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Managing Problem Learning Situations

During the course of clinical education, the clinical instructor (CI) may encounter a student who has difficulty meeting the objectives of his/her clinical experience. Although this can happen at any time during the educational process, it occurs most often during the final full-time clinical experiences. Successful management of performance problems involves problem identification and analysis, development of goals, formulation of a plan for remediation, selection of a learning experience, and assessing progress towards goal achievement. The CCCE and the ACCE can provide information and resources and offer support for the CI and the student, and thus should be involved in the problem-solving process.

Problem situations may first manifest themselves as a series of apparently unrelated, minor incidents. Careful documentation initiated early in the clinical experience may highlight performance problems and allow student learning to be redirected. Thus, the problems should be addressed as soon as they are recognized rather than waiting until midterm or final performance reporting. If these problems are related to any of the first five items in the Clinical Performance Instrument (red flag items), the ACCE should be contacted as soon as possible.

Documentation of problem learning situations can be accomplished in several ways. A chronological diary of observations is one method for recording unsatisfactory performance. An anecdotal record, which includes the incident, the student’s behavior, the CI’s interpretation, signatures of the student and CI, and the student’s comments, is another option. Performance problems and progress towards resolution must be addressed at midterm and final student evaluations.

Once a problem is identified and analyzed, goals and a plan for problem resolution must be determined. The student and the CI should develop the plan for remediation and goals jointly, with input from the CCCE and ACCE as needed. In addition, minimal acceptance performance should also be specified. After the goals and performance level are determined, the CI designs a learning experience which will allow the student the best chance to achieve the established goals. The student and CI should meet at least weekly to discuss progress towards goal achievement.

If the student is still unable to demonstrate satisfactory performance, then the CI should specifically document the student problems on the final performance report. The ACCE will then communicate this information to the faculty, who will meet to discuss the most appropriate course of action. A likely decision may be to require the student to repeat or extend one of his/her clinical experiences. If this does not provide the faculty with specific documentation of the student’s problem, then the faculty cannot legally require the student to repeat the experience.

The cooperation and communication between the student, the CI, the CCCE, and the ACCE are essential for successful management of performance problems. The clinical education “team” can collaborate on the development of goals and plans for correction of problems and establishment of expectations.