St. John’s Medical College, Bangalore, India.
St. John’s Medical College, Bangalore, India. 2012
Acknowledgements
We would sincerely like to place on record the many people who have supported this effort to adapt
and modify material, directly and indirectly, in the course of developing this Mentorship Workshop
material.
 Dr. Prem Pais, Dean, St. John’s Medical College, Bangalore, Karnataka, India
 Dr. Swarna Rekha Bhat and Our Team, Department of Medical Education, St. John’s Medical
College, Bangalore, Karnataka, India
 Dr. Sandy Gove, WHO, Geneva
 Dr. McHarry Kirsty, WHO, Geneva
 Dr. Po-Lin Chan, WHO, India
 Dr. Karthikeyan K, WHO-India
 Dr. Moses Christian, St. John’s Research Institute, Bangalore, India.
 Our Families for putting up with our travels and work – Celine and Rhea; Maria and Tarun; Our
Parents
2
Preface
For many years now, we at St. John’s have been supporting by training health care providers in the
delivery of chronic care and treatment primarily HIV related using a mentorship model. In addition,
faculty on our staff have played active roles as Clinical Mentors in districts of Karnataka State as well as
in Africa while on sabbaticals. These experiences and trainings that we developed and adapted formed
the basis of our present Mentoring Workshop design.
The content of this Mentoring Skills Participants Workbook is based on the “WHO recommendations for
clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resourceconstrained settings”, WHO, Geneva, 2006. We have used the insights, information, and many
perceptive quotations from “WHO recommendations for clinical mentoring to support scale-up of HIV
care, antiretroviral therapy and prevention in resource-constrained settings” to develop this practical
guide. This revision of the material includes additional advice, strategies, and resources for mentors that
can help them work more effectively as mentors.
Incorporated were elements of Teaching Learning based on our work as a Department of Medical
Education where we have periodically conducted Faculty Development Workshop material for our own
institution as well as for regional medical college faculty being a Medical Council of India’s (MCI) Nodal
Centre for Medical Education in South India. This Faculty Development Model was also what we
‘exported’ to our partners in Africa, the University of Nairobi, Kenya. The Mentoring Skill Workshop
material produced has both components of Mentoring and Clinical Teaching-Learning to strengthen the
training and build competencies.
We do hope all mentors, past, present and future, enjoy this attempt to strengthen Clinical Mentorship
Programs. We are happy to share this material with all requesting only to recognize the work whenever
used or adapted.
Dr. John Stephen, MD DNB, Professor of Dermatology and Medical Education
Dr. Sanjiv Lewin, MD DNB, Professor of Pediatrics, Clinical Ethics and Medical Education
For The Department of Medical Education
St. John’s Medical College
Bangalore, Karnataka, India 560034
([email protected]; [email protected])
Date: 8 January 2012
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4
Contents
1
2
3
4
5
Introduction
Clinical mentoring: Definition, purpose & relevance
Essentials of mentoring
Principles of Adult Learning
Mentoring skills
a Attending skills
b Listening skills
c Observational skills
d Appropriate use of names
e Speaking skills
f Responding skills
g Exploring skills (explore what is not clear; clarifying questions)
h Giving feedback
i Summarising skills
j Problem solving skills
k Evaluation skills
l Planning skills
m challenging and confronting (conflict management)
6 Approaches and tools
a Learning objectives, their domains
b Domain directed T-L Method selection
c One on One Learning
o One minute perceptorship
o Modelling
o TOSBA
7 Annexures
1. Rapport Building
2. Seven Pedagogical Strategies
5
7
8
13
15
19
36
38
39
42
43
43
48
50
6
1. Introduction
Introduct
This Participants Workbook is designed for the training of medical college teachers in a core set of basic
skills necessary for mentoring. This includes two training modules which address the range of skills
needed to be a good clinical mentor. The first module addresses the psychological preparation to be a
good clinical mentor, emphasizing the conceptual, personal, process and communication sets of skills
that are central to the mentorship process. The second module addresses the models and modes of
mentorship focusing on the methodologies related to bed side teaching.
The objectives:
By the end of the training, participants will:

Understand the role of mentorship

Understand the aims of mentorship

Understand the defining characteristics of mentorship

Understand the models of mentorship and modes of mentorship

Understand the sets of skills central to mentorship

Have learned and practiced communication and facilitation skills
7
2. Clinical Mentoring: Definition Purpose & Relevance
What is Mentoring?
Mentoring is a reciprocal relationship between an experienced, highly regarded, empathetic person
(the mentor) and a less experienced junior faculty/student member (the mentee) aimed at fostering
the professional and personal development of the junior faculty /student member.
The term “mentor” has a long history rooted in Greek mythology.
During the Trojan war, King Odysseus left Telemachus, his son and heir
to the throne in the care of his friend, Mentor. Odysseus entrusted
Mentor with the role of tutor and guide for young Telemachus. Mentor
fulfilled a complex role, combining a number of different functions,
teacher, guide, advisor, supporter, and advocate. Fundamentally, he
served to foster and promote Telemachus’ ongoing development. We
derive our current understanding of mentorship and its role from these
early roots.
The term “mentor” has more than twenty different definitions in the
literature and there is no consensus on any operational definition.
However, certain basic elements of mentoring relationships can be
generally agreed upon. A mentoring relationship is personal in nature, long lasting, and it involves direct
interaction. It furthermore involves emotional and psychological support, direct assistance with career
and professional development and role-modeling. It is reciprocal, where both the mentor and the
mentee derive emotional and tangible benefits but emphasizes the mentor’s greater experience,
influence and achievement within a particular field. The overall goal is to enhance and facilitate the
professional and personal development of medical students.
Purpose & Relevance
Mentorship has been applied in a range of contexts, industry and commerce, health and human service
professions, politics and education. Based on the context, there are several different definitions of
mentoring in literature. In the context of undergraduate medical/nursing education, mentoring has 3
essential purposes:
Continuing
education
Personal
support
Professional
development
8
Continuing education: Mentoring should be seen as part of the
continuum of education required to create competent doctors and
nurses.
The need and purpose of mentoring in many ways correlates with
Fink's five principles of good course design:
1. Challenges students to HIGHER LEVEL LEARNING. All
courses require some "lower level" learning, i.e.,
comprehending and remembering basic information and
concepts. But many courses never get beyond this.
Examples of "higher level learning" include problem solving,
decision making, critical thinking, and creative thinking.
Finks five principles
A "good course" is one which
meets the following five criteria:





