group. Remember that for some people too much eye contact may be experienced as threatening or disrespectful: good contextual knowledge will assist here.

R stands for relaxed posture: this means not fidgeting excessively or holding one’s body in a

tense manner. The mentor should convey a calm sense of containment to the mentee and should role model how patients may too be calmed and contained by this method.

While these attending skills mostly apply to face to face encounters, they can be used in a telephone conversation to maintain focus. Sitting up, leaning forward, being relaxed but alert, eyes focusing on something neutral, all help to keep the mentor “ in tune” with the mentee. It is also useful to think about appropriate use of touch. In some cultures it is acceptable and even desirable to convey empathy and understanding through a pat on the shoulder, a warm handclasp or even a hug. In others there may be strict limitations on cross gender touching. Working with people who

5. Mentoring Skills

20

are living with HIV or AIDS has special considerations around fears of infectivity and they may often feel untouchable. It would be useful to explore:

What are the norms around touch in the specific clinical setting?

How comfortable are you as a mentor with touch?

The mentee’s comfort levels with touch. This may be done through a direct question such as “When you greet a patient do you shake hands?” or “If a patient is crying how would you comfort them?”

B. Listening skills What is a mentor listening for in a mentoring encounter?

Themes and threads: in a presentation the mentor must extract key messages and link ideas so that sense is made of the material a mentee is presenting. These may be reflected back to the mentee to show that the mentor has been listening well.

What is said and not said: what does the mentee focus on in his or her presentation of a case and what is left out? She or he may be editing out mistakes, or being very matter of fact, or overly emotional. These are clues that tell the mentor something about the speaker.

Tone and delivery: these may tell the mentor about the personality of the mentee, about their social skills or about their comfort with presenting in a group. They may reveal information about how the mentee interacts with patients.

Feelings and facts: some mentees may present difficult patient stories in a very clinical and detached way, or they may become emotional about a dying patient. This is important information to store and work with.

Knowledge gaps: is the mentee revealing a key gap in clinical know-how? This gap needs to be tactfully corrected.

Strengths and weaknesses: the mentor may learn through good listening about a mentee’s clinical, intellectual, emotional and relational skills and growth areas. These all need to be factored into the responses and approach of the mentor.

Most of us listen in spurts and are unable to give close attention to what is being said for more than 60 seconds at a time. We concentrate for a while, our attention lags, then we concentrate again. This can be improved with some simple techniques. The following are typical listening challenges:

You had trouble understanding the speaker’s words or language usage. You were thinking of what you were going to say while the speaker was talking. You were preoccupied with how strongly you disagreed with the speaker’s views. You listened for what you wanted to hear. You were too tired mentally to pay attention. There were outside noises and distractions. The speaker had poor delivery – slow, irrelevant, rambling or repetitious. Something the speaker said intrigued you: you thought about it and when you tuned back in you

had lost the thread. The speaker had an accent you found hard to understand. You tuned out because you thought you knew what the speaker’s conclusions were going to be. You forgot to paraphrase and give feedback to show you were listening effectively. You felt you were being given far too much information.

21

Listening can be improved with some simple approaches:

You must care enough to want to improve. Without this motivation, it will be too much effort. Try to find an uninterrupted area in which to converse. Keeping your train of thought is difficult

when there are obstructions to conversation. Try not to anticipate what the mentee will say. Be mindful of your own prejudices or biases so they do not unduly influence your listening. Pay careful attention to what is being said – don’t stop listening to plan your rebuttal to a

particular point. Be aware of “red flag” words which trigger an overreaction or stereotyped reactions – when they

occur, mentally remind yourself to keep focused on what the mentee is saying. Don’t allow yourself to get too far ahead of the mentee by trying to understand things too soon. At intervals, paraphrase or summarise (see below) what the mentee has been saying – the more

accurate you are the more you show you have been listening. However even if you are wrong you should paraphrase in a tentative way so that the mentee can correct you and put you on track.

If you are not sure why a mentee is telling you something, ask. For example you could say “It’s not clear to me what point you are making, can you clarify it for me?”

If you are losing the train of the conversation, home in on key words or concepts to keep focus. Don’t interrupt the mentee to ask for clarification of a minor or irrelevant detail. If the mentee is making many points it is acceptable to jot down key words to keep track – but

make a point of using the attending skills to make up for the temporary loss of eye contact, for example through nodding in acknowledgement of what the mentee is saying.

C. Observational skills The mentor should use observational skills to get a sense of how the mentee is presenting him or herself. Aspects to look out for include:

What is the mentee’s general demeanour: are they positive and upbeat, pessimistic and depressed, angry and confused, defensive and wary?

What kind of body language is the mentee using? The ideas expressed in SOLER (above) are useful to think about – is the mentee open with the patient and the mentor, does the mentee use appropriate eye contact and physical distance, is the mentee tense and withdrawn in an encounter with a patient?

Is the mentee neat and appropriate in dress and physical presentation? Not only do these reflect the general wellbeing of the mentee but they suggest levels of professionalism in dealing with patients.

How does the mentee use language? Rate of speech, tone of speech and volume of speech may be key to how well the mentee can be understood and can also suggest mood and mental state. Sometimes it is appropriate to temporarily match these to “tune in” to the mentee and lead them to a calmer and more relaxed encounter. The mentor may also wish to ask the mentee to slow down to aid understanding.

The mentor should also observe what is going on in and around the mentoring context: how are wards maintained, what are the challenges clinician’s face, what levels of privacy exist, and so on? These need to be factored into the advice or support given to the mentee.

22

D. Appropriate use of names Is there an appropriate way to use names – first name only or surname as well? Think of the different impression this creates. It can be helpful to use a mentee’s name regularly – it helps to make and keep an empathic connection. Be prepared to say your name again (or more slowly) so that the mentee hears it and remembers it (if relevant). Some names are complicated: always check the correct spelling and pronunciation as this makes the mentee feel important (don’t say “What a strange name.”). Some people say their surname first when they give you their name: if you are not sure, check this out.

E. Speaking skills The mentor should develop an awareness of how she or he uses language and attempt to modify vocal skills to improve understandability and communication. Awareness of vocal style can be gained through taping of one’s voice and reviewing for clarity or by asking for feedback from others, including the mentee. The kinds of things to look out for include:

Tone of speech and volume of voice: the tone can convey warmth and empathy or indicate a desire to bring formality into a particular encounter. If a mentee is being rude to a patient the mentor can use a warm tone with the patient to model compassion. In a group mentoring context the mentor must be audible to all and be able to use volume to “take control” of the session.

Rate of speech: in general one should use a slower rate with an audience unfamiliar with one’s accent – but this should not become sing song or patronising.

Range of inflections: stressing certain words and varying emphasis will prevent boredom in an audience. Again, the mentor can model the way in which a patient should be spoken too by using this variety with the patient.

Modifying accent/pronunciation: it may be useful in some settings to adapt pronunciation of certain words to accommodate local style and usage, in order to improve comprehension.

Rhythm of speech: the mentor should try to modify their rhythm of speech to be clear and interesting.

Appropriate words and language: the mentor needs to understand the particular mentoring context to make better choices of words and phrases which mentees use and understand.

Use of minimal encouragers (“mmm, uh huh, I see”): these encourage the mentee to keep talking and show one is listening. This could go along with nods of the head. Minimal encouragers are particularly important in telephone sessions as the normal visual cues are absent.

F. Responding skills Responding skills are those skills which allow the mentor to respond directly to what a mentee has said to take the conversation further in a useful direction. They also show the mentor has been listening or, if the response misses the mark, gives permission to the mentee to put the mentor back on track. It is always important to begin a response with a qualifier such as “it seems to me” or “it appears that” and to use a tone of voice which conveys tentativeness. This is not because the mentor wishes to appear

23

uncertain but to show respect for the mentee’s right to be the final arbiter of the “truth” of their utterances, thoughts and feelings. Three key responding skills include:

Responding to content/facts through paraphrases This shows the mentee that the mentor has been listening well, allows the mentee to hear their own ideas reflected and digested through the ears of another, and begins the process of “ordering” the mentee thoughts and concerns. A paraphrase is a simple reflection of the key idea a mentee has expressed. If the mentee says “When I first saw the patient she seemed very sick and I wasn’t sure if she was going to survive. I wondered if she was a good candidate for ARVs because she seemed so far gone. Even her family seemed to have given up on her.” The response of the mentor could be “So it sounds like when you first saw this patient you didn’t think there was anything you could do for her”. Depending on the mentee this could go in the direction of an exploration of feelings of hopelessness in the mentee or in the direction of a clinical/technical decision about initiating ART in patients with low CD4 counts. In a group mentoring session the paraphrase can be used to “hear” two different points of view without taking sides, as in “Gabriel seems to think this patient should first have been supported nutritionally before commencing ART but you, Simeon, feel that the ART should start at the same time as the nutritional support.”

