4. Summative Assignment
The assignment takes the form of a written piece of work (3500 words ± 10% excluding references and any appendices) and is aligned with the module learning outcomes. The assignment has two parts.
For more information about what is and is not included in the word count see the Student Handbook, section Assessment Overview.
Part A – Critical Analysis of your teaching – 2000 words
Plan, with reference to the appropriate curriculum, and undertake a significant tutorial (either individually or in a small group) with appropriate learners, (we suggest a minimum duration of 1 hour). It should be based either on your own specialty training curriculum, or on the over-arching curriculum in your own university or the relevant curriculum from your own working environment. The tutorial should be based on how best to enable your students’ learning in the clinical environment and should reflect the complexity of them acquiring the skills described in the module.
Offer a critical analysis of the teaching session and its outcomes based on a careful analytical evaluation of your peer feedback, lesson plan, your learners’ evaluations and your tutorial with reference to the appropriate evidence. This analysis should be an integration of theory and practice and be based on the core literature around teaching and learning of skills. It also should lead you to explore how this might be developed in future teaching.
The feedback component is a critical element for Part A and in order to have some external feedback of the session, ask a *peer* to:
Observe your teaching using one of the two templates/models we have provided in the Peer Observation Checklistsdocument in Learning Skills.
Give you detailed feedback on the event.
Ask a learner or learners to:
1. Review/Evaluate your teaching session
2. Suggest any improvements/recommendations for the future delivery of this session.
This essay should be written in the 3rd person as it is not a personal account of your experience. It should include lesson plans** and other background documents (e.g. handouts, task sheets, slides etc.) from the teaching session as appendices (these will not be included in the word count). You are not required to provide a reflective account in Part A of the assignment.
*Please note that feedback from peers can be from those in your working/clinical context, peers within the module (either in the formative feedback exercise or at a virtual classroom) and tutor feedback from your formative submission.
** The lesson plan that you develop for your teaching session/event should be different from the lesson plan you submitted in the ‘Learning and Teaching’ module. We would advise that as far as possible you create a new lesson plan altogether. If you can’t please ensure that you change the lesson plan as much as you can. In addition, you will need to carry out the session with your learners. When you are critically appraising your teaching session you must use a different theoretical lens and or different dimensions of a previously used theory to provide justification for each component of your teaching event/session. Our rationale for suggesting the development of a new lesson is that if you are using the same lesson plan that you developed in the ‘Learning and Teaching Module’ you will likely receive a high similarity report which would constitute as self-plagiarism and a form of academic misconduct, potentially resulting in formal action being taken against you.
See also the Assessment Resources.
Part B – Critical Reflection – 1500 words
A reflective analysis of your own learning and development throughout the module: describe the impact that the module study activities and your teaching project experiences have had upon your own thinking and professional practice as a teacher. Your analysis should involve taking your reader through a reflective model addressing your planning, your experience, your feedback and your plans for development. (Select from Kolb, Johns or Gibbs and please indicate at the start of Part B which you are using – see below.)
This essay should be written in the first person, but please ensure that you use relevant literature and theory to support your assertions in your reflection.
Word Count
The word count for each part of this assignment is clearly stated. Please note that the documentary evidence and references are not included in this word count limit.
4. Summative Assignment
4.1. Coversheet
What is the purpose of the self-evaluation section?
We have asked students to evaluate their own assignment using key elements of the assessment criteria for several reasons: it prompts the learner to engage with the assessment criteria and reflect on whether there are gaps that should be addressed before submission; it is a way to promote critical thinking and it starts a conversation or dialogue with the tutor about what aspects you would like feedback on, to allow improved tailoring of feedback.
The self-evaluation section is formative, it does not impact upon your grade in anyway. [Download the Word version of the coversheet from the module outline.]
| Content
Understanding of theory, principles and/or models presented Evidence of evaluation and application of theory and relevant literature to inform the design/approach to selected teaching events/opportunities Evidence of critical reflection on: their own clinical teaching practice and learning throughout the module. Evidence of a theory and literature informed development of 2-3 principles to inform future clinical teaching practice. |
Self-evaluation: |
| Style, format and language (e.g. structure, coherence, flow, formatting, use of language) | Self-evaluation: |
| Sources and references (e.g. range of references cited, relevance, where relevant provides information about the approach to searching for and selecting literature, consistency, accuracy and completeness of referencing) | Self-evaluation: |
| Which aspect(s) of your assignment would you specifically like feedback on? | Student comment: |
| How did previous feedback inform this assignment? | Student comment: |
| Word count: | Student declared word count: |
4. Summative Assignment
4.2. Not able to deliver a teaching session?
Although we strongly encourage you to design and deliver a teaching session or tutorial as a key part of the module assignment, we realize that not everyone can do that in the short window of time available.
If you cannot deliver the teaching session at all, or not in time to include it in your assignment, here is an approach that will let you work around the lack of teaching delivery. It will allow you to submit an assignment that meets the criteria needed to pass the module, and to submit your draft assignments for formative (peer and tutor) review.
On either the Cover Sheet or at the top of Essay A, provide a clear rationale for not being able to deliver the teaching so that the tutor marking your assignment knows right at the beginning.
When writing Essay A, follow the guidance we have given you for this and describe how you’ve planned everything you are going to do based on your circumstances, the choices you’ve made and the reasons for these choices (your experience, opportunities, the literature etc.). When you get to the point where you’re not able to describe the actual delivery experience, and the peer and student feedback, then simply say so. However, it is strongly advised that you discuss the feedback that you have received on the module during the peer feedback week, or during the VC, and show how this will shape the future delivery of your session.
Balance the gap caused by not having done the teaching by adding more around your critical analysis of the stages of learning that you’ve gone through up to that point, including an enhanced literature review.
When writing Essay B you can additionally reflect on the experience up to that point and/or your feelings about not being able to deliver the teaching (yet or at all).
Remember, we still need you to demonstrate that you have achieved the module learning outcomes and so if you have less to tell us by not being able to deliver the teaching then we would expect you to tell us more about the planning part. Gayne’s events of instruction could be used as a guide to help provide the evidence of the key components you have considered, or will consider, for your teaching session.
We hope that this guidance helps but if you have any questions, please put them in the discussion forum.
5. Getting the most from your assignments
Assessment for learning is the most cost-effective way to improve your learning outcomes (Wiliam, 2010). To get the most from the feedback, try to ensure you have checked these points before submitting your formative and summative assignments, as this will save you time later:
Have you looked at the Criteria for Assessment: marking grid?
Have you given each of the main sections clear sub-headings?
Have you tried to evaluate key issues critically (not just described what you have done)?
Have you indicated which main literature references you are using and where you will use them?(Remember, all references should be cited and all citations referenced)
Have you used the APA referencing format?
Is your word-count within 10% and clearly stated on your cover page/first page?
Is your document in Word format?
Is the file name of your word document named as follows?: firstname and surname. Example: Joe Bloggs.docx
You must submit a clean copy of your word document (i.e. all comments and track changes removed)
Reference
Wiliam, D. (2010). An integrative summary of the research literature and implications for a new theory of formative assessment. In H.L. Andrade, G.J.Cizek. (eds.) Handbook of formative assessment (pp. 18–40). New York: Taylor & Francis.
6. Criteria for Assessment: marking grid
You should use this table to identify the strong points of your assignment, and the areas which should be improved before you submit your final version.
|
Criteria |
Criteria not met |
Criteria met |
Criteria exceeded |
| Demonstrate understanding of theory / principles | Demonstrate limited understanding of learning theory | Demonstrate some understanding of learning theory | Demonstrate thorough understanding of learning theory |
| Critical reflection | Limited evidence of critical reflection on theory / principles | Some evidence of critical reflection on theory / principles | Thorough evidence of critical reflection on theory / principles |
| Application of theory to own practice | Limited evidence of application of theory to own practice | Some evidence of application of theory to own practice | Thorough evidence of creative and / or innovative application of theory to own practice |
| Ability to identify own learning needs | Limited evidence of ability to identify learning needs in relation to module LO’s and materials | Some evidence of ability to identify learning needs in relation to module LO’s and materials | Thorough evidence of ability to identify learning needs in relation to module LO’s and materials |
| Structure | Lack of coherence and flow of ideas | Some coherence and flow of ideas | Exceptional coherence and flow of ideas |
| References / Citations (APA) | Referencing / citations deviate considerably from APA format and/or there are multiple inconsistencies between references and citations | Referencing / citations are reasonably consistent with APA format and there are few or no inconsistencies between references and citations | Referencing / citations are uniformly consistent with APA format and there are no inconsistencies between references and citations. |
WEEK 1
1. Aims and Learning Objectives for this week
Aim of this week is to help educators:
Explore the key features of dental education
Apply theory to the dental education context
Identify distinctive learning opportunities in the dental context
Explore the impact of different contexts on the clinical teaching process, and
Analyse and understand the opportunities for effective learning in the clinic
al workplace.
Learning Objectives:
By the end of this week participants should be able to:
Discuss learning theories in relation to learning in the workplace
Explain and discuss the different clinical contexts for learning
Consider the impact that the clinical working environment has on clinical learning
Reflect on your own clinical teaching practices
3. Activity 1.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45562
After completing the activity please return to this resource.
4. Task – Explore the key features of dental education
We will start by thinking about what we actually mean by the term ‘dental education’.
Make a list of what you consider are the key features of dental education – you may like to also ask your colleagues.
Read Manogue et al. (2011)’s paper ‘Curriculum structure, content, learning and assessment in European undergraduate dental education – update 2010’ (available in reading list essentials).
List the key features of dental education identified by the paper. How did it compare with your own list? If there were differences, do you agree with those differences? Why do you think there were differences?
Make notes in your personal journal.
5. Translating learning theories into practice
Having thought about the general and specific elements of dental education, now consider how this might impact on your own teaching practice.
Think about how you might tailor your teaching sessions to support different health professionals you might teach or students with differing levels of expertise. Think back to social and cognitive learning theories in the Learning and Teaching module. What influence does your knowledge of these have on your practice?
6. Metaphors of learning (Sfard 1998)
One way of broadly conceptualising learning is to think of the acquisition and participation metaphor.
Acquisition learning is individual and to be acquired and can be transferred across situations
Participation learning views learning as continuous and inextricably linked to context and embedded in social processes. Learning is about becoming a member of a community and developing a professional identity through participation in the activities of the community.
6. Metaphors of learning (Sfard 1998)
6.1. Activity 1.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45563
After completing the activity please return to this resource.
7. Theories
There are many different theories:
Situated learning
Learning by doing in context
Actor-network theory
Activity theory
Communities of practice
Zone of proximal development
Just to name a few and some of which you have been introduced to in the Learning and Teaching Module. We do not expect you to learn every theory but instead we want you to consider the main principles of these theories and why they are important for your clinical teaching.
7. Theories
7.1. Sociocultural Learning
Sociocultural learning theory assumes that learning is influenced not only by social interaction with peers but also impacted by an individual’s cultural beliefs and attitudes. This assumes that knowledge is embedded within the context and cannot be regarded separately from the activity and in the context in where the learning takes place.
This theory has never been more relevant that it is today in medical education particularly as a considerable amount of learning takes place within a workplace setting.
Healthcare professionals typically learn in the social context by observing the behaviors and actions of others. The learner then can role model the positive observations they witnessed, practice this behavior and when the situation arises implement it in practice. One of the benefits of this theory is that it integrates role modelling and cognitive deep learning processes so that the learner understands the how, why and for what reason a specific behavior/task/technique was used within this context.
The clinical teacher is responsible for enforcing positive role modelling, introduce new roles, guiding behavior and create opportunities for the learner to implement these new roles and or behaviors in practice. Learning occurs through participation in authentic activities giving rise to shared understanding about the purpose of the community or profession and a sense of belonging.
The theory and practice of situated learning is based on the notion that knowledge is contextually situated and is fundamentally influenced by the activity, context and culture in which it is used (Brown et al., 1996). That is, knowledge is co-produced through activity in context. Brown and colleagues compared knowledge to a set of tools, arguing that tools can be understood only through use, and using them appropriately requires understanding and adopting the belief system of the community and culture in which they are used.
“The culture and the use of a tool act together to determine the way practitioners see the world; and the way the world appears to them determines the culture’s understanding of the world and of the tools” (Brown et al., 1996, p. 24).
7. Theories
7.2. Community of Practice
A community of practice is defined as a ‘‘set of relations among persons, activity and world, over time and in relation with other tangential and overlapping communities of practice’’ (Lave and Wenger, 1991, p. 98).
Learners need a legitimate role in the community
Contributes to the community’s growth
Active participation in meaningful tasks that contribute to patient care
(Lave and Wenger 1991)
7. Theories
7.3. Communities of Practice and Social Exchanges
“Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly”
(Wenger 2012)
Initially people have to join communities and learn at the periphery. The things they are involved in, the tasks they do may be less key to the community than others. As they become more competent they become more involved in the main processes of the particular community.
“Learners inevitably participate in communities of practitioners and … the mastery of knowledge and skill requires newcomers to move toward full participation in the socio-cultural practices of a community. “Legitimate peripheral participation” provides a way to speak about the relations between newcomers and old-timers, and about activities, identities, artefacts, and communities of knowledge and practice. A person’s intentions to learn are engaged and the meaning of learning is configured through the process of becoming a full participant in a socio-cultural practice. This social process, includes, indeed it subsumes, the learning of knowledgeable skills.”
(Lave and Wenger 1991: 29)
A complex set of social relationships through which learning takes place.
Participation refers to people ‘‘being active participants in the practices of social communities and constructing identities in relation to these communities’’.
Learning takes place through engagement and participation in actions and interactions that are embedded in the culture and history forming the community of practice (Wenger, 1998, p. 4).
7. Theories
7.4. Participation in a Community of Practice
Lave and Wenger (1991) presented a theory of learning as a dimension of social practice where learning is historical and situated. They proposed that learning is a process of participation in a community of practice. Part of the process of becoming a full member they termed legitimate peripheral participation. This is the process of transition from newcomer to expert or “oldtimer” and involves movement from the periphery of a socio- cultural community of practice to its centre, the individual becoming progressively more engaged and more active within that socio-cultural perspective. A critical part of socialisation into practice is “authentic contribution” to workplace activities.
Thinking back to the module Learning and Teaching, we looked at the Zone of Proximal Development and Lev Vygotsky’s work. Lev Vygotsky (1978, 1986) was one of the founders of sociocultural perspectives on learning and proposed that learning occurred through interaction and co-operation with other people in their natural environment. Learning occurs in the context of shared tasks, so that cognition is distributed over several individuals; therefore, individual performance is supported or “scaffolded” by peers and experts. Techniques that would provide the scaffold learners need and move them toward independence include modelling, feedback, questioning, and instructing.
Lave and Wenger described the merits of ‘communities of practice’ in situated learning theory. Again, how might these inform your teaching? Some of this will be considered in a later week when we explore interprofessional learning and multidisciplinary teams. However, you should still reflect on the following questions as they should inform your thinking about your assignment. More importantly, they may inform how you tailor your teaching based on profession, level of expertise, and context. Using the lens of COP consider these questions below when thinking about your own clinical teaching practices.
Who are the different learners that you teach, both formally and informally?
How do identify the content, approach, or objectives of your teaching?
How do you check that the level of your teaching is appropriate?
How do you check the impact of your teaching?
You might want to write 2 or 3 short case studies for yourself based on these questions as they will help you to identify examples that will inform your assignment. Having thought about the general and specific elements of education within your own speciality, now consider how this might impact on your own clinical teaching practice. Think about how you might tailor your teaching sessions to support different healthcare professionals you might teach or students with differing levels of expertise. Think back to social and cognitive learning theories in the Learning and Teaching module. What influence does your knowledge of these have on your practice?
7. Theories
7.5. COP and Challenges to Learners Environment
COP has been criticized for being too broad and failing to deal with hierarchical structure and power dynamics within health professions education. For example, how does COP fit with trainees or students working in healthcare? Hay (1993) noted the inability of newcomers to shape the community when they are on the periphery until they become “masters”, by which point they may be socialised into following routines of practice.
Reflecting upon your own context and thinking about how you practice COP, what are the challenges for the learner in your specialty? How do the challenges vary in different contexts in terms of clinical teaching?
Challenges to learners include:
Lack of clear role within the team (this is a common complaint from medical students and early career doctors)
Explicit sharing of expectations
Competing demands between service delivery and teaching opportunities
Limited opportunities for observation and feedback
Linking the relevance of workplace based learning elements
Learners find difficulty in reconciling the activities they have to do (such as completing the portfolio) with what happens in the workplace.
Nonetheless COP can play an integral role in professional identity development, and place an important lens on the social components of learning within the workplace. Cruess, Cruess & Steinert (2018) put forward the argument that COP should be referred to as a ‘foundational theory’ and via the support of other theories (some of which we have discussed already) it can be used to influence the various educational practices and activities that take place within the community.
If we integrate COP into the cognitive domain in which we teach our students and implement various positive educational practices (including: creating supportive learning environments, regular engagement and evidence of role modelling, experiential learning and reflective practice) this may help to create more successful learning environments within medical education.
Eggleton et al (2019)
Cruess, Cruess & Steinert (2018)
8. Task – Apply theory to the dental context
Think about the learning theories that you have applied to your own dental education context.
Read the paper ‘Adult Learning Theories in Context: A Quick Guide for Healthcare Professional Educators’ (Mukhalalathi, 2019) (see the Reading List under Essential Reading).
Does this resonate with your own thoughts? Any areas you don’t agree?
Are there any other learning theories you are now thinking of applying?
Write notes in your personal journal
9. The Clinical Teaching Process
There is a lot of literature about the clinical teaching process and how it can impact the role of the clinical teacher and the learning that takes place within the workplace environment. Understanding the tools that enable a successful clinical teaching experience is important as they can help to promote positive learning experiences for the student/trainee and increase reflective practice for the clinical teacher.
9. The Clinical Teaching Process
9.1. Faculty Development Model
The Stamford Faculty Development Framework highlights the role of the clinical teacher (Skeff 1988) and ways of analysing one’s own teaching.
(a) Promote a positive environment
(b) Control the session
(c) Communicate goals
(d) Promote understanding and retention
(e) Evaluation
(f) Feedback
(g) Promote self-directed learning
It is important to establish a positive and supportive learning environment for all staff and students/trainees so that these individuals feel valued and engaged with their organizational culture. Without positive relationships within an organization the working and learning environment can becoming too challenging and be a detriment in terms of retainment of trainees/students.
9. The Clinical Teaching Process
9.2. Perceived organizational support
As indicated previously when discussing COP, relationships with colleagues are very important as these provide a web of interpersonal relationships that offer a supportive working and learning culture.
For newcomers, having role models, support and acknowledgement from experienced/established colleagues affects their organisational commitment positively (Filstad & McManus 2011).
Having a positive and supportive organizational culture that is based on supportive relationships with senior staff and colleagues can act as a buffer when challenging situations arise within the workplace learning environment (Scanlan et al, 2018). The organizational culture and the supportive experiences in early postgraduate training environment can have a critical impact on the career intentions of trainee/resident dentists. Thus, the components of POS should be considered in all workplace learning environments.
10. Activity 1.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/page/view.php?id=45564
After completing the activity please return to this resource.
11. Task: Identify distinctive learning opportunities in the dental context
In this task we will be looking at developing collaboration opportunities through interprofessional and multiprofessional education to stimulate teamwork and to improve patientcare in the dental context. ‘Interprofessional education’ refers to collaboration between two professional backgrounds for the purpose of effective learning and teaching. On the other hand, when people from more than two professional backgrounds learn together, it is known as ‘multiprofessional education’.
List the approaches you already use to enhance interprofessional and multiprofessional learning opportunities in your own dental education context.
Read Sabato et al (2018)’s ‘Integrating Social Determinants of Health into Dental Curricula: An Interprofessional Approach’ (see reading list essentials).
You may also explore other resources on interprofessional and multiprofessional education relevant to your own dental education context.
Revisit your list – are there any more you have now thought of? Are there any you would now like to try in the next year? Further into the future? What do you think would be beneficial to you the tutor, your students and your institution / workplace? What are the challenges?
Make notes in your personal journal.
12. Sociomaterial
Sociomaterial approaches to education research bring to the foreground the social and material world in which the individual is entangled.
The material world includes tools, technologies, bodies, actions, texts, discourse and objects, treated as continuous with and embedded in human relations.
Sociomaterial approaches incorporate theories such as complexity theory, actor–network theory and activity theory (Fenwick et al, 2012; Fenwick 2014)
see learning not as just the accumulation of knowledge and skills, but as a process of professional socialisation and identity formation
(Bleakley, 2012)
13. Clinical Teaching Opportunities
Workplace learning takes place in various contexts within dental education and thus could result in diverse experiences and opportunities to learn. However, it is important to explore what components and attributes are key in delivering successful clinical teaching opportunities within the workplace. For workplace teaching to be successful both the learner and teacher must play an important and collective role in the learning process. The key qualities and attributes that are needed to create an engaging learning environment are outlined on the next page.
13. Clinical Teaching Opportunities
13.1. The role of the good clinical student/trainee
Clinical students/trainees must be:
enthusiastic and driven
proactive in the activities they undertake within the clinic/theatre/community
knowledgeable, flexible, and competent in basic clinical/operational skills by the time they complete their designated training
able to communicate clearly and efficiently with team members and patients
self-directed learners
13. Clinical Teaching Opportunities
13.2. The role of a good clinical teacher must
be positive and engaging role models
have good inter-personal skills and build positive relationships with all team members
Consider the individual differences amongst students/trainees
Actively encourage participation of students/trainees during ward round/consultation etc.
have Clear understanding of learning principles and put them into practice
Offer learning strategies
Bee time efficient and productive
Offer workplace assessment and offer/receive feedback
be enthusiastic about all teaching moments
Effective clinical teachers are those that challenge their students by using a variety of teaching and learning methods across varying contexts, but they do not take students too far from their Zone of Proximal Development (ZPD). It is important for the teacher to consider the individual needs and differences of their students and develop interpersonal relationships that promote and develop the learning process.
Pushing student beyond their ZPD and not understanding the differing needs and individual characteristics of students can be detrimental to the teaching process and can result in demotivation and a lack of engagement. Reflecting back to the literature on POS theory it is important these components are considered when delivering our teaching/training to students so that we develop engaged and motivated workforce for the future.
(Goldie, Dowie, Goldie, Cotton & Morrison 2015)
14. Why Teach in the Clinical Setting?
There are four main advantages of teaching in a clinical setting:
Role modelling the complexity of care of patients
Demonstrating professional behaviours with members of healthcare team
Near-peer and peer related learning opportunities
Patient exposure and involvement
14. Why Teach in the Clinical Setting?
14.1. Peer and Near-Peer Opportunities in Clinical Teaching
Potential roles
Information provider
Role model
Facilitator
(Bulte et al 2007)
A big advantage of clinical teaching is the opportunity for peer learning. In a dental clinic, there may be a dental student, a junior dentist, specialist trainee and other health professionals and this affords opportunities for learning between individuals.
This would suggest that the promotion of peer learning and role modelling is crucial for a successful and thriving workplace learning environment.
Make notes
Thinking about your own professional context, ‘How do you /could you use peer and near peer learning experiences in your clinical teaching (if appropriate)? How could you use this type of teaching to create a COP within your context?
The differing styles of clinical teaching approaches and settings in which teaching takes place within medical education will be explored in more detail in the following weeks. We will unpack the concepts discussed above from a practical standpoint and we will encourage you to consider how the workplace learning theories influence your clinical teaching approaches as you progress throughout this module.
What principles from the workplace learning theories discussed in this chapter will you apply to your current context and in what ways will these concepts support the learning process of your trainees/students?
15. Activity 1.4
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45565
16. References
Bleakley, A. (2012). The proof is in the pudding: putting actor–network theory to work in medical education. Medical Teacher; 34:462–7.
Bulte, C., Betts, A., Garner, K., Durning, S. (2007) Student teaching: views of near-peer teachers and learners. Medical Teacher, 29:583-590.
Cleland, J., Tan, E.C.P., Tham, K.Y. et al. (2020) How Covid-19 opened up questions of sociomateriality in healthcare education. Advances in Health Science Education, 25, 479–482.
Cruess, R.L., Cruess, S.R., & Steinert, Y. (2018). Medicine as a Community of Practice: Implications for Medical Education. Academic Medicine, 93(2), 185‐191.
Eggleton, K., Fortier, R., Fishman, T., Hawken, S.J., & Goodyear-Smith, F. (2019) Legitimate participation of medical students in community attachments, Education for Primary Care, 30 (1), 35-40,
Fenwick, T. (2014). Sociomateriality in medical practice and learning: attuning to what matters. Medical Education, 48(1), 44-52
Fenwick, T., Edwards, R., & Sawchuk, P. (2011) Emerging approaches to educational research. London & New York: Routledge
Fenwick, T., Nerland, M., & Jensen, K. (2012). Sociomaterial approaches to conceptualising professional learning and practice. Journal of Education and Work, 25(1), 1-13.
Filstad, C., & McManus, J. (2011) Transforming knowledge to knowing at work: the experiences of newcomers. Journal International Journal of Lifelong Education, 30, 763-780.
Goldie, J., Dowie, A., Goldie, A., Cotton, P., & Morrison, J. (2015). What makes a good clinical student and teacher? An exploratory study. BMC medical education, 15, 40.
Hay, K. E. (1993). Legitimate peripheral participation, instructionism, and constructionism: Whose situation is it anyway? Educational Technology, 33(2), 33-38.
Lave, J., & Wenger, E. (1991). Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.
Scanlan, G.M., Cleland J., Walker, K., & Johnston, P. (2018) Does perceived organisational support influence career intentions? The qualitative stories shared by UK early career doctors. BMJ Open, 8:e022833
Sfard, A. (1998). On two metaphors for learning and the dangers of choosing just one. Educational Researcher, 27(2), 4-13.