Challenges students to
higher level learning
Uses active forms of learning
Gives frequent and
immediate feedback
Uses a structured sequence
of different learning
activities
Has a fair system for
assessing participants
2. Uses ACTIVE FORMS OF LEARNING. Some learning will be "passive", i.e., reading and listening.
But "higher level learning," almost by definition, requires active learning. One learns to solve
problems by solving problems; one learns to think critically by thinking critically; etc.
3. Gives FREQUENT and IMMEDIATE FEEDBACK to students on the quality of their learning. Higher
level learning and active learning require frequent and immediate feedback for students to
know whether they are "doing it" correctly. "Frequent" means weekly or daily; feedback
consisting of "two mid-terms and a final" is not sufficient. "Immediate" means during the same
class if possible, or at the next class session.
4. Uses a STRUCTURED SEQUENCE OF DIFFERENT LEARNING ACTIVITIES. Any course needs a
variety of forms of learning (e.g., lectures, discussions, small groups, writing, etc.), both to
support different kinds of learning goals and different learning styles. But these various learning
activities also need to be structured in a sequence such that earlier classes lay the foundation
for complex and higher level learning tasks in later classes.
5. Has a FAIR SYSTEM FOR ASSESSING AND GRADING STUDENTS. Even when students feel they are
learning something significant, they are unhappy if their grade does not reflect this. The grading
system should be objective, reliable, based on learning, flexible, and communicated in writing.
Creative
thinking
Critical
thinking
Clinical mentoring (bedside)
Decision making
Problem solving
Understanding concepts
Classroom based lectures
Remembering basic information
Comprehending
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Personal support: The term ‘support’ is often used in relation to the wider aspects of learner support,
which may include study skills, IT skills and library services, including the provision of academic or
personal support given to individual students, trainees or groups by clinical teachers.
Professional development: The responsibility for development must always lie with the individual, but
the active support of a wise colleague, in the role of a mentor, can be extremely helpful at particular
times, for example in the early stages of a career or in times of change.
The Difference between “Teaching” and “Mentoring”
NO
1
TEACHER
A teacher often tells you important information.
2
A teacher tells you to read a book; then tests you on
your retention of the facts.
A teacher understands his/her job to be that of
educating.
Syllabi can be planned
3
4
5
6
There is limitation in the amount of time that can be
given to the student
A teacher imparts the same information to each
student equally.
10
MENTOR
A mentor provides the opportunity for you to
discover the information.
A mentor reads a book with you; then discusses how
that book changed you both.
A mentor understands his/her job to be that of
inspiring the students to educate themselves.
The teaching moment will occur in some fashion
every time the mentor and the student interact
There is no limitation in the amount of time that can
be given to the student… it is more generous
A mentor observes each student and makes
suggestions based on their individual needs, passions,
or skill levels.
Activity 2.1:
Self-assessment questionnaire for use by clinical mentors in training
Instruction: Read each statement and tick the option A or B which most accurately describes you or your
response.
Follow the scoring and interpretation guide below after completing the exercise. This will help provide
some insights into your skills and approach that will influence your work as a mentor. You are doing this
privately.
1. People probably see me as…
2. I like my days to be…
3. When it comes to holidays, most organizations need...
4. When I evaluate people, my decisions are based on…
5. My approach to planning my personal activities is…
6. Most people generally see me as a person who is…
7. When it comes to social situations, I tend to…
8. I like to spend my leisure times in ways that are fairly…
9. I believe that leaders should be more concerned about people’s…
10. When I encounter people in need of help, I’m more likely to…
11. When I am in a group, I usually
12. Most people see me as being…
13. My friends know that I am…
14. If I were in a group of strangers, people would see me as a …
15. When it comes to expressing my feelings, most people see me as…
16. When people I depend on make mistakes, I am typically…
17. When I eat out, I generally order food that…
18. In general I prefer…
19. In a conflict when anger is involved, my emotional fuse is…
20. In an emergency situation, I would most likely be…
21. I prefer to express myself to others in ways that are…
22. I am likely to be ruled by…
23. In new and unfamiliar situations, I am usually…
24. In a festive social situation I am usually…
25. When I am wrongfully accused of something, my first response is to
26. In situations where I lose or get disappointed, I become…
27. Dealing with someone in tears is…
28. Most people see me as…
29. People think of me as…
30. If people were asked to make a choice, they would say I was…
31. At the end of a long party, I usually feel…
32. When I work on projects, I am best at getting them…
33. I believe people should approach their work with…
34. If I made a social blunder, I would be…
35. When faced with a major change, I get…
36. People are likely to see me as…
37. After a tough day I like to unwind…
38. Change is most often my…
39. My work and social like…
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A
a soft touch
spontaneous
fewer
mercy
easygoing
formal
hold back
unplanned
rights
avoid
follow
private
gentle
listener
reserved
patient
sounds unique
the theatre
long
calm
indirect
emotion
carefree
passive
listen
sad
awkward
an optimist
uncritical
too quiet
exhausted
started
dedication
embarrassed
excited
stern
alone
friend
are separate
B
hard nosed
planned
more
justice
orderly
casual
get involved
routine
feelings
assist
lead
open
firm
leader
comfortable
impatient
I know I like
parties
short
anxious
direct
logic
careful
active
defend
mad/angry
easy
a pessimist
critical
too loud
energised
completed
inspiration
amused
concerned
warm
with others
enemy
often overlap
Scoring and Interpretation
There are three subscales on this self-assessment exercise. Count up how many As and Bs you have for
each of the following three sub-scales by counting your ticks for A and B.
Sub – scale
A
B
High scores:
8 and above in the B column
Sociability (13 items):
1, 4, 7, 10, 13, 16, 19, 22, 25, 28, 31, 34, 37
Dominance (13 items):
Low scores:
5 and below in the B column
2, 5, 8, 11, 14, 17, 20, 23, 26, 29, 32, 35, 38
Openness (13 items):
3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33, 36, 39
Interpreting your profile
Sociability:
Mentors with a high sociability profile will find it easier to build rapport, express and share feeling
and have open dialogue with mentees. High sociability mentors will however need to be concerned
with avoiding a domineering role in the process of mentoring.
Low sociability mentors will tend to display a reserve making them somewhat unapproachable.
These mentors will need to concentrate on making a focused effort to facilitate mentees to be open
and to communicate freely with the mentor.
Dominance:
Mentors with a high dominance profile will have difficulty with control issues and sharing power in
the mentorship relationship. This is important given the understanding of mentorship based in a
partnership relationship characterised by shared power. High dominance mentors will need to focus
on active listening and be aware of and avoid dominating discussions.
Low dominance mentors should consider developing their leadership role in the relationship in order
to create a secure, developmental and learning environment for the mentee.
Openness
High openness mentors who easily share feelings and thoughts need to consider the effects of this on
less confident mentees. High levels of openness may be intimidating for some mentees.
Low openness mentors may have difficulty making appropriate emotional and interpersonal
connections with the mentee and this may impede the creation of a positive learning environment in
which mentees can take risks, experiment and learn through autonomous actions. These mentors
will need to address their cautious interpersonal style especially in the early phase of the mentor –
mentee relationship.
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3. Essentials of Mentoring
Mentoring is “the process whereby an experienced, highly regarded, empathetic person (the mentor),
guides another individual (the mentee) in the development and re-examination of their own ideas,
learning and personal and professional development”1.
Clinical mentors are experienced clinician-trainers who provide case review, problem solving, quality
assurance and continuing education in the context of an ongoing personal relationship. There are 5
essential steps in mentoring:
1.
2.
3.
4.
5.
Building relationships
Identifying strengths and gaps
Responsive coaching and modeling
Advocacy for work environment (patient and provider)
Giving feedback
Build Relationships (also check Annexure 2 on rapport building)
Establishment of a trusting and receptive relationship between the mentor and mentee(s) is the
foundation for an effective mentoring experience. This component is ongoing over the course of the
mentorship, as the relationship continues to evolve and grow.
What are the qualities of an effective mentor? What strategies do mentors use to engage and connect
with mentees? These questions are at the heart of all mentoring relationships.
Some Mentor-mentee relationships do well while others come apart. Studies have shown that the key
reasons had to do with the expectations and approach of the mentor. Most of the mentors in the
relationships that failed had a belief that they should, and could, “reform” their mentee. These mentors,
even at the very beginning, spent at least some of their time together pushing the mentee to change.
Almost all the mentors in the successful relationships believed that their role was to support the
mentee, to help him or her grow and develop. They saw themselves as a friend2.
1
Standing Committee on Postgraduate Medical and Dental Education in the United States of America
K.V., & Styles, M.B. (1995). Building Relationships with Youth in Program Settings: A Study of Big Brothers/Big Sisters.
Philadelphia: Public/Private Ventures. Available online at http://www.ppv.org/ppv/publications/assets/ 41_publication.pdf
2
13
What are the qualities of a mentor for good relationship building? The important features of successful
mentors’ attitudes and styles are:
1.
2.
3.
4.
5.
6.
7.
8.
Be friendly and approachable
Have realistic goals and expectations.
Give your mentee voice and choice in deciding on activities.
Be positive.
Listen.
Respect the trust your mentee places in you.
Remember that your relationship is with the mentee, not your employee, not his employee
Remember that you are responsible for building the relationship.
Identifying strengths and gaps
This component involves observation and assessment of existing systems, practices, and policies to
identify strengths and areas for improvement. This manual describes a number of tools that can help
with this assessment phase. This observation assessment allows the Mentor to identify strengths and
weaknesses (gaps). These identified strengths and gaps give direction to the Mentor’s to reinforce
strengths and assist Mentees work out solutions to existing gaps in their abilities to deliver quality care.
Responsive coaching and modeling
Mentors must demonstrate proper techniques and model good practices. During mentoring, this means
examining patients along with the mentee; using appropriate, systemic examination techniques with
gloves when appropriate; and hand washing. Mentorship is as much about setting a good example as it
is about directly intervening to improve mentee practice.
Advocacy for work environment (patient and provider)
This component relates to technical assistance in support of systems-level changes. Mentors work with
colleagues and the management to enhance the development of infrastructure, systems, and
approaches that can support the delivery of comprehensive care. For example, mentors might provide
technical assistance in support of proper flow of patients at the facility, advocate for provision of privacy
for patients during examination, or help to promote a multidisciplinary approach to care. In relation to
mentoring students, the mentor may be called upon to advocate for special postings, leave for attending
conferences, research funding,…etc.
Feedback
It is the ability to learn from mistakes that makes us competent health care providers. Mentoring
relationships can play an important role in facilitating the feedback loop – helping the mentees to reflect
on their learning and mistakes and to develop and become more competent health care providers.
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4. Principles of Adult Learning
Part of being an effective instructor involves
understanding how adults learn best. Compared to
children, adults have special needs and requirements as
learners. Andragogy (adult learning) is a theory,
pioneered by Malcom Knowles, that holds a set of
assumptions about how adults learn. This section will
describe these principles and how they can be applied to
improve the effectiveness of teaching-learning sessions.
The six principles of adult learning (Knowles)
1.
2.
3.
4.
5.
6.
Adults are internally motivated and selfdirected
Adults bring life experiences and
knowledge to learning experiences
Adults are goal oriented
Adults are relevancy oriented
Adults are practical
Adult learners like to be respected
1. Adults are internally motivated and self-directed
Adult learners resist learning when they feel others are imposing information, ideas or actions on
them. Your role is to facilitate a students'/participants’ movement toward more self-directed and
responsible learning as well as to foster the student's internal motivation to learn.
For learning to occur, adults have to do things. They must get involved and work at tasks and
exercises. They learn by doing and making mistakes and then discovering solutions for themselves.
Adults want to be consulted and listened to. Although trainers need to give direction at times, this
should be the exception rather than the rule.
As clinical educator you can:
 Set up a graded learning program that moves from more to less structure, from less to more
responsibility and from more to less direct supervision, at an appropriate pace that is
challenging yet not overloading for the student.
 Show interest in the student's thoughts and opinions. Actively and carefully listen to any
questions asked.
 Lead the student toward inquiry before supplying them with too many facts.
 Provide regular constructive and specific feedback (both positive and negative),
 Review goals and acknowledge goal completion
 Encourage use of resources such as library, journals, internet and other department resources.
 Set projects or tasks for the student that reflects their interests and which they must complete
and "tick off" over the course of the placement. For example: to provide an in-service on topic of
choice; to present a case-study based on one of their clients; to design a client educational
handout; or to lead a client group activity session.
2. Adults bring life experiences and knowledge to learning experiences
Adults like to be given opportunity to use their existing foundation of knowledge and experiences
gained from life experience, and apply it to their new learning experiences.
As a clinical educator you can:
 Adults want to test what they learn with what they already know. Encourage them to answer
questions from their own experience.
 Don’t just present information as truth… Use people’s different experiences to encourage
questioning and discussion so that they can arrive at the truth for themselves.
15


Assist them to draw on those experiences when problem-solving, reflecting and applying clinical
reasoning processes.
Facilitate reflective learning opportunities which can also assist the student to examine existing
biases or habits based on life experiences and "move them toward a new understanding of
information presented”.
3. Adults are goal oriented
Adult students become ready to learn when "they experience a need to learn it …. in order to cope more
satisfyingly with real-life tasks or problems" (Knowles, 1980). Your role is to:
o Facilitate a student's readiness for problem-based learning and
o Increase the student's awareness of the need for the knowledge or skill presented.
As educator, you can:
 Provide meaningful learning experiences that are clearly linked to personal, client and fieldwork
goals as well as assessment and future life goals.
 Provide real case-studies as a basis from which to learn about the theory and implications of
relevance.
 Ask questions that motivate reflection, inquiry and further research.
4. Adults are relevancy oriented
Adult learners want to know the relevance of what they are learning to what they want to achieve.
Adults prefer to focus on real life, immediate problems rather than on theoretical situations.
Adults see learning as a means to an end, rather than an end in itself
As educator, you can:
 Provide useful information that is relevant to their needs. Adults would rather focus on current
issues, rather than material that may be useful in the distant future.
 Tell adults about the purpose and benefits of the session, and about the process you intend to
follow. That way they will know what’s in it for them.
 Summarize and review regularly so they can see that progress is being made.
 Ask the student to do some reflection … on for example
• What they expect to learn prior to the experience
• What they learnt after the experience
• How they might apply what they learnt in the future
• How it will help them to meet their learning goals.
5. Adults are practical
By interacting with real patients and their real life situations, students move from classroom and
textbook mode to hands-on problem solving where they can recognize firsthand how their learning
applies to life and the work context.
As a clinical educator you can:
 Clearly explain your clinical reasoning when making choices about assessments, interventions
and when prioritising patient's clinical needs.
 Be explicit about how what the student is learning is useful and applicable to the job and patient
group you are working with.
 Promote active participation by allowing students to try things rather than observe.
16
6. Adult learners like to be respected
Respect can be demonstrated to your student by:
 Taking interest
 Acknowledging the wealth of experiences that the student brings to the placement;
 Regarding them as a colleague who is equal in life experience
 Encouraging expression of ideas, reasoning and feedback at every opportunity.
In summary…
Treat adult learners with respect. Encourage discussion and participation. Rather than being
the teacher with all the answers, try and be the facilitator who helps them to learn for
themselves. Both you and they will then have a much more rewarding and enjoyable
teaching-learning session.
17
Activity 4.1
The six principles of adult learning
1
2
3
4
5
6
Self-directed
Bring life experiences
Goal oriented
Relevancy oriented
Practical
To be respected
Discuss in your groups and identify: to which of the above principles does the
below mentioned relate to.
1 Lead the student toward inquiry before supplying them with too
many facts.
2 Provide real case-studies as a basis from which to learn
3 Encourage them to answer questions from their own experience
4 Encourage questioning and discussion
5 Tell adults about the purpose and benefits of the session, and
about the process you intend to follow.
6 Increase the student's awareness of the need for the knowledge
or skill presented
7 Encourage use of resources such as library, journals, internet and
other department resources.
8 Promote active participation by allowing students to try things
rather than observe.
9 Encouraging expression of ideas, reasoning and feedback at
every opportunity
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5. Mentoring Skills
Mentoring: psychological, interpersonal, and communication skills
Interpersonal communication skills are those skills which directly relate to initiating and maintaining
effective and open communication between the mentor and mentee – they are the micro skills of
listening and responding appropriately. These skills are used in a one-to-one session (face to face and
over the telephone) and in group facilitation.
A. Attending skills
Attending means being physically, intellectually and emotionally “present” in a mentoring session. These
skills indicate to the mentee that the mentor is listening, is aware and is ready to interact. They show in
a non-verbal way that the mentor is attentive and available. The acronym SOLER is often used to
summarise these basic skills:

S stands for sit or stand squarely: this means facing the mentee so that they can see the mentor
and communicate openly. Sometimes a more “conversational” sitting or standing style is used
where the mentor and the mentee sit or stand at right angles to each other while they talk. In a
group mentoring session the mentor must face the group to convey openness and attentiveness
and when appropriate turn his or her body to face a specific speaker.

