1 INTRODUCTION

This article answers a question asked by many clinicians: ‘There are students1 in my workplace, what next?’. Experience-based learning (ExBL), the evidence-informed theory we have progressively developed over 20 years, has provided answers and raised new questions.1-4 Our response has been to complement ExBL with an even finer-honed tool, which we introduce here. The acronym SMAC (Situation, Me, Act, and Check) summarises how clinicians can help students learn from encounters with patients.5, 6 Before elaborating on SMAC, the next paragraph and Box  summarise how ExBL helps create environments that favour clinical learning. While ExBL was developed to educate medical students, it is founded on principles that make it transferable, potentially, to students of any health profession.

SMAC (Situation, Me, Act, and Check) summarises how clinicians can help students learn from encounters with patients.

2 PROVIDING A FAVOURABLE LEARNING ENVIRONMENT: EXBL

It is likely you practise primarily to care for patients and secondarily to educate students. Maybe you do not even welcome students into your workplace in case this drains time and energy out of patient care. When researchers have timed clinician-educators practising with and without students, however, the small net increase in time was more than compensated for by the motivating effect of educating younger colleagues. Indeed, some clinicians found it hard to practise without students.7-10 Another obstacle to creating learning environments is the fear that patients will become ‘teaching fodder’. Research has shown that educating students does not have to be at patients' expense. In the hands of sensitive clinicians who ask patients' consent for students to participate, education has a neutral or even positive effect on care.11 So, providing a favourable learning environment is a potential win-win for the triad of student, patient, and clinician.

The small net increase in time is more than compensated for by the motivating effect of educating students.

When clinicians sensitively ask patients' consent for students to participate, education can have a positive effect on care.

Favourable learning environments are ones where clinicians form supportive working relationships that make it psychologically safe for students to participate in practice. In such relationships, clinicians delegate slightly more responsibility for patient care than students expect.3 They make this safe by providing at elbow, arms-length, or even more remote support,12 depending on how safety-critical the patient's situation is. Education in this zone of slightly more responsibility and slightly less support than students expect builds confidence and capability. It is more educational than either extreme: teaching students rather than involving them in practice; or tossing them in at the deep end to sink or swim. Box  turns these principles into practical suggestions.

3 SMAC TOOL: HELPING STUDENTS LEARN REFLECTIVELY FROM EXPERIENCE

Having used ExBL tools presented in Box  to establish a psychologically safe learning environment, SMAC helps students learn from practice. While classroom teachers provide rules governing what might happen, wise clinicians help students learn from what is happening or has happened.

Wise clinicians help students learn from what is happening or has happened.

Clinicians practise wisely by assessing situations, assessing their capability to deal with these, choosing the wisest actions, taking into account any rules that are relevant, double-checking their actions, and evaluating the consequences. They become effective educators by demonstrating exemplary practice, drawing students into the talk of practice, listening, asking questions, giving tips, and sharing insights. SMAC (Figure 1) provides ‘cognitive scaffolding’ (a mental framework) for doing this.

The Situation, Me, Act, and Check (SMAC) thought tool [Color figure can be viewed at wileyonlinelibrary.com]

As reported elsewhere, we developed SMAC by watching wise colleagues work, educating students, reviewing theory and evidence, and trialling/further improving SMAC.6 The next section explains how to use it. Box  presents its principles. Figure 2 shows the SMAC ‘spiral towards greater capability’.

The Situation, Me, Act, and Check (SMAC) spiral of reflective conversation between clinician and situation [Color figure can be viewed at wileyonlinelibrary.com] 3.1 Using SMAC: helping students learn by ‘thinking-aloud’

SMAC can be used in two ways: (1) BY A STUDENT: to structure their approach to any clinical situation; (2) BY AN EDUCATOR: to help a student learn reflectively from experience. This section presents SMAC as a series of questions and sub-questions that THE STUDENT could work through. Each is followed by an open question for THE EDUCATOR to ask, perhaps using selected sub-questions as prompts. So, for example, the educator might ask a student: ‘What was the overall situation?’ After hearing about the patient's situation, they might note that the student had not mentioned context and ask: ‘What was going on in the practice context?’. They might probe further: ‘What pressures did you (or the clinical team) experience?’ The questions below are available in downloadable format as supporting information.

