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Keywords

Clinical teaching, nurse practitioner education, precepting, teaching model, time-efficient teaching

 

Authors

  1. Gatewood, Elizabeth FNP-C, RN-BC, MS (Assistant Clinical Professor)

ABSTRACT

Background and purpose: Teaching models provide a systemic framework for didactic and clinical teaching. The One-Minute Preceptor (OMP) is one teaching model, providing five microskills to organize a learning experience for students in the clinical environment. This review aims to integrate the literature on the OMP model by highlighting potential use for nurse practitioners while identifying directions for future research.

 

Methods: Electronic databases were searched from December 2017 to January 2018 for articles published in English. The databases included PubMed, CINAHL, and MEDLINE using terms including "preceptor," "clinical teaching," "time-efficient teaching," and "precepting." Of 32 articles in the final search, only 12 experimental quantitative studies were included in the synthesis and 20 descriptive studies in the discussion.

 

Conclusions: The OMP model is supported by literature for its effectiveness as a teaching model and preference by students and preceptors. It has been shown to increase teaching techniques including feedback and assessment of students' clinical reasoning.

 

Implications for practice: The OMP model has the potential to overcome clinicians' barriers to precepting nurse practitioner students. Future research may evaluate the use of this model specific to nurse practitioner preceptors and students, perceived time benefits in clinical teaching, overall improvement in clinical teaching, and use in interprofessional precepting.

 

Article Content

Introduction

There are more than 234,000 nurse practitioners (NPs) in the United States (American Association of Nurse Practitioners [AANPs], 2018), and their numbers are on the rise. Research is finding that NPs are assuming care protocols once the domain of physicians and results demonstrate positive outcomes for their patients in both the ambulatory and acute settings (Chattopadhyay, Zangar & White, 2015; Swan, Ferguson, Chang, Larson, & Smaldone, 2015). Despite growth in the numbers of NPs, there is currently a shortage of preceptors and clinical placements for advanced practice nursing students, which decreases colleges' capacity to train NPs. A recent survey showed that 60% of responding NP programs were very concerned over the limited number of clinical sites (American Association of Colleges of Nursing, 2015).

 

Effective training of future health care providers, such as NPs, includes both didactic training and clinical training. Didactic training is provided through classroom experience and does not include hands-on-care of patients. Clinical training complements the didactic content, allowing students to apply what they learn in the classroom and from the literature to patient care. Preceptors provide support and feedback to students, allowing them to improve their clinical skills and provide safe, competent patient care. Clinical training is a key component of producing quality health care professionals (Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2012).

 

There are many incentives and barriers to becoming a preceptor of NP students. Incentives include a positive relationship with an NP program, support of their profession, support from their clinical environment, an opportunity to teach, and receipt of preceptor training (Germano, Schorn, Phillippi, & Schuiling, 2014; Webb, Lopez, & Guarino, 2015). Barriers to mentoring these students include lack of training or preparation, productivity demands, time burden, and lack of support from school programs (Germano et al., 2014; Webb et al., 2015).

 

The one-minute preceptor model

Currently, there are no standardized preceptor education requirements or federal support for NP preceptor training (Forsberg, Swartwout, Murphy, Danko, & Delaney, 2015). There are teaching models that structure the way that learning experiences are designed and delivered, and these can be adapted for NP preceptor training (Wilson, 2018). These models shape curriculums, design instructional materials and guide teaching (Joyce, Weil, & Calhoun, 2015), and can be used in in the classroom or clinical setting. One such teaching model is the One-Minute Preceptor (OMP), developed in 1992. It is a clinical teaching model aimed at improving teaching efficacy and efficiency (Neher, Gordon, Meyer, & Stevens, 1992). It provides a five-step structure for clinical education: (a) get a commitment; (b) probe for evidence; (c) teach a general rule; (d) reinforce what was done well; and (e) correct mistakes (Neher & Stevens, 2003).

 

The first step, getting a commitment, is a prompt for the clinical educator to ask the learner what he or she thinks is happening during a patient encounter. For example, the instructor might ask, "What do you think is the most likely diagnosis for this patient?" The prompt depends on the situation, but it requires the learner to assess the clinical situation. The learner gathers and synthesizes information. If the student struggles with this step, it is a clue to the teacher that the learner lacks didactic or content knowledge or experience in processing clinical information. This step allows the teacher to evaluate the learner and identify strengths and gaps in his or her learning.