O stand for open posture: this means not crossing arms or holding a folder/file in such a way
that it indicates a closed body, and possibly a closed or “switched off” mind. It can also refer to
minimising barriers between mentor and mentee, such as a desk or bed. If mentoring a mentee
next to a patient, try to stand next to each other.

L stands for leaning forward: this means

E stands for eye contact: this means keeping natural eye contact to show the mentee that the
leaning in to the mentee at appropriate times to
convey interest and concern. This should be used carefully so as not to intimidate a mentee too
soon in an encounter. In addition, mentors must be mindful of body space differences in people
from different backgrounds. Good observational skills will soon pick up what is an appropriate
space.
mentor is listening to what is being said. Eye contact in group sessions is vital to focus in on a
specific participant and to notice what is going on in the group. Remember that for some people
too much eye contact may be experienced as threatening or disrespectful: good contextual
knowledge will assist here.

R stands for relaxed posture: this means not fidgeting excessively or holding one’s body in a
tense manner. The mentor should convey a calm sense of containment to the mentee and
should role model how patients may too be calmed and contained by this method.
While these attending skills mostly apply to face to face encounters, they can be used in a telephone
conversation to maintain focus. Sitting up, leaning forward, being relaxed but alert, eyes focusing on
something neutral, all help to keep the mentor “ in tune” with the mentee.
It is also useful to think about appropriate use of touch. In some cultures it is acceptable and even
desirable to convey empathy and understanding through a pat on the shoulder, a warm handclasp or
even a hug. In others there may be strict limitations on cross gender touching. Working with people who
19
are living with HIV or AIDS has special considerations around fears of infectivity and they may often feel
untouchable. It would be useful to explore:



What are the norms around touch in the specific clinical setting?
How comfortable are you as a mentor with touch?
The mentee’s comfort levels with touch. This may be done through a direct question such as
“When you greet a patient do you shake hands?” or “If a patient is crying how would you
comfort them?”
B. Listening skills
What is a mentor listening for in a mentoring encounter?
 Themes and threads: in a presentation the mentor must extract key messages and link ideas so
that sense is made of the material a mentee is presenting. These may be reflected back to the
mentee to show that the mentor has been listening well.
 What is said and not said: what does the mentee focus on in his or her presentation of a case and
what is left out? She or he may be editing out mistakes, or being very matter of fact, or overly
emotional. These are clues that tell the mentor something about the speaker.
 Tone and delivery: these may tell the mentor about the personality of the mentee, about their
social skills or about their comfort with presenting in a group. They may reveal information about
how the mentee interacts with patients.
 Feelings and facts: some mentees may present difficult patient stories in a very clinical and
detached way, or they may become emotional about a dying patient. This is important
information to store and work with.
 Knowledge gaps: is the mentee revealing a key gap in clinical know-how? This gap needs to be
tactfully corrected.
 Strengths and weaknesses: the mentor may learn through good listening about a mentee’s clinical,
intellectual, emotional and relational skills and growth areas. These all need to be factored into
the responses and approach of the mentor.
Most of us listen in spurts and are unable to give close attention to what is being said for more than 60
seconds at a time. We concentrate for a while, our attention lags, then we concentrate again. This can
be improved with some simple techniques. The following are typical listening challenges:

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You had trouble understanding the speaker’s words or language usage.
You were thinking of what you were going to say while the speaker was talking.
You were preoccupied with how strongly you disagreed with the speaker’s views.
You listened for what you wanted to hear.
You were too tired mentally to pay attention.
There were outside noises and distractions.
The speaker had poor delivery – slow, irrelevant, rambling or repetitious.
Something the speaker said intrigued you: you thought about it and when you tuned back in you
had lost the thread.
The speaker had an accent you found hard to understand.
You tuned out because you thought you knew what the speaker’s conclusions were going to be.
You forgot to paraphrase and give feedback to show you were listening effectively.
You felt you were being given far too much information.
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Listening can be improved with some simple approaches:
 You must care enough to want to improve. Without this motivation, it will be too much effort.
 Try to find an uninterrupted area in which to converse. Keeping your train of thought is difficult
when there are obstructions to conversation.
 Try not to anticipate what the mentee will say.
 Be mindful of your own prejudices or biases so they do not unduly influence your listening.
 Pay careful attention to what is being said – don’t stop listening to plan your rebuttal to a
particular point.
 Be aware of “red flag” words which trigger an overreaction or stereotyped reactions – when they
occur, mentally remind yourself to keep focused on what the mentee is saying.
 Don’t allow yourself to get too far ahead of the mentee by trying to understand things too soon.
 At intervals, paraphrase or summarise (see below) what the mentee has been saying – the more
accurate you are the more you show you have been listening. However even if you are wrong you
should paraphrase in a tentative way so that the mentee can correct you and put you on track.
 If you are not sure why a mentee is telling you something, ask. For example you could say “It’s not
clear to me what point you are making, can you clarify it for me?”
 If you are losing the train of the conversation, home in on key words or concepts to keep focus.
 Don’t interrupt the mentee to ask for clarification of a minor or irrelevant detail.
 If the mentee is making many points it is acceptable to jot down key words to keep track – but
make a point of using the attending skills to make up for the temporary loss of eye contact, for
example through nodding in acknowledgement of what the mentee is saying.
C. Observational skills
The mentor should use observational skills to get a sense of how the mentee is presenting him or
herself. Aspects to look out for include:
 What is the mentee’s general demeanour: are they positive and upbeat, pessimistic and
depressed, angry and confused, defensive and wary?
 What kind of body language is the mentee using? The ideas expressed in SOLER (above) are useful
to think about – is the mentee open with the patient and the mentor, does the mentee use
appropriate eye contact and physical distance, is the mentee tense and withdrawn in an
encounter with a patient?
 Is the mentee neat and appropriate in dress and physical presentation? Not only do these reflect
the general wellbeing of the mentee but they suggest levels of professionalism in dealing with
patients.
 How does the mentee use language? Rate of speech, tone of speech and volume of speech may
be key to how well the mentee can be understood and can also suggest mood and mental state.
Sometimes it is appropriate to temporarily match these to “tune in” to the mentee and lead them
to a calmer and more relaxed encounter. The mentor may also wish to ask the mentee to slow
down to aid understanding.
 The mentor should also observe what is going on in and around the mentoring context: how are
wards maintained, what are the challenges clinician’s face, what levels of privacy exist, and so on?
These need to be factored into the advice or support given to the mentee.
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D. Appropriate use of names
Is there an appropriate way to use names – first name only or surname as well? Think of the different
impression this creates.
It can be helpful to use a mentee’s name regularly – it helps to make and keep an empathic connection.
Be prepared to say your name again (or more slowly) so that the mentee hears it and remembers it (if
relevant).
Some names are complicated: always check the correct spelling and pronunciation as this makes the
mentee feel important (don’t say “What a strange name.”).
Some people say their surname first when they give you their name: if you are not sure, check this out.
E. Speaking skills
The mentor should develop an awareness of how she or he uses language and attempt to modify vocal
skills to improve understandability and communication. Awareness of vocal style can be gained through
taping of one’s voice and reviewing for clarity or by asking for feedback from others, including the
mentee. The kinds of things to look out for include:
 Tone of speech and volume of voice: the tone can convey warmth and empathy or indicate a
desire to bring formality into a particular encounter. If a mentee is being rude to a patient the
mentor can use a warm tone with the patient to model compassion. In a group mentoring context
the mentor must be audible to all and be able to use volume to “take control” of the session.
 Rate of speech: in general one should use a slower rate with an audience unfamiliar with one’s
accent – but this should not become sing song or patronising.
 Range of inflections: stressing certain words and varying emphasis will prevent boredom in an
audience. Again, the mentor can model the way in which a patient should be spoken too by using
this variety with the patient.
 Modifying accent/pronunciation: it may be useful in some settings to adapt pronunciation of
certain words to accommodate local style and usage, in order to improve comprehension.
 Rhythm of speech: the mentor should try to modify their rhythm of speech to be clear and
interesting.
 Appropriate words and language: the mentor needs to understand the particular mentoring
context to make better choices of words and phrases which mentees use and understand.
 Use of minimal encouragers (“mmm, uh huh, I see”): these encourage the mentee to keep talking
and show one is listening. This could go along with nods of the head. Minimal encouragers are
particularly important in telephone sessions as the normal visual cues are absent.
F. Responding skills
Responding skills are those skills which allow the mentor to respond directly to what a mentee has said
to take the conversation further in a useful direction. They also show the mentor has been listening or, if
the response misses the mark, gives permission to the mentee to put the mentor back on track. It is
always important to begin a response with a qualifier such as “it seems to me” or “it appears that” and
to use a tone of voice which conveys tentativeness. This is not because the mentor wishes to appear
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uncertain but to show respect for the mentee’s right to be the final arbiter of the “truth” of their
utterances, thoughts and feelings.
Three key responding skills include:
Responding to content/facts through paraphrases
This shows the mentee that the mentor has been listening well, allows the mentee to hear their own
ideas reflected and digested through the ears of another, and begins the process of “ordering” the
mentee thoughts and concerns.
A paraphrase is a simple reflection of the key idea a mentee has expressed. If the mentee says “When I
first saw the patient she seemed very sick and I wasn’t sure if she was going to survive. I wondered if she
was a good candidate for ARVs because she seemed so far gone. Even her family seemed to have given
up on her.” The response of the mentor could be “So it sounds like when you first saw this patient you
didn’t think there was anything you could do for her”. Depending on the mentee this could go in the
direction of an exploration of feelings of hopelessness in the mentee or in the direction of a
clinical/technical decision about initiating ART in patients with low CD4 counts. In a group mentoring
session the paraphrase can be used to “hear” two different points of view without taking sides, as in
“Gabriel seems to think this patient should first have been supported nutritionally before commencing
ART but you, Simeon, feel that the ART should start at the same time as the nutritional support.”
Responding to feelings
Apart from responding to the “simple facts” of a mentee statement it is also possible to respond to the
emotional aspect of what they have said. Responding to feelings brings in a “relational” element in that
connecting to others at this level is usually deeper and more meaningful, conveys empathy and can build
trust if handled sensitively. Using the example above the mentor could have said “it seems that you
experienced a sense of hopelessness when you saw this patient for the first time.” If the feeling
identified is accurate, the mentee feels understood at an emotional level. This is always more effective
than saying “I understand how you feel.”
Working with feelings can be uncomfortable at first and it presupposes that the mentor is themselves
comfortable with their own emotions and is adept at identifying feelings. In some cultures a “feelings
vocabulary” may be limited or men may be socialised not to express feelings. These differences must be
respected but not necessarily seen as a barrier to some effort to working with feelings.
Linking feelings to content/facts
This enhances empathy because it starts to bring depth, meaning and texture to the mentoring
encounter. By associating the feeling with a situation or event the mentor is helping to tie up the
threads of the conversation and to help the mentor see why, in a certain situation, they responded in a
certain way. Using the example above, the mentor could have used this skill in saying “So it seems that
when you first met this patient you felt a slight sense of hopelessness because her illness seemed so far
advanced and those around her had also given up.” This shows a high level of listening and brings
together the various themes in the mentee’s statement.
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As the mentor becomes more skilled in using these ideas she or he can in effect draw together
paraphrasing, summarising and reflecting facts and feelings to show the mentee they have been
listening well, and perhaps even “listening between the lines.”
G. Exploring skills (explore what is not clear; clarifying questions)
In any communication with a mentee in which the ultimate aim is to understand the mentee, convey
information and promote MNCH care and management, the mentor will have to go beyond reflecting
what has been heard to explore what is not clear and to deepen understanding on both sides. The
mentor should use exploring skills after the first phases of the encounter have been completed (joining,
contracting and hearing the initial concerns, facts and feelings). This exploring can be done in a number
of ways.