Responding to feelings Apart from responding to the “simple facts” of a mentee statement it is also possible to respond to the emotional aspect of what they have said. Responding to feelings brings in a “relational” element in that connecting to others at this level is usually deeper and more meaningful, conveys empathy and can build trust if handled sensitively. Using the example above the mentor could have said “it seems that you experienced a sense of hopelessness when you saw this patient for the first time.” If the feeling identified is accurate, the mentee feels understood at an emotional level. This is always more effective than saying “I understand how you feel.” Working with feelings can be uncomfortable at first and it presupposes that the mentor is themselves comfortable with their own emotions and is adept at identifying feelings. In some cultures a “feelings vocabulary” may be limited or men may be socialised not to express feelings. These differences must be respected but not necessarily seen as a barrier to some effort to working with feelings.

Linking feelings to content/facts This enhances empathy because it starts to bring depth, meaning and texture to the mentoring encounter. By associating the feeling with a situation or event the mentor is helping to tie up the threads of the conversation and to help the mentor see why, in a certain situation, they responded in a certain way. Using the example above, the mentor could have used this skill in saying “So it seems that when you first met this patient you felt a slight sense of hopelessness because her illness seemed so far advanced and those around her had also given up.” This shows a high level of listening and brings together the various themes in the mentee’s statement.

24

As the mentor becomes more skilled in using these ideas she or he can in effect draw together paraphrasing, summarising and reflecting facts and feelings to show the mentee they have been listening well, and perhaps even “listening between the lines.”

G. Exploring skills (explore what is not clear; clarifying questions) In any communication with a mentee in which the ultimate aim is to understand the mentee, convey information and promote MNCH care and management, the mentor will have to go beyond reflecting what has been heard to explore what is not clear and to deepen understanding on both sides. The mentor should use exploring skills after the first phases of the encounter have been completed (joining, contracting and hearing the initial concerns, facts and feelings). This exploring can be done in a number of ways.

Clarifying what is not clear through asking questions for greater understanding or repeating mentee statements with a questioning inflection.

In both instances the mentor wants to get clarity on a specific point a mentee has made. For example if the mentee says “The patient told me that she always remembers to avoid unnecessary medication because of the child,” the mentor could respond in at least two ways:

By asking a clarifying question such as “When your patient said ‘because of the child’ what do you

think she meant?” By saying “because of the child?” with a rising inflection to indicate a question.

Both methods prompt the mentee to expand further on the particular point and clarify for the mentor what is meant.

Asking open questions: open questions have more than one answer and usually begin with “how” “when” or “what”, as in the example given above. These probes encourage mentees to think expansively and reflect an attitude of respect from the mentor because they assume the mentees have ideas and experience to draw on. Open questions also presume there is time for an extended discussion. In certain contexts a closed question, one which has a yes or no or some other forced choice answer, also has its uses, especially if time is limited or if the mentor wishes to be more directive. Some closed questions can be “leading” in that they point the mentee in a very specific and “socially desirable” direction – leaving the mentor unsure if learning has happened. For example if the mentor asks “You do understand this don’t you?” the mentee will often answer “Yes” because this is the expected answer and they do not wish to come across as foolish.

Asking hypothetical questions: these are usually open questions which prompt lateral thinking in mentees. An example would be “What would you do if a patient with a CD4 count of 250 presented with an AIDS defining illness? This explores knowledge and encourages mentees to be creative.

Asking reflecting questions: these are questions which encourage mentees to summarise or reflect on a particular discussion. This could be very effective in a group mentoring session where a number of cases had been presented and the mentor asks “What are the key themes that have come out of today’s cases?”

25

Asking evaluative questions: these are questions which take a specific issue and case and “evaluate” a course of action. For example if a mentee has embarked on ART with a patient who has a pre-existing cholesterol problem the mentor could ask “How do you think this will work over time?”

H. Giving feedback These skills tend to reflect on the “relationship” between the mentor & mentee or the “process” of what is happening i.e. “how are we getting on?” Feedback is a crucial part of facilitating and vital to the role of the mentor. This feedback may be of a technical nature (“The dosage you have prescribed is wrong.”), may relate to general improvement of the mentee (“You have made good progress as a clinician.”), may relate to the way in which a mentee has conducted him or herself in a mentoring session (“It seems it was difficult for you to hear the negative comments of your colleagues”) Feedback can be given to:

Let others know when you don’t understand what they’ve said Let others know when you like something they’ve said or done Let others know when you disagree with them Let others know when you think they’ve changed the subject or are going round in circles Let others know when you’re becoming annoyed Let others know when you feel hurt or embarrassed.

Feedback also helps to keep the mentor (or mentee, because the mentee is entitled to give feedback to the mentor and she or he should be open to this) in touch with their own reactions before they turn into serious negative feelings. To be effective, feedback should be given when there is a foundation of trust between the mentor and mentee, otherwise the feedback could be interpreted as a personal attack. Some tips for giving feedback:

Be sure the mentee is ready: if not the feedback will not fall on fertile ground. If possible, preface your feedback with something positive before giving negative or critical

feedback. Base your comments on facts not emotions. Be specific: give quotes and examples of exactly what you are referring to. Give feedback as soon after the event as possible: if you give the feedback immediately the

mentee is more likely to understand exactly what’s meant. But pick a convenient time: if the receiver is very busy with other urgent matters they will not be

able to concentrate on your feedback. Pick a private place: critical feedback given in front of others can be damaging rather than helpful

– one exception to this is feedback given to a group if there is conflict or avoidance in the group, not to address this would be a disservice to group process.

Concentrate on what can be changed. Request co-operation: invite the mentee to work with you and seek their “buy in” to the desired

change. Focus on one thing at a time: too much feedback will be overwhelming to the mentee.

26

Be helpful: always consider your own motives for giving your opinions – are you trying to be helpful to the mentee or are you unloading some of your own feelings (if you are angry say so but include a description of the behaviour that caused your anger).

Encourage the mentee to give feedback in return: giving feedback can become “one-upmanship”. Some tips for receiving feedback:

State what you want feedback about. Use paraphrasing to check what you’ve heard. Share your reactions to the feedback.

If you are giving feedback to a person who is being difficult you can use the following steps:

Describe the problem or situation to the person causing the difficulty. Define what feelings or reactions (anger, sadness, anxiety, hurt or upset) the problem behaviour

causes you. Suggest a solution or ask the person to provide a solution.

In a telephone mentoring session the immediacy skill may help to address situations which would be less problematic in a face to face session. For example, if there is a silence in a face to face session, it may be obvious from the mentee’s body language that they are thinking about a point the mentor has made. In a telephone encounter the mentor does not have the luxury of visual cues and may have to address the silence with a question or some other intervention such as a reflection or summary. Example: responding immediately to problems with feedback If, for example, the mentor says to the patient he and the mentee are examining, “Fatima when the doctor explained to you how to take your ARVs was it clear to you what to do?” and the mentee gets angry and says “of course it was clear”, the mentor may need to tackle the mentee’s response as soon as possible. This should be done in private and the mentor could respond in a number of different ways:

“Susan I noticed you got angry when I asked the patient about your discussion with her, what was going on for you in that moment?”

“Susan that seemed to be an awkward moment between you and me there, perhaps we should talk about it?”

“Susan it seemed inappropriate to me that you should get angry in front of the patient. Would you like to tell me what angered you?”

Susan’s angry response might have been because she felt humiliated or her skills doubted in front of the patient; she could have sensed a pattern of challenging questions from the mentor; or she could have been defensive because she knew she had done a poor job of explaining ARVs and adherence to Fatima. Attention to the process of what is going on and immediately addressing problems let the mentor get to the root of the issue and allow the air to be cleared. Once the issue is out in the open it can be addressed and the “relationship” between the mentor and mentee put back on an amicable and workable footing.