Skeff, K.M. (1988) Enhancing teaching effectiveness and vitality in the ambulatory setting. J. Gen Intern Med, 3 S26-S33
Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes (M. Cole, Trans.). Cambridge: Harvard University Press
Wenger, E. (1998). Communities of Practice: Learning, Meaning, and Identity. Cambridge: Cambridge University Press.
Yardley, S., Teunissen, P. W., & Dornan, T. (2012). Experiential learning: Transforming theory into practice. Medical Teacher, 34(2), 161-164.
WEEK 2
1. Introduction
Learning as a team is a good way of building a team
Quality care in clinical setting requires a whole team to work effectively together. This chapter considers the interprofessional skills necessary within a team, and teaching and learning approaches which promote effective collaboration.
1. Introduction
1.1. At the end of this chapter you will be able to:
Describe approaches to promoting learning appropriate for developing a multiprofessional/disciplinary team
Critically review the contribution of interprofessional education (IPE) in promoting collaboration
Review areas of interprofessional learning for different audiences and in different contexts
This week we will explore team-based learning in the dental education context. We will also explore integrated curricula for intra-professional and inter-professional education relevant to dentistry and you will be asked to identify future opportunities in your own context. The aims for this week are listed below:
Explore learning in the dental education team.
Explore intraprofessional and interprofessional education in the dental context.
Identify opportunities in your own context.
2. Activity 2.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/collaborate/view.php?id=45575
After completing this activity please return to this resource.
3. Task: Explore learning in the dental education team
What do you think about team-based learning in dental education? Do you think it can enhance learning and teaching in dental education? What are its strengths and weaknesses?
Read the paper ‘Peer-assisted Learning Associated with Team-based Learning in Dental Education’ (Kawas et al., 2017) (see Reading List)
Read the paper ‘Education for the dental team: make your practice a centre of learning excellence’ (Cure, 2009) (see Reading List)
Identify the importance of team-based learning in the dental education context from the papers. Compare with the ones you identified. How do you think team-based learning opportunities can be increased in the dental education context? How do you think it can benefit dental education students?
Make notes in your personal journal.
4. Interprofessional practice for quality care
Think about a patient you have recently treated. Use a piece of paper to map the patient’s journey from first experiencing symptoms and attending the dentist, to then undergoing investigations, having a diagnosis established and communicated to them to then a treatment plan decided on, planned and delivered. Add to your map all the health care professionals the patient will have met along this journey and even those that they have not met but have been involved in the necessary steps.
Consider how many of these professionals work collaboratively towards a common patient-centred goal and how they collaborate and coordinate efforts to provide integrated and effective care. You might want to consider how good this is in relation to the Institute of Medicine’s Six Domains of Quality – safe, effective, patient-centred, timely, efficient and equitable.
Now think about your own experiences in your department and the multidisciplinary team members you work with, how your skill sets complement each other and how learning together might enhance the quality of the care provided. The Six Domains can provide a useful goal-oriented focus for team learning.
Agency for Healthcare Research and Quality. (2015). Six Domains of Health Care Quality. Retrieved https://www.ahrq.gov/talkingquality/measures/six-domains.html
5. Clinical practice and interprofessional education (IPE)
In clinical practice there are regular multidisciplinary meetings to discuss and formulate patient management plans. In addition, in radiotherapy departments there is often a weekly planning meeting where diagnostic radiographers, therapeutic radiographers, physicists, dosimetrists, mould room technicians and oncologists will discuss patients who are booked to come for radiotherapy planning and treatment. These are examples of where a diverse of group of health professionals work together to improve the delivery of patient care. Consider situations in some of the different environments where health professionals learn from each other and factors that might influence learning.
As you may have identified, learning in such situations is often ad hoc or incidental. Over the last 25 years there has been a growing body of evidence to demonstrate the importance and value of teaching and learning which supports and develops collaborative practice. The Centre for the Advancement of Interprofessional Education (CAIPE), has been at the forefront of this internationally. They defines IPE thus:
“IPE occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care… and includes all such learning in academic and work-based settings before and after qualification, adopting an inclusive view of “professional”.” (CAIPE 2006)
The publications page of the CAIPE website offers numerous resources on principles and good practice in interprofessional education. Some of these may be useful in providing an evidence base when undertaking your assessment.
A good overview of the issues of interprofessional education can be found in Della Freeth’s chapter on the subject in Understanding Medical Education. This is available through the reading list.
Freeth D, Interprofessional education, Chapter 6, p81-96. Part of Swanwick T, Understanding Medical Education: Evidence, theory and practice, 2013
6. Reviewing your experience of interprofessional education
Do this rapid mental audit:
What is your experience of interprofessional teaching and learning as a participant?
Can you think of environments in which you have learnt from other professions and similarly you have taught other professionals?
Have you facilitated interprofessionalism or collaboration in your teaching methods? If not is there a reason behind this?
Do you think it is valuable for all participating professionals?
In the advent of high profile medical failures there has been a drive to promote and formalise IPE. IPE has been proven to improve the delivery of high quality patient care. The aim is for a heterogeneous group of health care professionals with different skill sets and with diverse knowledge and experience to learn from each other.
Interprofessional learning for collaborative working may seem like common sense particularly when labelled with the purpose of promoting equality, teamwork and a more patient-centred objective. Often where there are medical failures, teamwork and lack of communication are highlighted as the main problems. However, the notion of interprofessionalism can challenge embedded traditional hierarchies in health care resulting in conflict or avoidance.
Watch these two YouTube videos, one that explains what IPE is and its value, and then the clinical situation. Consider where there is a breakdown in collaborative practice and the learning that is required to avoid such situations. Hopefully the importance of supporting collaborative learning will then speak for itself.
7. Interprofessional education in your practice setting
Freeth (2014) describes the difference between Interprofessional education and Multiprofessional education as:
Interprofessional education (IPE) – learning with, from and about each other in order to improve collaboration and ultimately the quality of care.
Multiprofessional education (MPE) – learning side by side for whatever reason
Freeth describes MPE transforming to IPE if there is an exchange of knowledge from different professionals woven into the learning. Think about multidisciplinary meetings you have attended – do you think there is an exchange of knowledge and thus examples of IPE?
8. Task: Explore intra-professional and inter-professional education in the dental context
How would you define inter-professional and intra-professional education? How do you think they differ? What are their strengths and weaknesses?
Read Jones et al. (2017)’s paper ‘Dental and Dental Hygiene Intraprofessional Education: A Pilot Program and Assessment of Students’ and Patients’ Satisfaction’ (see Reading List).
Read the paper ‘Integrated Medical-Dental Delivery Systems: Models in a Changing Environment and Their Implications for Dental Education’ (Jones et al., 2017) (see Reading List).
Compare your definitions with the ones in the papers. Do they match your thoughts? How do you think intra-professional and inter-professional education can enhance learning and teaching. How would it impact patient satisfaction? What might the challenges be?
Make notes in your personal journal.
Interprofessional education in clinical practice
IPE is generally important but has some very specific relevance in practice where team-care is key, for example in clinical oncology when thinking about radiotherapy contouring planning and radiological image interpretation.
Consider the role of IPE in the following two situations (e.g. in oncology context) and the educational implications of these studies, which are available through the reading list:
A recurring theme when questioning radiation oncology trainees for feedback on their postgraduate training is the lack of training in cross sectional imaging. In a survey of clinical oncology trainees in 2015 only 7% reported they learnt radiology from a radiologist, the majority 84% reported self-directed learning.
Kosmin, S. Brown, C. Hague, J. Said, L. Wells, C. Wilson (2016), Current Views on Clinical Oncology Training from the 2015 Oncology Registrars’ Forum Survey, Clinical Oncology 28(9):e121-5
2. In a survey carried out by Jefferies et al (2009), they reported that 50% of trainees were dissatisfied by their exposure to image interpretation. They described 12 centres allocating time for trainees to collaboratively learn with medical physicists and treatment radiographers but no allocated time with radiologists (Jefferies, Taylor, & Reznek, 2009). Thus they did highlight some centres were embracing some aspects of interprofessional learning.
Jefferies, S., Taylor, A., & Reznek, R. (2009), Results of a national survey of radiotherapy planning and delivery in the UK in 2007, Clin Oncol (R Coll Radiol) 21(3):204-217
Do you think learning radiology anatomy for radiotherapy contouring is an example where IPE would work?
Is this IPE or rather one profession teaching another?
How could a more reciprocal learning environment be created?
10. Promoting interprofessional working (e.g. in oncology context)
Published work about IPE in oncology is limited, however a range of literature emphasises the importance of interprofessional working.
One tentative example exists where Horan et al, (2006) describe a pilot study that was carried out where radiologists and oncologists outlined on CT planning scans the target volumes for radiotherapy treatment. They were then compared both qualitatively and quantitatively.
The study highlighted 2 interesting points. Firstly there were differences between the clinicians target volumes, highlighting the lack of standardisation and supporting the case for peer review of radiotherapy treatment volumes in the future. Secondly, the experiment demonstrated interprofessional learning in action.
Oncologists learned from the radiologist image anatomy recognition, allowing them to then define treatment volumes more accurately, and the radiologist learned how the oncologists define treatment volumes and had more of an insight into treatment planning. This, in turn, could have benefited interprofessional working situations such as multidisciplinary meetings.
The paper is available through the reading list if you wish to read further;
Horan G, Roques TW, Curtin J, Barrett A (2006), “Two are better than one”: a pilot study of how radiologist and oncologists can collaborate in target volume definition. Cancer Imaging 28;6:16-9.
11. Task: Identify opportunities in your own context
Identify opportunities for team-based learning in your own dental education context. Think about how it may enhance learning and teaching. Do you think there might be any challenges for you as teacher and your students?
Identify opportunities for intra-professional and inter-professional education in your own dental education context. Think about how it may benefit the students, the teachers and the patients.
Think about how you may evaluate learning in the dental teams and the impact of integrated curricula in your own dental education context.
Make notes in your personal journal.
12. Examples of interprofessional learning
On the next few pages are four papers describing different approaches to supporting IPE, which are all available through the reading list. Speed read these papers and consider how you as an educator might adopt or adapt them.
Activity 1.5 – Choice – Week 2 virtual classroom attendance
Top of Form
Bottom of Form
12. Examples of interprofessional learning
12.1. Paper 1
A study carried out by Tan et al (2011) describes a form of interprofessional training, paired learning. A trainee radiographer and a trainee radiation oncologist were paired throughout a clinical attachment to facilitate collaborative learning. They reported it was a unique experience allowing the trainees to not only learn together but also to learn from each other.
Tan, K., Bolderston, A, Palmer, C , Millar, B. (2011). “We Are All Students:” An Interprofessional Education Approach to Teaching Radiation Oncology Residents. Journal of Medical Imaging and Radiation Sciences 42( 4), 183-188.
12. Examples of interprofessional learning
12.2. Paper 2
Giuliani et al (2014) undertook an evaluation of simulation or rehearsal that offers another potentially useful hands-on approach to promoting interprofessional working through a collaborative approach to learning. For example, when introducing a new radiotherapy technique to a department in this case Image Guided Radiotherapy (IGRT). The paper below describes oncologists, physicist and radiographers all attending an IGRT education conference that was advertised as IPE.
Giuliani M, Gillan C, Wong O, Harnett N, Milne E, Moseley D, Thompson R, Catton P, Bissonnette JP. Evaluation of high-fidelity simulation training in radiation oncology using an outcomes logic model. Radiat Oncol. 2014 Aug 28;9:189.
12. Examples of interprofessional learning
12.3. Paper 3
Gillan et al (2010) used a modified grounded theory approach to interview participants after IPE to assess the benefits and stresses such sessions. Benefits were noted in dissipating the stress of a new technology. This approach was seen to further collaboration, efficiency and improve professional role understanding.
Gillan, C., Wiljer, D., Harnett, N., Briggs, K., Catton, P. (2010). Changing stress while stressing change: the role of interprofessional education in mediating stress in the introduction of a transformative technology. J Interprof Care, 24(6), 710-721.
12. Examples of interprofessional learning
12.4. Paper 4
This paper describes interprofessional learning using simulation for a haematological oncology team, where nurses and physicians learned together.
James, T.A., Page, J.S., Sprague J. (2016). Promoting interprofessional collaboration in oncology through a teamwork skills simulation programme. J Interprof Care, 30(4), 539-41. doi: 10.3109/13561820.2016.1169261.
13. Extended team members and their learning needs
We have discussed how we may learn with and from other professionals, but there are also many different groups of health professionals to whom you may need to teach aspects of clinical skills and knowledge. We will address some of these after the next activity.
13. Extended team members and their learning needs
13.1. Learning needs of varied specialists
You may have to support the learning of a wide range of professionals and possibly non-professionals. Oral maxillofacial surgeons will have different learning requirements, compared to general dental practitioners, compared to core dental trainees.
Thinking point
Think of a specific session in your specialty that you might deliver for doctors in other specialties.
What would your considerations be when you designed this session? What criteria might you use to help you guide the content, the level, the teaching methods, and the assessment (if there needs to be one)?
Write a bullet point list in your notes, then look at the list of considerations in the hidden section below and compare it to your own.
These elements should all be considered when developing learning opportunities;
Who is your audience?
What stage of training are the audience?
What might you reasonably expect their background knowledge of the content to be?
How might I audit this knowledge (e.g. a quiz, brainstorming or questions and answers to start?)
How many participants will here be?
What key message(s) do I want to deliver?
What do they need to take away from this session in order to practice (more) safely and competently?
How long is the session?
In what is the physical learning environment will the session be, for example a lecture theatre, simulation room etc
How could I make the session interactive?
How might I assess if they’ve learned what I intended them to learn?
14. Activity 2.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45576
Please return to this resource after completing the activity.
15. Summary
In this Chapter, you have learned about interprofessional education and identified selected scenarios where learning together with other members of the multidisciplinary team may be beneficial. You have experienced different methods of approaching interprofessional education and considered some of the different audiences for whom you may need to create learning opportunities which both develop knowledge of dentistry and support collaborative practice.
16. Activity 2.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45577
◀︎ Activity 1.5 – Choice – Week 2 virtual classroom attendance
Top of Form
Bottom of Form
17. References
Al Kawas, S., & Hamdy, H. (2017). Peer-assisted Learning Associated with Team-based Learning in Dental Education. Health Professions Education, 3(1), 38-43.
Barton, M. B., Bell, P., Sabesan, S., & Koczwara, B. (2006). What should doctors know about cancer? Undergraduate medical education from a societal perspective. Lancet Oncology, 7(7), 596-601. doi: Doi 10.1016/S1470-2045(06)70760-4#
Cave, J., Woolf, K., Dacre, J., Potts, H. W., & Jones, A. (2007). Medical student teaching in the UK: how well are newly qualified doctors prepared for their role caring for patients with cancer in hospital? [Evaluation Studies
Cure, R. (2009). Education for the dental team: make your practice a centre of learning excellence. Primary Dental Care, 16(1), 4-6.
Research Support, Non-U.S. Gov’t]. Br J Cancer, 97(4), 472-478. doi: 10.1038/sj.bjc.6603888
Freeth, D. (2014). Interprofessional education [Book]. Understanding Medical education: Evidence, Theory and Practice, 1(Chapter 6), 81-96.
Gillan, C., Lovrics, E., Halpern, E., Wiljer, D., & Harnett, N. (2011). The evaluation of learner outcomes in interprofessional continuing education: a literature review and an analysis of survey instruments. [Review]. Med Teach, 33(9), e461-470. doi: 10.3109/0142159X.2011.587915
Gillan, C., Wiljer, D., Harnett, N., Briggs, K., & Catton, P. (2010). Changing stress while stressing change: the role of interprofessional education in mediating stress in the introduction of a transformative technology. [Research Support, Non-U.S. Gov’t]. J Interprof Care, 24(6), 710-721. doi: 10.3109/13561820903550796
Giuliani, M., Gillan, C., Wong, O., Harnett, N., Milne, E., Moseley, D., . . . Bissonnette, J. P. (2014). Evaluation of high-fidelity simulation training in radiation oncology using an outcomes logic model. [Research Support, Non-U.S. Gov’t]. Radiat Oncol, 9, 189. doi: 10.1186/1748-717X-9-189
Horan, G., Roques, T. W., Curtin, J., & Barrett, A. (2006). “Two are better than one”: a pilot study of how radiologist and oncologists can collaborate in target volume definition. Cancer Imaging, 6, 16-19. doi: 10.1102/1470-7330.2006.0003
James, T. A., Page, J. S., & Sprague, J. (2016). Promoting interprofessional collaboration in oncology through a teamwork skills simulation programme. J Interprof Care, 30(4), 539-541. doi: 10.3109/13561820.2016.1169261
Jefferies, S., Taylor, A., & Reznek, R. (2009). Results of a national survey of radiotherapy planning and delivery in the UK in 2007. Clin Oncol (R Coll Radiol), 21(3), 204-217. doi: 10.1016/j.clon.2008.11.017
Jones, V. E., Karydis, A., & Hottel, T. L. (2017). Dental and dental hygiene intraprofessional education: a pilot program and assessment of students’ and patients’ satisfaction. Journal of dental education, 81(10), 1203-1212.
Jones, J. A., Snyder, J. J., Gesko, D. S., & Helgeson, M. J. (2017). Integrated medical-dental delivery systems: models in a changing environment and their implications for dental education. Journal of dental education, 81(9), eS21-eS29.
Koo, K., Di Prospero, L., Barker, R., Sinclair, L., McGuffin, M., Ng, A., & Szumacher, E. (2014). Exploring attitudes of Canadian radiation oncologists, radiation therapists, physicists, and oncology nurses regarding interprofessional teaching and learning. J Cancer Educ, 29(2), 350-357. doi: 10.1007/s13187-014-0614-1
Kosmin, M., Brown, S., Hague, C., Said, J., Wells, L., & Wilson, C. (2016). Current Views on Clinical Oncology Training from the 2015 Oncology Registrars’ Forum Survey. Clin Oncol (R Coll Radiol). doi: 10.1016/j.clon.2016.04.043
Labranche, L., Johnson, M., Palma, D., D’Souza, L., & Jaswal, J. (2015). Integrating anatomy training into radiation oncology residency: considerations for developing a multidisciplinary, interactive learning module for adult learners. [Evaluation Studies]. Anat Sci Educ, 8(2), 158-165. doi: 10.1002/ase.1472
Lamb, B. W., Taylor, C., Lamb, J. N., Strickland, S. L., Vincent, C., Green, J. S., & Sevdalis, N. (2013). Facilitators and barriers to teamworking and patient centeredness in multidisciplinary cancer teams: findings of a national study. [Research Support, Non-U.S. Gov’t]. Ann Surg Oncol, 20(5), 1408-1416. doi: 10.1245/s10434-012-2676-9
Lave, J., & Wenger, E. (1991). Situated learning : legitimate peripheral participation. Cambridge England ; New York: Cambridge University Press.
Tan, K., Bolderston, A, Palmer, C , Millar, B. (2011). “We Are All Students:” An Interprofessional Education Approach to Teaching Radiation Oncology Residents. Journal of Medical Imaging and Radiation Sciences42( 4), 183-188.
Zahra, D., Belfield, L., Bennett, J., Zaric, S., & Mcilwaine, C. (2019). The benefits of integrating dental and dental therapy and hygiene students in undergraduate curricula. European Journal of Dental Education, 23(1), e12-e16.
WEEK 3
1. Aims and Learning Objectives
In week 3, we aim to help educators explore different clinical teaching approaches and consultation models that direct towards patient centred care. This will help you to understand and evaluate the importance of patient involvement in clinical education and surrounding ethical issues. In line with legal considerations, you will explore the importance of supervision and the different roles and responsibilities of the clinical supervisor. Reflecting on your prior knowledge and understanding on feedback, you will further research ways of optimising learning from feedback in your own context. We will also explore various concepts and standards of professionalism relevant to the dental education context. You will also be asked to identify professionalism standards and dilemmas in your own context.
Learning objectives:
By the end of this week you should be able to:
analyse different approaches to clinical teaching
validate the strengths and weaknesses of the different consultation models to promote student learning of the process
evaluate ways of actively involving patients in clinical teaching
explore various concepts and standards of professionalism.
appraise the different roles and responsibilities of the clinical supervisor
building on ways to conduct feedback to optimising learning in own context
How Do You Feel When You Are Teaching in Clinical Practice?
Do you feel like the picture on the left, where everything is calm and you are managing well, or more like the picture on the right, approaching rapids? I certainly know which one I feel like – there always seem to be different pressures but at least we are a team and hopefully all heading in the same direction.
Task
Make short notes in your journal on the common teaching problems in the Clinical Workplace.
3. Recent Trends in Healthcare
Awareness of patient mutuality or empowerment. We cannot be regarding patients as ‘guinea pigs’ or objects of student learning, but to be part of the learning process for students
Integrated care pathways – there is certainly more evidence for integrated care pathways from primary to secondary care. Knowing what is the best evidence‐based practice
Changing roles of practitioners – in the UK the scope of practice of dental hygienists and dental therapists significantly changed in 2013 allowing them to carry out a wider range of dental procedures and work independently of dentists (direct access). The UK General Dental Council (GDC) also introduced more Dental Care Professional (DCP) roles, including orthodontic therapists and clinical dental technicians. Similar changes have occurred in the hospital setting e.g. advanced nurse practitioners who have some of the traditional skills of physicians, and new roles e.g. physician assistant
More patients could consider virtual health as it helps patients deal directly with caregivers. Helps clinicians see more patients, deal with rising clinical complexities and better support patients.
There will be more focus on population health
(Ker & Bradley, 2013; Spencer et al., 2000; Al-Turjman et al, 2020)
4. Task – Explore concepts and standards of professionalism
Write your own definition of professionalism? Also think about how students may be encouraged to develop professionalism in the dental education context? Can you think of any attributes of professionalism?
Can you think of any professionalism standards for dental students you’ve come across?
Click on the link to access the ‘General Dental Council, UK (GDC)’ websiteand explore the student professionalism standards.
What are your thoughts on these standards of professionalism for dental students? Did they match your thoughts? Think about how you may use various guidelines, standards and concepts to encourage professionalism in dental education students.
Make notes in your personal journal.
5. Models and Approaches
When identifying learning opportunities with and for learners in the clinical environment there is a need for flexibility to align teaching moments with the curriculum with experiences, occurrences and clinical situations.
It is important to plan and prepare for sessions that involve patients. Before the session, think about:
what preparatory work the trainee needs to do (e.g. reading, skills, laboratory)
where the teaching will take place
which parts of the teaching session require direct patient contact
whether you will be present or absent when the student/trainee is with the patient
what role you will take (observer, instructor, demonstrator, questioner)
where discussions will take place and with whom (do discussions always have to be in the dental surgery in front of the patient, for example?)
how you will build in opportunities for patient feedback
how you will build in debriefs for learner and patient
what follow-up learning or reading should be carried out
There are many models of clinical teaching. It is difficult to identify which is the best, so we will share a few with you.
5. Models and Approaches
5.1. Three domain model
Domain 1. Attend to Patient’s Comfort
Skills:
Ask ahead of time
Introduce everyone to the patient
Brief overview from primary person caring for patient
Explanations to patient throughout, avoid technical language
Base teaching on data about that patient
Genuine, encouraging closure
Return visit by a team member to clarify misunderstandings
Domain II. Focused Teaching
Skills: Microskills of teaching—modified for the chairside
Diagnose the patient
Diagnose the learner
Observe
Question
Targeted teaching
Role model
Practice
Teach general concepts
Give feedback
Domain III. Group Dynamics
Skills:
Limit time and goals for the session
Include everyone in teaching and feedback
(Janicik & Fletcher, 2003)
5. Models and Approaches
5.2. Trialogue Approach
Relations and interactions
Model for analysis
Scaffolds learning
(McKimm, 2008)
A Trialogue is a discussion between three groups with different principles, backgrounds and expectations: a structured three-way conversation (myDictionary.com).
The ‘Trialogue’ focuses on relations and interactions. The relationship and interactions between clinician (as teacher), learner and patient help to explain and structure complex clinical teaching and learning activities.
The Trialogue provides a model for analysing complex interactions between the three ‘players’ in clinical teaching settings through the metaphor of a continually shifting dialogue.
It provides clinical teachers with a framework for:
scaffolding learning (e.g. cognitive apprenticeship)
facilitating learner and patient active engagement in the learning process
‘reflecting in action’ (Schön, 1991) to promote student learning whilst simultaneously attending to the needs of the patient
helping clinical teachers to pay conscious attention to the relationship and emerging dialogue between players.
It promotes thinking about the patient, the learner, and the interactions between them.
The Trialogue suggests that the ‘expert’ clinician operates within two sets of parallel processes: one attending to the patient (the inner clinical consultation) and one attending to the learner (the inner teaching dialogue).
5. Models and Approaches
5.3. The “Microskill” Models of Clinical Teaching
This practical teaching technique utilises simple discrete teaching behaviours or “microskills”. It is helpful in time-poor environments; helps instructors to assess learners’ knowledge, guide and understand their feedback. Some of the examples of “microskill” models (Irby, D. M., & Wilkerson, L., 2008) are listed below:
1. The 6 Question Plan (Ker, Cantillon & Ambrose, 2008)
2. The One-minute Preceptor Model (Neher et al., 1992)
3. The Aunt Minnie Model (Cunningham A.S., Blatt S.D., Fuller P.G. & Weinberger H.L., 1999)
4. The SNAPPS model (Wolpaw, Wolpaw & Papp, 2003)
5. ‘Activated’ Demonstration (Irby & Wilkerson, 2008)
Reflection point
Choose any two or three of the above microskill models and make notes. How could you apply these models in the context of your own clinical teaching practice?
