Be sure you are solving the right problem--that advice is as valid for managing student learning problems as for managing patient problems.  Explore the perceived problem fully before putting solutions in place.  When you perceive indications of a problem, share your perceptions with the student.  You do not need to label the problem, accuse or reprimand the student, or outline a solution.  Simply share your observations and ask for the student's interpretation.  Given the limited practicum time, it is very important to identify problems aggressively before bad habits develop or misinterpretations lead to irreconcilable differences.  Many perceived problems resolve as soon as preceptor and student clarify differing perceptions of expectations.  For example, you may perceive that your student, a mature, experienced nurse, is "just not getting it."  You may mentally "write her off" in terms of providing her active, enthusiastic involvement because you think she'll "never make it."  If you share your observations (not your dire predictions) with her, you may discover that as a mature, experienced nurse she has numerous, complex "brain files" that she searches and matches to incorporate new learning.  She knows herself well enough to tell you that she takes a little longer than her younger classmates to "get in the groove," but once she settles in she outperforms many of them.  The faculty member can validate student's learning history.  Despite trying a few approaches, you may think that you and the student are not communicating effectively about a potential problem that you are perceiving.  In this case, share your perceptions with the faculty member.

Identify the problem you perceive within the framework of domains of learning.  Is this a cognitive, an affective, or a psychomotor problem?  Problems in each domain respond best to strategies particular to that domain.

Having explored and identified a problem with a student, ask the student to identify factors that are contributing to the problem and ways to overcome these difficulties.  Offer suggestions (such as those above) and recommend resources, but give the student accountability for resolving the problem.

Ask the student to submit a written plan, with realistic time frames and steps toward solving the problem.  Share the plan with the faculty member.  Regularly document progress with both the student and the faculty member.  Ask the faculty member if a more formal contract or particular documentation needs to be completed.

Reflect upon these questions and raise them with the student and the faculty member:

• Is it realistic for the student to overcome the identified deficit within the time limits?
• Is it appropriate to recommend professional counseling?
• What are the appropriate considerations to take into account when designing the time frame for the learning contract?
• How much allowance should be given to family/personal problems interfering with the learning process?
• Is the outside time limit for continuing in the program clearly identified, realistic, and understood by all parties?
• Is there a mutual understanding and clear mutual expectations among the student, the faculty member, and the preceptor?

Applying One-Minute Preceptor Microskills To the Case of the Painful Ear

One Alternative Strategy:

Preceptor:  What do you think is going on?

Student:I think he has upper respiratory infection, probably otitis media.

Preceptor: What led you to that conclusion?     

Student:He has a history of repeated otitis media and currently has a fever, a painful right ear and a runny nose.

Preceptor: What would you like to do for him?

Student:First, I would like you to confirm my findings on the right ear.  If you concur about otitis media, then we should give him some antibiotics.  Since he doesn't have any allergies to medication, I think amoxicillin is a reasonable choice.

Preceptor:  You did a good job of putting the history and physical exam findings together into a coherent whole.  It does sound as if otitis media is the most likely problem.  There is great variability in ear problems.  The key features of otitis media that I look for in the physical exam are the appearance and mobility of the ear drum, landmarks, opacity of the drum, and mucus discharge, and in the history are prior upper respiratory infections and past problems with the ears.  This child would seem to fit these criteria.  With the lack of allergies, amoxicillin is a logical choice for an antibiotic.  I'll be glad to confirm your ear exam findings.  Let's go and see the patient.

As you read this alternative response, were you thinking, "But my student doesn't respond like the student in this ideal situation"?  The preceptor-student relationship is indeed a relationship--you can't conduct it effectively all by yourself.  One of the things the student needs to learn is how to learn successfully in a preceptorship.  Give the student some examples of the kind of responses you expect from the student.