27

I. Summarising skills Summaries are essentially paraphrases of a larger chunk of material or conversation from a mentee. A summary provides order and focus and sorts out relevant material to explore in an encounter. Good summaries act as natural “stopping and reflecting” points in a conversation and can also be used to bring a session to a close. In a group session a summary can be used to check out how well group members have been following the discussion, by asking someone to draw together the key points as they see them. It would be useful not to “pounce” on someone who clearly hasn’t understood the session! Other uses of summaries include:

To give direction to a mentoring encounter To prevent getting stuck on a particular issue To check out if the mentor has really understood what the mentee is trying to say To link different points and themes together. .

Some tips for summarising:

A good summary is brief and includes not only the facts and the words but also the feelings the mentee has expressed.

Put the ideas and descriptions at least partly into your own words but the language should still be primarily in the words used by the mentee.

J. Problem solving skills In general it is advisable to use problem solving skills after there has been a thorough exploration of all aspects of a problem. If this exploration is done in an engaging way solutions may naturally start to emerge, the mentee feels heard and the solution that is arrived at is relevant to the context or situation. The process of problem exploration also teaches the mentee a structured way of thinking about and approaching problems – the mentee can take this approach into other situations. Remember that giving solutions too soon encourages dependency and lazy thinking in mentees. The first step in problem solving is to partialise the problem, i.e. to break it down into its component parts or sub-problems. This is particularly useful when a problem appears to be large and overwhelming so that no one solution is immediately apparent. By breaking the problem down, the task of finding solutions is made easier because the smaller problems will then each be easier to solve. The next step is to agree on a clear definition of the problem (or sub-problem). It is often useful to define a problem in terms of specific needs. For example if the mentee has presented a case in which the patient has not disclosed to anyone but needs assistance with adherence, it may be helpful to define the problem as: “The patient needs help with disclosure,” rather than “The patient is resistant and reluctant to disclose”. Then encourage the mentee (or mentees in a group session) to brainstorm as many solutions as possible. These can be written down for review – all ideas should be considered as this is a creative process to stimulate lateral thinking. Only when the mentee has exhausted all ideas should the mentor make his or her contribution as this respects the ideas of mentees.

28

Sometimes the mentor could encounter resistance to change and finding solutions. Here are some ideas to counter this resistance:

“It can’t be done,” versus “What if we could do it?” “We can’t do it like that,” versus “What if this barrier didn’t exist?” They would never agree to it,” versus “What if we could get them to agree?” “It will be too expensive,” versus “What if we found a budget?” “This is too risky,” versus “What if we managed the risk?” “I don’t have the time,” versus “What if we reallocated resources?” “That’s already been tried,” versus “What if we tried again?”

Now evaluate each possible solution or option by considering the advantages or disadvantages of each. This can also be done as a simple list of pros and cons in the form of a balance sheet. Then allow the mentee to choose the best solution for his or her circumstances. Usually the best solution is the one with the fewest disadvantages and the most advantages. In some cases where the solution is a technical one, such as the right combination of ARVs or a specific treatment for an ARV side effect, the mentor would obviously need to ensure that this is the option that is acted upon. Perhaps is it useful here to distinguish between problems that have right or wrong answers and problems which could have a number of possible solutions. Then a decision has to be made to implement a specific decision. Mentees must learn to trust their own decision-making abilities and this includes committing to a course of action. Now a practical action plan is drawn up to take the decision forward. It is important to include specifics such as what, when, where and how this should happen. In some cases mentees may need to learn to be more flexible and open to creative solutions that go beyond stock answers. Some questions which can be asked at this point to move the mentee to action include:

What are you going to do? When will you do it? Will this action move you to your goal? What barriers might you have to overcome? Who else will be involved? What support do you need? Where will you find it? What other consequences are there of this course of action? What can I do to help?

Reviewing the outcome of the solution is desirable – this allows the mentor to assess with the mentee if the best solution was chosen and whether the mentee was capable of implementing the solution well. This allows for learning and promotes self evaluation.

K. Evaluation skills The mentor needs to be able evaluate how the session went in terms of the solution developed and whether the mentor/mentee relationship was amicable and productive. This process of reviewing and evaluating also brings a session to a close. Useful questions to consider include:

29

What can the mentee take away from the session that was useful? What about the session was less useful? Is there any unfinished business i.e. issues that were not adequately dealt with during the session?

The mentor should also ask the mentee about their evaluation of the session and whether it worked for them:

“How did you find the session?” Was the session helpful for you?” What did you take from this session?”

L. Planning skills Planning skills are those skills which help to structure the mentoring relationship and involve all pre-planning and post-evaluation to ensure smooth mentoring encounters. They also include the contracting process to ensure that expectations of mentor and mentee are realised. In addition, we have included a discussion on personal presentation (suitable dress codes etc) as this forms part of being suitably prepared for the mentoring. Much of the planning involves using core communication skills in their execution. So, for example, the mentor will use relevant listening and responding skills when negotiating the contract with the mentee.

M. Challenging and confronting (conflict management) Disagree tactfully: if you disagree with something a mentee has said it’s always important to do so in a way which does not humiliate or embarrass them. You can sometimes deal with this by first acknowledging the mentee’s point of view in a paraphrase and then re-directing the issue to the group: “What do other people feel?” Or you can say: “Well that is one way of viewing it, another school of thought suggests…” Or you could say: “I have a different take on this and I’d like to share it with you and the group for your consideration.” Manage conflicts: Inevitably there will be disagreement in a group – the mentor should not take sides but stay impartial and deal with the situation in a professional and objective manner. The ability to handle conflict in a group is one of the most important skills of a mentor in a group mentoring context. Thinking in a “process” way about the relational dynamics in a group of people is very helpful as it allows for issues to be addressed so that the work of training and discussion can happen more harmoniously. If a group conflict is not addressed the main business of the group, to understand and implement ART better, may be derailed. The basic approaches to resolving conflicts are:

Competition: one person or group wins, the other loses Accommodation: one person refuses even to state his or her wishes Compromise/collaboration: each person recognises the other’s rights. Each may need to

compromise on some points, but it is understood that the solution must take into account the needs and wishes of both.

The way to deal with conflict between mentees in the group: 1. Determine the cause(s) of the conflict. 2. Get the parties to define the interpretation of the conflict. 3. Set goals to deal with the conflict. 4. Get members to communicate their feelings and ideas.

30

5. Refer members to the ground rules that state that members agree to disagree. 6. Encourage members to understand the other party. 7. Set objectives for the resolution of the conflict. 8. Get the members to reach consensus on the way forward. 9. Jointly decide on a way to monitor the implementation of the solution. The way to deal with a disagreement between mentees in a formal mediation out of the session:

1. The opening statement: mediations are held in a neutral place at a time convenient to the parties. Sessions could last up to two hours. The mediator(s) open the session with a welcome and an explanation of what will happen.

2. Uninterrupted time: each person takes a turn speaking while everyone else listens. For the most part, this is open-ended: the person can talk briefly or at length about anything relevant to the situation.

3. The exchange: then the arguing and discussion begin. For a while people accuse each other and attempt to set each other straight on the facts. They explain why they are upset and make demands. The mediator(s) keep the discussion within limits, making sure that each person is heard and each is protected. The mediator(s) do not try to determine the truth or who is at fault. Rather, they listen for what matters to people and for possible areas of agreement. Sometimes, the exchange brings about what is called a “turning point” of reconciliation. Separate meetings can occur any time during the mediation and have many uses, checking out a person’s concerns, confronting unhelpful behaviour, or helping people think through their options.

4. Setting the agenda: discussion shifts towards the future: what will happen from now on? The parties agree on an agenda of issues which need resolution.

5. Building the agreement: the parties work through each issue on the agenda, generating a number of ideas, then weighing, adjusting, and testing the alternatives to craft a workable, mutually satisfactory solution.

6. Writing the agreement: if the parties are able to settle their differences, the mediator(s) write a formal agreement containing those decisions. Everyone present signs and takes a copy home.

7. Closing: the mediator(s) review what has been accomplished, remind people of next steps and wish them well.

The way to deal with a disagreement between a mentor and a mentee: 1. Ask for time to think things over. Take this chance to allow both of you to calm down. 2. Pay attention to your body’s reactions. Has the fight-or-flight instinct been triggered? Take a deep

breath to increase your oxygen intake to your brain so you analyse your situation more clearly. 3. Don’t snap at the person. You may regret a fast retort which may have lasting consequences. 4. Determine what it is you want that you’re not getting. Should you be willing to negotiate more – to

give in a little – so you can both win? 5. If the other person has “lost it”, don’t negotiate until calm returns. Adopting a quiet manner is

always your best approach. 6. Wait until the other person is willing to listen to your side of the story. Make sure you’re listening

carefully to his or her side of the story. 7. Make sure the other person knows you’re listening. Use paraphrasing on a regular basis to confirm

that what you’ve heard is what has been said.

