A clinical coach must safely and efficiently balance the realities of clinical care with the learner’s need for effective clinical skills practice. With the exception of simulated practice, your clinical coaching environment requires ongoing management of your patient's and your learner’s needs.
There are three key components to designing an effective environment for deliberate practice:
- The choice of a properly demanding practice objective.
- The opportunity to repeat the skill over and over, and in a variety of settings and contexts (mixed practice), until mastered.
- Performance feedback that is continuously available. A learner is only able to improve their technique by objectively understanding the effect of their performance.
Be clear on the practice objectives
Practice objectives should be designed to sharply define the elements of your learner’s technique and performance that need to be improved so that they can then intentionally engaging in activities to improve them. Define these elements with your learner using the SMART goals that you mutually agreed upon, or through your early observations of your learner's performance. Once the right practice objectives are identified, work with your learner to describe the outcomes that their practice is intended to achieve, and how to plan for that practice.
Consider opportunities for practice
Frequent and sufficient repetition of a skill is necessary to increase fluency and integration with related skills.
Organic Practice: Learning in an authentic environmnet enables learners to become acculturated to the realities that they will experience when their training is complete. You can make this experience more valuable for your learners by tailoring thie real enviornment when possible to match the learner's needs. Discuss with your learner the specific types of patients and encounters that will target their performance goals. Consider the patient care experiences that are regularly available in your clinical practice, and how your learner’s assignments might be managed to augment their unique practice needs, such as temporarily constraining the scope of your learner’s patient assignment in order to isolate practice on a given skill. Alternatively you might agree to intentionally add skill practice to routine care, or to expand the scope of their care (or practice) to as many new patient contexts as possible in order to assist learners to transfer an acquired skill to a new setting.
"Authentic Enough" Practice: Low fidelity simulation methods such as role-play, talking through “what if” and “how would you” scenarios, talking through the steps of a procedure, and using a doll or mannequin for physical exam or procedure practice can make effective use of time between patients. These “authentic enough” techniques can offer sufficient fidelity to engage your learner in effective practice. These techniques make effective use of time between patients, while waiting for an admission, before or after a clinic session, or over lunch or coffee - and they may offer suffience information to entrust your learner to move to observed or supervised practice.
Simulation: Access to virtual patients, standardized patients, task trainers (e.g. suturing models), and high fidelity simulation is rapidly increasing at most medical schools and academic health centers. Depending on your clinical practice site and learner population, consider integrating these resources into your coaching toolbox. Many centers offer free or low-cost access and training workshops for faculty.
Use the right practice “zone”
The learning environment should be designed specifically to improve your learner’s performance - and should be flexible enough to adjust to the learner's needs as their skills grow and practice needs change.
The Comfort Zone occurs when the learner's skill level significantly exceeds the performance expectations, and performance stress is low. When working within their Comfort Zone, your learners are performing skills that they have mastered through sufficient repetition in a wide variety of settings. Working in their Comfort Zone allows your learners to consolidate and maintain their current level of performance – often to the point of automaticity. However, only by choosing activities outside of their comfort zone can learners develop new skills or integrate different skills together.
The Learning Zone occurs when the learner's skill level is right at the edge of the performance requirements for a specific situation or encounter, and performance stress is moderate. When working within their learning zone, your learner is performing skills that are “just outside their reach” and stretch him or her just beyond their current abilities. This level of "positive stress" has been shown to facilitate learning.
One of your most important and difficult tasks as a coach is to maintain this learning zone while your learner's skills constantly grow and change through deliberate practice. To choose properly demanding activities, focus on skill components that are:
- Holding the learner back from progressing to the next milestone level
- Just at the edge of a new level of mastery
- Needed to promote the learner's progression to the next skill milestone level.
Sustained effort in this zone should be taxing for both of you. It requires constant engagement, focus and concentration - but with good coaching these efforts are ultimately very rewarding for your learner.
Some learners, particularly novices, find these efforts to continously seek and focus on areas of relative weakness uncomfortable. As their coach, be sure you are providing sufficient reinforcing feedback to help your learners to consolidate their experiences and solidify skill gains, choosing corrective feedback wisely, maintaining open channels of communication, and occasionally allowing “breaks” back into their Comfort Zone.
The Panic Zone occurs when learners are expected to perform at a level that significantly exceeds their current skills, or when the environment is significantly different from their prior experiences. A high level of this "negative stress", particularly if it is sustained over time, impairs learning. Avoid going too deeply or spending too much time in your learner's Panic Zone by communicating frequently and honestly about each of your expectations, and the learner's current level of performance and capacity. Discuss ways in which the environment and expectations can be adjusted to re-establish a good learning zone.
Deliberate practice is a team sport
Your ability to keep your learner’s practice in the Learning Zone requires a strong and flexible coaching relationship, with robust dialogue between you and your learner. You must continuously work to intentionally build in time for observation, reflection, and feedback into the demands of the clinical day. Based on your conversations, make ongoing adjustments so that your learner remains on the “learning edge” without moving too deeply into their Panic Zone, or sliding into their Comfort Zone. This flexibility and creativity during practice (theirs and yours) is the key to being a great coach – and to helping your learner become one of their own best coaches as well.
Coaching in a clinical environment also requires the participation of other members of the health care team, including your patients. Take the time to educate your colleagues, staff and patients about the skills your learner is practicing, and how they can help your learner as well. Once informed, most patients and staff will be more than willing to provide your learner with additional practice opportunities, as well as valuable feedback using a different perspective and lens. The ultimate goal of coaching is to assist learners to design their own practice. After your learner has become comfortable in your environment, encourage them to take the lead in communicating their own practice needs.
When constructing an effective environment, building in time and opportunities for Direct Observation ensures that you and your learner have the objective data needed to inform your coaching conversations.