 

The second step, probing for evidence, allows the clinical educator to get a better idea of how the learner came up with his or her assessment. Examples of this step may include, "Why do you think that is the most likely diagnosis?" "How did you decide that barrier is keeping the patient from getting better?" Or, "Did you consider any other diagnoses based on the patient's presentation and exam?" Responses to these prompts allows the educator to evaluate learners' clinical reasoning. Based on this assessment of a learner's process, the teacher is able to tailor his or her instruction to the student's current level of understanding.

 

The third step in the OMP is to teach a general rule. This is an opportunity for the educator to share his or her expertise. This can include information on a diagnosis such as, "In patients ages of 21-50, the diagnosis you mentioned is more (or less) likely." Another example might be, "Recently in X journal, there was an article that suggested we should carefully evaluate for suicidality prior to prescribing this medication." This should be succinct information so that the teacher does not overwhelm the learner.

 

The last two steps in the OMP model incorporate feedback. To be effective, feedback should be timely, selective, behavior related, specific, and provide the rationale for the corrective reasoning (Ende, 1983; Hewson & Little, 1998). The fourth step in the OMP model is to reinforce what the learner did well. In this step, the teacher provides positive feedback. For example, "You collected a thorough history of the patient's chief complaint." Or, "Your questions about the patient's family medical history were especially relevant and added to our ability to fully assess the patient's health." The last step in the OMP is to correct mistakes. This step provides corrective feedback such as, "For this patient's chief complaint a full neurological exam is indicated. The reason for this is that we need to evaluate[horizontal ellipsis]" Or, "Patients who are overweight or obese have a higher rate of diabetes, thus ordering a lab to check for diabetes would be indicated." These five steps in the clinical teaching model provide succinct guidelines for clinical educators and allow for the development of clinical reasoning.

 

The OMP was originally developed for training medical residents in ambulatory care (Salerno et al., 2002). Since then, it has been used across health professions in a variety of settings. Although there have been a number of articles on the OMP model, none of them has integrated the literature. Thus, this review aims to integrate the current literature on the OMP, identify relevance and utility for NPs, and highlight potential areas for future research.

 

Methods

We reviewed the current literature related to the OMP model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to guide the literature review and inclusion criteria (Moher, Liberati, Tetzlaff, & Altman, 2009). Figure 1 illustrates the PRISMA process for this systemic review. The literature review, conducted from December 2017 to January 2018, searched for peer-reviewed articles published in English from January 2008 to January 2018. We searched databases including PubMed, CINAHL, and MEDLINE with the following terms: OMP, clinical teaching model, time-efficient clinical teaching, and precepting. MeSH terms included time, teaching, and preceptorship (Figure 1).

  
Figure 1 - Click to enlarge in new windowFigure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.

A total of 599 articles were initially identified. Twelve quantitative articles were included in the final analysis. Twenty nonexperimental articles were excluded from the synthesis, but included in the discussion. After the initial search, when duplicates were excluded, 539 articles remained. An additional six articles from 2001-2008 were included because of their contributions to the synthesis of the literature. We excluded articles describing undergraduate nursing education or alternate clinical teaching models without a discussion of the OMP.

 

Evidence of quality using GRADE

To assess the quality of the articles reviewed, we analyzed them using the standardized approach of Grading of Recommendations Assessment, Development, and Evaluation system (GRADE) (Balshem et al., 2011). To appropriately assign a grade level, all five aspects, (a) methodology (risk of bias), (b) inconsistency, (c) indirectness, (d) imprecision, and (e) publication bias were evaluated for all 12 articles. GRADE rates the quality of the body of evidence on a scale from very low to high (Balshem et al., 2011). The overall GRADE level for the studies was moderate. The recommendation for the body of evidence is strong. The benefits of using the OMP model outweigh the risks. Most articles are not randomized controlled trials (RCTs). They are observational, thus grading started at a low level. The rating was upgraded because of the consistency in the body of literature.