Clarifying what is not clear through asking questions for greater understanding or repeating
mentee statements with a questioning inflection.
In both instances the mentor wants to get clarity on a specific point a mentee has made. For
example if the mentee says “The patient told me that she always remembers to avoid
unnecessary medication because of the child,” the mentor could respond in at least two ways:
 By asking a clarifying question such as “When your patient said ‘because of the child’ what do you
think she meant?”
 By saying “because of the child?” with a rising inflection to indicate a question.
Both methods prompt the mentee to expand further on the particular point and clarify for the mentor
what is meant.
 Asking open questions: open questions have more than one answer and usually begin with “how”
“when” or “what”, as in the example given above. These probes encourage mentees to think
expansively and reflect an attitude of respect from the mentor because they assume the mentees
have ideas and experience to draw on. Open questions also presume there is time for an extended
discussion. In certain contexts a closed question, one which has a yes or no or some other forced
choice answer, also has its uses, especially if time is limited or if the mentor wishes to be more
directive. Some closed questions can be “leading” in that they point the mentee in a very specific
and “socially desirable” direction – leaving the mentor unsure if learning has happened. For
example if the mentor asks “You do understand this don’t you?” the mentee will often answer
“Yes” because this is the expected answer and they do not wish to come across as foolish.
 Asking hypothetical questions: these are usually open questions which prompt lateral thinking in
mentees. An example would be “What would you do if a patient with a CD4 count of 250
presented with an AIDS defining illness? This explores knowledge and encourages mentees to be
creative.
 Asking reflecting questions: these are questions which encourage mentees to summarise or reflect
on a particular discussion. This could be very effective in a group mentoring session where a
number of cases had been presented and the mentor asks “What are the key themes that have
come out of today’s cases?”
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
Asking evaluative questions: these are questions which take a specific issue and case and
“evaluate” a course of action. For example if a mentee has embarked on ART with a patient who
has a pre-existing cholesterol problem the mentor could ask “How do you think this will work
over time?”
H. Giving feedback
These skills tend to reflect on the “relationship” between the mentor & mentee or the “process” of what
is happening i.e. “how are we getting on?”
Feedback is a crucial part of facilitating and vital to the role of the mentor. This feedback may be of a
technical nature (“The dosage you have prescribed is wrong.”), may relate to general improvement of
the mentee (“You have made good progress as a clinician.”), may relate to the way in which a mentee
has conducted him or herself in a mentoring session (“It seems it was difficult for you to hear the
negative comments of your colleagues”)
Feedback can be given to:
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Let others know when you don’t understand what they’ve said
Let others know when you like something they’ve said or done
Let others know when you disagree with them
Let others know when you think they’ve changed the subject or are going round in circles
Let others know when you’re becoming annoyed
Let others know when you feel hurt or embarrassed.
Feedback also helps to keep the mentor (or mentee, because the mentee is entitled to give feedback to
the mentor and she or he should be open to this) in touch with their own reactions before they turn into
serious negative feelings. To be effective, feedback should be given when there is a foundation of trust
between the mentor and mentee, otherwise the feedback could be interpreted as a personal attack.
Some tips for giving feedback:
 Be sure the mentee is ready: if not the feedback will not fall on fertile ground.
 If possible, preface your feedback with something positive before giving negative or critical
feedback.
 Base your comments on facts not emotions.
 Be specific: give quotes and examples of exactly what you are referring to.
 Give feedback as soon after the event as possible: if you give the feedback immediately the
mentee is more likely to understand exactly what’s meant.
 But pick a convenient time: if the receiver is very busy with other urgent matters they will not be
able to concentrate on your feedback.
 Pick a private place: critical feedback given in front of others can be damaging rather than helpful
– one exception to this is feedback given to a group if there is conflict or avoidance in the group,
not to address this would be a disservice to group process.
 Concentrate on what can be changed.
 Request co-operation: invite the mentee to work with you and seek their “buy in” to the desired
change.
 Focus on one thing at a time: too much feedback will be overwhelming to the mentee.
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 Be helpful: always consider your own motives for giving your opinions – are you trying to be
helpful to the mentee or are you unloading some of your own feelings (if you are angry say so but
include a description of the behaviour that caused your anger).
 Encourage the mentee to give feedback in return: giving feedback can become “one-upmanship”.
Some tips for receiving feedback:
 State what you want feedback about.
 Use paraphrasing to check what you’ve heard.
 Share your reactions to the feedback.
If you are giving feedback to a person who is being difficult you can use the following steps:
 Describe the problem or situation to the person causing the difficulty.
 Define what feelings or reactions (anger, sadness, anxiety, hurt or upset) the problem behaviour
causes you.
 Suggest a solution or ask the person to provide a solution.
In a telephone mentoring session the immediacy skill may help to address situations which would be less
problematic in a face to face session. For example, if there is a silence in a face to face session, it may be
obvious from the mentee’s body language that they are thinking about a point the mentor has made. In
a telephone encounter the mentor does not have the luxury of visual cues and may have to address the
silence with a question or some other intervention such as a reflection or summary.
Example: responding immediately to problems with feedback
If, for example, the mentor says to the patient he and the mentee are examining, “Fatima when the
doctor explained to you how to take your ARVs was it clear to you what to do?” and the mentee gets
angry and says “of course it was clear”, the mentor may need to tackle the mentee’s response as soon as
possible. This should be done in private and the mentor could respond in a number of different ways:

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“Susan I noticed you got angry when I asked the patient about your discussion with her, what
was going on for you in that moment?”
“Susan that seemed to be an awkward moment between you and me there, perhaps we should
talk about it?”
“Susan it seemed inappropriate to me that you should get angry in front of the patient. Would
you like to tell me what angered you?”
Susan’s angry response might have been because she felt humiliated or her skills doubted in front of the
patient; she could have sensed a pattern of challenging questions from the mentor; or she could have
been defensive because she knew she had done a poor job of explaining ARVs and adherence to Fatima.
Attention to the process of what is going on and immediately addressing problems let the mentor get to
the root of the issue and allow the air to be cleared. Once the issue is out in the open it can be addressed
and the “relationship” between the mentor and mentee put back on an amicable and workable footing.
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I. Summarising skills
Summaries are essentially paraphrases of a larger chunk of material or conversation from a mentee. A
summary provides order and focus and sorts out relevant material to explore in an encounter. Good
summaries act as natural “stopping and reflecting” points in a conversation and can also be used to
bring a session to a close. In a group session a summary can be used to check out how well group
members have been following the discussion, by asking someone to draw together the key points as
they see them. It would be useful not to “pounce” on someone who clearly hasn’t understood the
session!
Other uses of summaries include:
 To give direction to a mentoring encounter
 To prevent getting stuck on a particular issue
 To check out if the mentor has really understood what the mentee is trying to say
 To link different points and themes together.
.
Some tips for summarising:
 A good summary is brief and includes not only the facts and the words but also the feelings the
mentee has expressed.
 Put the ideas and descriptions at least partly into your own words but the language should still be
primarily in the words used by the mentee.
J. Problem solving skills
In general it is advisable to use problem solving skills after there has been a thorough exploration of all
aspects of a problem. If this exploration is done in an engaging way solutions may naturally start to
emerge, the mentee feels heard and the solution that is arrived at is relevant to the context or situation.
The process of problem exploration also teaches the mentee a structured way of thinking about and
approaching problems – the mentee can take this approach into other situations. Remember that giving
solutions too soon encourages dependency and lazy thinking in mentees.
The first step in problem solving is to partialise the problem, i.e. to break it down into its component
parts or sub-problems. This is particularly useful when a problem appears to be large and overwhelming
so that no one solution is immediately apparent. By breaking the problem down, the task of finding
solutions is made easier because the smaller problems will then each be easier to solve.
The next step is to agree on a clear definition of the problem (or sub-problem). It is often useful to
define a problem in terms of specific needs. For example if the mentee has presented a case in which
the patient has not disclosed to anyone but needs assistance with adherence, it may be helpful to define
the problem as: “The patient needs help with disclosure,” rather than “The patient is resistant and
reluctant to disclose”.
Then encourage the mentee (or mentees in a group session) to brainstorm as many solutions as
possible. These can be written down for review – all ideas should be considered as this is a creative
process to stimulate lateral thinking. Only when the mentee has exhausted all ideas should the mentor
make his or her contribution as this respects the ideas of mentees.
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Sometimes the mentor could encounter resistance to change and finding solutions. Here are some ideas
to counter this resistance:
 “It can’t be done,” versus “What if we could do it?”
 “We can’t do it like that,” versus “What if this barrier didn’t exist?”
 They would never agree to it,” versus “What if we could get them to agree?”
 “It will be too expensive,” versus “What if we found a budget?”
 “This is too risky,” versus “What if we managed the risk?”
 “I don’t have the time,” versus “What if we reallocated resources?”
 “That’s already been tried,” versus “What if we tried again?”
Now evaluate each possible solution or option by considering the advantages or disadvantages of each.
This can also be done as a simple list of pros and cons in the form of a balance sheet. Then allow the
mentee to choose the best solution for his or her circumstances. Usually the best solution is the one
with the fewest disadvantages and the most advantages. In some cases where the solution is a technical
one, such as the right combination of ARVs or a specific treatment for an ARV side effect, the mentor
would obviously need to ensure that this is the option that is acted upon. Perhaps is it useful here to
distinguish between problems that have right or wrong answers and problems which could have a
number of possible solutions.
Then a decision has to be made to implement a specific decision. Mentees must learn to trust their own
decision-making abilities and this includes committing to a course of action. Now a practical action plan
is drawn up to take the decision forward. It is important to include specifics such as what, when, where
and how this should happen. In some cases mentees may need to learn to be more flexible and open to
creative solutions that go beyond stock answers.
Some questions which can be asked at this point to move the mentee to action include:
 What are you going to do?
 When will you do it?
 Will this action move you to your goal?
 What barriers might you have to overcome?
 Who else will be involved?
 What support do you need?
 Where will you find it?
 What other consequences are there of this course of action?
 What can I do to help?
Reviewing the outcome of the solution is desirable – this allows the mentor to assess with the mentee if
the best solution was chosen and whether the mentee was capable of implementing the solution well.
This allows for learning and promotes self evaluation.
K. Evaluation skills
The mentor needs to be able evaluate how the session went in terms of the solution developed and
whether the mentor/mentee relationship was amicable and productive. This process of reviewing and
evaluating also brings a session to a close.
Useful questions to consider include:
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 What can the mentee take away from the session that was useful?
 What about the session was less useful?
 Is there any unfinished business i.e. issues that were not adequately dealt with during the session?
The mentor should also ask the mentee about their evaluation of the session and whether it worked for
them:
 “How did you find the session?”
 Was the session helpful for you?”
 What did you take from this session?”
L. Planning skills
Planning skills are those skills which help to structure the mentoring relationship and involve all preplanning and post-evaluation to ensure smooth mentoring encounters. They also include the contracting
process to ensure that expectations of mentor and mentee are realised. In addition, we have included a
discussion on personal presentation (suitable dress codes etc) as this forms part of being suitably
prepared for the mentoring. Much of the planning involves using core communication skills in their
execution. So, for example, the mentor will use relevant listening and responding skills when negotiating
the contract with the mentee.
M.Challenging and confronting (conflict management)
Disagree tactfully: if you disagree with something a mentee has said it’s always important to do so in a
way which does not humiliate or embarrass them. You can sometimes deal with this by first
acknowledging the mentee’s point of view in a paraphrase and then re-directing the issue to the group:
“What do other people feel?” Or you can say: “Well that is one way of viewing it, another school of
thought suggests…” Or you could say: “I have a different take on this and I’d like to share it with you and
the group for your consideration.”
Manage conflicts: Inevitably there will be disagreement in a group – the mentor should not take sides
but stay impartial and deal with the situation in a professional and objective manner. The ability to
handle conflict in a group is one of the most important skills of a mentor in a group mentoring context.
Thinking in a “process” way about the relational dynamics in a group of people is very helpful as it allows
for issues to be addressed so that the work of training and discussion can happen more harmoniously. If
a group conflict is not addressed the main business of the group, to understand and implement ART
better, may be derailed. The basic approaches to resolving conflicts are:
 Competition: one person or group wins, the other loses
 Accommodation: one person refuses even to state his or her wishes
 Compromise/collaboration: each person recognises the other’s rights. Each may need to
compromise on some points, but it is understood that the solution must take into account the
needs and wishes of both.
The way to deal with conflict between mentees in the group:
1.
2.
3.
4.
Determine the cause(s) of the conflict.
Get the parties to define the interpretation of the conflict.
Set goals to deal with the conflict.
Get members to communicate their feelings and ideas.
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5.
6.
7.
8.
9.
Refer members to the ground rules that state that members agree to disagree.
Encourage members to understand the other party.
Set objectives for the resolution of the conflict.
Get the members to reach consensus on the way forward.
Jointly decide on a way to monitor the implementation of the solution.
The way to deal with a disagreement between mentees in a formal mediation out of the session:
1. The opening statement: mediations are held in a neutral place at a time convenient to the parties.
Sessions could last up to two hours. The mediator(s) open the session with a welcome and an
explanation of what will happen.
2. Uninterrupted time: each person takes a turn speaking while everyone else listens. For the most
part, this is open-ended: the person can talk briefly or at length about anything relevant to the
situation.
3. The exchange: then the arguing and discussion begin. For a while people accuse each other and
attempt to set each other straight on the facts. They explain why they are upset and make
demands. The mediator(s) keep the discussion within limits, making sure that each person is heard
and each is protected. The mediator(s) do not try to determine the truth or who is at fault. Rather,
they listen for what matters to people and for possible areas of agreement. Sometimes, the
exchange brings about what is called a “turning point” of reconciliation. Separate meetings can
occur any time during the mediation and have many uses, checking out a person’s concerns,
confronting unhelpful behaviour, or helping people think through their options.
4. Setting the agenda: discussion shifts towards the future: what will happen from now on? The
parties agree on an agenda of issues which need resolution.
5. Building the agreement: the parties work through each issue on the agenda, generating a number
of ideas, then weighing, adjusting, and testing the alternatives to craft a workable, mutually
satisfactory solution.
6. Writing the agreement: if the parties are able to settle their differences, the mediator(s) write a
formal agreement containing those decisions. Everyone present signs and takes a copy home.
7. Closing: the mediator(s) review what has been accomplished, remind people of next steps and
wish them well.
The way to deal with a disagreement between a mentor and a mentee:
1. Ask for time to think things over. Take this chance to allow both of you to calm down.
2. Pay attention to your body’s reactions. Has the fight-or-flight instinct been triggered? Take a deep
breath to increase your oxygen intake to your brain so you analyse your situation more clearly.
3. Don’t snap at the person. You may regret a fast retort which may have lasting consequences.
4. Determine what it is you want that you’re not getting. Should you be willing to negotiate more – to
give in a little – so you can both win?
5. If the other person has “lost it”, don’t negotiate until calm returns. Adopting a quiet manner is
always your best approach.
6. Wait until the other person is willing to listen to your side of the story. Make sure you’re listening
carefully to his or her side of the story.
7. Make sure the other person knows you’re listening. Use paraphrasing on a regular basis to confirm
that what you’ve heard is what has been said.
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8. If the other person doesn’t seem to be listening to what you have to say, insist that you be listened
to. Say: “I’ve made a point of listening carefully to what you have to say. Can I ask that you do the
same for me?”
9. Ask: “What do you want me to do?” Clarify that you know what the other person wants. Listen to
the answer and confirm or correct.
10. State what you want, clearly and sequentially. Again, be willing to negotiate.
11. Once an agreement has been reached, summarise the particulars and go over pertinent areas again
to reconfirm your understanding.
Manage change (resistance): most people resist change and find it unwelcome and threatening. The
very nature of mentoring requires mentees to learn and grow and get feedback on their performance as
HIV/AIDS clinicians. Resistance could show itself in late coming, not abiding by ground rules, not coming
prepared to a mentoring session, argumentativeness, passive aggression, and so on. These should be
addressed individually through giving feedback and reminders of the rules. But the mentor could also:
 “think process” and ask the group to reflect on the dynamics which seem to be emerging in the
group and ask for their assistance in dealing with them
 normalise difficulties around change
 explore the benefits of change.
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Activity 5.1: Emotional Bank Account
A. Imagine you are making deposits (positive actions) into an emotional bank account. You must work
out the value of the deposits that you the mentor make for the student doctors/nurses or other
health workers that you are mentoring. For example, the deposit “constructive feedback” would
create a value “growth and positive reinforcement”.
Emotional or technical deposit by mentor
Value of deposit for the student (mentee)
Constructive feedback
Growth and positive reinforcement
1. Providing emotional/psychosocial support
2. Showing respect
3. Showing empathy
4. Openness and transparency
5. Helping understand and manage an emotionally
difficult patient
6. Reviewing and helping solve a complicated
clinical case
7. Recognizing achievements
8. Showing positive, professional interest in human
elements of mentee as a person
9. Recognizing and responding to signs of burn-out
10. Admitting “I don’t know, but I’ll find out”
B. Now consider the impact that withdrawal from your emotional or technical bank account (negative
actions) has on the student / health worker. For example, a mentor providing negative feedback
may have the impact of eroding confidence of the student / health worker. Incorporate your own
experiences, if any, in your responses. When we have negative experiences, we often re-enact this,
and do the same to others. If you are aware of this, you can break the chain.
Emotional/Technical withdrawals by mentor
Impact of withdrawals on student (mentee)
1. Negative feedback
2. When discussing cases, emphasizing lab
tests or CT scan results which are not
available at health centre level
3. Imposing solutions
4. Showing disrespect
5. Being deceptive
32
6. Failing to recognize achievements.
7. Lack of support
8. Failure to return phone calls or Emails
9. Breaking confidentiality
10. Pontificating, showing off very expert
knowledge
11. Being late
12. Pretending to know something when you
don’t
13. Treating male students differently from how
you treat female students.
Now, go over your answers in a small group. There is no “right answer”—use this as an opportunity to
discuss important qualities for a mentor; your own experiences as a health professional being mentored
or receiving feedback.
Activity 5.2
Your pocket clinical mentoring guidelines contain many suggestions and tips for good approaches to
both one-to-one and group mentoring.
Your facilitator will assign each of you to a specific skill section in these guidelines. Read through this
section and present a new recommendation that you think will be helpful in mentoring, or one that you
already commonly use and find useful. Later, you should read and reflect on the whole section.
a Attending skills
b Listening skills
c Observational skills
d Appropriate use of names
e Speaking skills
f Responding skills
g Exploring skills
h Giving feedback
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i Summarising skills
j Problem solving skills
k Evaluation skills
l Planning skills
m Conflict management
Activity 5.3: Review your own performances as a mentor3
A. For the mentee:
Complete the following sentences. Respond intuitively, using your work as the context.
1. My greatest lesson in the last month has been …
2. The best thing about mentorship is …
3. One thing I am scared of is …
4. My mentor …
5. I want …
6. The worst thing about mentorship is …
7. I am proud of …
8. My greatest need at the moment is …
9. I should …
10. It is frustrating …
11. I secretly …
12. I struggle with …
13. I cloud my clinical work with …
14. I hesitate when …
15. I need more …
16. My one bad habit is …
17. In ten years’ time I …
B. For the mentor: answer these prompts from a mentoring perspective
1. Mentorship is …
2. My greatest fear in terms of mentoring is …
3. I get frustrated when …
4. Being needed is …
3
Incomplete sentences worksheet developed by Aderyn Exley (2005).
34
5. I get angry when …
6. I feel proud when …
7. My relationship with (mentee’s name) is …
8. I wish …
9. I find boundaries in mentorship …
10. The most difficult thing is …
11. Cultural diversity in mentorship means …
12. My response to language differences in mentorship is …
13. Mentorship in rural communities is …
14. A healthy relationship means …
15. I know I am having mentorship difficulties when …
Activity 5.4: Observing & Feedback
Two volunteers to conduct a 10 minute feedback session, using the sample checklists. All other
participants should observe the interaction and make notes for feedback to the “mentor”.
Feedback Check List
1 Ensured mentee is ready
2 Prefaced negative feedback with something positive
3 Based comments on facts not emotions.
4 Was specific: gave quotes and examples.
5 Gave the feedback immediately, but at a convenient time for mentee
6 Gave feedback in a private place
7 Concentrated on what can be changed.
8 Invited the mentee to “buy in” to the desired change.
9 Focused on one thing at a time
10 Encouraged the mentee to give feedback in return
35
6. Approaches for clinical mentoring
Session Learning Objectives
At the end of this session participants should be able….
 To classify learning objectives into appropriate domains
 To select appropriate Teaching-Learning methods for each domain
 To demonstrate One On One Teaching methods to be used for clinical learning
 To demonstrate the Small Group Teaching method TOSBA to be used for clinical learning
Learning Objectives and Domains
Mager has said “If you are not certain of where you are going you may very well end up somewhere else
(and not even know it). “
The start of any teaching-learning should be the formation of clear Specific Learning Objectives as
determined by the training needs of the participants. They give direction to all educational activities and
determine end-points that can be measured to enable one to determine if the learning was successful or
not.
We know that Education is a process the main goal of which is to bring about a behavioural change in
the learner. A Learning or Educational objective is defined as “what the student should be able to do at
the end of a learning period, that they could not do before”. They define what the student, not the
teacher, should be able to do and hence the result sought following the teaching-learning activity.
To assist teachers in the correct formulation of educational/learning objectives, systems of
classifications into domains was created. It is always important to remember that in human behaviour
the three domains are often intricately connected and overlaps will occur. Within each domain are
different levels of the process which also needs to be considered while formulating objectives.
The three domains are:
 Cognitive – This refers to intellectual skills and knowledge (“Head”).
o E.g. At the end of the activity the student should be able to draw and label the life cycle
of the malaria parasite
 Psychomotor – This refers to as domain of practical skills predominately performed by “hand”.
o E.g. At the end of the activity the student should be able to draw blood from an adult
patient’s cubital vein using a syringe and needle maintaining standard precautions.
 Affective – this deals with attitudes and communication
o E.g. At the end of the activity the student should be able to empathically counsel a
family of a dying person.
36
Levels of each domain may be simplified into the following for easier understanding:
Cognitive: Knowledge/Intellectual Domain
Levels
Example
Recall Facts
Interpret data
List steps in the process of normal delivery
On being given a spectrum of laboratory reports of a patient with
Complicated Severe Malaria, the student is able to interpret, relate,
arrange and summarize all laboratory issues required for the
management of the patient.
The student is able to diagnose an HIV infected patient with
Cryptococcal Meningitis using a scientific clinical approach to
headache in spite of never seeing such a patient and his condition
before.
Solve a New Problem (Problem Solve)
Psychomotor: Practical Skill Domain
Levels
Example
Imitate actions of a model
A parent of a Diabetic child requiring home Insulin practices by
imitating the administration of subcutaneous injections using an
orange.
Intern is accustomed to suturing an episiotomy under supervision.
Exercise effective control over the
practical skill
Perform
the
practical
skill
automatically and with a high degree
of efficiency (Mastery)
The Resident is able to intubate rapidly many patients brought in from
an accident in the chaos of a busy Emergency.
Affective: Attitudes/ Communication Domain
Levels
Example
Show receptivity towards another
person
Supply a response to the affective need
of another person
Internalize a feeling
Noticing the anxiety of a mother waiting with her sick child in
Emergency
Reassuring the mother after assessment of the sick child in Emergency
When attending an Emergency calls your attitude to all patients clearly
demonstrates that you care for the child and the parent that enables you
ensure them of effective help and concern
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Domain directed T-L Method selection
Now that we have reminded ourselves of the concepts of Learning Objectives and the three Domains,
we need to consider possible Teaching-Learning activities/methods appropriate to achieve the same.
Listed below are some methods in our settings:
Large Group TL Methods

Lecture
Organized presentation of facts with explanations by a teacher for a large group of
students who are predominately passive. Knowledge and Cognitive Intellectual domains
are mainly covered.

