Cultural Expectations - Video Transcript

I want to start by saying it’s really important on the first day in orientation that you set this up. And that you say throughout your placement - I am going to give you feedback every day. So that when you actually say to a student – oh I need to give you some feedback. They don’t go – ehhhh! Scary. Because you’ve already set it up that you’re going to do this. Even if it’s a five minute thing, you know after a busy shift – you think oh, I just haven’t got time to actually sit aside and do this. But if it can be as easy as – tell me what the most challenging thing was for you today? What was that challenging thing? What made it challenging to you? Because we have all got our own different perspectives, as we have spoken about all day today.  Everyone has their own perspective on things. Why was that specifically challenging to you? It might have been that they had to visit an elderly person who reminded them of their grandfather that died last week. Or something similar to that, that has made that particularly challenging for them. But that actual behaviour could alter what happens in subsequent days for them. So actually teasing that out in the initial time is really quite important and getting to the bottom of it. And then trying to give them strategies that they can actually use that will help them progress in that area. 

So, for example they said – oh, I find it so hard to talk to old people. Well, that’s like 90% of our work, but anyway. So you can give them strategies about how they can deal with that. You can actually say – well ok, you follow Kim tomorrow because Kim’s really good at actually speaking and connecting with people. Her communication is really important to role model.  So when you go with her, I don’t want you to say anything. It was like Annette was saying this morning – you know, sit back, watch me. Watch the way I position, watch as Kim positions herself. Watch the way she maintains eye contact. Her facial expression, some of the cues in behaviour she says.  Role modelling is so so important. And you might think – oh a student’s coming with me tomorrow.  We’ve only got boring patients, there’s nothing for them to really do. But watching you, do what you do is so important for their learning and it’s about putting the cues together. Speaking out about what you’re doing so they don’t think, you know, this is just going and getting someone out of bed. Then putting them in a chair, I mean how boring is that?! It’s about talking to them about the slippery shoes, or about well fitted shoes, it’s about getting a chair that’s appropriate for them. You know, it’s all those things that we’ve already thought about and dealt with – the bed being at the right height to get them out , you know making sure that their sitting upright properly when they’re eating so that they don’t regurgitate or choke. It’s all of those things that if you speak it out loud it’s actually really exciting, everyday what we do is exciting to students. It’s naming it up in the first instance. Then you can give feedback regarding their progress to the end product. So if you set learning objectives, making sure that their realistic in the first instance, then you give feedback on their progress to meeting those objectives. So you don’t want a first year student, or on a first placement to actually look like a registered practitioner. Because that’s unrealistic. You want them to progress to the level of their placement. If that makes sense?

So when we’re giving feedback, what do we have to make sure it is? What does feedback look like? What should it be? Constructive. So when we say constructive, what do we actually mean by that?

  • Has some meaning to it.
  • Relevant
  • When do we give it? Frequently. Timely – is that a week down the track? No, as soon as practical. As soon as you can. Obviously you have to stay in touch about how you feel at that given time as well. Because if your very emotional about what just happened, it might not be the best time to give feedback. Especially if you’ve got a student who has done something that is really inappropriate and it’s made you a little bit frustrated. Then giving feedback there and then probably isn’t a good idea. Naming it up and saying – ok, um, you know we need to probably talk about what just happened then, so I will come and talk to you tomorrow. We will make a time tomorrow; we will do it after work tomorrow. So that you don’t put yourself into an uncomfortable situation.
  • Look after yourself – very important.
  • Non-judgemental
  • Open communication, so they have the opportunity to respond back to whatever feedback you’re giving them.
  • Private – needs to be in an appropriate place. Private is really hard to find these day’s isn’t it? There’s no room, there’s nowhere to do these things, but trying to find a space is a really important thing.

All of these things are really important. What I want to do now is – I’m going to give you out a scenario and its scenario 2 in case we give the wrong card out. I just want you to talk at your tables about how you might deal with the situation. Now this is very nursing orientated. My apologies, but it can be translated into your own areas as well. So tease out what the bottom issue is and how you would deal with the issues. We’ll just give this out. We will have five minutes just to discuss it and then we’ll come back together.

Consider the following scenario:

A student accompanies you to see a terminally ill patient. They are receiving anxiolytics subcutaneously and you offer the student the opportunity to give the injection. They perform the procedure well but then rejoice about their success in front of the patient and grieving family.

What feedback would you offer?

So, what did you tease out of this were the main issues?

The student had actually done a really good job with the procedure, but we are focusing on the perceptions of the family and they didn’t consider that. Feedback would be positive in regard to the procedure they need to do.  They did that well and it was good that they acknowledged that they did that well. But probably inappropriate that they did that at the time in front of the family and to tease out why that was. Big dilemma.

Anyone else got anything to add to that?

