The One-Minute Preceptor: A Framework for Clinical Education in the Field

EMS clinical education arrives at a point where quality improvement and clinical care intersect. Learning objectives to impart knowledge and behavioral objectives to improve performance arise from the clinical, operational, and financial metrics EMS clinical/quality improvement leaders measure for our organizations. The transition from the classroom to the field can be challenging!

If we’re teaching an ACLS or PHTLS course, or even if we develop our own program for our staff, there is a clear framework to follow and interact with students: presentation, Q&A, skills lab, clinical scenarios, assessment of KSA (knowledge, skills, abilities) acquisition for the endeavor at hand. In the field, unfortunately, not so much.

Bedside education is one of the most difficult undertakings for any clinical preceptor, but it is one of the best methods we have available to teach our students. It is a technique used since the time of Hippocrates to educate healthcare providers.

Do you remember your first preceptor? Was that person good or less than optimal? Good clinical educators develop the skills necessary to provide bedside instruction over time. Sometimes they’ve had fantastic examples to follow. Others they develop this skill through trial and error. The nightmare scenario I constantly hear from students is that their clinical preceptor barks orders at them or that the feedback they receive during a call amounted to a raised eyebrow. Sometimes the interaction between the student/new hire and field training officer is excellent, and sometimes it’s disheartening.

The issue I consistently hear from preceptors and field training officers is, while they may have forms and apps to assist with the individuals they’re charged with guiding through the process, the one-to-one interaction, the activity at the beside, posed the biggest hurdle for them.

The one-minute preceptor teaching model was developed at the University of Washington’s Department of Family Medicine several years ago and has been used in a variety of settings with a variety of students.¹ The model provides a starting point for new and even experienced educators to improve their encounters with students and new hires. 

A Structured Encounter

First a disclaimer: Is the one-minute preceptor model going to help you do all your precepting in one minute? No. Studies have shown that in the hospital the average teaching encounter takes 10 minutes. In healthcare, regardless of what field we’re discussing, the teaching of students encompasses three parts: presentation, questioning, and discussion. If we are adapting this to the EMS environment, it may look something like this: 

• Presentation—Anywhere from 30 seconds to six minutes for the student to perform their assessment of the patient and essentially “think out loud” their presentation to their preceptor. This time frame is based solely on patient acuity.
• Questioning—Take 30 seconds to three minutes for the paramedic preceptor to ask questions and clarify information. 
• Discussion—This essentially leaves one minute of discussion and teaching time. 

While this obviously totals to longer than one minute, the one-minute preceptor strategy provides a structure to the encounter that helps you maximize the amount of time for teaching your student or new staff member. 

The Five-Step Microskills Method

Now let’s explore how to achieve success using the five-step microskills method, also known as NERDS. The five steps are nickel down, evidence, rules, do, and stop. 

Nickel down: Get a commitment 

The first step is to get a “commitment” from the student about what they think is going on with the patient, what they think the plan or treatment should be, or how they think the case should be followed up. Ask questions. For example, “What do you think is going on here?” or “What would you like to do next?”

This commitment helps invest the student further in the case and helps you assess their problem-solving skills, which are essential to critical thinking. What you ask the student to commit to depends on their level. What you want to do is to encourage them to stretch beyond their current comfort level and problem-solve.

Evidence: Probe for supporting evidence 

The evidence step helps you assess the student’s knowledge and thinking process. It is meant to probe the student for evidence supporting what they’ve just committed to explore on the basis of their opinion. Was it a lucky guess, or was it a well-reasoned, logical answer? This step gives you insight into their clinical reasoning skills.

Examples of some questions you may ask are, “What factors support that this patient had CHF and not pneumonia?” and “Why did you choose that particular treatment protocol?”

Rules: Teach a general principle 

One of the most important and challenging tasks for the student is to take information from an individual situation and accurately generalize it to other situations. This can be about how a symptom usually manifests, treatment options, diagnostic tools, what resources are available in your EMS system, or what references to use. This allows learning to be more easily transferred to other situations.

The other key to teaching a general principle is that it shouldn’t be a preceptor preference but an educationally sound, clinically objective standard of care, piece of science, or treatment algorithm. It may be specific to a treatment or operational policy for an organization but if so, should be acknowledged as such, especially for a student preparing for the National Registry exam. It should never be something particular to an individual preceptor or instructor or that cannot be replicated anywhere else.

An example would be, “Limb lead placement is key for correctly acquiring 12-lead EKGs… 17%–28% of inferior wall MIs are missed when leads are moved from the limbs to the chest. For CHF patients, diabetics, patients whose primary language isn’t English, and those patients who use vague descriptors, poor limb lead placement may increase the chances we miss an MI.”

Do: Reinforce what was done well 

A feedback sandwich is where you give some piece of positive feedback, then the constructive feedback on what the student needs to correct, then wrap it up with another positive. Don’t do that! This tool is deeply unsound. The formula is so obvious that after you use it with your students once or twice, they can see it coming like a freight train. What ends up happening is you condition your students or new hires to react to any praise as, “Oh, man, how did I screw up this time?” It is so time-worn, it breeds mistrust and skepticism.

Yet students need some feedback. This is key, because this is where you develop rapport and trust with your student. Always start with positive feedback and reinforce what was done well.

Be honest, be direct. Skills and positive behaviors need repeated reinforcement to become firmly established. With a few sentences, you increase the likelihood these behaviors will be incorporated into future clinical encounters. Describe specific actions, behaviors, or tasks the student demonstrated (“good job” is too vague) and spell out their likely outcomes.

For example: “I liked that you accounted for the patient’s age, previous complaints, and current symptoms,” or “The way you determined the landmarks for that patients needle decompression was impressive.”

Stop: Correct mistakes and omissions 

Describe what was wrong (be specific), what the outcome for the patient might be, and how to correct it for the future. At the same time, don’t feel you must correct the student after every patient encounter. Only provide constructive feedback for improvement if there is something that needs to be addressed. Correcting mistakes forms the very foundation for improvement and builds trust between you and the student or new employee. 

For example: “During the intubation attempt it took too long to pass the tube. You were having a problem getting the tube over the bougie. Let me show you the Gerard technique to set up the endotracheal tube and bougie to achieve greater success and take less time when you need to intubate,” or “The patient seemed uncomfortable during auscultation of their lungs. What do you think the problem was?” Give the student an opportunity to answer. “Do you think the patient tensed up because the head of the stethoscope was too cold?” Give the student an opportunity to answer. “Can you show me what we can do next time to make the patient more comfortable?” Again give the student an opportunity to answer. 

Think about your wording: If you focus on actions and ways of changing and avoid negative labels such as “bad” or “poor,” the student will feel less like they’re being judged and be more likely to see the criticism as constructive and positive. It’s important to notice and provide feedback to the student on both the things they do well and areas they need to work on. 

Final Words

Keep your student or new hire focused on how they can improve and the problems they want to solve. Give them an opportunity to provide the answer—remember, they’re still finding their way, and it’s easy to become distracted. Consider this as a marathon, not a 100-meter dash. The skills and temperament they develop now will remain with them through (hopefully) a long and rewarding career.  

References 

1. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Amer Board Fam Practice, 1992; 5(4): 419–24. 

Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for Alameda, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.