Symposium
Series of brief talks by experts on various areas of a topic in logical sequence made for a
large group audience. There is usually no overlap or disagreements between speakers
and little audience participation except for a brief question time. . Knowledge and
Cognitive Intellectual domains are mainly covered.

Team Teaching
A series of teachers from one or various departments take a series of short lectures for a
large group of students in a relay fashion. This method leads to some horizontal
integration of content taught but remains predominately a passive learning for the large
group. Knowledge and Cognitive Intellectual domains are mainly covered.

Panel Discussion
A panel of experts are moderated by a person who presents a prepared scenario(s) or
raises questions on various issues directed to some or all panellist. The panellist in turn
openly discusses the approach to answer the questions put to them. The panel may
have disagreement, discussions and different viewpoints between panellists; however,
the audience are usually passive listeners in this process. Knowledge and Cognitive
Intellectual domains are mainly covered.
Small Group TL Methods

Small group discussions
A small group meets up and discusses on a topic of interest which may be a formal or
informal discussion. Knowledge and Cognitive Intellectual domains are mainly covered.

Bedside clinics
Commonest method of clinical training, where there is a wider scope for demonstration
and practice of psychomotor/practical skills relevant to physical examination and even
diagnostic/therapeutic interventions necessary for health care providers to learn. The
clinic at the bedside is extremely effective even for Knowledge/Cognitive and
Affective/Communications to be (role) modelled and demonstrated. The insight into
clinical approaches and interpretation of real time data becomes extremely relevant to
the learner.
38

Practical/Field work/Demonstrations
Similar to the Bedside clinic, practical sessions in a laboratory or in the field bridges the
gap between theoretical knowledge and its application as well as integration into
practical/ affective /communication skills.

Role plays
Acting out a structured and planned scenario allows for a demonstration and experience
especially towards effective learning of affective and communication domains.

Problem based Learning
Small group learning groups use a problem as a trigger to direct their identification of
their own learning needs. The individual members of each group then disperse and
complete their own research to answer the questions they have identified that they
need to answer. This method also assists in the development of skills necessary for team
work and increases the possibility of self-directed learning. The Tutor is usually a faculty
who may or may not be an expert in the area being discussed but only plays a
predominately facilitation role enabling the small group to lead and interact. Knowledge
and Cognitive Intellectual domains are mainly covered.

Tutorials
Following coverage of a difficult topic usually by a reading assignment or large group
lecture, small groups meet with a teacher to clarify issues and interact focusing on the
topic. Knowledge and Cognitive Intellectual domains are mainly covered.

Seminar
A small group of Experts meet together to discuss among themselves intricacies of their
common area of interest to enable a better understanding and challenge each other’s
understanding of the topic. Knowledge and Cognitive Intellectual domains are mainly
covered.
Individual Methods