31

8. If the other person doesn’t seem to be listening to what you have to say, insist that you be listened to. Say: “I’ve made a point of listening carefully to what you have to say. Can I ask that you do the same for me?”

9. Ask: “What do you want me to do?” Clarify that you know what the other person wants. Listen to the answer and confirm or correct.

10. State what you want, clearly and sequentially. Again, be willing to negotiate. 11. Once an agreement has been reached, summarise the particulars and go over pertinent areas again

to reconfirm your understanding. Manage change (resistance): most people resist change and find it unwelcome and threatening. The very nature of mentoring requires mentees to learn and grow and get feedback on their performance as HIV/AIDS clinicians. Resistance could show itself in late coming, not abiding by ground rules, not coming prepared to a mentoring session, argumentativeness, passive aggression, and so on. These should be addressed individually through giving feedback and reminders of the rules. But the mentor could also:

“think process” and ask the group to reflect on the dynamics which seem to be emerging in the group and ask for their assistance in dealing with them

normalise difficulties around change explore the benefits of change.

32

Activity 5.1: Emotional Bank Account A. Imagine you are making deposits (positive actions) into an emotional bank account. You must work

out the value of the deposits that you the mentor make for the student doctors/nurses or other

health workers that you are mentoring. For example, the deposit “constructive feedback” would

create a value “growth and positive reinforcement”.

Emotional or technical deposit by mentor Value of deposit for the student (mentee)

Constructive feedback Growth and positive reinforcement

1. Providing emotional/psychosocial support

2. Showing respect

3. Showing empathy

4. Openness and transparency

5. Helping understand and manage an emotionally

difficult patient

6. Reviewing and helping solve a complicated

clinical case

7. Recognizing achievements

8. Showing positive, professional interest in human

elements of mentee as a person

9. Recognizing and responding to signs of burn-out

10. Admitting “I don’t know, but I’ll find out”

B. Now consider the impact that withdrawal from your emotional or technical bank account (negative

actions) has on the student / health worker. For example, a mentor providing negative feedback

may have the impact of eroding confidence of the student / health worker. Incorporate your own

experiences, if any, in your responses. When we have negative experiences, we often re-enact this,

and do the same to others. If you are aware of this, you can break the chain.

Emotional/Technical withdrawals by mentor Impact of withdrawals on student (mentee)

1. Negative feedback

2. When discussing cases, emphasizing lab tests or CT scan results which are not available at health centre level

3. Imposing solutions

4. Showing disrespect

5. Being deceptive

33

6. Failing to recognize achievements.

7. Lack of support

8. Failure to return phone calls or Emails

9. Breaking confidentiality

10. Pontificating, showing off very expert knowledge

11. Being late

12. Pretending to know something when you don’t

13. Treating male students differently from how you treat female students.

Now, go over your answers in a small group. There is no “right answer”—use this as an opportunity to

discuss important qualities for a mentor; your own experiences as a health professional being mentored

or receiving feedback.

Activity 5.2 Your pocket clinical mentoring guidelines contain many suggestions and tips for good approaches to both one-to-one and group mentoring. Your facilitator will assign each of you to a specific skill section in these guidelines. Read through this section and present a new recommendation that you think will be helpful in mentoring, or one that you already commonly use and find useful. Later, you should read and reflect on the whole section.

a Attending skills

b Listening skills

c Observational skills

d Appropriate use of names

e Speaking skills

f Responding skills

g Exploring skills

h Giving feedback

34

i Summarising skills

j Problem solving skills

k Evaluation skills

l Planning skills

m Conflict management

Activity 5.3: Review your own performances as a mentor3 A. For the mentee: Complete the following sentences. Respond intuitively, using your work as the context.

1. My greatest lesson in the last month has been …

2. The best thing about mentorship is …

3. One thing I am scared of is …

4. My mentor …

5. I want …

6. The worst thing about mentorship is …

7. I am proud of …

8. My greatest need at the moment is …

9. I should …

10. It is frustrating …

11. I secretly …

12. I struggle with …

13. I cloud my clinical work with …

14. I hesitate when …

15. I need more …

16. My one bad habit is …

17. In ten years’ time I …

B. For the mentor: answer these prompts from a mentoring perspective 1. Mentorship is …

2. My greatest fear in terms of mentoring is …

3. I get frustrated when …

4. Being needed is …

3 Incomplete sentences worksheet developed by Aderyn Exley (2005).

35

5. I get angry when …

6. I feel proud when …

7. My relationship with (mentee’s name) is …

8. I wish …

9. I find boundaries in mentorship …

10. The most difficult thing is …

11. Cultural diversity in mentorship means …

12. My response to language differences in mentorship is …

13. Mentorship in rural communities is …

14. A healthy relationship means …

15. I know I am having mentorship difficulties when …

Activity 5.4: Observing & Feedback

Two volunteers to conduct a 10 minute feedback session, using the sample checklists. All other

participants should observe the interaction and make notes for feedback to the “mentor”.

Feedback Check List

1 Ensured mentee is ready

2 Prefaced negative feedback with something positive

3 Based comments on facts not emotions.

4 Was specific: gave quotes and examples.

5 Gave the feedback immediately, but at a convenient time for mentee

6 Gave feedback in a private place

7 Concentrated on what can be changed.

8 Invited the mentee to “buy in” to the desired change.

9 Focused on one thing at a time

10 Encouraged the mentee to give feedback in return

36

Session Learning Objectives At the end of this session participants should be able…. To classify learning objectives into appropriate domains To select appropriate Teaching-Learning methods for each domain To demonstrate One On One Teaching methods to be used for clinical learning To demonstrate the Small Group Teaching method TOSBA to be used for clinical learning

Learning Objectives and Domains Mager has said “If you are not certain of where you are going you may very well end up somewhere else (and not even know it). “ The start of any teaching-learning should be the formation of clear Specific Learning Objectives as determined by the training needs of the participants. They give direction to all educational activities and determine end-points that can be measured to enable one to determine if the learning was successful or not. We know that Education is a process the main goal of which is to bring about a behavioural change in the learner. A Learning or Educational objective is defined as “what the student should be able to do at the end of a learning period, that they could not do before”. They define what the student, not the teacher, should be able to do and hence the result sought following the teaching-learning activity. To assist teachers in the correct formulation of educational/learning objectives, systems of classifications into domains was created. It is always important to remember that in human behaviour the three domains are often intricately connected and overlaps will occur. Within each domain are different levels of the process which also needs to be considered while formulating objectives. The three domains are:

Cognitive – This refers to intellectual skills and knowledge (“Head”). o E.g. At the end of the activity the student should be able to draw and label the life cycle

of the malaria parasite Psychomotor – This refers to as domain of practical skills predominately performed by “hand”.

o E.g. At the end of the activity the student should be able to draw blood from an adult patient’s cubital vein using a syringe and needle maintaining standard precautions.

Affective – this deals with attitudes and communication o E.g. At the end of the activity the student should be able to empathically counsel a

family of a dying person.

6. Approaches for clinical mentoring

37

Levels of each domain may be simplified into the following for easier understanding:

Cognitive: Knowledge/Intellectual Domain

Levels Example Recall Facts List steps in the process of normal delivery

Interpret data

On being given a spectrum of laboratory reports of a patient with Complicated Severe Malaria, the student is able to interpret, relate, arrange and summarize all laboratory issues required for the management of the patient.

Solve a New Problem (Problem Solve)

The student is able to diagnose an HIV infected patient with Cryptococcal Meningitis using a scientific clinical approach to headache in spite of never seeing such a patient and his condition before.

Psychomotor: Practical Skill Domain

Levels Example Imitate actions of a model A parent of a Diabetic child requiring home Insulin practices by

imitating the administration of subcutaneous injections using an orange.

Exercise effective control over the practical skill

Intern is accustomed to suturing an episiotomy under supervision.

Perform the practical skill automatically and with a high degree of efficiency (Mastery)

The Resident is able to intubate rapidly many patients brought in from an accident in the chaos of a busy Emergency.