(Please spend 1 hour on this reflection)
5. Models and Approaches
5.4. Different Strategies
Other additional techniques rather than a model per se.
Videoconferencing interviews: The trainee’s interview with a patient is recorded and later viewed with the trainer. Needs consent from patient re. images; good for learning consultation and communication skills; can be done with a group or single trainee.
Case conference: A case is presented by the trainee and discussed by a wider audience. Useful for multi-professional learning and inputs; teacher supports trainee re. the type of questions that might come up and how to present a case
Wave scheduling: This is a technique for including teaching time into an outpatient clinic or GP surgery in which the trainee sees Patient 1 while the trainer sees Patient 2, then the trainer joins the trainee to see Patient 1 and there is a gap in the appointments. This is repeated so that alternate patients (i.e. 1, 3, 5) are seen by both trainer and trainee, and patients 2, 4, 6, etc., are seen by the trainer alone. This is a useful way of optimising busy outpatient clinics but needs careful scheduling, timekeeping and allocation of appropriate patients to the trainee’s ‘list’. Is this something you currently or could do in your dental practice?
(Doshi & Brown, 2005)
6. Person-Centred Care
Person-centred care has a number of characteristics:
Patients and their experiences are at the centre of their care (Coulter et al 2009).
Effective communication skills are an essential pre-requisite to high quality care and person-centredness (Lewin et al 2001).
Seeing things from a patient perspective when clinical teaching is important. Patients bring with them different belief systems. So, you need to consider patient and student perspectives as you are trying to enable both (Smith, 2001).
Reflection point
Take a step back and think of your own clinical practice. Pause and reflect on these questions:
What capabilities for consulting do you need as a healthcare practitioner?
What capabilities do you need as a teacher? Are there parallels?
7. Consultation Models
There have been a number of models for analysing the consultation over the last 30 years. Models can provide valuable preparation for sessions with patients.
Stott and Davis (1979) Four Square model
Bryne and Long (1979) Time sequence model
Pendleton (1984) Social skills model
Neighbour (1987) Checkpoint Model
Disease-illness Model
Middleton Agenda Model
Calgary – Cambridge
Some models are task-oriented, some are process or outcome-oriented, some are skills-based or incorporate a temporal framework, and some are based on the dentist-patient relationship or the patient’s perspective of their illness.
The diagram above shows the 4 areas to map the different models on to.
8. Activity 3.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45586
Please return to this resource after completing the activity.
9. Patient Involvement in Clinical Education
Engaging the patient as a team member can improve the safety and quality of their care (Week 2: Learning and Teaching in Multidisciplinary Team) as they are the value information source being the only member of the team who is always present during their care.
9. Patient Involvement in Clinical Education
9.1. The Continuum of Patient Involvement
The ‘Cambridge Framework’ (Spencer et al., 2000) was developed to encourage discussion about the involvement of patients in clinical education. It considers four sets of attributes in relation to situations and environments where patients, students and teachers interact:
Who: the individual background, culture and experience of each patient, their family and careers.
How: including, patient role (passive or active), nature of encounter, length of contact, degree of supervision.
What: the content of the education including type of problem (general versus specific) and the knowledge, skills and values to be learned.
Where: location of interaction (for example, community, hospital, clinic).
The continuum of involvement developed by Goss & Miller (1995) ranges from Level 1 on the left – no patient involvement through to level 5 on the right – partnership involvement.
Level 1: No involvement (e.g. using paper-based or electronic narratives of patient ‘cases’ developed by teachers rather than patients, practising communication skills through role-play with peers rather than real or simulated patients etc.)
Level 2: Passive involvement (e.g. using written or video patient narratives developed by patients, real patients giving their verbal histories to students as part of chairside teaching)
Level 3: Two-way communication: Patients as teachers (e.g. individuals with arthritis teaching musculoskeletal examination to students) and assessors (e.g. participating in multi-source feedback relating to workplace-based assessments, participating in selections committee)
Level 4: Listening and responsive: Examples could include patients being represented on curricula development groups, and evaluation of curricular such as governance and quality management.
Level 5: Partnership: patients involved at the institutional level, in addition to sustained involvement in teaching, curriculum development, evaluation etc.
9. Patient Involvement in Clinical Education
9.2. The Benefits and Challenges of Patient Involvement
Task
In your experience, list the benefits and challenges of patient involvement in clinical education for students and patients. Compare your list with the list we have prepared by expanding the subheadings below.
Benefits for Students
Treating patient as whole person rather than an illness or a body part.
Developing appropriate attitudes towards chronic illness, disability, mental health problems etc.
Learning clinical and communication skills including physical examination, procedural skills eg. venepuncture, blood pressure measurement etc.
Developing professional identities – helps students learn how they should think, feel and act like a doctor and also learn how to cope with uncertainty and stress.
Motivating student learning – many students contrast it with the ‘dry’ textbook learning they get as part of the formal curriculum and this is powerful. Working with patients also helps contextualise students’ academic learning.
Learning different models of doctor-patient relationship; patient-centred care, shared decision-making etc.
Benefits for Patients
Feeling empowered; enjoyed having a voice, feeling listened to and heard, raised self-esteem, development of coherent illness stories and new insights to their problems and a deeper understanding of the doctor – patient relationship.
Giving something back (in the NHS setting) – from a service that is free at the point of delivery.
Shaping future doctors.
Enjoyable social contact and to ease the boredom of waiting.
Better attention, care, information – students typically have more time to talk than qualified healthcare professionals so some patients find it easier to talk to students. Patients perceive that they receive better attention care and information by their participation in clinical teacher / student interactions particularly at the bedside where they might be listening in to conversations between the teacher and student and therefore getting more information about their condition, often using simpler language.
Challenges for Students
Anxiety about giving advice and not knowing what to do with patient disclosures.
Fears around confidentiality and breaching confidentiality.
Concerns about burdening patients, for example – if a patient has a painful abdomen and great signs and symptoms, is it appropriate for multiple students to examine the painful abdomen and cause the patient prolonged discomfort and pain? Students can be concerned that their intervention is detrimental to the patient.
Hostility/abuse from patients.
Vulnerability to patient emotion (e.g. breaking bad news) – students feeling uncomfortable about being observers of the process of breaking bad news.
Challenges for Patients
Being exploited as teaching material.
Involvement adversely affecting mental and physical health.
the repeated sharing of mental health issues could potentially have adverse effects on the mental health of those participating individuals.
Consent and confidentiality – patients are aware that students are not fully qualified so there may be concerns about issues of consent and confidentiality on the part of the students.
10. Ethical issues
Ethical issues to be considered when involving patients in teaching can be summarised as the three Cs: consent, choice and confidentiality. The main message emerging from policy documents, good practice and the literature is that simply assuming that patients will be involved in teaching and learning without making this explicit through systems, conversations and practice is no longer enough.
Consent
‘A mindset shift needs to occur within the medical profession to enable informed partnership rather than informed consent (patient)’ (PMETB, 2008, p. 7).
Medical/Dental law and ethics enshrines the principle of informed consent. This aims to protect those involved in clinical care, particularly when invasive procedures are involved. The lines are more blurred around patients ‘consenting’ to involvement in teaching and learning. It is good practice to inform patients (ideally through written information sent in advance) that students or trainees may be involved in their clinical care, obtaining consent should be:
‘a continuous process that begins with the first contact the service has with the patient’ (Howe & Anderson, 2003, p. 327).
Click the link to access and explore GDC patient leaflet about treatment undertaken by dental students.
The GDC has also adopted the term ‘valid consent’. To read more on the link.
Choice
How can clinical teachers facilitate patient choice in participating in teaching and learning when trainees need to learn from patients and practise procedures within the ‘turbulent here and now of care delivery’? (Hardy & Stanton, 2007)
Informing patients and seeking agreement should be done (Howe & Anderson, 2003, p. 327). Building in ‘moment-to-moment’ opportunities for patients to ‘say no’ to specific tasks that might be carried out by learners is another way of empowering patients and acknowledging their needs. (Benson et al., 2005, p. 4).
Confidentiality
Practical steps that help to maintain confidentiality include:
providing enough information to patients so they can assess and understand the boundaries of confidentiality
reassuring the patient and involving them in discussions
finding more private spaces to discuss intimate or distressing issues
discussing issues of confidentiality actively with trainees as part of the preparation and debrief
obtaining permission for the use of images, sound recordings and extracts from case notes, particularly around anything that might identify a patient.
Clinical teachers are key role models for their learners: keeping the three Cs in mind for both you and your learners ensures that these are seen as fundamental pillars of good medical practice, not as options.
11. Task – Identify ethical dilemmas in your own dental education environment
Can you think of an ethical dilemma you or your students have encountered? What was it? How did you tackle it? If faced with a similar situation in future, what would you do?
Read the paper ‘Even now it makes me angry’: health care students’ professionalism dilemma narratives‘ (Monrouxe et al., 2014) (see Reading List).
Read Sharp et al. (2005)’s paper ‘Ethical dilemmas reported by fourth-year dental students‘ (see Reading List).
Think about how you may identify ethical dilemmas in your own dental education context and help your students overcome them.
Make notes in your personal journal.
12. Supervision
Kilminster et al. (2000) defined supervision as ‘The provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainee’s experience of providing safe and appropriate patient care.’
The key points of difference between mentoring, clinical supervision and preceptoring were summarised by Mills et al. (2005) (Table 1). It is important to look at the difference between mentoring, clinical supervision and preceptoring, because these terms are often used interchangeably, and it is really important to determine the type of role as a supervisor.
Table 1: Key Points of Difference Between Mentoring, Clinical Supervision and Preceptoring (Mills et al., 2005)
|
Element |
Mentoring |
Clinical supervision |
Preceptoring |
| Context | Outside the immediate work setting | Within the work setting, but away from the immediate work area | Within the work setting |
| Time | Long time-frame with a progression of relationship phases | Long time-frame with a progression of relationship phases | Short period, usually 2-12 weeks |
| Relationship reporting | Confidential discussions; minimal reporting on relationship status in a formal setting | Confidential discussions; minimal reporting on relationship status in a formal setting | Formal reporting on the progress of the preceptee |
| Level of commitment | High level of commitment; may require a time commitment outside of the work setting | High level of commitment; hopefully conducted within working hours, but away from the work setting; may require a time commitment of the work setting | Lower level of commitment; conducted solely in the work setting |
| Outcomes | Broader outcomes that can encompass improved clinical practice, career progression, scholarly endeavour, personal achievement |
12. Supervision
12.1. Guidance for Supervisors in the UK:
The General Dental Council (GDC, 2013) has provided guidance for those employing, supervising or training trainee/students which are based on the ‘Standards for the dental team’.
The key principles include:
Put patients’ interests first
Communicate effectively with patients
Obtain valid consent
Maintain and protect patients’ information
Have a clear and effective complaints procedure
Work with colleagues in a way that is in patients’ best interests
Maintain, develop and work within your professional knowledge and skills
Raise concerns if patients are at risk
Make sure your personal behaviour maintains patients’ confidence in you and the dental profession
To learn more about it, click on this link for the resource ‘Standards for the Dental Team’ (GDC, 2013)
You can also access the website by clicking on this link: https://www.gdc-uk.org/education-cpd/students-and-trainees/guidance-for-employers-of-trainees-students
12. Supervision
12.2. Standards for Education in the UK
A range of standards have also been developed in the UK for Dental Education providers (GDC, 2015). These include:
Protecting patients
Quality evaluation and review of the programme
Student assessment
For more details refer to General Dental Council’s Standards for Education document.
12. Supervision
12.3. Models of Clinical Supervision
There has been considerable work over many decades looking exploring different models of clinical supervision (Beinhart. H., 2004, pg 36). The work of Goldhammer in the 1960s followed by Cogan’s work in the 1970s and then Acheson-Gall work in the 1980s predate our current model of clinical supervision in which it is proposed there should be a number of phases:
planning and pre-observation of the trainee;
observation phase;
structured analysis of practice;
feedback;
The relationship between the trainee and the clinical supervisor underpins the effectiveness of each of these.
12. Supervision
12.4. Roles of Clinical Supervisor
Examining the roles of the clinical supervisor, six key roles have been identified – manager, observer, feedback provider, facilitator/ instructor, counsellor and assessor (Rose & Best, 2005). It is important to think about which ‘hat’ you are wearing and to signpost this for the trainee eg., ‘I am acting as an observer now and will be providing feedback’. While the clinical supervisor may be aware of the role they are taking in a particular situation it is important that this is explicitly shared with and understood by the trainee.
13. Task – Identify ethical and professionalism standards in your own context
Explore local ethics and professionalism standards for students in your own dental education context. You can ask your students and colleagues if they are aware of any such standards. You can also search online for any national or institutional standards for students.
Identify the cultural values and common behaviours prevalent in your own environment. These may be identified through your own observations or by talking to other stakeholders such as your students or colleagues.
Explore the strengths and weakness in your local standards for students. Also think about how the cultural values and behaviours may have affected the application of these standards for students in your own context.
Explore possible solutions / recommendations to strengthen your local ethics and professionalism standards for students.
Think about how these standards for students can be taught effectively in your own dental education context.
Read the paper ‘Developing understanding and enactment of professionalism: undergraduate dental students’ perceptions of influential experiences in this process‘ (Ranauta et al., 2018) (see Reading List)
Were there any methods in the paper that you may use to teach professionalism to your own students? Did they match with the ones you identified?
Make notes in your personal journal.
14. Activity 3.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45587
Please return to this resource after completing the activity.
15. Feedback
Recapitulating the topic on Feedback in the Learning and Teaching; and Principles of Assessment modules, you have defined feedback, feedback in the learning cycle, problems with feedback, principles underpinning effective feedback and the impact of feedback.
Reflection point
Make notes about:
How feedback forms an integral component of our learning?
The importance of feedback in education and training.
(Please spend 1 hour on this reflection)
16. Feedback and Self-regulation
Read the two statements on the purpose of feedback below:
Feedback should develop the students’ capacity to make evaluative judgments about their own and others work
Feedback should serve the function of progressively enabling students to better monitor, evaluate and regulate their own learning, independently of the teacher
(Boud et al., 2010; Nicol & McFarlane-Dick, 2010)
Although the above statements are different, the common theme that run through is that feedback should be about promoting self-regulation of learning.
Self-regulation involves ‘self-generated thoughts, feelings, and actions that are planned and cyclically adapted to the attainment of personal goals’ (Zimmerman, 2002, p.15). Assessment and feedback processes should empower students to become self-regulated learners (Carless, 2006). Learning is enhanced when learners are self-regulating, actively engaging in setting learning goals, selecting strategies for achieving these goals and monitoring their progress toward these goals (Nicol & Macfarlane‐Dick, 2006). Self-regulation hinges on learners being able to access and interpret information that indicates how their present state relates to their learning goals (Nicol and Macfarlane‐Dick, 2006).
17. Effectiveness at giving feedback
We have identified that feedback is vital to good training and assessment, and gathered evidence that feedback is effective in improving learning.
At this point reflect on the following:
So how good are we at giving feedback?
How often do you give feedback to your trainee? If we asked your trainee – how often would they say they received feedback from you?
Despite the widely accepted importance and value of feedback in medical education, there is a significant gap between what the recommended practice is and what is happening ‘on the ground’. Holmboe et al (2004) also observed serious deficiencies in the feedback happening in current medical education practice.
Not only is frequency of feedback a concern, but when given, its quality is also often poor. Holmboe et al (2004) observed further that while 61% of feedback sessions after mini-CEX assessments included a response from the trainee, only 34% elicited self-evaluation by the trainee. Surprisingly, only 8% of mini-CEX encounters translated into a plan of action for improvement.
17. Effectiveness at giving feedback
17.1. Failure to give effective feedback
There are significant barriers to the delivery of effective feedback.
Think about the barriers that could exist that might prevent a trainer providing effective feedback to a trainee. Write down three of them.
Now compare your ideas with these potential barriers to the delivery of effective feedback which we have identified:
Trainer’s lack of skills in providing effective feedback.
Focus of current workplace-based assessment strategies, such as the Procedure Based Assessment, on assessment of learning rather than for learning.
Trainer’s lack of appreciation for feedback as a teaching tool.
Limited space for comments on the scoring sheets used for in-vivo assessment.
A fear of damaging the trainer–trainee relationship.
Trainee’s inability to receive constructive criticism and becoming defensive.
Generalised feedback with no specific facts or observations.
Lack of action plan on improving performance.
Inconsistency in feedback received from multiple sources.
17. Effectiveness at giving feedback
17.2. Giving more effective feedback
Watch this short video that discusses a lot of the concepts that we cover in this chapter. The video is about 6 minutes long and is an interview with Dr. Frank Fulco, Associate Program Director and Assistant Professor of Internal Medicine in the School of Medicine at Virginia Commonwealth University. In the video Dr Fulco talks about various aspects of effective feedback. Concentrate particularly on what he describes as the constituents of effective feedback.
https://youtu.be/aYsobmPNs5g
Giving Feedback, Dr. Frank Fulco
Uploaded to YouTube on 22 Oct 2014 by VCU SOM Office of Faculty Affairs
17. Effectiveness at giving feedback
17.3. Focus on improvement
For feedback to be effective it should focus on improving the performance of the trainee. Hattie and Timperley (2007: 86) proposed that effective feedback should answer three questions:
Where am I going? (What are the goals?)
How am I going? (What progress is being made toward the goal?)
Where to next? (What activities need to be undertaken to make better progress?)
The first question (where?) is related to the tasks that the learner needs to accomplish. The second question (how?) involves a comparison of learner’s performance with the goals. The third (where next?) is the action plan, for example further learning.
Similarly, Sadler (1989: 119) identified that for effective feedback the learner needs:
a learning goal
comparison with actual performance
action to reduce the gap between the two
He states that, “for students to be able to improve, they must develop the capacity to monitor the quality of their own work during actual production. This in turn requires that students possess an appreciation of what high quality work is, that they have the evaluative skill necessary for them to compare with some objectivity the quality of what they are producing in relationship to the higher standard.”
Sadler emphasizes a crucial point here – that feedback should not be entirely ‘given’ to the trainee. We need to ensure that feedback is a dialogue, as part of its purpose is to enable the trainee to evaluate their own performance and develop an action plan for improvement.
17. Effectiveness at giving feedback
17.4. Twelve tips
Read the following paper from 2012 in Medical Teacher, which is available through the reading list. It gives us twelve tips for giving effective feedback.
Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012 Oct;34(10):787–91.
What are the additional tips that we have not covered?
(Please spend 1 hour on this task)
18. Giving negative feedback
Giving negative feedback can be challenging and is one of the barriers identified to giving effective feedback. Sometimes faculty can tend to shy away from negative feedback and simply give positive or no feedback in this situation. Some of the reasons can include a fear of damaging the trainer-trainee relationship (Hesketh and Laidlaw, 2002).
It is important to remember the purpose of feedback in this situation – this is not about vilifying the trainee but exploring any performance problem and how it can be addressed. If the trainee is a consistently poor performer, then you may also need to be thinking about whether the trainee can actually attain the required level of performance.
Have you been faced with a struggling trainee in this situation?
What additional features might be important when you give them feedback?
18. Giving negative feedback
18.1. How to give negative feedback
In this situation it is even more important to have a dialogue with the trainee and use feedback to identify the problem with the trainee and explore how any performance deficiencies can be addressed:
Trainee should be given an opportunity to express their views first
Clarify the area of concern that you may have, as the trainee may not see it as a problem
Explore trainee’s insight into the concerns raised – whether they agree or not. (Use evidence to encourage a better understanding of performance in the trainee.)
Ensure that the problems are clearly defined to enable the construction of a remediation plan. Consider the need for more evidence to clarify the problem.
Discuss whether there are other factors (outside work) that may be impacting on performance. Feedback should be used to provide support to the trainee in addressing the problem (Archer, 2009)
Encourage the trainee to suggest ways to address the problem.
Set learning goals and timelines for improvement.
Collect more evidence, when the problem is not clear.
Discuss ways to provide help and support.
Document everything.
Remember – when giving negative feedback, it is important to explore the trainee’s insight into the problem areas. Incompetence not only results in poor performance but also the inability to recognise it. Experiments showed that the participants in the bottom quartile overestimated their performance as above average (Archer, 2009). Thus, the struggling trainee may be ‘unconsciously incompetent’ and not aware of their poor performance.
19. Models of Feedback
The purpose of having a model or template for the delivery of feedback is so as to provide a structured approach to the process. During a feedback session, both the trainers and their trainees should know what is expected of them.
There are several well-known models of feedback. These models can help provide a framework for giving feedback. We consider three main models here. While reading about these models, critique each of them with regard to what constitutes effective feedback and how far they are learner-centred.
19. Models of Feedback
19.1. Pendleton’s rules
In dental education, Pendleton’s rules are used as the conventional method of feedback. It is structured in such a way that the positives are acknowledged first by the trainer and trainee in order to create a safe environment. Then they discuss what could be done differently.
Check if the trainee is ready for feedback (Do not impose feedback).
Let the trainee give any comments about the performance that is being assessed.
Ask the trainee what was done well.
Then the trainer explains what was done well.
Ask the trainee what could be improved.
Then the trainer explains how it could be improved.
An action plan for future is made and agreed.
(Pendleton et al., 1984)
This framework has been criticised over its rigid and formulaic nature (Chowdhury and Kalu, 2004).
19. Models of Feedback
19.2. Agenda-led Outcomes Based Analysis (ALOBA)
This technique moves towards placing an increased importance on the trainee’s ability to recognise their own performance deficits and initiate discussion about these with their trainer. This has been called ALOBA or Agenda-led Outcomes Based Analysis, with the agenda being that of the trainee rather than the trainer.
This approach was originally used as the Calgary-Cambridge approach to communication skills teaching (Silverman et al, 1996).
Teachers start with the learners’ agenda and ask them what problems they experienced and what help they would like. Then you look at the outcomes that they are trying to achieve. Next you encourage them to solve the problems and then you get the trainer and eventually the whole group involved. Feedback should be descriptive rather than judgmental and should also be balanced and objective.
For additional information click on the link – Principles of Agenda-Led Outcome-Based Analysis.
19. Models of Feedback
19.3. SET-GO Method
The SET-GO of descriptive feedback is meant for a group looking at a learners clinical performance with facilitator to lead the group feedback session. It has 5 parts:
What I Saw.
What Else did you see?
What do you Think?
Clarify the Goal that the learner would like to achieve.
Look at Offers of how to get there.
◀︎ Activity 2.3 – End of Week Discussion – Reflection
Top of Form
Bottom of Form
20. Activity 3.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45588
After completing this activity, please return to this resource.
21. References
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Week4
1. Aims and Learning Objectives
In Week 4, we aim to help you to recapitulate about assessment from the previous module so that you could apply general principles of assessment and enhance your understanding and applicability of workplace-based assessment. This will lead you to visit competency framework and hence evaluate the various workplace-based assessment tools while understanding their strengths and limitations. The aims for this week are listed below:
Explore requirements and features of assessment in the dental context.
Identify assessment standards / requirements in your own context.
Apply assessment in the dental context.
Post your reflection on the discussion board and provide peer feedback.
Specific objectives:
By the end of this week you should be able to:
Appraise the theoretical basis of assessment using the Miller’s Pyramid model and the Dreyfus and Dreyfus model of skills acquisition
Critically evaluate different workplace-based assessment tools
Critically reflect on your own experiences with various workplace-based assessment tools and how to improve workplace-based assessment.
The study guide contains a variety of short presentations, texts, reading and thinking/ reflection points. There are also several formative tasks which are presented to help consolidate your understanding.
2. Task – Explore requirements and features of assessment (4 hours)
In Learning and Teaching you will have completed two formatives (one with tutor feedback, one with peer feedback) which guided you for your summative assessment. If you have already completed Principles of Assessment you will have studied more around the principles of formative and summative assessment. Watch the video below (2:22) for revision of the main differences between formative and summative:
We’re now going to apply those concepts specifically to dental education.
Task
Read Gerhard-Szep et al. (2016)’s paper ‘Assessment formats in dental medicine: An overview‘ (see Reading List).
Explore other requirements and features of assessment in dental education through your own reading – don’t forget to keep a record of any interesting papers you find. Your reading might include your own institution’s policies.
From these readings and your own experience of your institution, identify the key features and requirements of assessment.
Make notes in your personal journal.
3. Workplace-Based Assessments (WBA)
Workplace based assessments plays a key role in assessment system in addition to traditional examinations. An assessment system which is comprehensive will form an overall profile of an individual by testing their skills, knowledge, and behaviours against those identified in their professional body’s approved curriculum (e.g. GDC). The attributes of a good clinician are multiple and include not only specialty knowledge and skills, but also generic skills and attitudes such as integrity, communication and team working. Therefore, competence in these areas cannot be assessed accurately in a MCQ or oral test, and even an OSCE cannot reliably assess how a trainee will perform in the workplace.
According to Yeates et al (2012, p.326), “[W]orkplace based assessments … represent an attractive tool as they offer samples of performance from real practice, simultaneously assess multiple competencies in an integrated manner and offering opportunities for feedback“.
There are two main theoretical frameworks which are of great relevance to workplace-based assessment. These are the Miller’s Pyramid as a model of assessment (Miller, 1990), and the Skills Acquisition Model (Dreyfus and Dreyfus, 2005). Both of these will be described here, before considering individual types of workplace-based assessments.
3. Workplace-Based Assessments (WBA)
3.1. Miller’s Pyramid as a model of assessment
Miller (1990) conceptualised thinking about assessment in the healthcare professions by identifying four levels of assessment:
Knows – (knowledge)
Knows how – (understanding)
Shows how – (competence)
Does – (performance)
Miller’s work focused attention on a largely unmeasured level, what the doctor does in real-life settings. He wrote that “No single assessment method can provide all the data required for judgement of anything so complex as the delivery of professional services by a successful physician”. This has come to be called performance‐based assessment.