Individual/Group assignments-projects
Individual/Group self-study
Computer Assisted Learning
Counselling
All these methods are directed usually to the individual student and commonly focus on Knowledge
and Cognitive Intellectual domains. In the follow up to this session, specific ideas on individual
clinical teaching learning methods relevant to mentors will be discussed.
One to One Mentoring – Teaching and Learning
The cornerstone of any Mentorship is the development of Mentor-Mentee relationship which is
essentially a One on One relationship. The Mentor spends time with the Mentee in the latter’s
workplace accompanying, even assisting by modelling (e.g. assess FHS during ANC visit, glove up and
assist in a delivery, wrap up an exposed neonate, entering the growth chart, performing a respiratory
rate count for a child with cough, assisting positioning a baby breastfeed, etc.) with on-going tasks thus
39
observing all aspects of the on-going delivery of maternal , neonatal and child care and treatment. This
close observation allows the Mentor to be able to assist the Mentee in improving delivery of health care
through a mutually respectful relationship and sharing of experiences. Thus, the One-On-One
mentorship is an essential and the commonest means of a successful mentorship.
Sequence of a One on One Mentorship Encounter
1. Clinical Work Place attachment
2. Observation and Identification of strengths and weakness (gaps)
3. Immediate Responsive Methods
a. Responsive Coaching- Incidental Learning/ One –Minute Preceptorship
b. Modelling
c. TOSBA
4. Delayed Reinforcement Methods
a. Case based discussion and the Mini-lecture
b. Chart/Register Review discussions
c. Mini Lecture-Demonstrations
d. Role Plays/Video clips
e. Workplace Aids
1. Clinical Work Place attachment
To accomplish this One-On-One mentorship, the Mentor’s first step is joining in the Mentee’s work
routine which may be called a Clinical Workplace attachment. This enables the Mentor spend time
with the Mentee during work observing, even assisting, that further allows the Mentor identify
strengths and weaknesses (gaps). These identified strengths and gaps give direction to the Mentor’s
responsibilities and tasks to reinforce strengths and assist Mentees work out solutions to existing
gaps in their abilities to deliver quality care.
2. Observation and Identification of strengths and weakness (gaps)
Weaknesses (gaps) that are identified during observations of the Mentee by the Mentor in the
workplace may be predominately related to knowledge (cognitive), psychomotor skills and/or
affective/attitudes/communication domains. Knowledge (Cognitive) essentially means all matters
pertaining to the need to use one’s intellect (Brain). Psychomotor Skills indicates that the identified
issue is a task performed by hands. An Affective/Attitude/ Communication focus on tasks that
require empathy, understanding and feelings from the heart. Each of these domains to be learnt
require various combinations of teaching-learning methods that best suits each domain enabling the
learner achieve the learning.
During the visit, the Mentor may recognize that most pregnant women with hypertension don’t
receive Magnesium Sulphate for their Pregnancy Induced Hypertension. This fact after discussions
may be identified as a predominately knowledge (cognitive) issue of not comprehending and
applying knowledge of pregnancy induced hypertension (PIH) to prevent and treat seizures due to
the PIH (Eclampsia). This life saving measure prevents maternal morbidity and mortality. The
Mentor will needs to plug such as gap probably in an immediate response and it may need
additional reinforcement to make the learning possible. Other possible examples of identified gaps
could be that the nurse mentee is observed not washing hands between patients in the labour room
or that the nurses were unable to counsel woman to initiate breastfeeding within 30 min of a
normal delivery for their newborn. The hand-washing is an example of a psychomotor skill that
40
requires some knowledge transfer but certainly a demonstration followed by practice to enable
mentees perform better. The counselling will require knowledge certainly but specifically a
demonstration by role play or video followed by practice with feedback focusing on
affective/attitudes.
3. Immediate Responsive Methods
a. Responsive Coaching- Incidental Learning/ One –Minute Preceptorship
b. Modelling
c. TOSBA
If Inj Magnesium Sulphate is not prescribed for pregnant women with Pregnancy Induced
Hypertension (Pre Eclampsia and Eclampsia) when indicated, then the Mentor may use the work
place opportunity to provide additional knowledge on this aspect using a One-Minute Perceptorship
or Incidental Learning providing responsive immediate coaching. During rounds when one observes
that a patient’s blood pressure is elevated or even not taken, the Mentor may use the opportunity
to immediately ask “Why” is that Blood Pressure in Pregnancy of importance illustrating that PIH is a
common cause for maternal morbidity even mortality not forgetting preterm delivery and hence
neonatal challenges. This brief exchange of words could easily lead to the simple explanation of the
relevance of blood pressure recording, identification of PIH and the role of Inj Magnesium Sulphate
towards successful management. If one finds that there are additional issues that prevent the
utilization of Magnesium Sulphate such as pharmacy stock outs, non-availability outside working
hours or even that the medical officer has apparently no knowledge or protocol in place for this
medication in PIH/Eclampsia, and then additional steps may be warranted. One may decide upon
reinforcement even through team/small group discussions. One may discuss the finding during team
meetings, request for a mini-lecture on the management of the PIH/Eclampsia either by mentor but
preferably by other team members asking them to review texts, literature or existing national
guidelines from existing trainings. Providing clinic aids like posters for the wards and explaining the
protocols on them will also assist in learning.
If observations suggest that hand-washing is uncommon in the labour room or between neonates in
the post-delivery ward, then it could be the source of infection – both maternal and neonatal. The
challenge here would be the need for knowledge of various aspects of hand-washing from the why
to the how and the when of hand-washing. But all this knowledge would be of no use if the mentee
cannot demonstrate and perform the act of satisfactory hand-washing. Talking about hand-washing
may not be adequate for this psychomotor skill modelling by actually demonstrating hand-washing
protocols in the workplace situation (Modelling) followed by reinforcement through the team
meeting and small group discussions with clinic aids may be one possible method of enabling
learning. Additional long term feedback would be documenting the number of neonatal and
maternal sepsis attributed to poor hand-washing practices and demonstrating changes in trends
with initiation of hand-washing protocols. Similar methods of modelling and one minute
perceptorship may be used to enhance the learning of the affective/attitude related counselling.
Activity
Using a role play format demonstrate how you would teach on bedside rounds with a single
student in his or her clinical year. The student has worked up a patient’s history and
examination and presents the same to you. How would you proceed with the teaching at the
bedside? Remember you have a number of patients to see on rounds.
41
3a. One Minute Preceptoship
Neher et al described this method in 1993 and it focuses on the last one minute of bedside teaching.
There are five micro-skills used in this method are simple and easy to learn for effective one on one
learning to occur and that to at a higher level. They are as follows:
1. Get a Commitment
2. Probe for underlying reasoning
3. Teach general rules
4. Re-enforce what was correct
5. Correct mistakes
After the student completes the history and examination presentation to the preceptor, the student
is encouraged to commit to a diagnosis or a differential or an investigation or treatment
plan/approach. This challenge to make an intellectual commitment is the first step. Only after the
commitment has been made, does the preceptor proceed by probing for the rationale and reasons
and explanations for the decision/commitment made by the student. Here the WHY questions
become useful and the ability of the student to distinguish, differentiate and justify the decision
become evident. Following this probing for explanations and reasons, it becomes evident if there
are education gaps in the student’s armamentarium. Teaching general rules relevant to the scenario
being discussed is the next step that attempts to reinforce existing learning or teach the student to
plug gaps identified.
Then follow it up with re-enforcing what was correct in his or her arguments and rationale for the
committed decision made earlier. It is more effective to always be specific not just a broad
statement of praise. Finally it is a good idea for the student to be given the opportunity to critique
his or her own presentation and decisions in view of available information or ideas provided before
correcting identified mistakes.
Example:
A student presents details of a young child with fever, cold, cough followed by a rash.
During the history and examination presentation it is suggested that one rarely must interrupt except for
major clarifications required by the preceptor. At the end of the presentation, the preceptor asks for a
commitment of the diagnosis or differential.
The student says that he or she would like to give a differential, either Measles or Chickenpox. The
preceptor then challenges the student as to why he or she decided on the two possible diagnoses.
The student justifies the possibility of Measles by discussing points in favour ( the age of the child, the
history of prodrome of cold and cough, the 4th day of fever leading to a rash and the fact that the child is
unimmunized) He is not clear as to how to differentiate Chickenpox from Measles being unable to explain
why he added it as a differential on being probed for points for and against the decision/commitment.
The preceptor then describes the typical presentation of Measles as compared with Chickenpox
enumerating clinical features and explaining the underlying pathogenesis of both infections. A general rule
could be the fever time line and the onset of various rashes (Day 1 Chickenpox; Day 4 Measles; Day 7
Typhus). The Preceptor then analyses the student’s responses and praises him for the good history details
picked up – age, prodrome, rash onset and the lack of immunization. He corrects mistakes by reminding the
student of the need to describe the distribution pattern of the rash (face descending pattern, predominately
centripetal) and that the physical features of the rash need to be examined and described (Maculo-papular
versus Vesicular).
Activity: Identify and discuss the Five Micro-skills being used in this above example? Discuss how these
micro-skills could be augment your role play performed earlier?
42
3b. Modelling4
Much of professionalism is learnt from role models we encounter during our medical
training especially towards the clinical years. In addition, these models also enable us to
transition from student to physicians. Role models teach primarily by example and help
to shape professional identity and commitment through promoting observation and
comparison. Personal conduct, professional achievement, personality, power, influence,
lifestyle, and values may all determine the influence a teacher has on a student. It is
documented that outstanding clinical teachers who interact skillfully with patients,
providing supervision and demonstrating expertise at the bedside were more likely to
receive high ratings from medical students. Additional positive factors include selfcriticism, assuming responsibility, recognizing limitations, humility, respect, and
sensitivity for patients and trainees, and a wholesome sense of humor. Teachers of
medicine should reaffirm the enormous influence role models have on education.
Positive role models pass on perspectives that may have broad and long-term effects for
both patients and physicians. We must be constantly aware that our behavior and
attitudes influence students at all levels and that only through concerted effort,
demonstrated at the bedside, can we change their behavior and attitudes.
Critical thinking, psychomotor practical skills and attitudes including communication can
all be learnt while students observe role models at work in clinics and wards.
Activity
Spend a minute or two individually thinking back on your past clinical encounters during
student days or immediately after. Share these instances from your past or present where
Role models have demonstrated both, positive or negative influences.
3c. TOSBA Team Objective Structured Bedside Assessment5
The TOSBA is a ward-based teaching and formative assessment. It involves three groups
of five students rotating through three ward-based stations (each station consists of an
inpatient and facilitator). Each group spends 25 minutes at a bedside station where the
facilitator asks consecutive students to perform one of five clinical tasks. Every student
receives a standardised grade and is provided with educational feedback at each of the
three stations. Each station is comprised of an in-patient and an examiner. Consecutive
students in each group are each given 5 min to perform one of the five different
standardised clinical tasks:
 Targeted, brief history
 Targeted, perform a physical examination
 Generate a patient-specific differential diagnosis clearly stating points in favour
and against each of the proposed differentials
 Outline a plan or interpret existing investigations
 Outline treatment/care plan or discuss rational behind existing treatment
prescribed.
4
Reuler JB, Nardone DA: Role modeling in medical education. West j Med 1994; 160:335-337
5
Miller SD et al. Team Objective Structured Bedside Assessment (TOSBA): a novel and feasible way of providing formative
teaching and assessment. Med Teach. 2007 Mar;29(2-3):156-9; Meager FM et al. Predictive validity of measurements of clinical
competence using the Team Objective Structured Bedside Assessment (TOSBA): Assessing the clinical competence of final year
medical students. Med Teach 2009; 31: E545–E550
43
The students are directly observed performing the tasks, are graded on their
performance and provided with feedback by the examiner. On completion of the
TOSBA, all three examiners confer and an agreed final grade is awarded. Periodic
scheduling of such exercises weekly are an effective small group clinical teaching
method as well as provides much needed formative assessment. Below is tabulated the
TOSBA assessment scheme.
Grade
P+
P/P+
P
P/P P-
Descriptor
Honours standard
Pass with potential for Honours
Pass standard
Borderline standard
Fail standard
Activity: As groups, perform a role play that illustrates a TOSBA.
4. Delayed Reinforcement Methods
When issues identified are widespread in the facility or are cross cutting across all professional team
members (eg. Hand-washing, initiation of exclusive breastfeeding, management protocols, etc.),
there may be a need to reinforce learning at a later date in a relatively more planned and formal
way. Suggested Teaching-Learning methods for this delayed reinforcement are listed above.
a. Case based discussion and the Mini-lecture
A Small Group Discussion could be scheduled in consultation at the team meeting at a date
or time convenient to most usually during follow-up visits. It is always a good idea to suggest
that it will be an update and will be brief focusing on the task at hand. Active participation
by members of the audience either as presenters or lead discussants or as panellist is
recommended. Dividing subsections among each team member to be presented by 10 min
mini-lectures prevents boredom and increases active participation and learning. Adult
learning principles described elsewhere in this workbook/manual should be the cornerstone
of any such plan.
It is always interesting and demonstrates relevance if a patient’s case details from actual
case sheets or Out-patient notes/charts are discussed to trigger the discussion and seek
various views on the topic in focus. Remember to concentrate upon the WHY, HOW, WHEN
questions to trigger discussions and interactions between members of the team. If there is
no “case” or notes available then keeping prepared a relevant case summary from another
site even fabricated is still a good trigger.
Activity: Lead our small group using this sample In Patient Case Sheet in a discussion on a
missing Partogram and the listing of challenges and possible solutions.
b. Chart/Register Review discussions
With time and rapport that has developed on respect and non-judgemental interactions in
the past, discussions in time can focus on brief audits of specific issues such as registers that
document the completion of BCG vaccination at birth and those with missed opportunities,
44
referrals, etc. Statistics from registers or even random review of a series of charts can be
great triggers for small group discussions focusing not on individuals responsible for acts of
commission/omission at the focus of improved quality care but on
issues/challenges/ideas/solutions to reinforce good practices and plug gaps. Some of these
elements may also be tackled during Team meetings.
Activity: Lead our small group using this sample page of the last six months statistics on
Immunizations at the well-baby clinic in a discussion on missed opportunities and solutions
for prevention of the same.
c. Lecture-Demonstrations
Lecture-Demonstrations of identified psychomotor skills in need of reinforcement are good
methods to improve learning. Hand-washing, bag-valve-mask-ventilation, nebulization,
oxygen delivery, etc. would be some examples of skills requiring some learning of theory but
certainly a focus on be able to perform by demonstrating skills.
Activity: Teach our group using a 10 min mini-lecture on hand-washing followed by a
demonstration of the same.
d. Role Plays/Video clips
Role plays or video clips enable the learning of affective/attitudes/communication necessary
for all health professionals. The focus here must not be only the content and the theory but
the actual ability to demonstrate feelings, empathy, kindness and an understanding of the
situation and need. One may use a three point method for Role Plays where teams are
divided into three and in turn one member of the group plays the role of a patient, the
second a health care provider and the third an observer who uses a prepared checklist to
provide feedback to the role player (i.e. health care provider). These roles rotate if relevant
and are an example of active learning. Similarly a single role play or video clip may be
dramatized or viewed by the entire small group who in turn use a check list to discuss the
strengths and weaknesses of the communication and interaction. Topics for role plays may
center on counselling of exclusive breastfeeding, HIV testing, danger signs, immunization,
etc.
Activity: Demonstrate a three point Role Play using the counselling checklist provided for
explaining danger signs of pregnancy (Nurse-Pregnant woman-Observer)
e. Workplace Aids
Standardized protocols and schedules based on guidelines, even simple clinic aids including
checklists do make the health care provider’s task easier and more structured. Providing
such work based tools after explaining the WHAT, WHY, HOW and WHEN of each tool