Affective: Attitudes/ Communication Domain

Levels Example Show receptivity towards another

person

Noticing the anxiety of a mother waiting with her sick child in

Emergency

Supply a response to the affective need

of another person

Reassuring the mother after assessment of the sick child in Emergency

Internalize a feeling

When attending an Emergency calls your attitude to all patients clearly

demonstrates that you care for the child and the parent that enables you

ensure them of effective help and concern

38

Domain directed T-L Method selection Now that we have reminded ourselves of the concepts of Learning Objectives and the three Domains, we need to consider possible Teaching-Learning activities/methods appropriate to achieve the same. Listed below are some methods in our settings: Large Group TL Methods Lecture

Organized presentation of facts with explanations by a teacher for a large group of students who are predominately passive. Knowledge and Cognitive Intellectual domains are mainly covered.

Symposium

Series of brief talks by experts on various areas of a topic in logical sequence made for a large group audience. There is usually no overlap or disagreements between speakers and little audience participation except for a brief question time. . Knowledge and Cognitive Intellectual domains are mainly covered.

Team Teaching

A series of teachers from one or various departments take a series of short lectures for a large group of students in a relay fashion. This method leads to some horizontal integration of content taught but remains predominately a passive learning for the large group. Knowledge and Cognitive Intellectual domains are mainly covered.

Panel Discussion

A panel of experts are moderated by a person who presents a prepared scenario(s) or raises questions on various issues directed to some or all panellist. The panellist in turn openly discusses the approach to answer the questions put to them. The panel may have disagreement, discussions and different viewpoints between panellists; however, the audience are usually passive listeners in this process. Knowledge and Cognitive Intellectual domains are mainly covered.

Small Group TL Methods Small group discussions

A small group meets up and discusses on a topic of interest which may be a formal or informal discussion. Knowledge and Cognitive Intellectual domains are mainly covered.

Bedside clinics

Commonest method of clinical training, where there is a wider scope for demonstration and practice of psychomotor/practical skills relevant to physical examination and even diagnostic/therapeutic interventions necessary for health care providers to learn. The clinic at the bedside is extremely effective even for Knowledge/Cognitive and Affective/Communications to be (role) modelled and demonstrated. The insight into clinical approaches and interpretation of real time data becomes extremely relevant to the learner.

39

Practical/Field work/Demonstrations

Similar to the Bedside clinic, practical sessions in a laboratory or in the field bridges the gap between theoretical knowledge and its application as well as integration into practical/ affective /communication skills.

Role plays

Acting out a structured and planned scenario allows for a demonstration and experience especially towards effective learning of affective and communication domains.

Problem based Learning

Small group learning groups use a problem as a trigger to direct their identification of their own learning needs. The individual members of each group then disperse and complete their own research to answer the questions they have identified that they need to answer. This method also assists in the development of skills necessary for team work and increases the possibility of self-directed learning. The Tutor is usually a faculty who may or may not be an expert in the area being discussed but only plays a predominately facilitation role enabling the small group to lead and interact. Knowledge and Cognitive Intellectual domains are mainly covered.

Tutorials

Following coverage of a difficult topic usually by a reading assignment or large group lecture, small groups meet with a teacher to clarify issues and interact focusing on the topic. Knowledge and Cognitive Intellectual domains are mainly covered.

Seminar

A small group of Experts meet together to discuss among themselves intricacies of their common area of interest to enable a better understanding and challenge each other’s understanding of the topic. Knowledge and Cognitive Intellectual domains are mainly covered.

Individual Methods Individual/Group assignments-projects Individual/Group self-study Computer Assisted Learning Counselling

All these methods are directed usually to the individual student and commonly focus on Knowledge and Cognitive Intellectual domains. In the follow up to this session, specific ideas on individual clinical teaching learning methods relevant to mentors will be discussed.

One to One Mentoring – Teaching and Learning The cornerstone of any Mentorship is the development of Mentor-Mentee relationship which is essentially a One on One relationship. The Mentor spends time with the Mentee in the latter’s workplace accompanying, even assisting by modelling (e.g. assess FHS during ANC visit, glove up and assist in a delivery, wrap up an exposed neonate, entering the growth chart, performing a respiratory rate count for a child with cough, assisting positioning a baby breastfeed, etc.) with on-going tasks thus

40

observing all aspects of the on-going delivery of maternal , neonatal and child care and treatment. This close observation allows the Mentor to be able to assist the Mentee in improving delivery of health care through a mutually respectful relationship and sharing of experiences. Thus, the One-On-One mentorship is an essential and the commonest means of a successful mentorship.

Sequence of a One on One Mentorship Encounter 1. Clinical Work Place attachment 2. Observation and Identification of strengths and weakness (gaps) 3. Immediate Responsive Methods

a. Responsive Coaching- Incidental Learning/ One –Minute Preceptorship b. Modelling c. TOSBA

4. Delayed Reinforcement Methods a. Case based discussion and the Mini-lecture b. Chart/Register Review discussions c. Mini Lecture-Demonstrations d. Role Plays/Video clips e. Workplace Aids

1. Clinical Work Place attachment To accomplish this One-On-One mentorship, the Mentor’s first step is joining in the Mentee’s work routine which may be called a Clinical Workplace attachment. This enables the Mentor spend time with the Mentee during work observing, even assisting, that further allows the Mentor identify strengths and weaknesses (gaps). These identified strengths and gaps give direction to the Mentor’s responsibilities and tasks to reinforce strengths and assist Mentees work out solutions to existing gaps in their abilities to deliver quality care.

2. Observation and Identification of strengths and weakness (gaps) Weaknesses (gaps) that are identified during observations of the Mentee by the Mentor in the workplace may be predominately related to knowledge (cognitive), psychomotor skills and/or affective/attitudes/communication domains. Knowledge (Cognitive) essentially means all matters pertaining to the need to use one’s intellect (Brain). Psychomotor Skills indicates that the identified issue is a task performed by hands. An Affective/Attitude/ Communication focus on tasks that require empathy, understanding and feelings from the heart. Each of these domains to be learnt require various combinations of teaching-learning methods that best suits each domain enabling the learner achieve the learning. During the visit, the Mentor may recognize that most pregnant women with hypertension don’t receive Magnesium Sulphate for their Pregnancy Induced Hypertension. This fact after discussions may be identified as a predominately knowledge (cognitive) issue of not comprehending and applying knowledge of pregnancy induced hypertension (PIH) to prevent and treat seizures due to the PIH (Eclampsia). This life saving measure prevents maternal morbidity and mortality. The Mentor will needs to plug such as gap probably in an immediate response and it may need additional reinforcement to make the learning possible. Other possible examples of identified gaps could be that the nurse mentee is observed not washing hands between patients in the labour room or that the nurses were unable to counsel woman to initiate breastfeeding within 30 min of a normal delivery for their newborn. The hand-washing is an example of a psychomotor skill that

41

requires some knowledge transfer but certainly a demonstration followed by practice to enable mentees perform better. The counselling will require knowledge certainly but specifically a demonstration by role play or video followed by practice with feedback focusing on affective/attitudes.

3. Immediate Responsive Methods a. Responsive Coaching- Incidental Learning/ One –Minute Preceptorship b. Modelling c. TOSBA

If Inj Magnesium Sulphate is not prescribed for pregnant women with Pregnancy Induced Hypertension (Pre Eclampsia and Eclampsia) when indicated, then the Mentor may use the work place opportunity to provide additional knowledge on this aspect using a One-Minute Perceptorship or Incidental Learning providing responsive immediate coaching. During rounds when one observes that a patient’s blood pressure is elevated or even not taken, the Mentor may use the opportunity to immediately ask “Why” is that Blood Pressure in Pregnancy of importance illustrating that PIH is a common cause for maternal morbidity even mortality not forgetting preterm delivery and hence neonatal challenges. This brief exchange of words could easily lead to the simple explanation of the relevance of blood pressure recording, identification of PIH and the role of Inj Magnesium Sulphate towards successful management. If one finds that there are additional issues that prevent the utilization of Magnesium Sulphate such as pharmacy stock outs, non-availability outside working hours or even that the medical officer has apparently no knowledge or protocol in place for this medication in PIH/Eclampsia, and then additional steps may be warranted. One may decide upon reinforcement even through team/small group discussions. One may discuss the finding during team meetings, request for a mini-lecture on the management of the PIH/Eclampsia either by mentor but preferably by other team members asking them to review texts, literature or existing national guidelines from existing trainings. Providing clinic aids like posters for the wards and explaining the protocols on them will also assist in learning. If observations suggest that hand-washing is uncommon in the labour room or between neonates in the post-delivery ward, then it could be the source of infection – both maternal and neonatal. The challenge here would be the need for knowledge of various aspects of hand-washing from the why to the how and the when of hand-washing. But all this knowledge would be of no use if the mentee cannot demonstrate and perform the act of satisfactory hand-washing. Talking about hand-washing may not be adequate for this psychomotor skill modelling by actually demonstrating hand-washing protocols in the workplace situation (Modelling) followed by reinforcement through the team meeting and small group discussions with clinic aids may be one possible method of enabling learning. Additional long term feedback would be documenting the number of neonatal and maternal sepsis attributed to poor hand-washing practices and demonstrating changes in trends with initiation of hand-washing protocols. Similar methods of modelling and one minute perceptorship may be used to enhance the learning of the affective/attitude related counselling.