 

Some of the articles we reviewed had methodological concerns. The most consistent concern within the studies was a lack of inclusion and exclusion criteria. Many of these studies used a convenience sample. For example, the study by Arya et al. (2018) included 25 pediatric residents and did not specify how these residents were included or excluded. Similarly, Irby, Aagaard, and Teherani (2004) did not specify any inclusion and exclusion criteria for the faculty who participated in the research. In addition, there is risk of bias or methodological flaw because of the lack of validity of the measurement tool in some of the studies. This occurred with many of the studies including the one conducted by Aagard and Irby (2004), Arya et al. (2018), and Seki et al. (2016). Some studies had missing data because participants did not complete the study. Two studies had unknown interrater reliability and unknown intertrainer reliability, which is concerning for inconsistency in implementation and evaluation. This included the study by Eckstrom, Homer, and Bowen (2006), which could have had intertrainer variation. The second was the study by Chan et al. (2015), which also had unknown interrater reliability. Publication bias was not apparent in any of the articles. Despite these concerns, the overall evidence supports the efficacy, feasibility, and acceptability of the OMP model for preceptors (Irby & Wilkerson, 2008; Kertis, 2007). Because of the consistency of the literature and the minimal risk from introducing the educational model, we make a recommendation to incorporate training clinicians in this model of clinical teaching.

 

Findings

Table 1 summarizes the 12 studies in the final analysis, providing information on (a) authors, years published, and study designs; (b) characteristics of the setting and sample; (c) results and their implications; and (d) quality of the evidence. The analysis revealed three themes: (a) the OMP model is preferred by students and preceptors; (b) the OMP model increases the use of teaching techniques including feedback and assessment of clinical reasoning; and (c) the OMP is an effective model for quality clinical teaching for learners (Table 1).

  
Table 1-a. Summary o... - Click to enlarge in new windowTable 1-a. Summary of the studies included (

Preferred by students and preceptors

Overall, the OMP model has demonstrated significant improvement in preceptors' teaching skills, as perceived by students and teachers, particularly in teacher feedback on students' performances and assessment of students' clinical reasoning. In four of the articles in this review, students and preceptors expressed a preference for the OMP model over traditional clinical teaching models, calling it an efficient and effective teaching model. In a study by Furney et al. (2001), 87% of residents trained by preceptors using the OMP model said that they found it "useful or very useful." Similarly, Aagard and Irby (2004) surveyed 116 preceptors across multiple universities and found that the OMP model was rated more efficient and effective than traditional teaching methods (p = .00). In a study by Salerno et al. (2002), preceptors believed that the OMP model made learning encounters more successful than traditional teaching methods (p = .03). Aagaard, Teherani, and Irby (2004) supported this finding (p = -0.00). In 2018, Arya and colleagues found that pediatric residents perceived the model to improve the efficiency and effectiveness of the teaching encounter (n = 23, 100%) and requested incorporation of the model into future trainings. In a Delphi Process study by Ignoffo et al. (2017), experienced resident preceptors determined that the OMP model teaches students in a more effective manner (n = 15, 100%) and enables preceptors to spend time more efficiently than traditional clinical teaching (n = 14, 93%).

 

Although the literature is inconclusive, students preferred the OMP model to traditional teaching models. In 3 of our 12 studies, students preferred the OMP. Two studies found no change in students' perception of the quality of teaching with or without the OMP model. Teherani, O'Sullivan, Aagaard, Morrison, and Irby (2007) found that the OMP model was preferred by third- and fourth-year medical students over a traditional teaching model (p = .001). Students requested the same information from the teachers in the OMP and control teaching models. In a study by Furney et al. (2001), students believed that there was improvement in overall teaching with the OMP model (p < .05). Salerno et al. (2002) found an increase in the amount of time that teachers spent listening to their students after training in the OMP (p < .01). However, Chan et al. (2015) revealed that there was no difference in learning experiences when the OMP model was used in the gross anatomy laboratory. Similarly, Ong et al. (2017) detected no significant change in perception of quality or quantity of clinical teaching in a dental residency in China (p > .05). The rest of the studies did not evaluate the students' perception of the OMP.

 

Feedback skills

Feedback in clinical education is important because it demonstrates an opportunity and a commitment to improving students' clinical performances (Van de Ridder, Stokking, McGaghie, & ten Cate, 2008). Students also perceive feedback as a key characteristic of a good clinical experience and educator (Kaphagawani & Useh, 2013). Five of the 12 studies in this review found significant improvement in feedback after educators trained in the OMP model. Arya et al. (2018) noticed that pediatric residents believed teachers who followed the OMP model and provided constructive feedback with suggestions for improvement (n = 22, 95.6%). Eckstrom et al. (2006) also showed improvement in feedback. Faculty in psychiatry trained in the OMP model showed statistically significant improvement in giving positive reinforcement (p = .59). Residents also reported improvement, which was not statistically significant, in receipt of positive (p = .12) and corrective feedback (p = .82). Furney et al. (2001) found that residents rated the performance of all five microskills as improved with use of the OMP model. Of the five microskills, feedback improved the most and was statistically significant, including corrective feedback and learner perception of the frequency of feedback (p < .05). Ignoffo et al. (2017) found that the OMP model provides feedback in a timelier manner (n = 15, 100%). Salerno et al. (2002) discovered that feedback for medical students doubled after training in the use of the OMP model, including negative feedback (p = .03). Only the study by Ong et al. (2017) found no change in dental residents' perceptions of receiving positive or corrective feedback (p = 1.0).