Figure 1: Miller’s pyramid as a model of assessment (Miller, 1990)
What the doctor (or other health professional) does in real life is at the top of the Miller’s Pyramid and is what happens in day to day practice (not in an examination room situation). As Miller described in 1990, as is quoted above, we need to use several different workplace-based assessments to capture the doctor’s performance.
3. Workplace-Based Assessments (WBA)
3.2. The Skills Acquisition Model (Dreyfus and Dreyfus)
Dreyfus and Dreyfus (2005) described a model of skills acquisition from novice to expert. They described five levels, and from bottom to top these are:
Novice
Advanced beginner
Competent
Proficient
Expert
A model of these levels appears below:
Figure 2. The Dreyfus and Dreyfus model of skills acquisition
It is important to assess at the right level. What is appropriate for a Year 2 dental student, at the novice stage, will be different from a Foundation Year One dentist, when we would expect them to be very competent.
3. Workplace-Based Assessments (WBA)
3.3. What are we assessing?
Rethans et al. (1991) emphasised the importance of performance-based assessment by showing that scores awarded to general practitioners by simulated patients in an examination setting were significantly higher than the scores awarded for the same tasks in a real-life setting. Hence the need to assess what healthcare professionals do in practice. Traditional examinations such as essays, oral examinations and tests of basic factual knowledge such as multiple-choice question examinations cannot assess what the candidate ‘does’ in real-life settings, and a battery of assessment tools has been produced to assess performance as work-based assessment. Most work-based assessment tools are based on checklists of descriptors and rating scales.
What does performance include? Make a list of what you should be assessing when measuring a dentist’s performance – then have a look at the list below.
Such a list will usually include history and examination skills, investigations, making a diagnosis, management of the patient, prescribing, technical (practical skills), communication skills, attitudes, behaviours, and professionalism. Also, knowledge is important, as without it all is probably lost. It is not just factual knowledge, but the understanding and use of knowledge, including analysis, synthesis and evaluation of knowledge in coming to a diagnosis.
3. Workplace-Based Assessments (WBA)
3.4. Reliability of WBAs
Accurately assessing the performance and skills of dentists in training remains a significant challenge. In addition, the reliability of WBA’s can always be questionable.
Three factors are thought to impact upon reliability:
the number of encounters observed;
the number of assessors;
aspects of performance being assessed.
Dentists’ performance is usually case specific and poorly predictive of performance in other cases. A result of this is that trainees must be observed multiple times to ensure confidence in the results.
Additionally, there is evidence that multiple assessors should be employed to make assessment of each trainee to further improve reliability, although a single assessor over time may be better positioned to comment on progression of a trainees’ performance. Thus, the reliability of WBA’s demands that multiple assessments are performed by multiple assessors.
Think of each assessment being a pixel of information about that trainee’s performance. If we only have a limited amount of pixels we have a very poor view of that trainee’s performance and progress. The more pixels, or assessments, that we build up, the clearer the picture becomes, and hopefully the assessment results become closer to the ‘truth’ about that trainee’s performance.
3. Workplace-Based Assessments (WBA)
3.5. Recap – Watch the video on WBA
Watch this nine-minute video produced by Health Education England. It explores the concepts behind workplace-based assessment. Pay attention to the concepts of reliability and validity as applied to workplace-based assessments.
3. Workplace-Based Assessments (WBA)
3.6. Implementation of WBA – Barriers and Solutions
A number of issues have been identified in relation to WBAs including issues around inappropriate timing of assessments, difficulty getting assessments completed, concerns about their validity/reliability and the trainee/trainer engagement with the whole process (Eardley et al., 2013).
Think of your own practice, and what prevents you from using WBAs as effectively as you might.
What barriers can you identify to the effective implementation and use of WBAs in your practice? Write down 3 barriers.
Now think of solutions as to how you might overcome these barriers.
4. Clinical Competence
“Assessments of clinical competence, however, are somewhat different than other evaluation settings (e.g. intelligence testing), in which there are ordinarily just 2 main sources of variance in measurement: (1) ‘exam’ factors and (2) ‘examinee’ factors. […] Almost by definition … the assessment equation in the context of health professions education contains a third variable representing ‘patient’ factor (or disease process or clinical task)”
(Levine et al, 2013, p.138).
There are many skills and domains that are required to make a safe and competent clinician. This has been reflected in most countries now adopting some sort of competency framework for dental education which try to capture the wide range of skills and behaviours that are needed to train a competent clinician.
Competency frameworks
American Dental Education Association (2008) in the US has coalesced around six competences for the new general dentist:
Critical Thinking
Professionalism
Communication and Interpersonal Skills
Health Promotion
Practice Management and Informatics
Patient Care
Assessment, Diagnosis, and Treatment Planning
Establishment and Maintenance of Oral Health
For more details, visit the American Dental Education Association (ADEA)’s website.
In the UK, the General Dental Council (2015) identifies four broad competences categories for dentists, dental therapists, dental hygienists, dental nurses, orthodontic therapists, and dental technicians. These include:
Clinical
Communication
Professionalism
Management and Leadership
To read more on this, refer to GDC document ‘preparing for practice: dental team learning outcomes for registration’(GDC, 2015).
Is there one single assessment that will address all these aspects? Seems like a tall order – and so full assessment will need to consist of different assessment tools to assess these different aspects.
5. Task – Identify assessment standards / requirements in your own context
Explore your institutional, local or national assessment standards and/or requirements for dental education.
Identify what you agree with and what you think can be improved. What are the strengths and weaknesses? Were there any standards /requirements you weren’t aware of? Can you think of any problems associated with applying these standards / requirements?
Make notes in your personal journal.
◀︎ Activity 3.3 – End of Week Discussion – Reflection
Top of Form
Bottom of Form
6. Workplace-Based Assessment Tools
There are a number of workplace-based assessment methods which are designed to assess different aspects of performance. Assessment tools will fit into one of the following categories (Swanwick & Chana, 1990; Miller & Archer, 2010):
Observation of clinical activities
Discussion of clinical cases
Feedback from peers, co-workers and patients
The following workplace-based assessment tools will be covered this week:
The Mini Clinical Evaluation Exercise (miniCEX)
Case-Based Discussion (CBD)
Direct Observation of Procedural Skills (DOPS)
Procedure Based Assessment (PBA)
Multi-Source Feedback (MSF) – often called 360-degree assessment
7. Mini-Clinical Evaluation Exercise (Mini-CEX)
The Mini-CEX assesses history taking, examination, communication skills, clinical judgement, professionalism, organisation and overall clinical care. A supervisor watches the dentist carrying out the interaction with the patient and assesses the dentist on these domains on a numerical scale. After the assessment, there is a period of feedback (hopefully constructive) lasting 5-10 minutes.
The original Mini-CEX was developed with a nine-point scale where 1‐3 is unsatisfactory, 4¬6 is satisfactory, and 7‐9 is superior. In the UK Foundation Programme and in many UK Specialty Training Programmes a six-point scale has been adopted, with 1-2 being unsatisfactory, 3 being borderline, 4 being satisfactory and 5‐6 being superior.
Norcini et al. (1995) and the American Board of Internal Medicine (ABIM) developed the Mini-CEX to assess short, specific tasks within a patient encounter (e.g. history taking, examination of the cardiovascular system). A copy of the generic Mini-CEX is in the public domain from the ABIM website is attached as Appendix 1. The Mini-CEX replaced the CEX (Clinical Evaluation Exercise), which assessed an entire patient encounter (e.g. both history taking and physical examination). The main reason for this change was to enhance sampling of the assessment material; i.e. patients with different conditions and to increase the number of examiners or raters. Originally developed for formative assessment, it has also been used for summative assessment – as in the Foundation Programme (for doctors in their first two years after qualification as a doctor) and in many specialty training programmes where trainees may be asked to provide up to six assessments per year in their ePortfolio. Although initially developed for postgraduate assessment, it has also been successfully adopted in undergraduate assessment. A patient encounter in the undergraduate version, however, is reported to take much longer (30-45 minutes), than the original, 15 to 20 minute, postgraduate Mini-CEX.
Mini-CEX has also been used for undergraduate as well as postgraduate students in dentistry to assess clinical skills, professionalism, communication skills, and clinical judgement and organization (Pande, Neelam & Deshpande, 2014; Behere, 2014). Most students and examiners reported positive perceptions of the assessment method and recommended its use to enhance the learning process.
7. Mini-Clinical Evaluation Exercise (Mini-CEX)
7.1. Limitations of Mini-CEX
In real life, there are problems with the use of the mini-CEX. There are no descriptors for the various domains being assessed. Reliability is a major problem (Holmboe & Hawkins, 2008), with variations between raters, variability from patient to patient, and the scores being completed by raters without observing the actual encounter.
In Jackson and Wall’s 2010 study, up to 38% of encounters were not observed directly. Trainees were not happy with the tool and scored only 3.8 out of 10 on a satisfaction scale. Only 28% had found it useful to gain feedback, but when feedback was given, this was highly valued by trainees. Many complain about the tool being merely a “tick box exercise” and not being motivated to improve.
8. Case-Based Discussion (CbD)
In the USA the assessment tool known as the Chart Stimulated Recall (CSR) has been developed and used to assess clinical decision making and the application and use of dental knowledge in real cases managed by the trainee. The format is usually a two-hour, standardised oral exam with each case taking five to ten minutes to assess. Reported reliabilities vary from 0.65 – 0.88 in the USA.
The method has been adopted in the UK for the assessment of doctors in training in both Foundation Training and specialty training where it is called case-based discussion (CbD). Here, the trainee selects two sets of patient case notes, for which the trainee has recently seen the patients, and in which the trainee has made notes, and provides the case notes to an assessor (a more senior trainee or a consultant or general practitioner trainer). The assessor then questions the trainee on one of the cases and rates the trainee on:
Medical record keeping
Clinical assessment
Investigation and referrals
Treatment
Follow-up and future planning
Professionalism
Overall clinical judgement
A six-point rating scale is used that identifies, with regard to completion of training, whether the trainee is below expectations (scores 1 and 2), is borderline (score of 3), meets expectations (score of 4), or is above expectations (scores of 5 and 6). There is also an opportunity to flag up an “unable to comment” box where a specific competence has not been observed in the case. The discussion is expected to last no more than 20 minutes, including five minutes for feedback.
8. Case-Based Discussion (CbD)
8.1. Limitations of CBD
The record may not adequately reflect what occurred in the clinical encounter. The record may have left out important information. Vital information such as diagnosis, consent, procedures and investigations done – may not be documented in over 50% of case records (Nagurney et al., 2005). Reliability among reviewers may be low.
In terms of reliability Brown et al. (2011) stated that probably eight cases were needed to achieve an acceptable level of reliability.
Thinking point
What is an acceptable level of reliability, and how would you work this out?
Top tip
If you are going to use the CBD, it is essential that you make time to meet with the trainee yourself, look at the records they have made, make the scores, and then spend time immediately afterwards while the encounter is still fresh in giving constructive and helpful feedback.
8. Case-Based Discussion (CbD)
8.2. Activity 4.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/page/view.php?id=45599
After completing the activity please return to this resource.
9. Direct Observation of Procedural Skills (DOPS)
Directly observed procedural skills (DOPS) is designed for the assessment of clinical procedures or investigations. A supervisor watches the dentist carrying out the procedure with the patient and assesses the dentist on these domains on a numerical scale. After the assessment, there is a period of feedback (hopefully constructive) lasting 5‐10 minutes.
DOPS is designed to assess:
Understanding of indications for the procedure / investigation, relevant anatomy and technique
Obtaining informed consent
Preparation pre-procedure
Appropriate use of sedation or analgesia; Technical ability;
Aseptic technique
Seeks help where appropriate
Post-procedure management including complications
Communication skills Consideration for the patient; Interpretation of results
Overall ability to perform the procedure.
The time taken for the assessment depends on the length of the procedure and feedback to the trainee requires approximately a further five minutes.
Top tip
If you are going to use the DOPS, it is essential that you make time to observe the encounter yourself, make the scores, and then spend time immediately afterwards while the encounter is still fresh in giving constructive and helpful feedback. With practical procedures, it is useful to pass on ‘tricks of the trade’ you have learned yourself over many years in terms of the ease, safety and success of the procedure.
10. Procedure-Based Assessment (PBA)
Procedure Based Assessment (PBA) has been developed by the Royal Colleges of Surgeons in the UK, for assessing surgical skills in the operation theatre.
For orthopaedic surgery, examples of procedures for which specific PBAs are available extracapsular include ankle fracture fixation, fixation of an extracapsular fracture and hemiarthroplasty of the hip.
For oral surgery, examples of procedures for which PBAs are available include surgical removal of lower third molar, removal of root from antrum, implant placement and removal of mandibular cyst.
The agreement of both trainer and trainee is necessary to trigger a PBA, and it is the trainer’s responsibility to provide the level of supervision appropriate for the individual trainee. The PBA rating form includes six aspects:
Consent
Pre-operative planning
Pre-operative preparation
Exposure and closure
Intra-operative technique
Post-operative management
The trainer rates the trainee on each of the six aspects as either:
N – not observed or not appropriate for the trainee level of training and ability
U – unsatisfactory or needs improvement
S – satisfactory
The PBA form contains areas for written comments and trainers are required to identify what needs to be done to improve when a U rating is given. There is an additional global rating for each procedure that the trainer is required to give:
Level 0 – Insufficient evidence observed to support a judgement
Level 1 – Unable to perform the entire procedure under supervision
Level 2 – Able to perform the procedure under supervision
Level 3 – Does not usually require supervision but may need help occasionally
Level 4 – Competent to perform the procedure unsupervised and can deal with complications
10. Procedure-Based Assessment (PBA)
10.1. Reliability of PBA
Marriot et al. (2011) studied the reliability and acceptability of PBAs. They evaluated 81 trainees in six surgical specialties, and assessed 749 PBAs across 348 operations by 57 clinical supervisors and four independent assessors. So how many PBAs did they find were needed to give reliability above 0.8 G coefficient? The reliability for total item score was acceptable using 4 assessments, and the reliability for global summary score was acceptable for using 3 assessments.
In conclusion, they commented that:
“PBA demonstrated good overall validity and acceptability and exceptionally high reliability. Trainees should be assessed adequately for each given procedure.”
11. Multi-Source Feedback – MSF (360-degree assessment)
Multisource feedback (or 360-degree assessment as it is often called) is a way of collecting evidence from people who know you and asking them to rate certain defined behaviours and attitudes about you. Such people may include senior colleagues, junior colleagues, peers, nurses, hygienists, receptionists, and patients.
Figure 3. A representation of multi‐source feedback
Questions about Multisource feedback
How many raters do you think you need for a valid and reliable answer?
Who should the raters be?
Who should select the raters?
Can you rate yourself in a valid and reliable way?
How do you feedback the results?
Do you need descriptions of behaviours – or just numerical scores?
This method can be used for both summative and formative assessment. Though more widely used in postgraduate medical education (Whitehouse et al., 2002) and continuing medical education (Sargeant et al., 2007) settings, it has also been used in undergraduate medical education (Norcini & Burch, 2007). Its use is now accepted as a valid and reliable method of assessing professional behaviours and attitudes, rather than clinical knowledge or clinical skills. So, in terms of assessing knowledge, skills and attitudes, think of multisource feedback as an attitude assessment method.
The purposes of multisource feedback include identification of those with problems in terms of communication (communicating with patients, communicating with colleagues and working and communicating within a team), and with unacceptable attitudes to work (dishonesty, turning up late, leaving early and being difficult to contact when on duty). It is also useful to reward good performance in terms of communication, attitudes and behaviours. In practice, the process usually results in gratifying, descriptive praise for dentists from their co-workers.
12. Other Assessment Tools
There are also a wide variety of other assessment tools out there. Many of them are used simply for research purposes but many have applications in training.
Can you think of any other assessment tools?
◀︎ Activity 3.3 – End of Week Discussion – Reflection
Top of Form
Bottom of Form
12. Other Assessment Tools
There are also a wide variety of other assessment tools out there. Many of them are used simply for research purposes but many have applications in training.
Can you think of any other assessment tools?
◀︎ Activity 3.3 – End of Week Discussion – Reflection
Top of Form
Bottom of Form
13. Task – Apply Assessment in the Dental Context
Identify your personal experiences of various assessment methods in your own dental education context. How effective do you think they are? How do you think they can be improved in future?
Read the paper ‘The Structured Clinical Operative Test (SCOT) in dental competency assessment’ (Mossey & Newton, 2001) (see Reading List).
Explore other methods that may help you improve your assessment practise.
Think about the assessment methods you may use in your own dental education context in future.
Make notes in your personal journal.
14. Entrustable Professional Activities (EPA)
We have looked at competency framework, a variety of workplace-based assessment tools and have also seen various types of rating scale – from general performance to very procedure specific sections of the PBA and also different global scales anchored to year of training or ability to perform an operation unsupervised.
Olle ten Cate makes a strong case for establishing a unifying theme to run through all aspects of postgraduate training. He argues that clinical supervisors’ judgement focus on the construct of ‘entrustability’ (‘Do I trust this trainee?’) (Crossley et al, 2011, p.562).
14. Entrustable Professional Activities (EPA)
14.1. Task – Read and Make Notes on EPA
This self-directed task is aimed to help you grasp the concept and build on your understanding of EPA.
The following article by ten Cate (2013), available through the Reading List, gives a brief introduction to this concept of Entrustable Professional Activities (EPAs). Look closely at Table 2 in the paper which gives a framework of what an EPA consists of.
Olle ten Cate. (2013). Nuts and Bolts of Entrustable Professional Activities. Journal of Graduate Medical Education, 5(1): 157-158.
Read further article by ten Cate (2018) which is available through the Reading List, looking at how EPA relates to competencies and building workplace curriculum with EPAs.
Cate O. T. (2018). A primer on entrustable professional activities. Korean journal of medical education, 30(1), 1–10.
(Please spend 2 hours on this task)
14. Entrustable Professional Activities (EPA)
14.2. Recap – Watch the Video on EPA
Watch this seven-minute video by Dr Mick O’Keeffe, which provides an overview of the concept of Entrustable Professional Activities.
14. Entrustable Professional Activities (EPA)
14.3. Activity 4.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45600
After completing this activity, please return to this resource.
15. Activity 4.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45601
16. References
American Dental Education Association. (2020). Competencies For The New General Dentist. [online] Available at: https://www.adea.org/about_adea/governance/Pages/Competencies-for-the-New-General-Dentist.aspx
Behere, R. (2014). Introduction of Mini-CEX in undergraduate dental education in India. Education for Health, 27(3), 262.
Bindal, T., Wall, D., & Goodyear, H. M. (2011). Trainee doctors’ views on workplace-based assessments: are they just a tick box exercise?. Medical teacher, 33(11), 919-927.
Bindal, N., Goodyear, H., Bindal, T. & Wall, D. (2013). DOPS assessment: a study to evaluate the experience and opinions of trainees and assessors. Medical Teacher, 35(6), e1230¬e1234.
Brown, N., Holsgrove, G., & Teeluckdharry, S. (2011). Case-based discussion. Advances in psychiatric treatment, 17(2), 85-90.
Bullock, A. D., Hassell, A., Markham, W. A., Wall, D. W., & Whitehouse, A. B. (2009). How ratings vary by staff group in multi‐source feedback assessment of junior doctors. Medical education, 43(6), 516-520.
Burford, B., Illing, J., Kergon, C., Morrow, G., & Livingston, M. (2010). User perceptions of multi‐source feedback tools for junior doctors. Medical education, 44(2), 165-176.
Cate O. T. (2013). Nuts and bolts of entrustable professional activities. Journal of graduate medical education, 5(1), 157–158.
Cate O. T. (2018). A primer on entrustable professional activities. Korean journal of medical education, 30(1), 1–10.
Chaudhry. U., Ibison. J., Harris. T., Rafi. I., Johnston. M., Fawns. T. (2020). Experiences of GP trainees in undertaking telephone consultations: a mixed-methods study. BJGP Open; 4(1).
Crossley, J., Johnson, G., Booth, J. & Wade, W. (2011). Good Questions, Good Answers: Construct Alignment Improves the Performance of Workplace‐Based Assessment Scales. Medical education, 45 (6): 560-569.
Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R. T. K. E., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Jama, 296(9), 1094-1102.
Dreyfus, H. L., & Dreyfus, S. E. (2005). Peripheral vision: Expertise in real world contexts. Organization studies, 26(5), 779-792.
Eardley, I., Bussey, M., Woodthorpe, A., Munsch, C. & Beard, J. (2013. Workplace-Based Assessment in Surgical Training: Experiences from the Intercollegiate Surgical Curriculum Programme. ANZ Journal of Surgery, 83 (6): 448-453.
Eva, K. W., & Regehr, G. (2005). Self-assessment in the health professions: a reformulation and research agenda. Academic medicine, 80(10), S46-S54.
Falchikov, N., & Boud, D. (1989). Student self-assessment in higher education: A meta-analysis. Review of Educational Research, 59(4), 395-430.
General Dental Council. (2015). Preparing For Practice: Dental Team Learning Outcomes For Registration. [online] Available at: https://www.gdc-uk.org/docs/default-source/quality-assurance/preparing-for-practice-(revised-2015).pdf
General Medical Council (2010). Workplace Based Assessment: A guide for implementation. GMC, London
Mendes da Costa T (2014). Procedure-based assessments: an appropriate assessment tool? Bull R Coll Surg England, 96: 236–238
Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic medicine, 65(9), S63-7.
Miller, A., & Archer, J. (2010). Impact of workplace-based assessment on doctors’ education and performance: a systematic review. BMJ (Clinical research ed.), 341, c5064.
Nagurney, J. T., Brown, D. F., Sane, S., Weiner, J. B., Wang, A. C., & Chang, Y. (2005). The accuracy and completeness of data collected by prospective and retrospective methods. Academic Emergency Medicine, 12(9), 884-895.
Norcini, J. J., Blank, L. L., Arnold, G. K., & Kimball, H. R. (1995). The mini-CEX (clinical evaluation exercise): a preliminary investigation. Annals of internal medicine, 123(10), 795-799.
Norcini, J., & Burch, V. (2007). Workplace-based assessment as an educational tool: AMEE Guide No. 31. Medical teacher, 29(9-10), 855-871.
Norcini, J. & Talati, J. (2009). Assessment, Surgeon, and Society. International Journal of Surgery, 7 (4): 313-317
Pande, N., Raisoni, P., & Deshpande, S. (2014). Perceptions of dental postgraduates about Mini-cex: A Pilot Study. Journal of Education Technology in Health Sciences, 26-29.
Rethans, J. J., Sturmans, F., Drop, R., Van Der Vleuten, C., & Hobus, P. (1991). Does competence of general practitioners predict their performance? Comparison between examination setting and actual practice. Bmj, 303(6814), 1377-1380.
Sales. B., Scallan. S., Crane. S. & Lyon-Maris.J. (2015). The audio-COT (consultation observation tool): developing a new assessment tool for GP training, Education for Primary Care, 26:5, 335-339.
Sargeant J, Mann K, Sinclair D, van der Vleuten C, Metsemakers J (2007). Challenges in multisource feedback: intended and unintended outcomes. Med Educ., 41(6):583-591.
Swanwick T, Chana N. (2009). Workplace-based assessment. Br J Hosp Med (Lond);70:290-3.
Wall, D., Singh, D., Whitehouse, A., Hassell, A., & Howes, J. (2012). Self-assessment by trainees using self-TAB as part of the team assessment of behaviour multisource feedback tool. Medical teacher, 34(2), 165-167.
Whitehouse, A., Walzman, M., & Wall, D. (2002). Pilot study of 360 assessment of personal skills to inform record of in training assessments for senior house officers. Hospital Medicine, 63(3), 172-175.
Whitehouse, A., Hassell, A., Wood, L., Wall, D., Walzman, M., & Campbell, I. (2005). Development and reliability testing of TAB a form for 360 assessment of senior house officers’ professional behaviour, as specified by the General Medical Council. Medical teacher, 27(3), 252-258.
Whitehouse, A., Hassell, A., Bullock, A., Wood, L., & Wall, D. (2007). 360 degree assessment (multisource feedback) of UK trainee doctors: Field testing of team assessment of behaviours (TAB). Medical teacher, 29(2-3), 171-176.
Wood, L., Hassell, A., Whitehouse, A., Bullock, A., & Wall, D. (2006). A literature review of multi-source feedback systems within and without health services, leading to 10 tips for their successful design. Medical teacher, 28(7), e185-e191.
Activity 4.1 – Video – Case-Based Discussion
Please watch the video below.
What did you think of the presenter of the case and the assessor?
How would you rate them?
Make notes on your thoughts.
Week 5
1. Aims and Objectives
Aims of this week:
An essential component of clinical teaching is the ability to reflect not only on the many aspects of patient care but also your own professional development as a skilled practitioner. This week will build on the introduction to Critical Reflection chapter in the Learning and Teaching in Medical Education module and focus on the theoretical and practical approaches to Reflective Professional Practice which will enable both you, as an educator, and your students to embed reflective practice into the everyday clinical activities undertaken by practitioners. These approaches will also lead to reflection becoming a more meaningful and effective activity.
At the end of this week you should be able to:
Define reflection and its key attributes (models and frameworks).
Understand the range of current approaches and ‘tools’ that encourage reflective practice and embed them into your teaching practice.
Enhance your own skills as a reflective practitioner.
1. Aims and Objectives
1.1. Activity 5.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45611
After completing the activity, please return to this resource.
2. Why a Learning Journal
During this module in particular and the course as a whole we suggest you keep a ‘Learning Journal’ to record your thoughts and ideas. Many of you may already do this and might even use a portfolio structure which has been developed over many years however the actual method used does not matter too much as long as the overall intention of the record achieves some of the benefits listed below.