Activity Using a role play format demonstrate how you would teach on bedside rounds with a single student in his or her clinical year. The student has worked up a patient’s history and examination and presents the same to you. How would you proceed with the teaching at the bedside? Remember you have a number of patients to see on rounds.

42

Example: A student presents details of a young child with fever, cold, cough followed by a rash.

During the history and examination presentation it is suggested that one rarely must interrupt except for major clarifications required by the preceptor. At the end of the presentation, the preceptor asks for a commitment of the diagnosis or differential.

The student says that he or she would like to give a differential, either Measles or Chickenpox. The preceptor then challenges the student as to why he or she decided on the two possible diagnoses.

The student justifies the possibility of Measles by discussing points in favour ( the age of the child, the history of prodrome of cold and cough, the 4th day of fever leading to a rash and the fact that the child is unimmunized) He is not clear as to how to differentiate Chickenpox from Measles being unable to explain why he added it as a differential on being probed for points for and against the decision/commitment.

The preceptor then describes the typical presentation of Measles as compared with Chickenpox enumerating clinical features and explaining the underlying pathogenesis of both infections. A general rule could be the fever time line and the onset of various rashes (Day 1 Chickenpox; Day 4 Measles; Day 7 Typhus). The Preceptor then analyses the student’s responses and praises him for the good history details picked up – age, prodrome, rash onset and the lack of immunization. He corrects mistakes by reminding the student of the need to describe the distribution pattern of the rash (face descending pattern, predominately centripetal) and that the physical features of the rash need to be examined and described (Maculo-papular versus Vesicular).

3a. One Minute Preceptoship Neher et al described this method in 1993 and it focuses on the last one minute of bedside teaching. There are five micro-skills used in this method are simple and easy to learn for effective one on one learning to occur and that to at a higher level. They are as follows:

1. Get a Commitment 2. Probe for underlying reasoning 3. Teach general rules 4. Re-enforce what was correct 5. Correct mistakes

After the student completes the history and examination presentation to the preceptor, the student is encouraged to commit to a diagnosis or a differential or an investigation or treatment plan/approach. This challenge to make an intellectual commitment is the first step. Only after the commitment has been made, does the preceptor proceed by probing for the rationale and reasons and explanations for the decision/commitment made by the student. Here the WHY questions become useful and the ability of the student to distinguish, differentiate and justify the decision become evident. Following this probing for explanations and reasons, it becomes evident if there are education gaps in the student’s armamentarium. Teaching general rules relevant to the scenario being discussed is the next step that attempts to reinforce existing learning or teach the student to plug gaps identified.

Then follow it up with re-enforcing what was correct in his or her arguments and rationale for the committed decision made earlier. It is more effective to always be specific not just a broad statement of praise. Finally it is a good idea for the student to be given the opportunity to critique his or her own presentation and decisions in view of available information or ideas provided before correcting identified mistakes.

Activity: Identify and discuss the Five Micro-skills being used in this above example? Discuss how these micro-skills could be augment your role play performed earlier?

43

3b. Modelling4 Much of professionalism is learnt from role models we encounter during our medical training especially towards the clinical years. In addition, these models also enable us to transition from student to physicians. Role models teach primarily by example and help to shape professional identity and commitment through promoting observation and comparison. Personal conduct, professional achievement, personality, power, influence, lifestyle, and values may all determine the influence a teacher has on a student. It is documented that outstanding clinical teachers who interact skillfully with patients, providing supervision and demonstrating expertise at the bedside were more likely to receive high ratings from medical students. Additional positive factors include self-criticism, assuming responsibility, recognizing limitations, humility, respect, and sensitivity for patients and trainees, and a wholesome sense of humor. Teachers of medicine should reaffirm the enormous influence role models have on education. Positive role models pass on perspectives that may have broad and long-term effects for both patients and physicians. We must be constantly aware that our behavior and attitudes influence students at all levels and that only through concerted effort, demonstrated at the bedside, can we change their behavior and attitudes. Critical thinking, psychomotor practical skills and attitudes including communication can all be learnt while students observe role models at work in clinics and wards.

Activity Spend a minute or two individually thinking back on your past clinical encounters during student days or immediately after. Share these instances from your past or present where Role models have demonstrated both, positive or negative influences.

3c. TOSBA Team Objective Structured Bedside Assessment5 The TOSBA is a ward-based teaching and formative assessment. It involves three groups of five students rotating through three ward-based stations (each station consists of an inpatient and facilitator). Each group spends 25 minutes at a bedside station where the facilitator asks consecutive students to perform one of five clinical tasks. Every student receives a standardised grade and is provided with educational feedback at each of the three stations. Each station is comprised of an in-patient and an examiner. Consecutive students in each group are each given 5 min to perform one of the five different standardised clinical tasks:

Targeted, brief history Targeted, perform a physical examination Generate a patient-specific differential diagnosis clearly stating points in favour

and against each of the proposed differentials Outline a plan or interpret existing investigations Outline treatment/care plan or discuss rational behind existing treatment

prescribed.

4 Reuler JB, Nardone DA: Role modeling in medical education. West j Med 1994; 160:335-337 5 Miller SD et al. Team Objective Structured Bedside Assessment (TOSBA): a novel and feasible way of providing formative

teaching and assessment. Med Teach. 2007 Mar;29(2-3):156-9; Meager FM et al. Predictive validity of measurements of clinical competence using the Team Objective Structured Bedside Assessment (TOSBA): Assessing the clinical competence of final year medical students. Med Teach 2009; 31: E545–E550

44

The students are directly observed performing the tasks, are graded on their performance and provided with feedback by the examiner. On completion of the TOSBA, all three examiners confer and an agreed final grade is awarded. Periodic scheduling of such exercises weekly are an effective small group clinical teaching method as well as provides much needed formative assessment. Below is tabulated the TOSBA assessment scheme.

Grade Descriptor

P + Honours standard

P/P+ Pass with potential for Honours

P Pass standard

P/P - Borderline standard

P - Fail standard

Activity: As groups, perform a role play that illustrates a TOSBA.

4. Delayed Reinforcement Methods When issues identified are widespread in the facility or are cross cutting across all professional team members (eg. Hand-washing, initiation of exclusive breastfeeding, management protocols, etc.), there may be a need to reinforce learning at a later date in a relatively more planned and formal way. Suggested Teaching-Learning methods for this delayed reinforcement are listed above.

a. Case based discussion and the Mini-lecture

A Small Group Discussion could be scheduled in consultation at the team meeting at a date or time convenient to most usually during follow-up visits. It is always a good idea to suggest that it will be an update and will be brief focusing on the task at hand. Active participation by members of the audience either as presenters or lead discussants or as panellist is recommended. Dividing subsections among each team member to be presented by 10 min mini-lectures prevents boredom and increases active participation and learning. Adult learning principles described elsewhere in this workbook/manual should be the cornerstone of any such plan. It is always interesting and demonstrates relevance if a patient’s case details from actual case sheets or Out-patient notes/charts are discussed to trigger the discussion and seek various views on the topic in focus. Remember to concentrate upon the WHY, HOW, WHEN questions to trigger discussions and interactions between members of the team. If there is no “case” or notes available then keeping prepared a relevant case summary from another site even fabricated is still a good trigger. Activity: Lead our small group using this sample In Patient Case Sheet in a discussion on a missing Partogram and the listing of challenges and possible solutions.

b. Chart/Register Review discussions

With time and rapport that has developed on respect and non-judgemental interactions in the past, discussions in time can focus on brief audits of specific issues such as registers that document the completion of BCG vaccination at birth and those with missed opportunities,

