Working with the “Difficult” Student: Part 1

Step 1- Define Difficult
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For the purposes of the next two blog posts, we are going to look at two different definitions of difficult:
1. Students who are experiencing academic difficulty
2. Students who you are uncomfortable working with.
There are other definitions but making this distinction allows us to approach this issue with two very different solutions. This Blog will examine definition #1.

Students who are Experiencing Academic Difficulty

Step 2 – Diagnose the Difficulty
This step requires knowledge about the Learning Cycle developed in 1962 by P.Dubin. Everyone who is learning something new goes through the following 4 stages.
1. Unconscious Incompetence
At this stage, the person has no idea that they don’t know and in some cases may even assume that they do know because watching an expert makes it look easy or they may dismiss the importance of learning because the student fails to see the relevance. Sometimes this student will aggressively try to prove you wrong or blame others. In some cases, they learned incorrectly the first time and the incorrect behaviour is automatic. This is the most dangerous stage for patients who work with the student and the most difficult for preceptors to cope with.
2. Conscious Incompetence
This stage represents the beginning of willingness to learn something new. Occasionally students will be so afraid of appearing incompetent that they will avoid admitting that they are at this stage. This person may avoid learning by standing at the back of a group, giving joke responses to questions, freezing up or missing a session.
3. Conscious Competence
This stage is the awkward stage, every step has to be rehearsed, fingers don’t seem to work properly, or the student may forget a step and freeze. The preceptor is often tempted to do or reteach the steps for the student because they seem so slow.
4. Unconscious Competence
At this stage the student is doing things automatically. In the case of skills, muscle memory has kicked in, and they can use their minds to do other things like talk about the weather. The draw back with this stage is they have forgotten the steps they took to learn the skill and teaching it to someone else can be frustrating.
Techniques that can help you identify which stage the student is at can be found here.
Step 3 – Treat the Difficulty
Once you have a clear diagnosis, you can move on to developing a strategy for working with the student. Rewards and punishment are ineffective because they have unpleasant long term consequences.
1. Unconscious Incompetence
The simplest solution at this stage is to demonstrate what you expect but that won’t work with a student who is seriously imbedded in this stage and denying that they need to change. Here are some alternatives:
• direct feedback
• 360 degree feedback from nurses, patients, and/or families
illness scripts
• videotaped encounters
• failure as a last resort.
2. Conscious Incompetence
At this stage, the student needs direct teaching. Some things to think about with a student having a difficult time at this stage are:
• use numbered steps
• use repetition by asking students to explain steps to the patient or you before they practice
• if a student is fearful of appearing incompetent, build their confidence by
o giving them written steps to memorize
o asking them questions they can answer
o asking them to demonstrate a piece of something
o using positive support strategies.
3. Conscious Competence
This is the practice stage and students need to do X until it becomes automatic. If there aren’t patients, use simulators; no simulators, practice on self, family, each other. This is the stage when students should be teaching each other and students in lower levels because the act of teaching improves the skill level of the teacher.
4. Unconscious Competence
At this stage, the person needs new challenges.