A systematic form of structured reflection
Records anecdotes and observations and/or reflective narrative
Seen as a key process of reflection and utilised by several professions as evidence of CPD
Perceived as a way of bringing order to the chaos of clinical work
Asserts evidence-based practice orientation
Promotes honesty and transparency
Our memories are very good at protecting us from unpleasantness; the written word does not. If we document an event at or close to the time it occurs, our writing tends to accurately reflect our feelings and concerns. If we wait too long, the immediacy of the event changes and the edges blur. In time we may even reinterpret the event very differently. While you may already think about what you do, reflecting upon your experience is more systematized.
Please also share your thoughts on what you want to get from a journal and also what approaches you favour for the layout of a journal. (Activity 5.1)
2. Why a Learning Journal
2.1. Reflective journaling
A key part of reflection in professional practice is the recording of it in some sort of diary/log/blog/journal and perhaps the best known approach to reflective journaling is that created by Jenny Moon who offers this list of uses of journal writing, many of which may promote reflection:
To record experience
To develop learning in ways that enhances other learning (by valuing personal observation and knowledge)
To deepen the quality of learning, in the form of critical thinking or developing a questioning attitude
To increase active involvement in learning and personal ownership of learning
To enhance problem solving skills
To explore the self, personal constructs of meaning and understand one’s view of the world
As a means of slowing down learning, taking more thorough account of a situation or situations
To enhance creativity by making better use of intuitive understanding
To provide an alternative voice for those not good at expressing themselves
Reflective writing was explored in the Critical Reflection chapter in the Learning and Teaching in Medical Education module through the Jenny Moon 4 level analysis of reflective writing. Here is further information about her approach through a short guide which offers a short summary along with questions and prompts that facilitate deeper and more profound reflection.
Jenny Moon: Reflective Writing – some initial guidance for students (click on link).
Moon J. 1999. Reflection and Learning in Professional Development. Abingdon: Kogan Page
3. Overview: Getting started with reflective practice
This week will explore the importance of reflective practice along with some of the approaches and tools that we can use to enable our students to achieve deep and meaningful reflection.
Roger Neighbour in his book ‘The Inner Apprentice’ writes that;
“people are intrinsically self–educating as long as the right information is provided in the right way at the right time“
The enablement of ‘self-education’ is the ultimate goal of many educational programmes however the full implication of Neighbours philosophy is that it’s our job as clinical educators to make sure that all three of these ‘right’ components are not only provided to students but also that all three are provided together at the same time. Whilst this is relatively straightforward for classroom based teaching and learning it is much harder in the severely restricted time available for teaching in busy clinics. Neighbour further suggests one way to achieve the three ‘rights’ in clinical teaching is to encourage what Schon described as ‘reflection in action’ where it is possible to look at key learning points in a short space of time and also ‘reflection on action’ where there is more time to look back on the experience and learning can be achieved through the use of ‘awareness raising questions under conditions of safe insecurity’.
It is a UK General Dental Council (GDC) requirement to carryout reflection as part of the Personal Development Plan for life long Continuing Professional Development (GDC, 2018). To read more on GDC’s Enhance CPD Guidance click on the link: GDC – Enhanced CPD Scheme
So now let us look at the definitions, approaches and models that have led to reflection becoming a core part of professional learning today.
Neighbor, R. (2005). The Inner Apprentice : An awareness-centred approach to vocational training for general practice (2nd ed.). Oxford: Radcliffe.
3. Overview: Getting started with reflective practice
3.1. Definitions of and approaches to reflection
Here are some definitions and/or approaches proposed by the ‘gurus’ of Reflective Practice.
Dewey (1910) notes that it is a “conscious and deliberate act that begins when learners recognize that something within their understanding is incorrect or incomplete and ends when they have addressed this shortcoming”.
Schon (1983/1987) calls this “Enlightened professional artistry” – through reflection in action (thinking on your feet) and reflection on action (retrospective thinking). He also created the six stage learning model (see next page)
Kolb (1984) developed his ‘Experiential Learning Cycle’ to enable learner to go through the stages that help with the ‘making sense’ process; concrete experience, reflective observation, abstract conceptualization and active experimentation.
Boud (1985) defines it from the learner’s point of view: He describes it as “a generic term for those intellectual and effective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation.”
Argyris and Schon (1996) Organizational learning II: Theory, method, and practice. Creation of the concept of ‘single loop learning’ (changes made to the actions under consideration) and “double loop learning” (values and norms underlying the theory in use are modified.)
Gibbs (1998) Learning by doing. Six stage cycle; description, feelings, evaluation, analysis, conclusions and action plan.
Moon (1999). Reflection is a form of mental processing – like a form of thinking – that we may use to fulfil a purpose or achieve some anticipated outcome. Alternatively we may simply ‘be reflective, and then an outcome can be unexpected. The term “reflection” is applied to relatively complex of ill-structured ideas for which there is not an obvious solution and it largely refers to the further processing of knowledge and understanding that we already possess.
The list is arranged chronologically so that you can ‘track’ the development of the concept over time showing how the initial theory developed into the more practically focused definitions that are relatively well known today.
3. Overview: Getting started with reflective practice
3.2. A brief look at models
Some of the models associated with the theory of reflective practice were introduced in the Critical Reflection chapter in the Learning and Teaching in Medical Education module however everyone has their own preferred model that helps students understand that reflection is a cyclical process. We include three here which are often used in Significant Event Analysis approaches to review clinical events however again, please do add your own preferred approach if you have one already.
Schon – six steps and how it can be used for ‘reflection in action’ and ‘reflection on action’
Kolb – learning spiral
Gibbs – learning by doing.
Consider their effectiveness in your experience individually and then make you choice as to the approach that works best for you and your students.
3. Overview: Getting started with reflective practice
3.3. Schon’s model
A key part of being a healthcare professional is to learn by experience. Most of the time we consider this to be a case-based approach, often with shared learning with colleagues in situations such as ‘Grand Rounds’.
Schon’s description of a six-stage learning cycle includes this, and is another way to consider what happens when we learn by experience. The four middle stages (2-5) are representative of what goes on inside our minds – it is a cyclical process as we select data based on our beliefs and then make assumptions based on the interpretation we make, and so on up and then around again. The bottom and top boxes are what happens on the outside. We have to be ‘open’ to new ideas, new ways of ‘seeing data’ and so on within this process, otherwise nothing much will change.
Watch the video (2:56) below for a quick overview on reflective learning
3. Overview: Getting started with reflective practice
3.4. A Kolb’s Learning Spiral
Educational Theorist, David A. Kolb developed this model of experiential learning (1984) to illustrate the stages involved in the learning process:
Experience
Reflection
Analysis
Action
There is no beginning or end and it is possible to join the process at any stage. It is a spiral because we never come back to the same point; after each experience our understanding has changed.
Watch the video below (2:47) for a quick overview on Kolb’s learning spiral:
3. Overview: Getting started with reflective practice
3.5. Gibb’s Reflective Cycle
Graham Gibbs’ Reflective Cycle (1988) develops Kolb’s four stage model into a six stage model which you can use to guide your critical reflection on this course as well as your clinical teaching practice.
Description
Feelings
Evaluation
Analysis
Conclusion
Action Plan
These are the sort of questions you might want to ask yourself when working through the Gibbs reflective cycle:
How was I feeling and what made me feel that way?
What was I trying to achieve?
Did I respond effectively?
What went well? Why?
What went wrong? Why?
How were others feeling? Why?
What factors influenced my response?
What knowledge informed my response?
To what extent did I act for the best and in line with my values?
How does this situation relate to prior experience?
How could I respond more effectively?
What would be the consequences of alternative responses?
How do I now feel about this experience?
What have I learned from this experience?
3. Overview: Getting started with reflective practice
3.6. The Use of Reflection in Medical/Dental Education
Many of you will already be experienced in both reflecting on your learning and/or enabling your students to do so. However it is always worth reviewing the concept in a more general sense and there is an excellent (and short) overview of the reflection in medical education in this AMEE guide, available through the reading list:
Sandars J (2009), The use of reflection in medical education: AMEE Guide No. 44, Medical Teacher, 31:8, 685-695, DOI: 10.1080/01421590903050374
This guide gives a basic overview of the uses of reflection in medical education. You should read it and make notes on any key elements that are less familiar to you.
3. Overview: Getting started with reflective practice
3.7. How to write reflectively?
It is important that students understand that reflective writing is quite different to note taking or writing case reports however there are no absolute rules as to how to help them develop their skills in reflective writing in a way that leads to deep understanding. However like many skills practice and feedback are key and many university courses own encourage students to create their own ‘portfolios of learning’ with faculty staff having access to some parts where they are able to give feedback on the writing.
In the Critical Reflection chapter in Learning and Teaching in Medical Education module you explored the Jenny Moon concept of four levels of depth in reflection. She suggests that in the fourth level: ‘There is clear evidence of standing back from an event and there is mulling over and engagement’ and there is one chapter in her book that takes you through the levels to help you compare and contrast the approaches.
However it can be hard to explain this to students who are being asked to reflect more deeply on an experience and so here is a link to a shortened guide by Jenny Moon – ‘Resources for use with reflection or learning journals‘ from her book Learning Journals – a handbook for reflective practice and professional development (Routledge Falmer, 2006 – second edition). This describes the four stage levels of reflective writing along with an ‘critique’ of a worked example of the ‘GP’s story’ and is a useful approach to enabling your students to understand how to achieve deeper and more analytical refection in their own writing.
Also there are a lot of creative and innovative way to help ‘unlock’ the more exciting ways of writing on a regular basis so much so that they become fully integrated into your students skills etc. Many of them are not only creative but good fun and can be used with groups of students working together as well as writing on their own.
When you have time and want to look for new ideas for different approaches to teaching about reflective practice, the following e-book has a large range of activities that you can try out in your teaching (and learning). It might be helpful if you find any that are particularly effective in your own teaching that you share that information with colleagues. This optional resource is available through the reading list:
Wood, J. (2013), Transformation Through Journal Writing: The Art of Self-Reflection for the Helping Professions. Library ebook, London: Jessica Kingsley Publishers.
3. Overview: Getting started with reflective practice
3.8. Sharing Reflective Writing
Whilst reflective writing is mostly done as a way of experiencing your own thoughts and feelings about events that have happened to you personally, it can also be used as a tool to allow you to shift your perspective on a situation or problem. This is done by writing about the experience as if you were someone other than yourself either also involved in the event or an observer of it and then sharing your writing (or extract of your writing) with others. This can often lead to new insights in both thinking and feeling.
However when sharing your writing it is important to be sensitive to each other’s uncertainty and insecurities about using a different approach to personal writing. Guidance is given by Gillie Bolton (2018) and reproduced here:
Be positive and supportive; negative opinions are more readily received when preceded by positive ones.
Comment on the writing, not the writer. Consider writings as fiction, reducing possibility of hurt or loss of confidentiality.
Consider everything read and discussed as confidential.
Make particular parameters for discussions clear to mentor or group.
Your writing is as wonderful an experience as everyone else’s: apologetic competitions are not fruitful.
Enjoy deepening the reflective process, whether verbally or in writing.
If you want to read more about Gillie Boltons’ work on Reflective Journal writing then one of her books (The Therapeutic Potential of Creative Writing : Writing Myself. (1999)) is available through the Optional Reading List. Chapter 3 on ‘Keeping a Journal: The Diamonds of the Dustheap’ is particularly interesting.
Reference; Bolton, G. (2018). Reflective Writing: A ‘How-To Guide’ In ‘Reflective Practice, Writing and Professional Development’ (5th ed., pp. 157–182). Delderfield Russell.
3. Overview: Getting started with reflective practice
3.9. Activity 5.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45612
After completing the activity, please return to this resource.
4. Integrating reflection into learning, teaching and assessment.
There are a great many learning opportunities in healthcare education that are enhanced by reflective practice. These range from formal classroom activities designed to teach reflective practice explicitly to fully integrated case based learning where reflection is an implicit part of the clinical reasoning process. We will look at some (but not all) examples of approaches that support both ‘reflection-in-action’ and ‘reflection-on-action’ in this section.
However it is also important to consider the different roles educators can have when supporting learners in reflective practice. some of these roles are being a lecturer in a large group setting, a facilitator or tutor in small group settings, a clinical supervisor with students on placement, a coach and/or mentor supporting career development and progression, an examiners/assessors at formal examinations and an appraiser either as a line manger or external appointment for professional regulatory reviews.
The nature of the relationships in all these roles is different as are the obligations and responsibilities that go with the roles. For most of us it is usual to have to adopt different roles at different times and whilst there is not enough time this week to examine each of them in detail, it might be helpful for you to reflect on the nature of your relationship in each of your roles and how that affects the way you support reflective practice within that relationship.
This might also be a good time to review your notes from Chapter 3 on Supervision and also Giving Feedback .
4. Integrating reflection into learning, teaching and assessment.
4.1. Teaching Reflective Practice as a Concept
Although the skills of reflective practice are best learned through experience you may want to ‘front-load’ that experience by explaining what reflective practice is all about in a classroom setting. Tips and hints are always helpful so please look at the article, available in the reading list;
Aronson L. (2011). Twelve tips for teaching reflection at all levels of medical education. Medical teacher, 33(3), 200–205.
Tips range from defining reflection to reflecting on the process of teaching reflection itself. Decide for yourself which are relevant to your own teaching.
Some approaches you will already have experienced and you may have developed some yourself. Below is a link to materials that can be adapted for your own purpose.
The Quality Assurance Agency for Higher Education Scotland’s Enhancement Theme on Transition
Critical Self-Reflection tab (which we will explore in more detail in Week 8) has a presentation and worksheets that are useful.
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4. Integrating reflection into learning, teaching and assessment.
4.2. Reflection is needed – making a mistake
Medical errors happen and when they do healthcare professionals have a duty of candour and so must be open and honest about them. Formal discussions such as team based Significant Event Analysis (SEA) can be carried out with the intention to discover that went wrong so lessons can be learned to prevent similar occurrences in the future however despite the establishment of a no-blame culture SEA’s can be stressful especially for less experienced students and practitioners. As educators therefore it is desirable that we try and help our students learn to cope with stressful situations particularly when it is intended to be a learning experience and it’s hard to learn when stressed.
One way to do this is for students to gain some experience of looking at clinical mistakes either at the time they happen through reflection-in-action or at after the event through reflection-on-action and it can also be useful to gather together some ‘ready worked’ anonymised examples which can create a sense of safety if students are new to this activity.
The next activity uses a podcast which once listened to can be explored within the safety of a group setting.
4. Integrating reflection into learning, teaching and assessment.
4.3. Activity 5.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/page/view.php?id=45613
After completing the activity, please return to this resource.
4. Integrating reflection into learning, teaching and assessment.
4.4. Professional Identity formation through reflection
Reflection can enhance all forms of learning in several ways and experiential learning in particular. Not only does it allow learners to identify their own learning needs and knowledge gaps, they also can synthesize theory and practice in a way that then enables them to build on previous experiences and adapt their learning when in different situations. When reflecting on clinical cases they can develop a deeper understanding of their own values and beliefs and this supports not only personal development but also the development of professional identity.
The development of ‘Professional Identity’ has become much more of a focus in medical education based on the work of the Carnegie Foundation described by Cooke et al (2010). This has been further developed by Cruess et al (2019) who suggest that in order to do this it must be made explicit in the formal curriculum and learners must be aware of the process of how and where professional identity formation occurs.
To gain a better understanding of this and how it might inform your teaching, please read the following article and note how often both reflective practice and communities of practice are identified as being key element of professional identify formation.
Cruess, S.R., Cruess R.L., Steinert, Y. (2019) Supporting the development of a professional identity: General principles, Medical Teacher, 41:6, 641-649, DOI:10.1080/0142159X.2018.1536260. (Available in reading list)
Reference:
Cooke,M., Irby, D.M.,O’Brien, B.C. (2010). Educating physicians: a call for reform of medical school and residency. San Francisco (CA): John Wiley and Sons.
4. Integrating reflection into learning, teaching and assessment.
4.5. Case study – integrated reflection to change practice
Read the following paper which describes an exploratory case study of the views of students who had completed a Masters programme in Diabetes Care, Education and Management in Kuwait, which had critical reflection embedded throughout the module teaching and also integrated into the assessment process. The outcome of the research was that reflection was not only appreciated by students they acknowledged how much it had changed their practice. An additional point to note about this group of students is that they are also describing the benefits of their having been in a strong community of practice whilst on the programme working together to change the way healthcare was delivered to patients with diabetes in Kuwait.
Muir, F. Scott, M. McConville, K. Behbehani, K. Sukkar, S. (2014). Taking the learning beyond the individual: how reflection informs change in practice. International Journal Of Medical Education, 5, 24-30.
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5. Task – Reflective Practice in Dental Education
In this activity, we will explore incorporation of reflective practice in the context of dental education.
Think of the ways you would encourage your dental education students to be involved in reflective practice. What challenges do you think you might face? How would it benefit your students?
Read the paper by Strauss et al (2003) ‘Reflective Learning in Community-Based Dental Education (In Reading Link Essentials).
Was there anything in the paper you may apply in your own dental education practice.
Write notes in your personal journal.
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6. Reflection in action – ‘in the moment’
“Skilled physicians speak of being able to recognize a particular disease, on occasion, the moment a person afflicted with it walks into their office. The recognition comes immediately and as a whole, and although the physician may later discover in his examination of the patient a full set of reasons for his diagnosis, he is often unable to say just what clues triggered his immediate judgment” (Schon 1987)
Many clinicians can relate to that experience only too well – some call it ‘intuition’ also known as ‘highly skilled learned behaviour’, however if you wish to have a deeper understanding of some of the theoretical constructs that help explain it then read the full Chapter in Schon’s book by accessing it via the Reading List link.
Chapter 2 Teaching artistry through reflection-in-action. in Schön, Donald A. Educating the Reflective Practitioner, 22-40. Jossey-Bass. © This material is used by permission of John Wiley & Sons, Inc
This ‘I just know’ concept can be explained by Noel Burch’s Conscious Competence Ladder which is useful when explaining to students concerned that they will not be able to develop the apparent ‘intuitive’ skills of their teacher or supervisor. It can also be useful when helping students as they move up through the competency levels when learning a new skill to understand the benefits of reflective practice and there is a great deal of additional information on this model at the BusinessBalls site which might of use to you.
6. Reflection in action – ‘in the moment’
6.1. Reflection-in-action – capturing the moment
The clinical environment is rich with opportunities to teach and in an ideal world we could spend as long as necessary to enable students to reflect and learn on every case they see however the reality is that time is short and so we have to adopt different ways to trying to capture the ‘in the moment’ thoughts and feelings in order to use them as learning opportunities.
So options for making a record of what’s happened to return to as soon as possible are;
Very short notes – either on paper or on a mobile – (with or without emoticons!)
Voice recording to yourself on mobile phone
Selfie photo (not just the scene but also your facial expression at the time)
The emphasis should be on not just what clinical conundrums the students are struggling with at the time but also their feelings at the time as revisiting them in the discussion afterwards is a very effective way to get them back to being ‘in the moment’.
6. Reflection in action – ‘in the moment’
6.2. The One Minute Preceptor
Earlier in Week 3 we introduced the concept of the ‘One Minute Preceptor’ as a way to provide a structured approach to allowing a student to interview and examine a patient and then present the findings to you, the teacher in a very short space of time. It is called the one minute preceptor as, in this type of teaching, it is thought that in a 10 minute teaching slot only one minute is spent in discussion and teaching as the rest is taken up by the student doing the presentation along with some questioning about specific details of fact. Consider this approach again from the perspective of the difference between reflection-in-action and reflection-on-action.
Remind yourself of the principles and steps involved by watching the video LEGO Surgery: One Minute Preceptor on the next page, but here are the steps detailed out for you as well.
If you’ve not done so already try out the process as soon as you can, and decide for yourself how useful it might be in your teaching.
Steps
The technique identifies 6 steps:
Get a commitment
Probe for Supporting Evidence
Reinforce what was done well
Give guidance about errors and omissions
Teach a general principle
Conclusion
1. Get a commitment
“I am keen to know what is it you are thinking as it will help me identify the key learning points for you”
What do you think is going on with this patient?
What do you want to do?
2. Probe for supporting Evidence
Listening carefully lets you understand the student’s clinical reasoning and you may find gaps in their knowledge base
What factors did you consider in making that decision?
What other options did you consider and discard?
3. Reinforce what was done right
Feedback should be given using a positive approach, e.g.
Balanced, timely, focus on behaviour, personal to the student, and with a clear simple main message.
4. Give guidance about errors
Patient safety issues take a high priority here and so errors or omissions can be explored as considerations of “what if”. Errors also have an impact on other members of the team and on the student themselves. Proportionality is important when exploring error.
“That may not be the best approach because…”
5. Teach a general principle
Once you are aware of what the student knows and how they are thinking about clinical problems, then it is easy to expand the learning point to more general principles e.g.
“All patients with heart failure should be…”
Or
“The evidence show that this if left undiagnosed leads to…”
6. Conclusions
Students will take away a few key messages and if you’re lucky maybe even a few more. These might be the things you ask the student to do next or even do again with the patient. Also, at the end of the discussion you can ask the student to tell you what the “take home “message from this patient might be.
Further reading
Irby, D. M., & Wilkerson, L. (2008). Teaching when time is limited. The BMJ, 336(7640), 384-387
6. Reflection in action – ‘in the moment’
6.3. Activity 5.4
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/page/view.php?id=45614
After completing the activity, please return to this resource.
7. Between one and six minutes
Other ways of capturing events in a way that enable the later discussion to focus on the ‘in the moment’ issues are:
Three a day – three things that are important with no restriction on what kind of ‘things’ they might be
Credit card – write enough detail but no more than would fit on a credit card
Gillie Bolton (1999) in Chapter 3 ‘Keeping a Journal’ describes a method for starting to write creatively; the ‘six-minute write’.
Six minute write – writing for 6 minutes continuously about whatever is in your head at the time.
7. Between one and six minutes
7.1. Task -The ‘six-minute write’
Follow these steps:
Write whatever is in your head without censoring it
Write without stopping for 6 minutes
Don’t stop to think or be critical of what you are writing or thinking
Allow your writing to flow with no thought for spelling, grammar etc
Give yourself permission to write anything
Whatever you write will be right: it is yours *
When you have finished, read over all you have written in the six minutes and add or amend as you wish. Enter this into your reflective journal.
* please note – this can be a great icebreaker for a session on effective practice, however, if using this as an ‘ice-breaker’, stress the fact that it is not to be shared in the group. It can also be used as a ‘break-out’ activity as a way of ‘resetting’ the group when in a teaching session the participants are becoming tired/confused/stuck etc.
Bolton G. (1999) The therapeutic potential of creative writing: writing myself. Philadelphia, London: Jessica Kingsley Publishers. Available as an eBook online through University of Dundee library.
8. Reflection on action
There are a variety of different activities in both learning and clinical practice that have integrated reflective practice in order to make the learning more effective which take place in a range of settings – one to one supervision, small group work, larger group activities or even lectures.
The most commonly used ‘classroom’ based activities in medical and healthcare education are
Problem Based Learning (PBL) – a student-centred approach in which students learn about a subject by working in groups to solve an open-ended problem created to encourage motivation and learning.
Case Based Learning (CBL) – an approach that uses human cases to impart relevance and help to connect theory to practice. The impact of CBL can reach from simple knowledge gains to changing patient care outcomes.
Team based Learning (TBL) – an evidence based collaborative learning approach designed around units of instruction taught in a three-step cycle: preparation, in-class readiness assurance testing, and application-focused exercise.
If you have not had experience of all of these approaches you should familiarize yourself with them and consider which approach is most suited to your teaching style, your topic, your student group and your institutional preferred approach.
Here is an article that looks at CBL vs. PBL, which might influence your choice or highlight areas were you need to research more into the method:
Williams, B. (2005) Case based learning—a review of the literature: is there scope for this educational paradigm in prehospital education? Emergency Medicine Journal 2005;22:577-581.
Additionally there are specific clinical tools such as Significant Event Analysis (SEA) and Plan Do Study Act (PDSA) that are not covered here however they all fundamentally include the process of reflection and reflective writing.
8. Reflection on action
8.1. Facilitating Reflection-on-action
In addition to the group activities such as PBL, CBL and TBL in education within the healthcare environment it has been normal practice for many years to carry out team based case discussion/presentation activities both formally and informally. These might be teaching ward rounds where current cases are examined, clinical placements in OP clinic and GP practices and primary care team meetings are part of every day activity.
Teams also meet to explore when things go wrong (or more rarely when things go exceptionally well) using tools such as Plan Do Study Act (PDSA), Significant Event Analysis (SEA) clinco-pathological conference (CPC), and group based case presentations such as in Balint type groups. As these take place in groups or teams they usually have a facilitator (either officially or unofficially appointed) who is able to structure the discussion in a way that leads to more effective outcomes.
We will cover this in more detail in Week 9 but here is the beginning of an article ‘Case Discussion; Chat or Challenge‘ written by Mairi Scott and Marshall Marinker many years ago as part of a study guide for GP trainers. It’s interesting to note that not once is the word ‘Reflection’ included, although perhaps you might agree it was implicit throughout that that was the activity that was being undertaken!
“Case discussion is a common form of small group work in vocational training and its process closely reflects the processes of the general practice consultation, in which diagnoses are considered and tested and possible management proposed. The intention is that all the group members should together examine the evidence from a wide variety of viewpoints, challenge the evidence for each other’s views and attempt to come to a shared agreement about the nature of the patient’s problem and the doctor’s management.