3.2 Situation

STUDENT'S ANALYTICAL QUESTION: WHAT IS HAPPENING HERE?

SUB-QUESTIONS:

Who is the patient?

As a person?

As defined by their:

… present situation?

… main clinical problem?

… comorbidities?

What would they like me to do?

How would they like me to involve them?

Who else is involved, and what do they need and want?

Family?

Other clinicians?

What is going on in the practice context?

Pressures on me?

Possibilities for me?

EDUCATOR's OPEN QUESTION TO STUDENT: WHAT IS [WAS] THE OVERALL SITUATION?

3.3 Me

STUDENT'S ANALYTICAL QUESTION: WHO IS THE ‘ME’ THAT IS FACING THIS SITUATION?

SUB-QUESTIONS:

What makes me more or less capable of managing this situation?

… my capabilities

… my prior experiences

… my feelings

… the support available to me

… what is available or unavailable to me

EDUCATOR's OPEN QUESTION TO STUDENT: HOW DO [DID] YOUR CAPABILITIES MATCH THE SITUATION AND CONTEXT?

3.4 Act

STUDENT'S ANALYTICAL QUESTION: WHAT IS THE WISEST ACTION TO TAKE?

SUB-QUESTIONS:

What options exist for me to manage this situation?

Which seems the wisest option?

How could I make that option even wiser?

Given my capabilities, the situation, and the context, should I?

Manage the situation directly in the wisest way? Reassess? Seek information or help?

EDUCATOR'S OPEN QUESTION TO STUDENT: WHAT ACTION WILL [DID] YOU [THE TEAM] TAKE AND WHY DOES [DID] THAT SEEM THE WISEST OPTION?

3.5 Check

STUDENT'S ANALYTICAL QUESTION: WHAT CHECKS ARE NEEDED?

SUB-QUESTIONS:

Have I made any obvious slips?

Is a later check needed; if so, why, when, and by whom?

If so, have I ensured this will happen?

EDUCATOR'S OPEN QUESTION TO STUDENT: HOW WILL [DID] YOU CHECK THE WISDOM OF YOUR ACTION?

4 ROUNDING OFF A SMAC CONVERSATION: LEARNING POINTS AND BEHAVIOURAL COMMITMENTS

No reflective conversation is complete until the person facilitating it has heard a student answer two questions: what have you learned; and what will you do on future occasions? (Figure 2).

4.1 What have you learned?

Because we hold logical memory verbally, putting learning points into words helps us remember them. In practice, this means asking students to express one or more of them simply, clearly, and very specifically and, ideally, write them down.

4.2 What will you do on future occasions?

Committing to behave in specific ways in future makes us more likely to do so. Educators do this by asking students to make specific, measurable, achievable, realistic and time-bound (SMART) commitments and write these down too.

Committing to behave in specific ways in future makes us more likely to do so.

5 HOW TO USE THE TOOLS IN PRACTICE

Here are some ways we have used ExBL and SMAC. (See also Box ).

5.1 Situation 1: ExBL creating conditions to use SMAC

You are asked to take over the education of medical students who spend a week in your unit. Until now, they were told to go onto the wards and take histories from patients. ExBL tools help you optimise the learning environment by welcoming students and organising for a junior doctor on the ward to introduce them to patients. You schedule a session each Friday when each student talks about a patient they saw and what they learned from this. You use the Me tool to ask students how capable they felt and what might make them more capable.

5.2 Situation 2: SMAC in action

You are assessing a very sick patient in the emergency department (ED). You ask the student with you to speak to the paramedic who brought the patient to hospital. The three of you use the Situation tool to pool your assessments. You use the Me tool to help the student decide if they are capable of telephoning the patient's daughter, anxiously waiting for news. You use the Act tool to brainstorm, with all present, how to act most wisely.

5.3 Situation 3: SMAC on action

You decide to motivate a group of students by asking them, in pairs, to seek out a sick patient whose situation is relevant to a specific topic (e.g., giving intravenous fluids) and put themselves in the shoes of a doctor renewing the patient's prescription. When you meet the group the following week, you question each pair using the S, M, A, and/or C tools as appropriate and then ask students individually, having heard all their peers' experiences, to verbalise (a) a learning point and (b) something they will do in their future practice.