through active participatory discussions followed by an actual demonstration of utilizing the
tool for day to day work. The NRHM has provided various posters for mounting in places
that require these ready reckoners (Eg. Management of Pregnancy Induced Hypertension,
Immunization Schedule, Post-partum haemorrhage, Newborn resuscitation protocols, etc.).
Activity: Teach our group using adult learning principles and the poster provided (National
Protocols)
45
Activity 6.1
Individually read through all the below listed Learning Objectives and tick the appropriate box to its right
that indicates the predominate domain.
Discuss the same among your group and be prepared to present the same when asked to the entire
audience.
No. Learning Objective.
Knowledge Practical Affective
At the end of the session, the student should be able to
…………
1
To diagnose Iron Deficiency Anemia given relevant blood
laboratory reports.
2
To create, implement and interpret a survey of a sample of
a village population’s to determine their health seeking
behaviour for febrile illnesses.
3
To measure the weight of a newborn given an electronic
weigh scale
4
To pre-test counsel a pregnant woman at her first ANC visit
requiring an HIV Rapid Screening test
5
To determine the environmental health hazards of a family
by making three home visits
6
Identify using a light microscope stained sputum samples of
the following three bacteria: Mycobacterium TB,
Hemophilus influenza and Pneumococcus.
7
To detect by palpation of the abdomen a splenomegaly
more than 2 cm in size
8
To successfully approach an apprehensive child visiting your
clinic so as to elicit cooperation for a routine history and
examination
Activity 6.2
Individually read through the same listed Learning Objectives which now have the predominate domain
identified. Using the list of potential T-L methods listed above decide how (what method) you intend to
use for your student to learn as a mentor.
Discuss the same among your group and be prepared to present the same when asked to the entire
audience.
N Learning Objective.
Knowledge T-L Method Plan
o. At the end of the session, the student should be able
/ Practical/
…………
Affective
1
To diagnose Iron Deficiency Anemia given relevant blood
laboratory reports.
2
To create, implement and interpret a survey of a sample of a
village population’s to determine their health seeking
behaviour for febrile illnesses.
3
To measure the weight of a newborn given an electronic
weigh scale
46
4
5
6
7
8
To pre-test counsel a pregnant woman at her first ANC visit
requiring an HIV Rapid Screening test
To determine the environmental health hazards of a family
by making three home visits
Identify using a light microscope stained sputum samples of
the following three bacteria: Mycobacterium TB,
Hemophilus influenza and Pneumococcus.
To detect by palpation of the abdomen a splenomegaly
more than 2 cm in size
To successfully approach an apprehensive child visiting your
clinic so as to elicit cooperation for a routine history and
examination
Activity 6.3
Using a role play format demonstrate how you would teach on bedside rounds with a single student in
his or her clinical year. The student has worked up a patient’s history and examination and presents the
same to you. How would you proceed with the teaching at the bedside? Remember you have a number
of patients to see on rounds.
Activity 6.4
Match each listed teaching-learning method to the suitability of the predominate domain gap in
practice.
Teaching – Learning Method
Incidental
Learning/One
mInute Perceptorship
Modelling
Case based Discussion
Gap identified
Growth chart incomplete
Partogram incomplete
Iron and Folic acid tablets not
prescribed at exit from ANC
High drop out for post-test (HIV)
counselling
Hypothermic neonates during
immediate newborn period
Child with features of bloody
Diarrhea not prescribed ORS
Weights of Mothers not checked
periodically at ANC visits
Irrational Antibiotic usage in the
wards for community acquired
pneumonias CAPs
Chart/Register Review
Mini Lecture-Demonstration
Role Play/Video clips
Workplace aids
TOSBA
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7. Annexure 1: Rapport Building
Rapport building is the single most important aspect of our communication.
In fact, all communication efforts can get futile if we do not have a rapport with our students/peers.
 Greeting
Welcome the student. Introduce yourself to your student while looking him/her in the
eye. Ask how he/she's doing, addressing him/her by name.
 Posture
For example, the simple practice of leaning forward is associated with student
relaxation, satisfaction, and recall. Adopt a similar stance to them in terms of your body
language, gestures, voice tone and speed
 Mirroring
Another step in building rapport as rapidly as possible is for the doctor to model and
mirror the student's physiology. Sit the way they sit; if their legs are crossed at the knee
or ankle, cross your legs similarly; if they hold their head slightly tilted, slightly tilt your
head, etc. Be as much like the student as you can. This will help build rapport very
quickly.
It is important to understand the difference between imitating and mirroring. In
response to the student who crosses his/her left leg over the right, the imitator will
duplicate the student’s movement by crossing his/her left leg over his/her right.
However, the physician practicing physical mirroring will do the opposite by crossing the
right leg over the left, as if the student was looking in a mirror.
Verbal Mirroring
In casual conversation outside the office, doctors often nod their heads and say “Okay,”
“I see,” “Uh huh,” etc. When they repeatedly use this in the office to confirm they have
heard what the student just said, they may appear disingenuous and lose a valuable
opportunity to build rapport. In contrast, some degree of quietness on the part of the
physician can be soothing. In addition, maintaining an appropriate amount of eye
contact that is considered respectful in the student’s culture may demonstrate the
doctor’s interest in the student.
It is important to understand the difference between paraphrasing and verbal mirroring.
Paraphrasing involves editing and summarizing the student’s words and, therefore, it
risks distorting what the student says. Verbal mirroring occurs when the physician
approximates the student’s voice tone and repeats the student’s last few words or word
and occasionally uses a slight questioning inflection. This mirroring process avoids
distorting the student’s words and encourages the student to say more.
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 Eye contact
The physician's gaze is of particular importance. For example, a warm gaze can signify
comfort and even encourage student disclosure thereby facilitating doctor-student
rapport, whereas a lack of eye contact between doctor and student can have a
dehumanizing effect in addition to being a strong sign of deception. It has been found
that the facial expressions of doctors are carefully scrutinized by students; this
information is believed to impact how deeply students trust their doctors
A special note on making eye contact ... holds eye contact only as long as the student
holds eye contact. If you try to hold eye contact longer than the student prefers, they
will feel you are starring and become uncomfortable.
 Facial expression
Facial expression can portray and communicate such emotions as interest, disinterest,
sympathy, concern, disgust, …etc
 Touch
Touching the student as an expression of caring (e.g., a student who is upset) is often a
strong statement of a physical and psychological connection.
It is also useful to think about appropriate use of touch. In some cultures it is acceptable
and even desirable to convey empathy and understanding through a pat on the shoulder,
a warm handclasp or even a hug. In others there may be strict limitations on cross
gender touching. It would be useful to explore:
What are the norms around touch in the specific clinical setting?
How comfortable are you as a doctor with touch?
The student’s comfort levels with touch.
 Listening
Listen to student. When the student is speaking, listen carefully to the student without
interrupting. You'll encourage the student’s trust and also may identify previously
unsuspected problems. If the student expresses dissatisfaction, acknowledge the
complaint without blaming anyone. (Covered in greater detail in the section on “mentoring skills”)
 Rate and tone of speech
Rapport involves being able to see eye-to-eye with other people, connecting on their
wavelength. So much (93 per cent) of the perception of your sincerity comes not from
what you say but how you say it and how you show an appreciation for the other
person's thoughts and feelings
Listen for the style of language and match your language style to theirs. The tone of a
doctor's voice is an important element in setting the environment for the interaction
between his/her student.
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 Genuinely caring attitude
Students are not merely a collection of “case presentations and tests”. Each is a unique
individual, with an individual story, feelings, needs, and wants – all of which must be
acknowledged.
The most important determinant of student – physician relationship is the degree to
which a physician projects a genuinely caring attitude toward the student
Most students come to us wearing a mask, or façade, which has become a protective
“comfort zone” to them. Often, students have become identified with the façade,
believing it to be who they truly are. It is our responsibility to create an environment
where students can feel safe enough to risk being unsafe – letting down the mask and
revealing true feelings, thoughts, and experience. The student must feel safe and
trusting enough to let another human being truly know him, trusting that he will be met
with compassion, understanding, without judgment, and that the physician mentor can
actually do something to help. It is only by knowing who the student is, where he is in his
struggle: his thoughts, feelings, and inner experience, that we can know how and what
to help.
 Do not be judgmental
Rather than being fully present and available to feel and react spontaneously to the
experience and feelings of others, our heads are filled with positions, opinions, and
judgments about them, or about ourselves. All of this blocks our internal sensitivity to
the real and valuable signals that the student is constantly providing. Rather than
saying, “Yes, tell me more,” to the student’s experience, we judge, ignore, avoid, or
defend against it.
 Personal support
The doctor should let the student know that he or she is there, personally, for the student
and wants to help.
Eg:
“You can contact me if you need any help”
In terms of building rapport — you are the message. And you need all parts of you working in harmony:
words, pictures, and sounds. If you don't look confident — as if you believe in your message — people
will not listen to what you are saying. Rapport involves being able to see eye-to-eye with other people,
connecting on their wavelength. So much (93 per cent) of the perception of your sincerity comes not
from what you say but how you say it and how you show an appreciation for the other person's
thoughts and feelings.
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8. Annexure 2: Seven pedagogical strategies
(Nilsson et al. Pedagogical strategies used in clinical medical education: an observational study BMC Medical
Education 2010, 10:9)
There are seven pedagogical strategies found to be applied in clinical teaching, namely
1. Questions and answers
2. Lecturing
3. Piloting
4. Prompting
5. Supplementing
6. Demonstrating
7. Intervening
The clinical teacher frequently made use of these strategies to help the students solve problems or
complete tasks. The strategies were used flexibly and could be changed during clinical teaching
depending on situation, context and preferences of the clinical teacher.
Questions and Answers:
This strategy is observed when clinical teachers ask questions in order to activate the students; make
them discuss and describe how to deal with medical problems; and management specific to the
patients. The teachers’ point of departure is the students’ reasoning in combination with their own
preferences in the main focus of the clinical problem. The teacher occasionally made a conclusion,
summarizing the student’s thoughts and argumentations.
Lecturing:
By asking questions and observing students’ behaviour, the clinical teacher could assess students’ level
of knowledge. In cases where students showed a lack of knowledge, the teachers’ intention changed
from questioning to lecturing about the actual area of knowledge. Lecturing could also occur if teachers
observed errors in any areas or a deficit in students’ behaviour or reasoning. Lecturing took place
frequently throughout the teaching session and examples of the strategy included: defining the meaning
of medical terms; explaining symptoms of illnesses and localisations; and surgical and medical
treatments. The clinical teacher clearly explained what areas of medical treatment required the most
attention. Lecturing not only included medical theories and facts, but also, implicitly, medical attitudes
and guiding principles in problem solving: for example, how to act and communicate with patients in
consultation.
Piloting:
The meaning of this strategy is that the clinical teacher uses guiding questions, statements or signals to
ensure the student pays attention to and focuses on specific content in order to reach an expected or
previously decided goal. By piloting, the teachers prevent students from getting stuck in the
management of a particular task. The teachers used guiding statements, invitations or questions in
order to make them continue what they were doing. The students acted according to the teacher’s
directives, but the students’ understanding and reasons for their actions were not discussed and there
was no request for critical thinking or understanding from the teacher. Easing the student’s actions by
piloting does not necessarily lead to the intended perception or increase of knowledge. Students acted
according to the teacher’s directives without discussing the meaning or intended goal. In such situations
there was no request for critical thinking or understanding from the teacher. Consequently, by piloting,
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the teachers guide the students around the difficulties in a clinical situation. Piloting could also be used
by the clinical teacher when they aimed to place students in a situation where they were expected to
develop their understanding or/ and experience-based knowledge.
Prompting:
This strategy is characterized by the clinical teacher prompting a student to prevent the student “losing
face” in front of the patient or other personnel. This approach is similar to piloting, but the focus of
using prompting is found in the process. By prompting, the teacher supported the student in, for
example, communication with a patient; whilst using piloting, the purpose was to direct the student to
the correct answer or action. Accordingly, by prompting, the teacher supported the student in adopting
the role of doctor. This approach was observed in situations where the students appeared to need help
in their assessment, problem solving or in communication with patients or nurses. The teacher provided
advice and/or directives by prompting.
Supplementing:
This approach is characterized by clinical teachers’ supplementing during students’ communications
with patients or other personnel. The strategy is characterised by the teachers either adding some
complementary important facts, or in some cases completely taking over the student’s communication.
This strategy demands teachers’ sensitivity and awareness in deciding whether students are in need of
support to handle a situation, otherwise loss of face is inevitable.
Demonstrating:
With this strategy the clinical teacher demonstrates how to act, assess, communicate, and perceive a
problem. This is demonstrated when teachers deliberately illustrate how to act or what to focus on, by
displaying the correct behaviour in a clinical situation; for example when communicating with patients,
or in assessment or evaluation. Demonstrating also included situations where the clinical teacher
facilitated student perception of the learning object (seeing, hearing, listening or feeling). The purpose
was to illustrate and create a perceptual understanding of a physical phenomenon.
Intervening:
Significant in this strategy is the teacher taking an authoritative role, interrupting the student and taking
over the situation. In intervening, the clinical teacher focuses on getting the assignment completed. In
this situation the student’s actions being interrupted when the clinical teacher intervenes and takes
over. The student has to stand aside and assume the role of an observer. Using this strategy, patient
management, organisational demands and limitations were demonstrated to the student. We observed
that the students could thus experience a lack of feedback resulting in a lack of explanation and
diminished understanding of their actions and how they managed the situation. Sometimes they felt
“excluded” and their knowledge undervalued.
Ramsden P: Learning to teach in higher education London: Routledge Falmer 2003.
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Teaching Perceptives
The meaning of this strategy is that the clinical teacher uses guiding questions, statements or signals to
ensure the student pays attention to and focuses on specific content in order to reach an expected or
previously decided goal. By piloting, the teachers prevent students from getting stuck in the
management of a particular task. The teachers used guiding statements, invitations or questions in
order to make them continue what they were doing. This strategy is characterized by the clinical teacher
prompting a student to prevent the student “losing face” in front of the patient or other personnel. This
approach is similar to piloting, but the focus of using prompting is found in the process. By prompting,
the teacher supported the student in, for example, communication with a patient; whilst using piloting,
the purpose was to direct the student to the correct answer or action. Accordingly, by prompting, the
teacher supported the student in adopting the role of doctor. This approach was observed in situations
where the students appeared to need help in their assessment, problem solving or in communication
with patients or nurses. The teacher provided advice and/or directives by prompting. This approach is
characterized by clinical teachers’ supplementing during students’ communications with patients or
other personnel. The strategy is characterised by the teachers either adding some complementary
important facts, or in some cases completely taking over the student’s communication. This strategy
demands teachers’ sensitivity and awareness in deciding whether students are in need of support to
handle a situation, otherwise loss of face is inevitable. With this strategy the clinical teacher
demonstrates how to act, assess, communicate, and perceive a problem. This is demonstrated when
teachers deliberately illustrate how to act or what to focus on, by displaying the correct behaviour in a
clinical situation; for example when communicating with patients, or in assessment or evaluation.
Significant in this strategy is the teacher taking an authoritative role, interrupting the student and taking
over the situation. In intervening, the clinical teacher focuses on getting the assignment completed.
53