Two models have contributed to the approach to, and content of, small group case discussions in general practice, though their format and intentions are different. The first, derived from the experience of hospital medicine, is the clinico-pathological conference (CPC). This may involve a large number of people in a lecture theatre, rather than a small fixed group in a seminar room, and the consideration of post mortem specimen slides – with the patient’s disease, rather than his feelings and social context, providing the major puzzle to be solved. The important characteristics of the CPC include respect for the evidence, close attention to factual clinical detail, and the sharp edge of critical debate. At best the CPC provides a display of critical analysis, medical logic and respect for reliable evidence; at worst, an intellectual exercise not guided by common sense or concern for the humanity of the subjects it purports to study.
The second, and perhaps more important, model on which contemporary case discussion is built is that of the Balint seminars, whose tradition is rooted in the experience of general practice though it is also widely misunderstood by general practitioners. In essence, Balint seminars are case discussions concerned with the doctor/patient relationship not, as popular myth supposes, with the psychology, let alone psychopathology, of the doctors in the group. They are not therapy groups for doctors – they are enquiries into the human condition of the patient which take into account the way the doctor feels. In many ways there are strong parallels between the CPC and the Balint seminar. Both exhibit at their best a reverence for evidence. Both attempt to test that evidence against the record. Both employ discussion, at times adversarial, to attempt to locate the truth, or at least the best guess that the group is capable of making.
Modern case discussion is a synthesis of these two approaches. The aim is to formulate the diagnosis simultaneously in physical, psychological and social terms. What characterizes the best case discussion, like the best music or the best poetry, is a combination of creativity and strict internal discipline. Creativity depends on the feelings in the group, the talents of its individual members, the sense of discovery and surprise which the experienced small group tutor can create. Discipline is easier to describe, and, to be frank, sounds rather dull.”
Scott, M., Markinker, M. (1992) Case Discussion: Chat or Challenge. MSD foundation Leadership Study guide (not published)
9. For or against assessing reflection?
One of the commonest approach to recording reflection is though the use of a Professional portfolio and for many healthcare practitioners they are required by the regulators as a way of demonstrating continuing competence as a practitioner. This requires some sort of judgment to be made as to the validity of the material within the portfolio along with evidence that continuing professional development is taking place. Portfolios are also used in undergraduate programmes and in the Dundee MBChB they are used as part of the final MBChB assessment with portfolios reviews being carried out both formatively and then summativley.
The evidence of the worth of these types of portfolio assessments is limited and so the decision about whether the portfolio should only be formative or only summative or a combination of both is challenging and can be likened to arguments about whether the chicken or the egg comes first! However in order to form your own opinions please read the following articles, available through the reading list:
Driessen, E. (2016) Do portfolios have a future? Adv in Health Sci Educ (2017) 22:221–228 DOI 10.1007/s10459-016-9679-4
O’Sullivan,O,J., Howe,A.C., Miles,s., Harris,p., Hughes C.S., Jones,P., Scicluna,H., Leinster,S.J. (2012) Does a summative portfolio foster the development of capabilities such as reflective practice and understanding ethics? An evaluation from two medical schools, Medical Teacher, 34:1, e21-e28, DOI: 10.3109/0142159X.2012.638009.
Make notes for you own use in response to the questions below:
Driessen (2016) suggest that “It could be argued that mass adoption without careful attention to purpose and format may well jeopardize portfolios’ viability in health sciences education.”
O’Sullivan et al (2012) state that “Portfolios need to be evaluated to determine whether they encourage students to develop in capabilities such as reflective practice and ethical judgment.”
When you have read both articles, consider:
Should portfolios be ‘assessed’ at all?
If assessed should it be formative and/or summative (detail the pros and cos for both approaches)?
What might the assessment approach/tool/rubric look like and how could it be used to at least mitigate some of the previous ‘cons’?
What would be needed to support your decision one way or another?
If you wish additional reading in the shape of a systematic review then BEME Guide No.11 is a good place to start:
Buckley, S., Coleman, J., Davison, I., Khan, K. S., Zamora, J., Malick, S., Morley, D., Pollard, D., Ashcroft, T., Popovic, C., & Sayers, J. (2009). The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11.
10. Activity 5.5
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45615
11. References
Argyris,C. Schon,D. (1996) Organizational learning II: Theory, method and practice. . Addison-Wesley Publishing Company.
Aronson, L. (2011). Twelve tips for teaching reflection at all levels of medical education. Medical teacher, 33(3), 200–205. https://doi.org/10.3109/0142159X.2010.507714
Bolton G. Write to Learn: Reflective Practice Writing InnovAiT. 2009; 2(12); 752 – 754. Available online through University of Dundee library.
Bolton, G. (1999) The therapeutic potential of creative writing: writing myself. Chapter 3; Keeping a Journal. Philadelphia, London: Jessica Kingsley Publishers. Available as an eBook online through University of Dundee library.
Bolton, G. (2018) Reflective Practice, Writing and Professional Development. ’Chapter 8 ‘Reflective Writing: A ‘How-To Guide’. Delderfield, Russell; Fifth edition
Boud, D, (1985) Reflection: Turning Experience into Learning. London: Croom Helm.
Buckley, S., Coleman, J., Davison, I., Khan, K. S., Zamora, J., Malick, S., Morley, D., Pollard, D., Ashcroft, T., Popovic, C., & Sayers, J. (2009). The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11.
Cooke,M., Irby, D.M.,O’Brien, B.C. (2010). Educating physicians: a call for reform of medical school and residency. San Francisco (CA): John Wiley and Sons.
Cruess, S.R., Cruess R.L., Steinert, Y. (2019) Supporting the development of a professional identity: General principles, Medical Teacher, 41:6, 641-649, DOI:10.1080/0142159X.2018.1536260
https://doi.org/10.1080/0142159X.2018.1536260
Dewey,J. (1910) How we Think. D.C. Heath & Company.
Driessen, E. (2016) Do portfolios have a future? Adv in Health Sci Educ (2017) 22:221–228 DOI 10.1007/s10459-016-9679-4
General Dental Council. (2018). Enhanced CPD Guidance. Retrieved from https://www.gdc-uk.org/docs/default-source/enhanced-cpd-scheme-2018/enhanced-cpd-guidance-for-professionals.pdf?sfvrsn=edbe677f_4%22
Gibbs, G. (1998) Learning by Doing A Guide to Teaching and Learning Methods. Oxford Brooks University, Oxford.
Kolb,D. A. (1984, 2014) Experiential Learning: Experience as the Source of Learning and Development. FTP Press.
Lave, J., Wenger,E. (1991) Situated Learning: Legitimate Peripheral Participation, Cambridge University Press, Cambridge
Moon J. (2006) Resources for use with reflection or learning journals’ from her book Learning Journals – a handbook for reflective practice and professional development (Routledge Falmer, 2006 – second edition). http://dera.ioe.ac.uk/12994/1/4213.pdf
Moon J. 1999. Reflection and Learning in Professional Development. Abingdon: Kogan Page https://efs.weblogs.anu.edu.au/files/2018/01/Moon-on-Reflective-Writing.pdf
Muir, F. Scott, M. McConville, K. Behbehani, K. Sukkar, S. (2014). Taking the learning beyond the individual: how reflection informs change in practice. International Journal Of Medical Education, 5, 24-30.
Neher, J., Gordon, K., Meyer, B., & Stevens, N. (1992). A five-step “microskills” model of clinical teaching. Journal of American Board of Family Practice, 5, 419-424. http://preceptor.healthprofessions.dal.ca/?page_id=457
Neighbor, R. (2005). The Inner Apprentice : An awareness-centred approach to vocational training for general practice (2nd ed.). Oxford: Radcliffe.
O’Sullivan,O,J., Howe,A.C., Miles,s., Harris,p., Hughes C.S., Jones,P., Scicluna,H., Leinster,S.J. (2012) Does a summative portfolio foster the development of capabilities such as reflective practice and understanding ethics? An evaluationfrom two medical schools, Medical Teacher, 34:1, e21-e28, DOI: 10.3109/0142159X.2012.638009. https://doi.org/10.3109/0142159X.2012.638009
Sandars J (2009) The use of reflection in medical education: AMEE Guide No. 44, Medical Teacher, 31:8, 685-695, DOI: 10.1080/01421590903050374.
https://doi.org/10.1080/01421590903050374
Schon, DA. (1983, reprint 1995) The reflective practitioner: how professionals think in action, Arena, Aldershot
Schon,D. (1987)Chapter 2 Teaching artistry through reflection-in-action. in Schön, Donald A. Educating the Reflective Practitioner, 22-40. Jossey-Bass. © This material is used by permission of John Wiley & Sons, Inc (DIGITISED)
Scott, M., Markinker, M. (1992) Case Discussion: Chat or Challenge. MSD foundation Leadership Study guide (not published)
Strauss, R., Mofidi, M., Sandler, E. S., Williamson Iii, R., McMurtry, B. A., Carl, L. S., & Neal, E. M. (2003). Reflective learning in community‐based dental education. Journal of Dental Education, 67(11), 1234-1242.
Williams, B. (2005) Case based learning—a review of the literature: is there scope for this educational paradigm in prehospital education? Emergency Medicine Journal 2005;22:577-581.
https://emj.bmj.com/content/22/8/577
Wood, J. (2013) Transformation Through Journal Writing : The Art of Self-Reflection for the Helping Professions. Library ebook London : Jessica Kingsley Publishers
WEEK 6
1. Learning outcomes for Week 6
Simulation-based education is widely adopted to support clinical teaching in all of the healthcare professions from novices to experts and offers learning opportunities that may be difficult to access by other methods. For example, technical or procedural skills can be repeatedly taught, practiced, and refined in a learner-centered simulated environment, and non-technical skills can be explored within interprofessional, multi-agency team-based and systems testing scenarios either in simulation centres or in situ.
Therefore this week we take a look at the fundamental elements of simulation-based education and focus on what, why, and how you may incorporate, or further develop, opportunities for the use of simulation-based education to teach technical and non-technical skills in your clinical context.
As you read the literature you may notice the use of the terms simulation-based education or training, learning, etc. and these terms are used interchangeably, we will adopt the terms simulation and simulation-based education (SBE) here.
By the end of this week participants should be able to:
Discuss the context and relevance of SBE for their clinical teaching practice
Appraise the use of common educational theories in SBE
Discuss their understanding of “technical skills” and ‘non-technical skills’
Explain the pros and cons of technical skills and non-technical skills acquisition in simulation and clinical practice
Explain the term “deliberate practice” and discuss the role and importance of feedback in skill acquisition and non-technical skill acquisition.
Provide an overview of the categories, elements and behaviours in your clinical setting compared with other specialty/disciplines behavioural marking systems
Explore, identify, and evaluate SBE opportunities in your own dental education context.
2. What is simulation-based education?
“A technique, not a technology – to replace or amplify real experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” (Gaba, 2004).
This definition of simulation is probably the most frequently cited in the simulation literature (Cant and Cooper, 2019, Walsh et al., 2018). It makes an important distinction between the concept of simulation as a pedagogy (technique) in contrast with the infrastructure, artefacts or tools which are associated with facilitating simulation (technology). The definition of simulation below is from the Society for Simulation in Healthcare Dictionary (2016). Do these definitions resonate with your understanding of simulation-based education?
A technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain an understanding of systems or human actions.
Simulation-based education is a very versatile technique that can be used to facilitate any learning in the cognitive, psychomotor or affective domains (Battista and Nestel, 2019, Ker and Bradley, 2014). It can offer clinical teaching opportunities to participants whether novice to expert, across all health professions, targeting the spectrum of clinical skills, and in a diversity of clinical contexts. A number of simulation possibilities are captured below from box 11.1, p152 in Swanwick et al., 2019. In what ways do you apply simulation in your clinical teaching and do you see examples of your experience in this list?
| Box 11.1 Common applications of simulation in medical education [4]
Patient safety: training of teams in crisis resource management patient-specific rehearsal of planned, novel, or infrequent interventions (e.g. pre-surgical rehearsal) design and testing of new clinical equipment design and testing of new patient wards or workflows Skills training and competency assessment: routine learning and rehearsal of clinical and communication skills at all levels routine basic training of individuals and teams practice of serious and/or rare events (e.g. cardiac arrest management) induction into new clinical environments and use of equipment performance assessment of health professionals at all levels refresher training of health professionals at all levels Ameliorating clinical teaching constraints: replacement of up to 25% of clinical rotations when clinical sites are limited ensure predictable and reliable clinical experiences for learners Simulation-based interprofessional collaborative practice: explore professional identity and learn about the professional roles of other health care professionals |
Simulation is typically associated with activities positioned in a purpose-built facility, whereas in situ simulation can create alternative possibilities for learning in the real clinical setting. This can be paper-based exercises and role-play; or teaching and rehearsing procedural skills using benchtop simulators and manikins; practicing drills and scenarios in small groups, through to simulations involving the whole clinical team in real or virtual reality environments replicating their context. Whatever your particular clinical context simulation techniques are varied and adaptable and can be used to underpin the clinical teaching of technical and non-technical skills which are the focus for the use of simulation for this week of study.
Later in this week we will discuss in detail the nature of technical and non-technical skills. There is some critical debate in the simulation literature about the use of the terms, particularly non-technical skills.
Thinking point
What do you understand by these terms?
What would you identify as examples of technical and non-technical skills in your clinical practice?
The term non-technical skills is defined by Flin et al. (2008) as the cognitive, social, and personal resource skills that complement technical skills and contribute to safe and efficient task performance, and originates from the aviation industry. However, Nestel (2011) has argued that defining something by what it is NOT is misleading, whereas Gaba (2011) suggests the terms are so embedded that arguing to change this would be futile, and Glavin (2011) has argued that the use of the term skills under-represents the complexity of teaching non-technical skills in the health professions. Murphy et al (2019) continued this debate suggesting that a change in the use of language may highlight the importance of ‘behavioural’ skills as well as clinical skills in health professions curricula education.
Simulation, Technical and Non-Technical Skills (Study Guide) – Dentistry
3. Drivers for Simulation
The Society for Simulation in Healthcare (ssih.org) states that simulation has four main purposes – education, assessment, research, and health system integration in facilitating patient safety. A principal driver for the use of simulation in the health professions has been an ethical imperative to address concerns about patient safety in healthcare in particular since the seminal publications To err is human (Kohn et al, 2000) and An organisation with a Memory (Donaldson, 2002) which highlighted the extent of adverse event and the degree of harm that patients experience as a consequence of healthcare systems and clinical practice. In response, certain medical specialties in particular have embraced the benefits of simulation for learning technical and non-technical skills such as anaesthetics (Higham and Baxendale, 2017).
Here in the UK there are also a number of other coinciding circumstances that have driven demand for and created possibilities for simulation-based education including changes in undergraduate and postgraduate training programmes, changes in working terms and conditions, and the increased possibilities of technology-enhanced learning (Motolo et al, 2013). What are your current circumstances?
Of course, the COVID19 pandemic has likely changed and/or increased the reasons why we wish to engage in simulation because of restrictions upon learning opportunities in clinical settings, and there are added challenges in delivering simulation due to social distancing in clinical teaching facilities. What impact has this had in your simulation practice?
4. Activity 6.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45632
After completing the activity, please return to this resource.
5. Educational Theories underpinning simulation-based education
Educational theory is often likened to a lens through which to view a field of practice (Bordage, 2009), and adopting this stance Nestel and Bearman, 2015 consider the use of theory as a “framework of ideas which illuminates simulation-based education practices”.
You may be familiar with some of the predominant educational theorists frequently cited in relation to clinical teaching and simulation for example Knowles Principles of adult learning (1973, 1980) which draw upon the Humanist traditions of Maslow. Knowles is associated with adopting the term andragogy to distinguish the adult from the child learner, however, the need for such a distinction is argued to be more relevant to guiding instructional principles for the level and characteristics of the task at hand than the age of the learner, so the term pedagogy remains widely used in ‘adult’ education. Knowles’ principles act for us as guidelines about how to teach learners who tend to be at least somewhat independent and self-directed, and are summarised as follows:
Establish an effective learning climate, where learners feel safe and comfortable expressing themselves
Involve learners in mutual planning of relevant methods and curricular content
Involve learners in diagnosing their own needs—this will help to trigger internal motivation.
Encourage learners to formulate their own learning objectives—this gives them more control of their learning
Encourage learners to identify resources and devise strategies for using the resources to achieve their objectives
Support learners in carrying out their learning plans
Involve learners in evaluating their own learning—this can develop their skills of critical reflection.
from Kaufman and Mann chapter 2 in Understanding Medical Education: Evidence, Theory and Practice, Second Edition. Edited by Tim Swanwick. © 2014 The Association for the Study of Medical Education. Published 2014 by John Wiley & Sons, Ltd.
Thinking of your own practice, for each of the principles listed above write an example of that principle being enacted by you as a clinical teacher.
|
Principle |
Your example |
| Establish an effective learning climate | |
| Involve learners in mutual planning | |
| Involve learners in diagnosing their own needs | |
| Encourage learners to formulate their own learning objectives | |
| Encourage learners to identify resources and devise strategies for using them | |
| Support learners in carrying out their learning plans | |
| Involve learners in evaluating their own learning |
‘Principles of Adult Learning’ from Lieb, S., & Goodlad, J. (2005)
You may also be familiar with simulation experiences described in terms of Kolb’s experiential learning (1984). is a frequently cited theory which is used to illustrate the continuous cycle of simulation experiences and reflection.
Kolbs model includes concrete experience (apprehension) and abstract conceptualisation (comprehension) as means of perceiving experience, and critical reflection (intension) and active experimentation (extension) as a means of transforming the experience (Ker and Bradley, 2014).
In the context of simulation-based education, Kolb’s model frames the opportunities for shared exploration of repeated experiences, in a controlled environment, allowing reflection, feedback, and discussion to form new ideas and seek improvement in performance and the development of competence for practice.
In your key reading, Battista and Nestel (2019) suggest that “theories can inform the initial educational design, such as making decisions about what simulation modality to choose and why…“, and in this chapter in your reading list; in particular the section entitled “Integrating Theory into Simulation-based learning” (p153) you will recognise the broad educational traditions (Behaviourism, Cognitivism and Constructivism) which we considered in the Learning and Teaching module. Perhaps take time to consider this short section of reading now and see if it resonates with your experience or intentions for designing or reflecting on simulation.
This is not essential reading, but the following website and blog is a really helpful resource for reading and thinking more about applying theory to inform or explore health professions education generally (it is not specific to simulation) but it presents some excellent examples which might help you link theory to your end of week reflections for this topic:
ICE blog: A New Series on Education Theory
6. Task: Identify clinical skills teaching and simulation-based learning approaches in your own context
Identify the clinical skills teaching and simulation-based learning approaches used in your own dental education context.
Capture at least two pictures of clinical skills teaching & simulation-based learning in your own context (make sure you have consent from any people who might be in the pictures).
Think about how the clinical skills teaching and simulation-based learning approaches impact you as tutor and your students.
Identify the clinical skills teaching and simulation-based learning approaches you may use in future in the dental education context. Think about how they may enhance learning and teaching. Any challenges you may face?
Make notes in your personal journal.
7. Key principles of SBE
This assertion by Kneebone (2005) helpfully captures the key principles of simulation-based education which we take time to consider here:
“Simulation should allow for sustained, deliberate practice within a safe environment; should provide access to expert tutors; should map onto real-life clinical experience; should provide a supportive, motivational, and learner-centered milieu that is conductive to learning.”
Battista and Nestel (cited in Swanwick Chap 11, 2019) suggest a structured approach to achieve this should include the elements of briefing, simulating, and debriefing, and these are the 3 key principles of developing a simulation-based structured event.
And as we move to discuss these elements, take time to recall from our conversations in the Learning and Teaching module a concept called Constructive Alignment, and as we think about applying a simulation-based approach to teaching a technical or a nontechnical skill, you should remind yourself of this triad again:
what is it that you want your learners to learn – the intended learning outcome
how will you teach and engage participants using – the learning activity
how will you know it has been learned – assessment
“When there is alignment between what we want students to learn, what we teach, and what we assess, teaching is likely to be much more effective than when it is not.” (Biggs & Tang, 2011)
7. Key principles of SBE
7.1. A safe and effective learning environment
Safe Environment
A key principle of simulation-based education is that it can provide a safe learning environment for learners as a bridge between the simulation and the clinical environment. Simulation can offer valuable learning experiences at convenient times and locations, which can be difficult to achieve in real-life practice. Some complex procedures and medical emergencies do not present enough opportunities for gaining competence and confidence. This is a gap that simulation training methods can help fill.
A simulation centre allows the conditions stresses and time constraints of the clinical setting to be removed, creating a largely predictable environment for learning, and almost any clinical scenario or learning tasks can be scheduled repeatedly. Repetitive practice of technical and non-technical skills can take place in a learner-centered environment, where a range of cognitive and psychomotor skills can be addressed such as decision-making, effective communication, teamwork, and clinical procedures.
Psychological Safety
However, a simulated learning environment is not inherently safe in itself and so as a clinical teacher how do we prepare learners for and facilitate safety as educators in the simulated environment? Rudolph et al., 2014 suggest 4 key principles to enable a safe container for simulation activities and debriefing conversations to take place.
“Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a “fiction contract” with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety.“
Read the full article to appreciate these principles:
Rudoplh, J. W., Raemer, D. B. & Simon, R. (2014) Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simulation in Healthcare, 9, 339-349
Simulation can accommodate a range of learners from novices to experts. Beginners can gain confidence and “muscle memory” for tasks that then allow them to focus on the more demanding parts of care. Experts can better master the continuously growing array of new technologies from dental procedures to minimally invasive surgery, and radiology catheter-based therapies to robotics without putting the first groups of patients at undue risk.
Safe and Effective
To reflect on this idea further, you might be interested to read this paper (not essential). The short paragraph entitled “Environment of practice” on p.452 focuses on what the challenge point framework means from a safety and effectiveness viewpoint in terms of the increasing the level of complexity of learning from novice to expert in technical and non-technical skills.
Guadagnoli, M., Morin, M.P. & Dubrowski, A. (2012). The application of the challenge point framework in medical education. Medical education, 46, 447-453.
According to this paper which one of the following graphs shows the challenge point framework of the novice versus the expert learner? The challenge point framework, is relevant to both safety and effectiveness. The more difficult a task, the more effective the learning, up to a certain point of difficulty.
However, the more difficult the task, the greater the deterioration in (immediate) performance, i.e. the greater the risk of failure.
This risk of failure may be considered by some an unsafe learning environment. However one of the take-home messages from this paper should be, not that we must avoid learner failure to increase safety, but rather that we must create an environment in which it is “safe” to fail.
Thinking point
Draw upon what you have read in this chapter so far as well as your own experiences, and consider what are the characteristics of a ‘safe to fail’ environment? How have you created a safe and effective learning environment as an educator? What steps have you taken, once the environment has been established, to prevent it from being eroded?
7. Key principles of SBE
7.2. The simulation activity – making it real
There is a fuller discussion of the varying approaches to teaching technical and non-technical skills activities further in this week of content, and so here we will consider a key concept in associated with a simulation called Fidelity.
Looking at the examples you see in this image the versatility and spectrum of simulation experiences are very broad and can be applied to every clinical context, for example, the image of the truck is our mobile simulation facility here in Scotland which travels to bring simulation to colleagues in the remote and rural islands, highlands and lowlands!, the photo top left is of a colleague practicing neonatal resuscitation on a tabletop in Malawi in contrast with the top left image of the bank of hi-tech virtual dental simulators, etc. All are examples of different modalities of simulation, in the differing clinical environment offering different activities.
Certain clinical specialties are more commonly associated with engaging in simulation and we will consider some examples here to illustrate the concept of fidelity.
What do we mean by fidelity?
The definitions of simulation established that it is a representation of reality. The commonly used term for the accuracy with which simulation represents reality is called the FIDELITY of the simulation. Fidelity within simulation refers to the exactness or likeness of the simulation to real-life circumstances it aims to mirror (Thomas, 2013). This applies not only to the authenticity of the appearance of the simulation (physical fidelity) but also behaviours required within the simulated environment (psychological fidelity) (Levine et al., 2013).
For example, in surgical skills training, it is often functional fidelity that is important – which is the degree to which the simulated device or environment reproduces the physical characteristics of the real-world task.
Functional fidelity – does it feel like the real thing
Physical Fidelity – does it look like the real thing
Psychological fidelity – does it behave like the real thing
If the simulation is apparently very realistic this is often termed as being high fidelity, and if it is not representative of the real thing then we term it as having low fidelity. So, for instance, a laparoscopic box trainer may have:
a high degree of functional fidelity (it will teach you to tie laparoscopic knots in the same way that you would in a real operation) but…
low physical fidelity (it doesn’t look like the real thing) and
low psychological fidelity (the trainee won’t ever be fooled into thinking they are operating on a live patient)
However, if your task is simply to teach laparoscopic suturing then this is perfect for that learning outcome. If your learning outcome is to teach how to do a laparoscopic cholecystectomy, then this box trainer will not be sufficient for your needs.
The short videos below show examples of simulation supported by advanced technology in a dental setting:
The cutting edge (excuse the pun!) technologies illustrated here offer simulation experiences to develop, practice, refine technical skills in a safe learning environment and that is safe for the patient and offers the opportunity for repeated deliberate practice, haptic feedback and tutor facilitated debriefing the key elements of simulation. What aspect of fidelity do these example represent?
Of course, many of us may not have access to such sophisticated facilities, but neither do we need them.
Thinking of an alternative example in the dental setting, for example, the technology which supports the learning activities in these videos would be unrealistic, indeed would inhibit a simulation involving a role play where for example, your intended learning outcome was to demonstrate gaining consent for a procedure from a very anxious patient. The focus of learning in this simulation and role-play is consultation and communication skills. How do you create fidelity for this scenario? This links us back to the article by Rudolph et al (2014) who describe the fiction contract – gaining agreement from the participants in simulation that the situation is real is more important than the technology in this example.