5.4 Situation 4: An SMAC case study

The following, more detailed, vignette describes a real example of how we used our tools. We have disguised the situation and used pseudonyms.

Sinead, a senior medical student, was helping a foundation trainee, Aisling, care for Brian, a person with diabetes recently admitted to the Acute Medical Unit. Brian's prior assessment in the ED had delayed his evening insulin dose. Shortly after he gave himself the delayed dose, Niall (a nurse) measured Brian's blood glucose, found it was high, consulted ward guidelines, and bleeped Aisling several times, asking her increasingly insistently to prescribe extra insulin. Aisling was hectically busy, wanted to avoid a confrontation with Niall and feared losing face if she called her grumpy senior house officer (SHO) to discuss such a simple request. She prescribed extra insulin. Brian became hypoglycaemic overnight and was furious because he had known the prescription was unnecessary.

Sinead took up the offer of a reflective discussion, which one of us conducted over Zoom. Situation: The chain of events started with Niall being anxious he would be blamed if Brian came to harm. Bleeping Aisling repeatedly forced her hand to prescribe more insulin rather than allow the adequate dose given earlier to take effect. Me: Sinead, who was aware that fluctuations in blood glucose do not necessarily cause harm, felt she would have been capable of discussing the situation with Brian and Niall, resisting pressure to prescribe and calling the grumpy SHO if Brian's health demanded it. Act and Check: Sinead suggested an alternative action: Niall could have monitored Brian's blood glucose and let Aisling know if it remained above 20 mmol/L on two occasions an hour apart and/or Brian became ill, in which case an additional dose was needed. Sinead learned from this experience that taking a moment to find out from Brian why the blood glucose was high could have alleviated Niall's anxiety, prevented everyone involved feeling terrible and increased their confidence in one another. She committed herself to Involve patients in management decisions whenever possible Resist pressure to take one action when she is confident that an alternative is wiser Call for help if she cannot resolve interprofessional tension and/or come up with a wise action plan. Her learning points were The value of contingency plans in patients' notes That fear of losing face might prevent her from calling for help when she really needed it The value of a doctor, nurse, and patient working as a single team rather than individuals. 6 SUMMARY Any wise clinician can help any health professions student learn from any patient in any clinical situation by: Supporting students' participation in practice Helping students learn reflectively from experience ‘Supporting’ students means relating to them, helping them feel legitimate, and giving them access to patients. ‘Participation’ means motivating students by asking them to take slightly more responsibility than they expect with slightly more independence than they want.

‘Supporting’ students means relating to them, helping them feel legitimate, and giving them access to patients.

Students are motivated by having slightly more responsibility than they expect with slightly more independence than they want.

SMAC supports students' reflection in action (during patient care) and on action (afterwards). Reflecting-in-action means students use SMAC to help them analyse situations that arise in practice, analysing themselves in relation to those situations, choosing the wisest actions and double-checking actions and effects. Reflection-on-action means educators use SMAC to help students analyse situations after the event, identify one or more learning points and make one or more SMART commitments to future behaviour. Those wanting to access the large body of theoretical and empirical science that gives ExBL and SMAC their validity may access our publications; a few are cited in the references below and others on the Act Wisely website.5 This website provides other tools, information about workplace learning and a bibliography of our published work. ACKNOWLEDGEMENTS

The authors thank Angela Carrington, Rosie Donnelly, Deborah Millar, Heather Daly and Sara Carse for their tireless work on the Making Insulin Treatment Safer project, which made a foundational contribution to the pedagogic model we present here.

FUNDING INFORMATION

The writing of this article was not funded. The funders of the research that preceded the writing were acknowledged in individual articles.

CONFLICT OF INTEREST

The authors have no conflict of interest to disclose.

ETHICS STATEMENT

Ethical approval for the many projects that contributed to our research programme is identified, study-by-study, in earlier articles, synthesising that work into this pedagogic model did not create any new requirement for ethics approval.

ENDNOTE

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