 

Assessing students' clinical reasoning

Traditional teaching models focus on students' history-taking and presentation skills, whereas the OMP model emphasizes teaching and assessing cognitive skills, such as differential diagnosis, management plans, and the presentation of diseases (Irby et al., 2004). Increased focus on cognitive skills supports the key elements of successful precepting, including the development of students' clinical reasoning (McSharry & Lathlean, 2017). Four of the 12 studies found that the OMP model facilitated preceptors' assessment of students' clinical reasoning skills. The study by Irby et al. (2004) demonstrated that the use of the OMP model increased teaching points related to a differential diagnosis, diagnostic tests/evaluations, and presentation of the disease by medical faculty (p < .05) versus use of traditional teaching models. Salerno et al. (2002) demonstrated that teachers were better at evaluating the learners (p = .03) and allowing them to come to a clinical decision (p = .001) after being taught the OMP model. Preceptors in the study by Aagard et al. (2004) had greater confidence in assessing the students' history/physical examination skills, presentations, clinical reasoning and fund of knowledge, and were more confident in rating students' presentations, clinical reasoning, and fund of knowledge (p = .00). In the study by Ignaffo et al. (2017), preceptors believed that the OMP model improved students' critical thinking (n = 12, 80%) and promoted student involvement in decision making (n = 15, 100%). Arya et al. (2018) also found that the OMP model involves the student in clinical reasoning and the decision-making process (n = 20, 87%).

 

Overall effectiveness of the OMP model

The OMP model has been evaluated for effectiveness and quality of clinical teaching, as well as incorporation of the five microskills into practice, and sustainability of these skills over time. Seven of the 12 studies noted the utilization and effectiveness of the OMP model. One study by Ong et al. (2017) found no change in the use of the five microskills among dental residents' perceptions. Salerno et al. (2002) demonstrated that training faculty in the OMP model leads to incorporation of the microskills in practice (p = .03). The study by Eckstrom et al. (2006) also demonstrated use of the microskills as perceived by faculty and residents. Faculty improved in all five microskills, with three statistically significant improvements: get a commitment (p = .0004), probe for supporting evidence (p = .0017), and give positive reinforcement (p = .0343). The study by Aagaard, Teherani, & Irby (2004) showed that using the OMP model improved a preceptor's ability to diagnose a patient (through a student's presentation) (p = .02). Arya et al. (2018) agreed that the OMP model improves efficiency and effectiveness of the teaching encounter (n = 23, 100%). Furney et al. (2001) found that 87% of the intervention group rated it as "useful or very useful." Ignoffo et al. (2017) found that all respondents believed that the OMP model should be taught at preceptor trainings (n = 15, 100%). Teherani et al. (2007) found a significant effect for use of the OMP model (p = .001). In the study by Ong et al. (2017), there was no change in clinical teaching (p = .480), and they concluded that the one-time training did not affect the use of the five microskills.

 

Discussion

Although originally designed for the ambulatory care setting, the OMP model has been used in various settings across health professions. In this review, nine of the 12 quantitative studies were in medicine. The study by Chan et al. (2015) took place in a gross anatomy laboratory with medical students. Despite the wide uptake of the OMP model in medicine, Brand et al. (2013) found that there is variation within specialties. They evaluated current knowledge and use of the OMP model and teaching and found that family medicine residents were more familiar with the five microskills than psychiatry residents (55% vs. 25%), although the difference was not statistically significant. However, confidence in applying the model to teaching methods was significant, with family residents more confident than psychiatry residents (p < .01). Ignaffo et al. (2017) conducted their study with pharmacy preceptors and found that experienced preceptors believed that the OMP model should be taught in pharmacy preceptor trainings (n = 15, 100%).

 

In addition to the studies included in this integrative review, it is worth discussing the other 20 descriptive articles found in the literature, which were nonexperimental in nature.