Alternatively, you may consider a simulation enacted in situ in a dental setting in which there is a medical emergency and the interprofessional team can rehearse a scenario and consider the skills and drills (technical) and the behavioural or non-technical skills required to manage this simulated scenario to prepare for a real-life situation. This is the authentic and real environment and so the reality of in situ simulation can also allow the opportunity for systems testing of the clinical environment.
The point is that simulation technology does not equate with fidelity, and simulation offers a very broad spectrum of learning opportunities and there are different modalities to suit each from role-play to AI (artificial intelligence) and everything in between. As the clinical teacher it is important to consider what simulated activity suits the intended learning outcome best, and determining what level of fidelity or reality is important to allow the participant sufficient realism to ‘suspend disbelief’ in order to fully immerse themselves in the simulation.
The following article from Rudolph et al 2007 discusses this further for those interested in a deeper dive into fidelity and reality:
Rudoplh, J. W., Simon, R. & Raemer, D. B. (2007) Which reality matters? Questions on the path to high engagement in healthcare simulation.
7. Key principles of SBE
7.3. Feedback and debrief
There is considerable evidence to support the use of simulation in dental education.
Feedback in technical skill acquisition is, arguably more straightforward. You can observe the technical skill being carried out and then help the learner understand which steps were in the wrong order, which hand position to adopt, how to use equipment, etc.
Feedback in nontechnical skills is/should be slightly more of a complex learning conversation. Although you are still making sure that you only consider observed behaviours, the point of the feedback is to explore mental frames or assumptions. You want to understand why the learner did what they did during a simulation.. It is only by exploring the mental frames of the learner that you will be able to help them change. Merely commenting on why the observed behaviour itself was good/bad will not be as effective (Rudolph et al., 2007).
A longer discussion on feedback takes place elsewhere in the module, however, an aspect of facilitating feedback that is fundamental to simulation practice is the opportunity for a reflective learning conversation which is debriefing which is the opportunity for the participants in simulation, facilitated by the educators to engage in a supported reflective conversation.
The TALK tool is designed to guide clinical team debriefing, and so could be used after a routine or an adverse clinical incident or a simulated learning activity, to promote a culture of learning and patient safety. The Talk Foundation resources are accessible here – TALK Framework: Background
8. Task: Evaluate the impact of clinical teaching and simulation in the dental education context
Think about the assessment methods you may use to provide feedback and evaluate performance of students for clinical skills and simulation in your own dental education context.
Talk to your students and colleagues about how they feel about the assessment methods used in clinical teaching and simulation in your own dental education context.
Read Taylor et al. (2013)’s paper ‘Assessing the Clinical Skills of Dental Students: A Review of the Literature’ (see Reading List).
Were there any points you did not consider before reading the paper? Compare them with the ones you identified. How would you shape your assessment to enhance students’ clinical skills learning. Also think about the aspects that were mentioned by your colleagues and students.
Read Frye et al. (2012)’s paper ‘Program evaluation models and related theories: AMEE guide no. 67’ (see Reading List)
Think about the model you may use and how you may evaluate the impact of clinical teaching and simulation in your own dental education context. What might the challenges be?
Make notes in your personal journal.
9. Summary
We have introduced and broadly discussed the key issues in simulation-based education which are relevant whatever your clinical teaching and practice context and now will go onto to discuss in detail the approaches to teaching technical and non-technical skills.
For those with a particular interest in simulation, a highly recommended vCOP and resource is Simulcast, described further here by:
Thoma, B., Brazil, V., Spurr, J., Palaganas, J., Eppick, W., Grant, V. & Cheng, A. (2018) Establishing a Virtual Community of Practice in Simulation: The Value of Social Media. Simul Healthc, 13, 124-130
and
Symon, B., Spurr, J. & Brazil, V. (2020) Simulcast: a case study in the establishment of a virtual community of simulation practice. Advances in Simulation, 5, 1-5
10. The Learning of Technical Skills in the Clinical Teaching Context
Before you read on you may wish to consider how you would define a “technical skill”?
10. The Learning of Technical Skills in the Clinical Teaching Context
10.1. What is a technical skill?
Despite the widespread use of the term “technical skill”, a definition is not easily found. In aviation, where much of the non-technical skills work has been carried out, technical skills refer to “aircraft control, system management and Standard Operating Procedures” (van Avermaete, 1998, p.29). A technical skill may therefore be defined as the ability to complete a (manual) task, distinct from the non-technical skills which refer to social and cognitive skills.
Consider the following list and decide which of the following are technical skills?
Prioritising which task to carry out first
Performing an oral examination
Gathering information from patient
Carrying out a tooth extraction
Following the correct steps in the anaphylaxis protocol
Using an SBAR to handover information
Make your own notes before revealing.
Prioritising which task to carry out first (NTS)
Performing an oral examination (TS)
Gathering information from patient (NTS)
Carrying out a tooth extraction (TS)
Following the correct steps in the anaphylaxis protocol (both TS and NTS)
Using an SBAR to handover information (both TS and NTS)
The latter two examples have been chosen to make it clear that, at times, the distinction between technical and non-technical skills is not clear-cut. Sometimes whether something is a technical or non-technical skill can be in the eye of the observer or a question of focus (e.g. are you focusing on the SBAR as the ability to use this particular communication tool (TS) or as the ability to exchange information within the (extended) team (NTS)?)
In order to help improve the way that we teach it is important to have some knowledge of how we think people learn. In this section there are elements that should be familiar to you from the learning and teaching module. Some of that material is reiterated here to help make connections between what you should already know about how we learn.
Malcolm Knowles (follow the link for more information about him) introduced the term “andragogy” to describe “the art and science of helping adults learn.”
10. The Learning of Technical Skills in the Clinical Teaching Context
10.2. Knowles’s seven principles of andragogy
Most theorists agree that andragogy is not really a theory of adult learning, but they regard Knowles’ principles as guidelines on how to teach learners who tend to be at least somewhat independent and self directed. His principles can be summarised as follows:
Establish an effective learning climate, where learners feel safe and comfortable expressing themselves
Involve learners in mutual planning of relevant methods and curricular content
Involve learners in diagnosing their own needs—this will help to trigger internal motivation.
Encourage learners to formulate their own learning objectives—this gives them more control of their learning
Encourage learners to identify resources and devise strategies for using the resources to achieve their objectives
Support learners in carrying out their learning plans
Involve learners in evaluating their own learning—this can develop their skills of critical reflection.
Kaufman (2003)
THINK – were these principles applied when you were trained?
In the box – for each of the principles listed above write an example of that principle being enacted by you (as the trainer) in the operating theatre.
|
Principle |
Your example |
| Establish an effective learning climate | |
| Involve learners in mutual planning | |
| Involve learners in diagnosing their own needs | |
| Encourage learners to formulate their own learning objectives | |
| Encourage learners to identify resources and devise strategies for using them | |
| Support learners in carrying out their learning plans | |
| Involve learners in evaluating their own learning |
11. The teaching/learning of technical skills
Traditionally technical skills were acquired in the apprenticeship model and the “see one, do one, teach one” approach was practiced in a number of institutions. More recently, in the UK at least, there is a move towards showing improvement in competency over time, with the first attempts in a number of skills being carried out on a simulated model.
11. The teaching/learning of technical skills
11.1. Teaching a Procedural Skill
There are a number of different ways that we could approach the teaching/learning of a technical skill. There are several validated models for teaching psychomotor skills. One of best known was devised by the surgeon Rodney Peyton. Qutieshat (2018) integrates Gagne’s instructional design model and Peyton’s four-step approach to teach inferior alveolar nerve block to undergraduate dental students. Read the paper available in the reading list, under module essentials:
Qutieshat, A. (2018). Using Gagne’s theory and Peyton’s four-step approach to teach inferior alveolar nerve block injection. Journal of Dental Research and Review, 5(3), 75.
After reading the paper answer these questions:
What are the four steps of Peyton’s model?
How were peyton’s four-step approach integrated with Gagne’s events of instructions in the paper?
Answer to Question 1
Step 1 – “Demonstrate”: The trainer demonstrates the skill at a normal pace and without additional comments.
Step 2 – “Deconstruct”: The trainer demonstrates the respective skill while describing each procedural sub-step in detail.
Step 3 – “Explain”: The trainer performs the skill for a third time, based on the sub-steps described to him by the trainee.
Step 4 – “Perform”: The trainee performs the skill on his or her own.
Krautter et al (2011:245)
Answer to Question 2
Peyton’s Step 1 i.e. Demonstration with Gagne’s 4th stage i.e. Presenting stimulus
Peyton’s Step 2 & 3 i.e. Deconstruction & Explanation with Gagne’s 5th stage i.e. providing learning guidance
Peyton’s Step 4 i.e. Performance with Gagne’s 6th stage i.e. Practice
11. The teaching/learning of technical skills
11.2. Acquisition of Motor Skills
There are a number of theories that exist to explain how we learn practical or motor skills. We describe three such theories that are of some use in describing how we learn practical/motor skills, and that can be used to understand how we can improve our training within our own professional context:
Fitts-Posner three-stage theory of motor skill acquisition
Dreyfus and Dreyfus model of skills development
Ericsson’s Deliberate Practice
Fitts and Posners (1967) seminal work continues to be relevant today for motor skills learning. In analysing learning needs it is important to recognize where the student’s level of expertise lies for each of the procedural skills they need to do.
As an introduction (or a refresher if you have met it before), here is a short video which summarises the Fitts and Posner model, using examples from sports coaching:
https://youtu.be/OHGE68ZS8g4
Here is an outline of what happens at each of the stages:
| Cognitive Phase
Reading Watching The learner intellectualizes the task into its component steps Performance is erratic and step-like in nature Associative Phase With hands-on practice and feedback: Learner begins to integrate knowledge of task into the appropriate motor behaviours Performance becomes more fluid with fewer interruptions Autonomous Phase Final stage With practice: Performance becomes smooth and autonomous Minimal cognitive inputs |
Mitchell EL, Arora S. How educational theory can inform the training and practice of vascular surgeons. Journal of Vascular Surgery. 2012;56(2):530-537.
Another model of skills acquisition is that of Dreyfus and Dreyfus. They described five stages that a student progresses through when acquiring new skills, starting at novice and working up to expert level. Look at the breakdown of the classification below – and think about how you might need to change your teaching according to each stage that your trainee had reached. Would you need to use a different technique for a novice and a trainee who was competent? How would you tell what level they were at and if they were progressing from one level to the next?
The diagram below summarises the Dreyfus and Dreyfus framework of skill acquisition from novice to expert:
11. The teaching/learning of technical skills
11.3. Further Reading
Stuart E. Dreyfus. The Five-Stage Model of Adult Skill Acquisition. Bulletin of Science Technology & Society. 2004; 24:177.
Please access this reading through the Reading List.
11. The teaching/learning of technical skills
11.4. Task
You have a new trainee/student starting that you have not met before. Using one of the 2 frameworks discussed so far (Fitts and Posner or Dreyfus and Dreyfus) consider how you would be able to tell the stage that trainee/student had reached by observing their performance. What would you look for?
11. The teaching/learning of technical skills
11.5. Deliberate Practice and Mastery Learning
The progression of skill level from novice to expert across a variety of fields, including chess masters, musicians, pilots, and medical education, has been studied by Anders Ericsson. His research shows that individuals achieve expertise in a given skill not simply from the amount of practice, but from deliberate practice, which he defines as practice that is highly concentrated, specifically designed to improve performance, and pushes an individual to the limit of his or her current abilities. Furthermore, Ericsson states that it is the deliberate practice of specific training tasks with coaching and feedback that allows a learner to progress from novice to expert.
Deliberate practice and simulation based mastery learning of clinical skills is an evidence based practice which allows participants to achieve and demonstrate levels of competence and expertise in a simulated environment to prepare for and hone their clinical skills for clinical practice, (Ericsson, 2004, Wayne et al., 2006, Barsuk, 2009, Butter et al., 2010, McGaghie et al., 2011).
Mastery learning is an example of competency-based education that enables learners to acquire fundamental knowledge and skill, measured rigorously against pre-determined achievement standards, but without regard for the time required to achieve the desired competency outcome. In mastery learning programs the educational results are standardised with minimal variation, the variation is in the time taken for learners to demonstrate the skill required to the exacting standards (McGaghie et al, 2020).
Research in this field unequivocally demonstrates that clinical skills acquired during simulation-based mastery learning with deliberate practice, translate to improved patient care processes and outcomes (McGaghie, 2011) and post-training competency if deliberate practice is sustained (McGaghie et al., 2020).
The table from your core text Battista and Nestel, Chap 11 in Swanwick 2019, illustrates the essential steps in the use of simulation‐based mastery learning from McGaghie, W.C. (2015). When I say … mastery learning. Medical Education 49 (6): 558–559.
| Box 11.2 Steps associated with mastery learning
Baseline, or diagnostics, testing Clear learning objectives, sequenced as units usually of increasing difficulty Engagement in educational activities (e.g. deliberate skills practice, calculations, data interpretation, reading) focused on reaching the objectives A set minimum passing standard (e.g. test score) for each educational unit Formative testing to gauge unit completion at a pre-set minimum passing standard for mastery Advancement to the next educational unit given measured achievement at or above the mastery standard Continued practice or study on an educational unit until the mastery standard is reached [47] |
12. Technical skill acquisition on a simulator
Earlier in this week we considered the use of simulation.
Please list the pros and cons of acquiring/perfecting a technical skill on a simulator. When you have done this, see how your list compares with ours.
Repeated practice. Multiple attempts in short period of time. Safe (no patient). No patient getting anxious as you show your lack of expertise. Model may allow different parts of the anatomy to be seen using layers or cutaways. Opportunity to be provided with an acceptable procedural hierarchy, as opposed to the variation in clinical practice seen with different operators.
Away from workplace. Lack of realism. If a “one off” session, then time is limited. Part-task trainers and pieces of equipment show “wear and tear” and need replacing. Lack of stress can lead to a surprise when faced with real situation.
12. Technical skill acquisition on a simulator
12.1. How to use a simulator?
Most of us have used some sort of simulator in our practice. Perhaps a “phantom head” to practice restorations. Some of this may have been in full-day “restoration courses” or shorter workshops. Some of it may have been ad hoc, using a piece of equipment which happens to be available and “having a go”. Because we want to focus on effective practice, it is worth considering how best to use a simulator in order to achieve a technical skill.
One of the most successful, published, uses of a simulator to improve technical skills is the work carried out by William McGaghie and others at Northwestern University, Illinois, USA. Their “mastery learning” technique sets a “pass mark” which all learners are expected to achieve. The variable is the time taken to achieve the pass mark – some will be faster than others.
12. Technical skill acquisition on a simulator
12.2. When to use a simulator?
A simulator may be useful at the outset of technical skill acquisition to allow repeated practice with feedback. A simulator may also be used to refine a technique or to alter a step in a technique once a learner is competent. Lastly a simulator can be used immediately prior to carrying out a technical skill on a real patient. Some researchers have shown an improvement in performance with these warm-up exercises (Lee, et al., 2012; Do, et al., 2006), while others have not (Polterauer, et al., 2106).
You will note that these are surgical papers, this is because there has been very little research so far on whether other clinical specialties would benefit from similar exercises.
13. Technical skill acquisition on a patient
Please list the pros and cons of acquiring/perfecting a technical skill on a real patient. Then compare them with our list.
Real patient with real tissues etc. In the workplace, carrying out a needed procedure (being useful).
Potential for real harm. Delay in operating list due to extra time taken by learner.
At some stage the learner is going to have to “practice” on a real patient. Although in the UK this may have been preceded by a number of simulated attempts, this is not possible for all procedures, nor is it possible in many resource-poor countries. The challenge is to ensure quality (efficient, effective, safe, etc.) while appreciating that the learner will make mistakes. That is, you must create an environment in which it is safe for the learner to fail. This is the fundamental difference between the simulated and real environment; the potential for patient morbidity and mortality if you fail the learner.
Let’s think about a typical technical skill carried out in your practice. What are the considerations for ensuring patient safety during the procedure while also providing the learner with a useful learning experience? What could you do before the list? During the procedure? And after the procedure or list has finished?
14. A systematic approach to technical skills proficiency
One might assume that a difference between the simulator-based and patient-based technical skills teaching is the fact that the former is more systematic. A workshop or course designed around a technical skill, in theory, allows one to construct learning in a much more focused way than the ad hoc “the next patient needs a central line” way found in clinical practice.
There are a number of ways that one can make the clinical part of technical skills acquirement more systematic.
DOPS are a way of assessing procedural skills in the workplace. These are formative assessments that provide evidence about the students/trainees’ ability at one point in time and encourages learners to keep up with their procedural skills. These are formative assessments and could be improved by showing performance over time. (see the quote by Lewis Pugh: “Practise things until you can’t get them wrong. Not until you get them right. There’s a big difference.”).
OSCE checklists can be useful to standardise sequence of skill.
Can you think of any in your own clinical teaching/learning?
15. The role of feedback in TS acquisition
The authors of “Outliers” (Gladwell. 2008) and “Bounce” (Syed, 2010) cite the now well-known number of 10,000 hours required to become expert at a given skillset (e.g. violin-playing, chess, composing music).
There are two caveats to the “10,000 hour rule”. The first is that the “10,000 hours” was chosen almost arbitrarily, probably because it’s easy to remember and that it’s an average in a given field (violin-playing). The second caveat is that just spending 10,000 hours doing something, such as plucking the strings on your guitar, will not make you an expert. Please read the following article in which Anders Ericcson and Robert Pool explain Gladwell’s mistakes:
Anders Ericsson & Robert Pool (2016) argue that Malcolm Gladwell got us wrong: Our research was key to the 10,000-hour rule, but here’s what got oversimplified, Ericsson and Pool use the term “deliberate practice” which: “involves constantly pushing oneself beyond one’s comfort zone, following training activities designed by an expert to develop specific abilities, and using feedback to identify weaknesses and work on them” (Ericcson & Pool, 2016)
Therefore, the often-quoted maxim “Practice makes perfect” is incorrect.
Practice does not make perfect, it makes permanent. The American football coach Vince Lombardi had a similar quote: “Practice does not make perfect. Only perfect practice makes perfect.”
For a discussion on what Vince Lombardi’s “perfect practice” might be referring to, please read Noa Kageyama’s blog post: Kageyama, N. The Problem with “Perfect Practice” [Accessed 26 July 2021].
An essential component of deliberate practice is feedback. You will no doubt have delivered and received a large amount of feedback in your career. This feedback will have been of varying quality and styles (e.g. “feedback sandwich”, Pendleton’s rules.) For a thorough update on the use of feedback in skills training please read:
Hatala, R., Cook, D.A., Zendejas, B., Hamstra, S.J. & Brydges, R. 2014. Feedback for simulation-based procedural skills training: a meta-analysis and critical narrative synthesis. Advances in Health Sciences Education, 19, 251-272.
For a quick self-test of your understanding of the above paper you can answer the following true/false questions:
Feedback is better than no feedback.
For novices learning simple tasks, feedback interspersed at specific points during the procedure is better than feedback at the end.
Feedback from more than one source is better than from just one person.
Vygotsky’s social development theory argues against constructivism as a theory of learning.
True
False
True
False
In the next chapter of this week we will move on and discuss NTS within the clinical teaching context and the implications of these within the clinical workplace.
16. The Learning of Non-Technical Skills in the Clinical Teaching Context
Previously we discussed technical skills and appreciated the fact that, although some skills were obviously “technical” while others were “non-technical”, at times the labelling of a skill as “non-technical” can be a matter of focus. With that provison, this section will aim to stay within the boundaries of “pure” non-technical skills. In addition, in early this week we discussed knowledge and knowledge acquisition. It must be remembered that the appropriate deployment of non-technical skills is dependent on the underlying foundation of knowledge.
16. The Learning of Non-Technical Skills in the Clinical Teaching Context
16.1. What is a non-technical skill?
Non-technical skills might be defined as: “the cognitive and social skills that complement a worker’s technical skills” (Shields & Flin 2012).
Non-technical skills and human factors are terms that are often used interchangeably (although non-technical skills are actually an element of human factors). Watch this video for a brief overview on Human Factors:
16. The Learning of Non-Technical Skills in the Clinical Teaching Context
16.2. A brief history of non-technical skills
Non-technical skills in healthcare were adapted primarily from aviation. One of the main drivers for the widespread adoption of non-technical skills training (originally called cockpit resource management (CRM)) was the 1977 Tenerife air disaster, which claimed the lives of 583 people. Two airworthy Boeing 747s collided on the runway after a number of non-technical skills lapses. This short video explains the disaster in more detail:
Individual airlines developed their own in-house CRM training and assessment. In the mid-1990s the European Joint Aviation Authority (JAA) initiated a group which would design a pan-European assessment framework called NOTECHS (Flin, Martin et al, 2003). Professor Rhona Flin, from the University of Aberdeen’s Industrial Psychology Research Centre, was one of the lead researchers involved in this work.
In 2003 Professor Flin, in collaboration with the Aberdeen Royal Infirmary Department of Anesthesia and the Scottish Clinical Simulation Centre (SCSC), developed ANTS (Anesthetists’ Non-Technical Skills), an equivalent non-technical skills framework for anesthetists (Flin, Fletcher et al., 2003). Since 2003 there has been a significant increase in non-technical skills frameworks for other specialties, including surgeons (NOTTS), scrub practitioners (SPLINTS) and anesthetic assistants.
The ANTS framework
The ANTS framework is one of a number of examples of NTS frameworks in use to facilitate teaching and learning about NTS.
The Anaesthetists’ Non-Technical Skills (ANTS) framework identifies the following non-technical skills, dividing them up into 4 skills categories and 15 skill elements:
|
Skill Group |
Skill Category |
Skill Element |
| Cognitive (mental) | Situation Awareness | Gathering information |
| Recognising & understanding | ||
| Anticipating | ||
| Decision-making | Identifying options | |
| Balancing risks & selecting options | ||
| Re-evaluating | ||
| Social (interpersonal) | Task Management | Planning & preparing |
| Prioritising | ||
| Providing & maintaining standards | ||
| Identifying and utilising resources | ||
| Team working | Coordinating activities with team | |
| Exchanging information | ||
| Using authority & assertiveness | ||
| Assessing capabilities | ||
| Supporting others |
16. The Learning of Non-Technical Skills in the Clinical Teaching Context
16.3. Why focus on non-technical skills?
Although the disaster in Tenerife was the biggest loss of life in aviation to date, it wasn’t the only one with non-technical skills attributed as a major factor. A 1979 workshop convened by the National Aviation and Space Administration (NASA) found that failures in CRM were responsible for 60-80% of aviation accidents (Cooper, White and Lauber, 1980). When catastrophes in other industries were analysed, failures in non-technical skills were seen to play major roles. This included the Piper Alpha oil rig explosion and the Chernobyl nuclear power plant disaster.
Unsurprisingly, when evidence was sought, poor non-technical skills were found to be a major contributor to patient harm, and in 2000, the Chief Medical Officer of England published a report entitled “An organisation with a memory” which detailed the scale of the problem and the types of errors that were occurring in the NHS (Chief Medical Officer. 2000).
17. What are Human Factors?
“A simple definition of human factors is: Making it easy for people to do the right thing (and hard to do the wrong thing)“
(Although this definition omits the focus on well-being)
17. What are Human Factors?
17.1. Why are human factors important?
Because human factors concerns itself with all aspects of human performance, clinical human factors has the potential to allow us to investigate how we can provide a high-quality service in healthcare.
Please have a look at this video:
The video identifies 7 key human factors in healthcare. Can you remember what they are?
Please select from the following:
| Stress | Fatigue | Tasks |
| Cognitive Workload | Leadership | Design |
| Equipment | Teams | Culture |
| Stress | Fatigue | |
| Cognitive Workload | Design | |
| Equipment | Teams | Culture |
One of the problems with this list is that it talks about 7 key “human factors”. Unfortunately this lack of precise terminology is rife within healthcare. The term “human factors” should preferably be used solely to refer to the science. We might refer then to 7 key areas of concern or 7 areas leading to performance variability.
The other problem is that the list refers to 7 areas, probably because this was thought to be a nice (memorable) number, rather than 8 or 6.
The last problem is that the list does not provide you with a structured way of considering where human factors might be applied.
In terms of the 7 areas referred to in the video we can see that:
Stress, Fatigue (which some would define as a type of stress) and Cognitive Workload would be considered “Person” specific
Equipment would be dealt with under “Task”
Teams would be placed under “Team”
Culture could be placed under a number of headings, including “Socio-political”, “Organisation” and “Team”
Design could be placed under all the headings except for, perhaps, “Person” and “Patient”
Not only does human factors allow us to look at providing better quality healthcare, it can also look at how we teach/learn to become better healthcare professionals. This means human factors science can provide us with powerful tools to improve the learning experience.
17. What are Human Factors?
17.2. The Application of Human Factors in the Clinical Workplace
Learning in clinical practice is not only essential to ensure ongoing development of staff and students but also for the safety of our patients. There is a wealth of evidence to indicate that deficits, in skills, knowledge attitudes and experience may compromise patient safety
The list below is of the top causes of adverse events. Think about how you might approach learning in the clinical workplace to address these:
Communication
60% of errors (wrong site drain insertion)
70% poor team communication (Errors of omission of communication)
Prescribing (i.e. patient prescriptions switched)
Patient assessment
Procedural compliance
Environmental security
Leadership
Joint Commission of Accreditation of Healthcare Organisations 2005 & NPSA 2006
Errors can occur due at a social, relational, systematic and/or individual level.