Tell them how they can improve. It doesn’t matter if they do it absolutely beautifully, the procedure that you ask them to do. There’s always growth isn’t there? There’s always an extension about that procedure into another dimension and so actually taking it to another step. Who would have passed if you were doing an assessment around this actual procedure, who would have passed the student? When you look at knowledge, skills, attitude, behaviour like we were talking about earlier – they didn’t get that third component did they? They didn’t get the attitude and the behaviour right. They didn’t get that at all. So basically two thirds were ok, but a third wasn’t.

Now we might just, because you know as experienced practitioners we don’t get the opportunity to actually watch someone give feedback very often.  So we are going to do a bit of a role play which is very confronting for us, because everyone hates this. We do too. It’s quite a good learning experience. So we are going to say that this is Maggie and we went to see Mrs Harrison.

Carolyn: Ok, Maggie, maybe we could just go and I’ll give you some feedback about this whole procedure, so just come with me.

  • Go somewhere private, sit down, face each other. The whole kind of stance open share posture that Juliette was talking about before. Bring all of that with you. Open face.

Carolyn:  Ok,

Maggie: I did it!

Carolyn:  Tell me how you think it all went.

Maggie:  I was really scared at first, but yep, I got it.

Carolyn:  So specifically I want to talk about the, when you finished the actual procedure. Can you tell me about what happened then?

Maggie:  I was just really glad that I got to do it because I’ve been wanting to give an injection, but I’ve been a bit scared about it. So, yeah, I was wrapped.

Carolyn: So when we actually walked into Mr Harrisons room. What did you notice around you when you walked in?

Maggie: Well, I didn’t look at anyone because I just didn’t want to get nervous. Because I was a bit worried about all those people watching me do it. So I just kind of blocked them all out. Then went to do the procedure.

Carolyn:  So, in hand over, what is your recollection of what they actually said was going on with Mrs Harrison?

Maggie:  Um, regular pain medication. That they had a lot of visitors. That we were to keep them comfortable.

Carolyn:  Yeah, why would we be doing that? What do you think, what’s the underlying – why does she need so much pain relief and to be kept comfortable. What’s going on?

Maggie: Well, the cancer is causing it.

Carolyn:  Yeah, so when they said in hand over that she’s been having palliation? What does that mean? What’s palliation?

Maggie: That they are just here for pain and pain management, management of their nausea and that they probably won’t go home.

Carolyn:  No, so she probably hasn’t got a lot of time to live. So putting yourself into the relative’s kind of shoes during that kind of procedure where we went in and we did the old Wooohoooo! At the end of that – how would you think they might feel about that?

Maggie:  I hadn’t really thought about that.

Carolyn:  Yeah, often we get very tunnelled vision on the task that we’re doing instead of kind of sitting back and having a bit of a look.

Maggie:  Yeah I wasn’t thinking about that.

Carolyn:  Yeah

Maggie:  I didn’t think about the relatives, I was just nervous of them being spectators really.

Carolyn:  Yeah, and that was probably confronting and something that I should have managed a bit better too. I should have probably removed them from the room while we gave the pain relief. However, what do you think we should do now?

Maggie: We should probably apologise to them.

Carolyn:  It’s probably not a bad idea, isn’t it? Only just to explain you know what actually occurred and just to, when you go into the same situation next time it’s probably a good idea to just too really scan the room and just get the feeling of what’s going on in there. Just to take in those visual cues about what’s going on in the room.

Maggie: Yeah I didn’t really think about that.

Carolyn:  Yeah, but that’s you know, you do get very engrossed a task rather than the whole picture. I think we have both probably learnt something from this. Something we will both need to keep in mind if we go to do that again.

Maggie: Yeah, I feel really bad now.

So what did you pick up about that kind of conversation?

  • You lead her to come to her own conclusion. Which means she takes ownership. It’s her problem, not mine and so often we rescue people. We try and give them solutions and we try to make them understand what we are thinking, rather than come to that realisation themselves. Unless you do come to that realisation yourselves, you don’t take ownership for it. You just think – oh god they were picking on me today. I did this great thing, you know I did this injection perfectly and there was always something wrong with it. You know then just pick on me. So it’s just a way of kind of getting her to that point herself.

For yourself, should you have worded her up before you went into the room?

  • Yes, absolutely and that’s another good point. Because we presume that they know what palliation means. We presume that they are going to think about all of those things. They are almost lay people, like we were talking about before. They don’t have that understanding or insight. So it is up to us to work it up and give them those cues if you like, before you go into the room – exactly right.
  • Anticipatory guidance. A bit of a pre-brief.
  • They are the kind of things that we take for granted, and I think we can become really complacent in our practise sometimes and don’t kind of think about how somebody else is seeing things. You played that part beautifully, by being absolutely – I don’t look at those people, they are not part of my future because I’m task orientated. That’s all I’m going to be. That’s what I’m doing. That was a good example.
  • We had a SIM lab with experienced clinicians. With our SIM man 3G and said – you just have to go in there and do a set of obs. Go, off you go and do it. We walked out, we watched them on the TV screen and it made a really simple task look incredibly awkward. Because they didn’t know the environment. We didn’t tell them what they were going in there to do. We just dumped them in there, and said take these sets of obs. Never orientated them to any space. Didn’t even give them a pen to write down the observation. It looked really bad, and we were all standing there watching. I said – look we can reduce experienced clinicians down to, look like idiots. If we don’t actually give a pre-brief. Provide enough information and orientate them to the space. Everyone was just kind of like – ahhhhhhhhhhhh, we do that to students all the time! Just go in there and do a set of obs, have you got a pen?