 

Most studies describe the use of the OMP model in various health profession specialties. They did not measure or evaluate implementation of the OMP model within their specialties. Articles reviewing and applying the OMP model were found in the literature in ambulatory care, adolescent gynecology, midwifery, psychiatry, the anatomy laboratory, and the emergency department (Farrell, Hopson, Wolff, Hemphill, & Santen, 2016; Lockspeiser & Kaul, 2015; Raisler, O'Grady, & Lori, 2003; Tsao, 2010). These articles were largely descriptive in nature, suggesting the use of the OMP model as a tool for precepting or ways to adapt the model for various settings (Cayley, 2001; Chan & Wiseman, 2011; Pascoe et al., 2015; Rashid et al., 2017; Sokol, 2017; Zeidman et al., 2015). Despite this large amount of literature, there are few quantitative studies evaluating the use of the model across health professions. The recent study by Ong et al. (2017) in dental surgery, which showed little impact, suggests that this research can add to our understanding of the OMP model across professions. Similarly, there is a lack of research on use of the OMP model in nursing and advanced practice nursing.

 

Despite this lack of research, the OMP is recommended as a tool for undergraduate nurse preceptors (Bott, Mohide, & Lawlor, 2011; Kowalski, 2017). One recent article by Kowalski (2017) describes the possible use of the OMP model for nurse preceptors. In particular, the article suggests that new graduates, newly hired nurses, and nurses transitioning to new specialties benefit from well-prepared preceptors and that the OMP model is a tool that all of these professions can use. Bott et al. (2011) also suggested use of the OMP model in undergraduate nursing preceptorship. These studies are limited in their generalizability to nurse practitioners because of the different models of precepting and scope of practice between nurses and nurse practitioners. Although nurses hold different roles in hospital and clinic settings, a nurse practitioner's role is similar to that of a medical doctor in many settings. NPs now practice in many of the areas in which the OMP model is used, including ambulatory and in patient settings (Chattopadhyay, Zangaro, & White, 2015; Swan et al., 2015). The OMP model was designed for use in primary care where more than 87% of NPs practice (AANP, 2018). Thus, the OMP model is a relevant teaching model for the NP preceptor. Yet, the gap in research specific to the field of nursing highlights the need for future research.

 

Future research can evaluate the use of the OMP model specific to NP preceptors and NP students. Although there are many documented barriers to precepting (Roberts, Wheeler, Tyler, & Padden, 2017; Webb et al., 2015), no research has analyzed whether the OMP model actually overcomes any of these barriers. Future research might examine whether the OMP model decreases preceptors' perceived time burden of clinical teaching or meets the perceived need for training. In addition, much of the research is limited to clinicians or faculty who have jobs that include expectations of clinical teaching. Many nursing schools rely on volunteer faculty for their preceptors. Evaluation of the perception of community clinicians who volunteer to teach will further support or identify areas for change in the OMP model. Use of the model in interprofessional clinical precepting environments also warrants a closer look. As we face a shortage of health professionals, clinicians frequently find themselves teaching in other professions (i.e., MDs teaching NP students or NPs teaching medical students). Is the OMP model effective for preceptors teaching across professions? Using RCT research designs will optimize the impact of future research studies further supporting use of the OMP across settings and health professions, including nurse practitioners.

 

Conclusions

Current evidence supports the value of the OMP as an effective model of clinical teaching that students appreciate. It improves training through assessments of clinical reasoning, feedback, and corrective support. Although research is limited mostly to other health professions, it is practical to suggest adoption of this teaching model as a tool for NP preceptors. Further research to evaluate the effectiveness of the OMP model in NP education is warranted.

 

Acknowledgments:E. Gatewood's faculty time for development of this manuscript is supported by HRSA grant D09HP28680.

 

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For more than 128 additional continuing education articles related to Professional Issues, go to http://NursingCenter.com/CE.

 

Instructions:

 

* Read the article.

 

* The test for this CE activity can be taken online at http://www.NursingCenter.com/CE/JAANP. Find the test under the article title.

 

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Registration Deadline: January 1, 2020.

 

Disclosure Statement:

 

The authors and planners have disclosed that they have no financial relationships related to this article.

 

Provider Accreditation:

 

This activity is approved for 1.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. Activity ID 18123466. This activity was planned in accordance with AANP CE Standards and Policies.

 

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.25 contact hours. Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia Board of Nursing, Georgia Board of Nursing, and Florida Board of Nursing, CE Broker #50-1223.

 

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