45

referrals, etc. Statistics from registers or even random review of a series of charts can be great triggers for small group discussions focusing not on individuals responsible for acts of commission/omission at the focus of improved quality care but on issues/challenges/ideas/solutions to reinforce good practices and plug gaps. Some of these elements may also be tackled during Team meetings. Activity: Lead our small group using this sample page of the last six months statistics on Immunizations at the well-baby clinic in a discussion on missed opportunities and solutions for prevention of the same.

c. Lecture-Demonstrations

Lecture-Demonstrations of identified psychomotor skills in need of reinforcement are good methods to improve learning. Hand-washing, bag-valve-mask-ventilation, nebulization, oxygen delivery, etc. would be some examples of skills requiring some learning of theory but certainly a focus on be able to perform by demonstrating skills. Activity: Teach our group using a 10 min mini-lecture on hand-washing followed by a demonstration of the same.

d. Role Plays/Video clips

Role plays or video clips enable the learning of affective/attitudes/communication necessary for all health professionals. The focus here must not be only the content and the theory but the actual ability to demonstrate feelings, empathy, kindness and an understanding of the situation and need. One may use a three point method for Role Plays where teams are divided into three and in turn one member of the group plays the role of a patient, the second a health care provider and the third an observer who uses a prepared checklist to provide feedback to the role player (i.e. health care provider). These roles rotate if relevant and are an example of active learning. Similarly a single role play or video clip may be dramatized or viewed by the entire small group who in turn use a check list to discuss the strengths and weaknesses of the communication and interaction. Topics for role plays may center on counselling of exclusive breastfeeding, HIV testing, danger signs, immunization, etc. Activity: Demonstrate a three point Role Play using the counselling checklist provided for explaining danger signs of pregnancy (Nurse-Pregnant woman-Observer)

e. Workplace Aids

Standardized protocols and schedules based on guidelines, even simple clinic aids including checklists do make the health care provider’s task easier and more structured. Providing such work based tools after explaining the WHAT, WHY, HOW and WHEN of each tool through active participatory discussions followed by an actual demonstration of utilizing the tool for day to day work. The NRHM has provided various posters for mounting in places that require these ready reckoners (Eg. Management of Pregnancy Induced Hypertension, Immunization Schedule, Post-partum haemorrhage, Newborn resuscitation protocols, etc.). Activity: Teach our group using adult learning principles and the poster provided (National Protocols)

46

Activity 6.1 Individually read through all the below listed Learning Objectives and tick the appropriate box to its right

that indicates the predominate domain.

Discuss the same among your group and be prepared to present the same when asked to the entire

audience.

No. Learning Objective. At the end of the session, the student should be able to …………

Knowledge Practical Affective

1 To diagnose Iron Deficiency Anemia given relevant blood laboratory reports.

2 To create, implement and interpret a survey of a sample of a village population’s to determine their health seeking behaviour for febrile illnesses.

3 To measure the weight of a newborn given an electronic weigh scale

4 To pre-test counsel a pregnant woman at her first ANC visit requiring an HIV Rapid Screening test

5 To determine the environmental health hazards of a family by making three home visits

6 Identify using a light microscope stained sputum samples of the following three bacteria: Mycobacterium TB, Hemophilus influenza and Pneumococcus.

7 To detect by palpation of the abdomen a splenomegaly more than 2 cm in size

8 To successfully approach an apprehensive child visiting your clinic so as to elicit cooperation for a routine history and examination

Activity 6.2 Individually read through the same listed Learning Objectives which now have the predominate domain

identified. Using the list of potential T-L methods listed above decide how (what method) you intend to

use for your student to learn as a mentor.

Discuss the same among your group and be prepared to present the same when asked to the entire

audience.

No.

Learning Objective. At the end of the session, the student should be able …………

Knowledge/ Practical/ Affective

T-L Method Plan

1 To diagnose Iron Deficiency Anemia given relevant blood laboratory reports.

2 To create, implement and interpret a survey of a sample of a village population’s to determine their health seeking behaviour for febrile illnesses.

3 To measure the weight of a newborn given an electronic weigh scale

47

4 To pre-test counsel a pregnant woman at her first ANC visit requiring an HIV Rapid Screening test

5 To determine the environmental health hazards of a family by making three home visits

6 Identify using a light microscope stained sputum samples of the following three bacteria: Mycobacterium TB, Hemophilus influenza and Pneumococcus.

7 To detect by palpation of the abdomen a splenomegaly more than 2 cm in size

8 To successfully approach an apprehensive child visiting your clinic so as to elicit cooperation for a routine history and examination

Activity 6.3 Using a role play format demonstrate how you would teach on bedside rounds with a single student in his or her clinical year. The student has worked up a patient’s history and examination and presents the same to you. How would you proceed with the teaching at the bedside? Remember you have a number of patients to see on rounds.

Activity 6.4 Match each listed teaching-learning method to the suitability of the predominate domain gap in practice.

Teaching – Learning Method Gap identified

Incidental Learning/One mInute Perceptorship

Growth chart incomplete

Modelling Partogram incomplete

Case based Discussion Iron and Folic acid tablets not prescribed at exit from ANC

Chart/Register Review High drop out for post-test (HIV) counselling

Mini Lecture-Demonstration Hypothermic neonates during immediate newborn period

Role Play/Video clips Child with features of bloody Diarrhea not prescribed ORS

Workplace aids Weights of Mothers not checked periodically at ANC visits

TOSBA Irrational Antibiotic usage in the wards for community acquired pneumonias CAPs

48

Rapport building is the single most important aspect of our communication.

In fact, all communication efforts can get futile if we do not have a rapport with our students/peers.

Greeting

Welcome the student. Introduce yourself to your student while looking him/her in the eye. Ask how he/she's doing, addressing him/her by name.

Posture For example, the simple practice of leaning forward is associated with student relaxation, satisfaction, and recall. Adopt a similar stance to them in terms of your body language, gestures, voice tone and speed

Mirroring Another step in building rapport as rapidly as possible is for the doctor to model and mirror the student's physiology. Sit the way they sit; if their legs are crossed at the knee or ankle, cross your legs similarly; if they hold their head slightly tilted, slightly tilt your head, etc. Be as much like the student as you can. This will help build rapport very quickly. It is important to understand the difference between imitating and mirroring. In response to the student who crosses his/her left leg over the right, the imitator will duplicate the student’s movement by crossing his/her left leg over his/her right. However, the physician practicing physical mirroring will do the opposite by crossing the right leg over the left, as if the student was looking in a mirror.

Verbal Mirroring

In casual conversation outside the office, doctors often nod their heads and say “Okay,” “I see,” “Uh huh,” etc. When they repeatedly use this in the office to confirm they have heard what the student just said, they may appear disingenuous and lose a valuable opportunity to build rapport. In contrast, some degree of quietness on the part of the physician can be soothing. In addition, maintaining an appropriate amount of eye contact that is considered respectful in the student’s culture may demonstrate the doctor’s interest in the student. It is important to understand the difference between paraphrasing and verbal mirroring. Paraphrasing involves editing and summarizing the student’s words and, therefore, it risks distorting what the student says. Verbal mirroring occurs when the physician approximates the student’s voice tone and repeats the student’s last few words or word and occasionally uses a slight questioning inflection. This mirroring process avoids distorting the student’s words and encourages the student to say more.

7. Annexure 1: Rapport Building

49

Eye contact The physician's gaze is of particular importance. For example, a warm gaze can signify comfort and even encourage student disclosure thereby facilitating doctor-student rapport, whereas a lack of eye contact between doctor and student can have a dehumanizing effect in addition to being a strong sign of deception. It has been found that the facial expressions of doctors are carefully scrutinized by students; this information is believed to impact how deeply students trust their doctors A special note on making eye contact ... holds eye contact only as long as the student holds eye contact. If you try to hold eye contact longer than the student prefers, they will feel you are starring and become uncomfortable.

Facial expression Facial expression can portray and communicate such emotions as interest, disinterest, sympathy, concern, disgust, …etc

Touch Touching the student as an expression of caring (e.g., a student who is upset) is often a strong statement of a physical and psychological connection. It is also useful to think about appropriate use of touch. In some cultures it is acceptable and even desirable to convey empathy and understanding through a pat on the shoulder, a warm handclasp or even a hug. In others there may be strict limitations on cross gender touching. It would be useful to explore: What are the norms around touch in the specific clinical setting? How comfortable are you as a doctor with touch? The student’s comfort levels with touch.