Can you take some ownership of that situations?

  • That should really make your student feel marginally better. Well I did, and you know this is the thing. Because I didn’t set it up properly I’m actually half to blame. Because it is my job and as her preceptor or her clinical supervisor to actually set it up properly for her.

There were people in the room, and should I remove them? Yes I should.

Going back to our student here. If we got out of the room after doing this – Wooohoooo! Little  act. Then she showed immediate remorse – going oh my god, I can’t believe I did that! That’s a completely different situation isn’t it, because she’s actually showing insight into what she’s done straight away? So maybe with a conversation around that, if we were assessing her on that behaviour, if she showed that remorse and demonstrated insight into what her behaviour was that would change the whole outcome. What happens next, and the feedback that you give is as important as the actual procedure that happens.

We might go to the next one quickly. Two minutes to have a look through this one, a quick discussion and we’ll come back.

Consider the following scenario:

A second-year student is on placement with you for three weeks. Staff have commented that she sits in the office socialising and doesn’t seem interested in performing any of her duties. She refuses to care for or perform urinary catheter care on a male patient.

It is the end of week 1 – give the student feedback regarding her progress to date.

What did you tease out of that one?

Where is the supervisor if she’s in the office? Who is she socialising with?

We thought she might be avoiding the issue of dealing with male genitalia or something.

It could be cultural.

A lot of these are very young people we are talking about when they are doing these course. Often that life experience hasn’t broadened their horizons too far, so they may be very scared to go into those situations.

What other things were teased out?

It said staff had commented on it. So you don’t know her point of view on the situation either.

Absolutely, so it’s all hearsay isn’t it?

Definitely a conversation around this. Even if I was to see for example a clinical facilitator going into an office area, or a supervisor and observing this behaviour – I would still be asking: why is she here? Why isn’t she doing patient care? Why isn’t she doing her job that she’s there to do? But it could be a cultural thing as well. She may come from a background where all the care giving is done by health professionals; it’s actually done by family. And so that may be a barrier to all of this as well. So may have very little cultural exposure to what is occurring here as well.  She may be so fearful of doing the wrong thing that she’s sitting in a very safe environment – the office. Where you can’t act outside your scope of practise. You’re not doing anything; you’re not getting involved, but not being unsafe. So that may be another issue just scared of doing the wrong thing.

  • I’ve had students that were waiting for direction and felt they couldn’t do anything until they were told to do something.

Yes – so giving people the option to actually get immersed in the practise, and they need to be immersed in practise. This maybe the only exposure they may have to your environment, wherever you are – this may be the only time in their whole training that they are going to be in that situation. So they need to be immersed in practise and be given permission and instruction on how to be immersed in practise.

So this is definitely a conversation. How would you open a conversation up?

  • Probably just go and ask her how she’s feeling about her placement really.  How are you going? Are you enjoying your time on the ward? It would be nice to hear her perspective on how her placement is going.

If she says, yep I’m having a lovely time, making friends. Where do you go from there?

  • Ask what she’s been doing? What she’s experienced?

What has been your biggest challenge so far? See if that teases it out.

That’s when she may come out with – well, I have a real aversion to looking after male patients and then this is why. At the end of the day she needs to be competent in her profession. She needs to, if she’s a nurse. She has to reach a beginning level, a practitioner level as a registered nurse with the AMC competency. If she’s an allied health professional she has to meet the competency standards for an allied health professional. Which all involve dealing with men. Talking to patients. You need to become immersed in practise. You need to be able to get through and these are really good at wording up where you’re supposed to be at the end of this (hand out on the allied health professional and AMC competency standards of practise).

So if they say well I’m not going to do that, I just can’t do that then it’s actually challenging their whole professional attitude and where they are actually heading and so you need to push a learning contract around that if they just say – no I’m not doing it. Then you have to help them do it. You just can say – come with me and I’m going to put this male catheter in. We just had a conversation a moment ago, in some organisations there are different regulations regarding what you can and can’t do as a practitioner. You need to be very aware of those before you even embark on the procedure. However, watch me, watch what I do, watch how I protect the patient’s privacy and make it less intimidating. Watch how I barricade the door so no one can come in while I’m doing the procedure to protect the male patient’s privacy. Listen to the tone of my voice and the conversations that I have to help you develop your own set of skills.

When you’re talking about feedback, it really needs to be: SMART

S – Specific

M – Measurable

A – Attainable

R – Relevant

T – Timely

If you put it under than you can’t go wrong.

That’s brought us to the end of the workshop. Thank you everyone so much for coming and spending your time with us. Now there is that evaluation, if you could complete that. It is a health work Australia pilot program for us.