Listening Listen to student. When the student is speaking, listen carefully to the student without interrupting. You'll encourage the student’s trust and also may identify previously unsuspected problems. If the student expresses dissatisfaction, acknowledge the complaint without blaming anyone. (Covered in greater detail in the section on “mentoring skills”)

Rate and tone of speech Rapport involves being able to see eye-to-eye with other people, connecting on their wavelength. So much (93 per cent) of the perception of your sincerity comes not from what you say but how you say it and how you show an appreciation for the other person's thoughts and feelings Listen for the style of language and match your language style to theirs. The tone of a doctor's voice is an important element in setting the environment for the interaction between his/her student.

50

Genuinely caring attitude Students are not merely a collection of “case presentations and tests”. Each is a unique individual, with an individual story, feelings, needs, and wants – all of which must be acknowledged. The most important determinant of student – physician relationship is the degree to which a physician projects a genuinely caring attitude toward the student Most students come to us wearing a mask, or façade, which has become a protective “comfort zone” to them. Often, students have become identified with the façade, believing it to be who they truly are. It is our responsibility to create an environment where students can feel safe enough to risk being unsafe – letting down the mask and revealing true feelings, thoughts, and experience. The student must feel safe and trusting enough to let another human being truly know him, trusting that he will be met with compassion, understanding, without judgment, and that the physician mentor can actually do something to help. It is only by knowing who the student is, where he is in his struggle: his thoughts, feelings, and inner experience, that we can know how and what to help.

Do not be judgmental Rather than being fully present and available to feel and react spontaneously to the experience and feelings of others, our heads are filled with positions, opinions, and judgments about them, or about ourselves. All of this blocks our internal sensitivity to the real and valuable signals that the student is constantly providing. Rather than saying, “Yes, tell me more,” to the student’s experience, we judge, ignore, avoid, or defend against it.

Personal support The doctor should let the student know that he or she is there, personally, for the student and wants to help. Eg: “You can contact me if you need any help”

In terms of building rapport — you are the message. And you need all parts of you working in harmony: words, pictures, and sounds. If you don't look confident — as if you believe in your message — people will not listen to what you are saying. Rapport involves being able to see eye-to-eye with other people, connecting on their wavelength. So much (93 per cent) of the perception of your sincerity comes not from what you say but how you say it and how you show an appreciation for the other person's thoughts and feelings.

51

(Nilsson et al. Pedagogical strategies used in clinical medical education: an observational study BMC Medical Education 2010, 10:9)

There are seven pedagogical strategies found to be applied in clinical teaching, namely 1. Questions and answers 2. Lecturing 3. Piloting 4. Prompting 5. Supplementing 6. Demonstrating 7. Intervening

The clinical teacher frequently made use of these strategies to help the students solve problems or complete tasks. The strategies were used flexibly and could be changed during clinical teaching depending on situation, context and preferences of the clinical teacher. Questions and Answers: This strategy is observed when clinical teachers ask questions in order to activate the students; make them discuss and describe how to deal with medical problems; and management specific to the patients. The teachers’ point of departure is the students’ reasoning in combination with their own preferences in the main focus of the clinical problem. The teacher occasionally made a conclusion, summarizing the student’s thoughts and argumentations. Lecturing: By asking questions and observing students’ behaviour, the clinical teacher could assess students’ level of knowledge. In cases where students showed a lack of knowledge, the teachers’ intention changed from questioning to lecturing about the actual area of knowledge. Lecturing could also occur if teachers observed errors in any areas or a deficit in students’ behaviour or reasoning. Lecturing took place frequently throughout the teaching session and examples of the strategy included: defining the meaning of medical terms; explaining symptoms of illnesses and localisations; and surgical and medical treatments. The clinical teacher clearly explained what areas of medical treatment required the most attention. Lecturing not only included medical theories and facts, but also, implicitly, medical attitudes and guiding principles in problem solving: for example, how to act and communicate with patients in consultation. Piloting: The meaning of this strategy is that the clinical teacher uses guiding questions, statements or signals to ensure the student pays attention to and focuses on specific content in order to reach an expected or previously decided goal. By piloting, the teachers prevent students from getting stuck in the management of a particular task. The teachers used guiding statements, invitations or questions in order to make them continue what they were doing. The students acted according to the teacher’s directives, but the students’ understanding and reasons for their actions were not discussed and there was no request for critical thinking or understanding from the teacher. Easing the student’s actions by piloting does not necessarily lead to the intended perception or increase of knowledge. Students acted according to the teacher’s directives without discussing the meaning or intended goal. In such situations there was no request for critical thinking or understanding from the teacher. Consequently, by piloting,

8. Annexure 2: Seven pedagogical strategies

52

the teachers guide the students around the difficulties in a clinical situation. Piloting could also be used by the clinical teacher when they aimed to place students in a situation where they were expected to develop their understanding or/ and experience-based knowledge. Prompting: This strategy is characterized by the clinical teacher prompting a student to prevent the student “losing face” in front of the patient or other personnel. This approach is similar to piloting, but the focus of using prompting is found in the process. By prompting, the teacher supported the student in, for example, communication with a patient; whilst using piloting, the purpose was to direct the student to the correct answer or action. Accordingly, by prompting, the teacher supported the student in adopting the role of doctor. This approach was observed in situations where the students appeared to need help in their assessment, problem solving or in communication with patients or nurses. The teacher provided advice and/or directives by prompting. Supplementing: This approach is characterized by clinical teachers’ supplementing during students’ communications with patients or other personnel. The strategy is characterised by the teachers either adding some complementary important facts, or in some cases completely taking over the student’s communication. This strategy demands teachers’ sensitivity and awareness in deciding whether students are in need of support to handle a situation, otherwise loss of face is inevitable. Demonstrating: With this strategy the clinical teacher demonstrates how to act, assess, communicate, and perceive a problem. This is demonstrated when teachers deliberately illustrate how to act or what to focus on, by displaying the correct behaviour in a clinical situation; for example when communicating with patients, or in assessment or evaluation. Demonstrating also included situations where the clinical teacher facilitated student perception of the learning object (seeing, hearing, listening or feeling). The purpose was to illustrate and create a perceptual understanding of a physical phenomenon. Intervening: Significant in this strategy is the teacher taking an authoritative role, interrupting the student and taking over the situation. In intervening, the clinical teacher focuses on getting the assignment completed. In this situation the student’s actions being interrupted when the clinical teacher intervenes and takes over. The student has to stand aside and assume the role of an observer. Using this strategy, patient management, organisational demands and limitations were demonstrated to the student. We observed that the students could thus experience a lack of feedback resulting in a lack of explanation and diminished understanding of their actions and how they managed the situation. Sometimes they felt “excluded” and their knowledge undervalued. Ramsden P: Learning to teach in higher education London: Routledge Falmer 2003.

53

Teaching Perceptives The meaning of this strategy is that the clinical teacher uses guiding questions, statements or signals to ensure the student pays attention to and focuses on specific content in order to reach an expected or previously decided goal. By piloting, the teachers prevent students from getting stuck in the management of a particular task. The teachers used guiding statements, invitations or questions in order to make them continue what they were doing. This strategy is characterized by the clinical teacher prompting a student to prevent the student “losing face” in front of the patient or other personnel. This approach is similar to piloting, but the focus of using prompting is found in the process. By prompting, the teacher supported the student in, for example, communication with a patient; whilst using piloting, the purpose was to direct the student to the correct answer or action. Accordingly, by prompting, the teacher supported the student in adopting the role of doctor. This approach was observed in situations where the students appeared to need help in their assessment, problem solving or in communication with patients or nurses. The teacher provided advice and/or directives by prompting. This approach is characterized by clinical teachers’ supplementing during students’ communications with patients or other personnel. The strategy is characterised by the teachers either adding some complementary important facts, or in some cases completely taking over the student’s communication. This strategy demands teachers’ sensitivity and awareness in deciding whether students are in need of support to handle a situation, otherwise loss of face is inevitable. With this strategy the clinical teacher demonstrates how to act, assess, communicate, and perceive a problem. This is demonstrated when teachers deliberately illustrate how to act or what to focus on, by displaying the correct behaviour in a clinical situation; for example when communicating with patients, or in assessment or evaluation. Significant in this strategy is the teacher taking an authoritative role, interrupting the student and taking over the situation. In intervening, the clinical teacher focuses on getting the assignment completed.