Interpersonal communication is concerned with what is said and how it is said. The tone, pitch and stress we attach to our verbal communication impacts on our understanding. Thus, it’s important to not only focus on communication with patients but also communication with the rest of the team.
Read the paper in the reading list (essential):
Walshaw, E., & Mannion, C. J. (2018). Dentists are humans too–education in human factors within dental care. British dental journal, 224(11), 901.
18. The teaching/learning of non-technical skills
Traditionally the concept of non-technical skills (NTS) was not addressed at medical school or during specialty training. This means that some who are completing this module will not have had any non-technical skills theory or training. We would recommend Professor Flin’s excellent “Safety at the sharp end” (see Additional reading) if you find yourself in this position.
This may mean that unlike procedural skills that you have gained and developed throughout your education and training, you do not have the fundamental NTS skills to fall back on e.g. communication or team working.
19. Helping your learners
While the curriculum may not ask much of the trainees (and therefore you as an educator) we appreciate that poor non-technical skills are a major contributor to patient harm in clinical practice. They therefore deserve significant attention.
The first step in being able to help your learners is that you understand the vocabulary. For example, if you don’t know what the 3 elements of situation awareness are then you will not be able to help your learners understand them.
As we mentioned earlier NTS was traditionally a professional competence that was not always regarded as important as TS. However, there has been a significant shift in this perspective highlighting the importance of these key skills in professional practice.
NTS skills should be included in all forms of dental education and this has been facilitated in the past two decade (or so) via simulation-based education. Medical students having increased exposure to NTS during SBE.
Exposing students/trainees to NTS training during supportive SBE sessions has been linked to deeper and more meaningful cognitive processing of these skills which have been beneficial in preparing for professional practice. Creating immersive SBE has helped to create learning opportunities that prepare students/trainees for reality of professional practice and fully explore the key components in involved in delivering these skills, including (but not limited to) the cognitive, emotional, social and cultural elements that can influence NTS.
Kerins, J., Smith, S. E., Phillips, E. C., Clarke, B., Hamilton, A. L. & Tallentire, V. R. (2020) Exploring transformative learning when developing medical students’ non‐technical skills. Medical Education, 54, 264-274
Phillips, E. C., Smith, S. E., Clarke, B., Hamilton, A. L., Kerins, J., Hofer, J. & Tallentire, V. R. (2020) Validity of the Medi-StuNTS behavioural marker system: assessing the non-technical skills of medical students during immersive simulation. BMJ Simulation and Technology Enhanced Learning, bmjstel-2019
Mellanby, E. A. (2015) Development of a behavioural marker system for the non-technical skills of junior doctors in acute care.
The ANTS handbook is invaluable in this regard (and freely downloadable). You should be able to recall the categories and elements of the ANTS system. In addition, you should be able to recall some examples of behavioural markers for every element.
Thinking point
Thinking about your own specialty/context, what are the behavioural markers outlined in your professional framework that are used to evidence competency of NTS skills in your students/trainees?
In what ways do you think SBE could be used to encourage transformative learning of NTS skills? How could you facilitate this type of teaching within your context and in what ways would this benefit your learners? What educational impact would these sessions have on your learners?
Reflecting back to the Martin Bromiley video this not only reminds us why NTS are so important but also allows us to appreciate the need to be able to identify those skills (using a framework) so that they can be improved.
The practicalities of non-technical skills teaching can follow the route set by the technical skills teaching. i.e. Repeated deliberate practice with timely feedback provided by you.
20. Activity 6.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45633
After completing the activity, please return to this resource.
21. The role of feedback in NTS acquisition
Feedback in technical skill acquisition is, generally speaking, straightforward. You can observe the technical skill being carried out and then help the learner understand which steps were in the wrong order, which hand position to adopt, how to use equipment, etc. Feedback in NTS is/should be slightly more complex. Although you are still making sure that you only consider observed behaviours, the point of the feedback is to explore mental frames. You want to understand why the learner did what they did, e.g. why did it make sense to them to turn the fresh gas flow down? Why did they not ask for help sooner? It is only by exploring the mental frames of the learner that you will be able to help them change. Merely commenting on why the observed behaviour itself was good/bad will not be as effective (Rudolph et al., 2007).
22. Activity 6.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45634
23. References
Simulation Based Education References
Frye, A. W., & Hemmer, P. A. (2012). Program evaluation models and related theories: AMEE guide no. 67. Medical teacher, 34(5), e288-e299.
Qutieshat, A. (2018). Using Gagne’s theory and Peyton’s four-step approach to teach inferior alveolar nerve block injection. Journal of Dental Research and Review, 5(3), 75.
SWANWICK, T. (2014) Understanding Medical Education : Evidence, Theory and Practice, Hoboken, UNITED KINGDOM, John Wiley & Sons, Incorporated.
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Walshaw, E., & Mannion, C. J. (2018). Dentists are humans too–education in human factors within dental care. British dental journal, 224(11), 901.
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MOTOLA, I., DEVINE, L. A., CHUNG, H. S., SULLIVAN, J. E. & ISSENBERG, S. B. (2013) Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Medical teacher, 35, e1511-e1530
MURPHY, P., NESTEL, D. & GORMLEY, G. J.:(2019) Words matter: towards a new lexicon for ‘nontechnical skills’ training. BioMed Central.
NESTEL, D. & BEARMAN, M. (2015) Theory and Simulation-Based Education: Definitions, Worldviews and Applications. Clinical Simulation in Nursing, 11, 349-354
NESTEL, D., WALKER, K., SIMON, R., AGGARWAL, R. & ANDREATTA, P. (2011) Nontechnical Skills: An Inaccurate and Unhelpful Descriptor? : Simulation in Healthcare. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 6, 2-3
RUDOLPH, J. W., RAEMER, D. B. & SIMON, R. (2014) Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simulation in Healthcare, 9, 339-349
RUDOLPH, J. W., SIMON, R. & RAEMER, D. B.: (2007a) Which reality matters? Questions on the path to high engagement in healthcare simulation. LWW.
RUDOLPH, J. W., SIMON, R., RIVARD, P., DUFRESNE, R. L. & RAEMER, D. B. (2007b) Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology clinics, 25, 361-376
SWANWICK, T. (2014) Understanding Medical Education : Evidence, Theory and Practice, Hoboken, UNITED KINGDOM, John Wiley & Sons, Incorporated.
SWANWICK, T., FORREST, K. & O’BRIEN, B. C. (2019) Understanding Medical Education : Evidence, Theory, and Practice, Newark, UNITED KINGDOM, John Wiley & Sons, Incorporated.
SYMON, B., SPURR, J. & BRAZIL, V. (2020) Simulcast: a case study in the establishment of a virtual community of simulation practice. Advances in Simulation, 5, 1-5
THOMA, B., BRAZIL, V., SPURR, J., PALAGANAS, J., EPPICH, W., GRANT, V. & CHENG, A. (2018) Establishing a Virtual Community of Practice in Simulation: The Value of Social Media. Simul Healthc, 13, 124-130
THOMAS, M. P. (2013). The Role of Simulation in the Development of Technical Competence During Surgical Training: A Literature Review. International journal of medical education, 4: 48-58.
WALSH, C., LYDON, S., BYRNE, D., MADDEN, C., FOX, S. & O’CONNOR, P. (2018) The 100 most cited articles on healthcare simulation: a bibliometric review. Simulation in Healthcare, 13, 211-220
Technical Skill References
Do, A.T., Cabbad, M.F., Kerr, A., Serur, E., Robertazzi, R.R. & Stankovic, M.R. 2006. A warm-up laparoscopic exercise improves the subsequent laparoscopic performance of Ob-Gyn residents: a low-cost laparoscopic trainer. Journal-society of laparoendoscopic surgeons, 10, 297-301.
Ericsson, K. A., Krampe, R. T. & Tesch-Römer, C. (1993. The Role of Deliberate Practice in the Acquisition of Expert Performance. Psychological review, 100 (3): 363-406.
Fitts, P. M. & Posner, M. I. (1967). Human Performance, Belmont, CA, Brooks/Cole.
Gladwell, M. 2008. Outliers: The story of success, London, Penguin Books.
Kaufman, D. M. (2003. Abc of Learning and Teaching in Medicine: Applying Educational Theory in Practice. British Medical Journal, 326 (7382): 213-216.
Krautter M, Weyrich P, Schultz J-H, Buss SJ, Maatouk I, Jünger J, Nikendei C. Effects of Peyton’s Four-Step Approach on Objective Performance Measures in Technical Skills Training: A Controlled Trial. Teaching and Learning in Medicine. 2011; 23(3): 244-250.
Lee, J.Y., Mucksavage, P., Kerbl, D.C., Osann, K. E., Winfield, H.N., Kahol, K. & McDougall, E. M. 2012. Laparoscopic warm-up exercises improve performance of senior-level trainees during laparoscopic renal surgery. Journal of Endourology, 26, 545-550.
Polterauer, S., Husslein, H., Kranawetter, M., Schwameis, R., Reinthaller, A., Heinze, G. & Grimm, C. 2016. Effect of Preoperative Warm-up Exercise Before Laparoscopic Gynecological Surgery: A Randomized Trial. Journal of surgical education, 73, 429-432.
Syed, M. 2010. Bounce: The myth of talent and the power of practice, London, HarperCollins UK.
van Avermaete, J.A.G. 1998. NOTECHS: Non-technical skill evaluation in JAR-FCL, Amsterdam, The Netherlands, National Aerospace Laboratory NLR.
Non-Technical Skill References
Barach, P., Johnson, J. K., Ahmad, A., Galvan, C., Bognar, A., Duncan, R., Starr, J. P. & Bacha, E. A. 2008. A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease. The Journal of Thoracic and Cardiovascular Surgery, 136, 1422-1428.
Catchpole, K., Mishra, A., Handa, A. & McCulloch, P. 2008. Teamwork and error in the operating room: analysis of skills and roles. Annals of Surgery, 247, 699-706.
Cooper, G. E., White, M. D. & Lauber, J. K. 1980. Resource management on the flight deck, Moffett Field, California, USA, National Aeronautics and Space Administration, Ames Research Center.
Flin, R., Fletcher, G., McGeorge, P., Glavin, R., Maran, N. & Patey, R. 2003. Rating Anaesthetists’ Non-Technical Skills—The Ants System. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2003. SAGE Publications, 1498-1501.
Flin, R., Glavin, R., Maran, N. & Patey, R. 2003. Anaesthetists’ non-technical skills (ANTS) system handbook v1.0. Aberdeen: University of Aberdeen.
Flin, R., Martin, L., Goeters, K.-M., Hormann, H. J., Amalberti, R., Valot, C. & Nijhuis, H. 2003. Development of the NOTECHS (non-technical skills) system for assessing pilots’ CRM skills. Human Factors and Aerospace Safety, 3, 97-120.
Rudolph, J.W., Simon, R., Rivard, P., Dufresne, R.L. & Raemer, D.B. 2007. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology Clinics, 25, 361-376.
Sarvadikar A., Prescott G. D. Williams D. 2010. Attitudes to reporting medication error among differing healthcare professionals European. Journal of Clinical Pharmacology 66: 843-853.
Shields, A. & Flin, R. 2012. Paramedics’ non-technical skills: a literature review. Emergency Medicine Journal. doi: 10.1136/emermed-2012-201422
https://pgmed.dundee.ac.uk/mod/resource/view.php?id=45638
Week 7
No content
Week 8
1. Aims and Objectives
This week will focus on defining /conceptualising the term ‘organisational culture’ and the impact this has on learners as well as the role of the regulators in helping to ‘shape’ that culture. It will also explore some of the approaches that can be taken to support both educators and learners in the creation of a positive learning culture. Building on principles introduced in earlier weeks it will include opportunities to consider how best to the apply some of these principles to clinical teaching along with a consideration of the role of the educator in supporting students to maintain their own well-being and develop resilience.
Learning Objectives:
By the end of this week you will be able to:
Define ‘organisational culture’; the implications and impact it has on clinical teaching.
Develop different approaches (both internal and external) to changing culture
Evaluate the impact of environment in your own dental education context.
Understand the types of professional challenges health care workers face (as students and as practitioners) and consider different ways to offer support.
The sections contain a variety of short presentations, texts, reading and thinking points. There are also several formative tasks which are presented to help consolidate your understanding.
2. Overview
“The learner’s ability to develop the appropriate professional values, knowledge, skills and behaviours is influenced by the learning environment and culture in which they are educated and trained.”
GMC (2015). Promoting Excellence: Standards for Medical Education and Training
The switch to developing ‘outcome-based education’ in medical and health care education (both undergraduate education and post-graduate specialty training) has been described by Professor Ronald Harden as ‘the most important development in education in the past two decades’. (Harden 2015) Healthcare educators have responded by creating curricula based on the competencies the learning outcomes are expected to achieve and professional regulators have responded by creating frameworks designed to ensure consistency, relevance and the monitoring of achievement of competencies throughout.
Whilst this has led to national (and at times international) compliance with standards the focus has mostly been on learning content and assessment rather than the learning environment. Additionally those that have focused in some part of the learning environment have restricted it to the role and place of the teacher and learner rather than that of the healthcare organisational environment in which most of the clinical teaching and learning takes place.
This week’s topic will focus on:
Organizational culture (both internal and external through healthcare regulators)
Transitioning
Stress within the workplace
Harden, R. (2015). Why outcome-based education (OBE) is an important development in medical education. In Bin Abdulrahman. K.A., Mennin.S., Harden.R., Kennedy.C. (Eds.) Routledge International Handbook of Medical Education
For a quick overview on ‘what is culture?’ watch the video below (YouTube, 1:56):
2. Overview
“The learner’s ability to develop the appropriate professional values, knowledge, skills and behaviours is influenced by the learning environment and culture in which they are educated and trained.”
GMC (2015). Promoting Excellence: Standards for Medical Education and Training
The switch to developing ‘outcome-based education’ in medical and health care education (both undergraduate education and post-graduate specialty training) has been described by Professor Ronald Harden as ‘the most important development in education in the past two decades’. (Harden 2015) Healthcare educators have responded by creating curricula based on the competencies the learning outcomes are expected to achieve and professional regulators have responded by creating frameworks designed to ensure consistency, relevance and the monitoring of achievement of competencies throughout.
Whilst this has led to national (and at times international) compliance with standards the focus has mostly been on learning content and assessment rather than the learning environment. Additionally those that have focused in some part of the learning environment have restricted it to the role and place of the teacher and learner rather than that of the healthcare organisational environment in which most of the clinical teaching and learning takes place.
This week’s topic will focus on:
Organizational culture (both internal and external through healthcare regulators)
Transitioning
Stress within the workplace
Harden, R. (2015). Why outcome-based education (OBE) is an important development in medical education. In Bin Abdulrahman. K.A., Mennin.S., Harden.R., Kennedy.C. (Eds.) Routledge International Handbook of Medical Education
For a quick overview on ‘what is culture?’ watch the video
3. Task – Explore the impact of the wider environment
Think about the key aspects of the dental education environment.
Read the paper ‘The dental education environment’ (Haden et al., 2006) (see Reading List).
Identify the key aspects of the dental education environment from the paper. How do you think they impact learning and teaching? Were there any you did not think of?
Identify various physical learning environments in your own dental education context.
Capture pictures of any two learning environments you would like to reflect on (make sure you have consent from any people who might be in the pictures).
Think about how the physical environment may impact your teaching as well as student learning.
Write notes in your personal journal.
4. Organisational Culture
It is helpful to note that terms such as ‘organisational culture’, educational environment, learning environment are used interchangeably. Generally speaking they are intended to describe
“a set of features that gives each circumstance and institution a personality, a spirit, a culture and describes what it is like to be a learner within that organization” (Holt and Roff, 2004 as cited in Gruppen et al 2018)
However, there are even inconsistencies in the features contained within that description and a more sophisticated definition might be
“a complex psycho-social-physical construct co-created by individuals, groups, and organizations in a particular setting, and shaped by contextual climate and culture” (Palmgren, 2016 as cited in Gruppen et al 2018).
Before you begin this week’s activities look back at your notes on Week 1; Workplace Learning Theory which explored both Sociocultural and Sociomaterial learning. Based on your understanding of these concepts now consider your own ‘organisational culture’ and how you might define it in respect to the ways it supports teaching and learning and also the ways in which is discourages or hinders it and if it’s the latter then what can you do to change that.
The following article describes a literature review of interventions relevant to improving the organisational culture in education for health professionals. It might be helpful to note the key points in the article as we will return to it in later sections.
Read the following article, accessible through the reading list:
Gruppen L, Irby D, Durning SJ, Maggio LA. (2018) Interventions designed to improve the Learning Environment in Health Professions: A scoping review. MedEdPublish.
4. Organisational Culture
4.1. External factors; The regulatory frameworks.
‘Nobody knew healthcare could be so complicated’ DJ Trump 2017
All aspects of health care delivery no matter where it is complicated and healthcare regulation is just as complicated. This includes the complexity of multiple professional regulatory bodies who lay down organizational requirements which the organizational must comply with in order to be able to train and employ healthcare staff.
Consequently the professional regulators play a significant part in shaping and re-shaping health care organizational culture often focusing on the need for the organizations to support high quality education and training for students, trainees and the post-qualified professionals. Some also frame their regulatory requirements in a way that explicitly links patient safety to the educational standards. Recently the GMC linked patient safety to the well being of health care staff in it’s report of UK wide review; ‘Caring for doctors Caring for Patients’ (2019). This review was set up to explore the reasons for poor staff retention and the factors that impacted on the mental health and well-being of medical students and doctors and it discovered that organizations which prioritized a culture that supported learning and also patient safety, not only had higher levels of patient satisfaction but were also able to recruit and retain more qualified staff.
Whilst other regulatory frameworks follow a similar approach the extent to which they explicitly address the notion of organisational culture is varied.
Look through your own relevant regulatory* framework (both for you as a practitioner and as an educator) and identify how often there is explicit reference made to ‘organisational or learning culture’ rather than it only being implied. At the same time look for any practical approaches described that would allow you to ‘operationalise’ that learning culture within your own teaching.
*relevant by locality, specialty, level (undergraduate/postgraduate training or CPD) or a combination of these factors
4. Organisational Culture
4.2. Activity 8.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45649
After completing the activity, please return to this resource.
4. Organisational Culture
4.3. Internal factors: How to shape organisational culture?
There is no doubt that clinical teaching in medical/dental education is changing and as Professor Ronald Harden says ‘The status quo is not an option and every teacher has a responsibility to contribute to plans for the future direction of their school’.
In his paper entitled ‘Ten key features of the future medical school—not an impossible dream.’ Harden (2018) invites us to consider our response to the change in healthcare delivery which makes the ‘old ways of teaching not only inappropriate but also impractical. What Professor Harden suggests in each of his ten continua will require a considerable shift in the culture that makes up all our medical schools and as such may well be resisted.
Read the article and make notes on the points made about organizational culture that your feel are most relevant to you as an educator and with that in mind let us turn now to the specific elements that make up the learning culture within your own organization and your own specialty, and how you might be able to impact that for the development of your own teaching practice.
4. Organisational Culture
4.4. ‘Culture Eats Strategy for Breakfast’ (Peter Drucker)
1.1 ‘Culture Eats Strategy for Breakfast’ (Peter Drucker)
Although Peter Drucker is credited as having said this in regard to the Ford Motor Car Company’s reluctance to change the way they did things it is no less true of many organizations including many medical schools. So what aspects of culture can be changed and how will we know when it changes?
Looking again at the article ‘Interventions Designed to Improve the Learning Environment in the Health Professions: A Scoping Review’ (Gruppen et al 2018) and it’s description of a conceptual framework for the learning environment based on synthesis of multiple conceptual frameworks. This framework has four ‘overlapping and interactive’ components: personal, social, organizational and space (both physical and virtual) detailed in Figure 1 (adapted and inserted here).
Study the diagram and then go to Activity 8.2 and post your comments on the forum.
4. Organisational Culture
4.5. Activity 8.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45650
After completing the activity, please return to this resource.
5. Transitioning – Crossing the threshold into a new learning environment
‘Transitions have been defined as ‘dynamic movement across different expectations, tasks and responsibilities’ (Teunissen& Westerman. 2011).
Task
Read the following papers available in reading list (essential):
Serrano, C. M., Botelho, M. G., Wesselink, P. R., & Vervoorn, J. M. (2018). Challenges in the transition to clinical training in dentistry: an ADEE special interest group initial report. European Journal of Dental Education, 22(3), e451-e457.
Botelho, M., Gao, X., & Bhuyan, S. Y. (2018). An analysis of clinical transition stresses experienced by dental students: A qualitative methods approach. European Journal of Dental Education, 22(3), e564-e572.
Additional Resources
If you would like more information/resources about transition then The Quality Assurance Agency for Higher Education tackles an ‘Enhancement Theme’ topic each year and in 2017 they produced information on Transitions. The web site has a lot of information in regard to all transitions along with an interactive map that allows you to look at the areas you are most interested it.
Enhancement Theme – Transition Skills and Strategies
The video below is introducing the transitions map:
5. Transitioning – Crossing the threshold into a new learning environment
5.1. Activity 8.3
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/page/view.php?id=45651
After completing the activity, please return to this resource.
6. Stress within healthcare organisations
“There is abundant evidence that workplace stress in healthcare organizations affects quality of care for patients as well as doctors’ own health” (GMC 2019)
In Week 1 we identified some of the challenges learners’ experience when in the workplace and the argument that enabling effective CoP can have a positive influence. Similarly in Week 5 we explored the importance of reflective practice in experiential learning.
Review you notes on these concepts and consider them now in regard to your further analysis of your organisation.
6. Stress within healthcare organisations
6.1. Responding to Organisational Stress
As mentioned earlier, the GMC published a review ‘Caring for doctors Caring for Patients’ in 2019, which explored factors that negatively impacted the health and well-being of medical students and medical staff and suggested the steps needed to address them.
They identified 3 core needs which are required to ensure well-being and motivation at work and to reduce workplace stress, 6 urgent steps and also highlight the need for organizational leaders and managers to provide educational supervisors and medical schools should consider student well-being as one of their Key Performance Indices (KPI’s) and stated that these will be monitored by the GMC.
| Core Needs | Steps needed |
| A. Autonomy and Control | Voice, influence and fairness
Work conditions Work schedule and rotas |
| B. Belonging | Team Working
Culture and Leadership |
| C. Competence | Workload |
| Appendix 1 includes 2 additional sections on: | |
| Management and supervision | Organisations responsible for education and training of doctors and medical students should ensure they have an appropriate level of high-quality educational and clinical supervision provided by well-trained and compassionate supervisors. |
| Training, learning and development | Medical schools should establish a key performance indicator for student well-being across all learning environments and review feedback to assess performance. |
This review is presented as an example of a framework that allows consideration of workplace stress at individual and organizational level. You might want to review your own organizational (and regulatory) guidance to become aware of those frameworks and then consider ways in which you as an educator can:
Introduce the concept of self-care into your teaching (both explicitly and implicitly)
Identify areas where your educational programme might lead to increases stress (e.g. times of transition)
Develop approaches to reduce stress both at organizational level and within your own work with students and colleagues.
The report acknowledges that the challenges faced by healthcare professionals (students, trainees and practitioners) in clinical practice are as wide and varied as the practitioners themselves are rarely ‘single-issue’ problems and that there is a need to work with other support services to help reduce stress and its’ consequent impact on mental health and well-being.
6. Stress within healthcare organisations
6.2. Resilience
The link between professional well-being and resilience has become increasingly emphasized by both educators and regulators, so much so that in the BMJ article ‘Resilience in action: leading for resilience in response to Covid-19’ (Barton at al 2020) the authors stated that:
‘In popular culture and everyday conversation, resilience is often framed as an individual character trait where some people are better able to cope with and bounce back from adversity than others. Research in the management literature highlights that resilience is more complicated than that – it’s not just something you have, it’s something you do.’ (Barton et al 2020)
According to the GMC the ‘something that you do’ is ‘true professionalism is about striving for excellence’. To achieve this you also need to ‘develop healthy ways to cope with stress and challenges (resilience)’.
(GMC & MSC 2016)
In order to help our students cope with challenges the GMC first decided to explore what those challenges might be and along with along with other organizations such as the BMA, the Medical Schools Council etc., they carried out a series of events across the UK and produced a report with recommendations entitled ‘Medical Professionalism Matters’. (GMC 2016)
They grouped the challenges into 6 themes:
The compassionate doctor
The resilient doctor
The doctor’s dilemma
The collaborative doctor
Patient safety and quality improvement
The doctor as scholar.
The report is available here:
https://www.gmc-uk.org/-/media/documents/mpm-report_pdf-68646225.pdf
6. Stress within healthcare organisations
6.3. Activity 8.4
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45652
After completing the activity, please return to this resource.
7. Task – Evaluate the impact of environment in dental education
This task should help you explore and think about applying various methods to evaluate the impact of your own dental education environment.
Think about how exploring the perceptions of students on the dental education environment may help enhance learning and teaching.
Read the paper ‘DREEM-ing of dentistry: Students’ perception of the academic learning environment in Australia’ (Stormon, 2018) (see Reading List).
Read the paper ‘In the students’ own words: what are the strengths & weaknesses of the dental school curriculum?’ (Henzi et al,. 2007) (see Reading List).
Think about how you may use tools such as DREEM, SWOT analysis etc. to evaluate the impact of your own dental education environment. Would there be any benefits for the students and the tutors? Would it help enhance learning and teaching? What are the challenges?
Write notes in your personal journal.
8. Activity 8.5
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45653
9. References
Atherley, A., Dolmans, D., Hu, W., Hegazi, I., Alexander, S. and Teunissen, P.W. (2019), Beyond the struggles: a scoping review on the transition to undergraduate clinical training. Medical Education, 53: 559-570. doi:10.1111/medu.13883
Barton MA, Christianson M, Myers CG, et al (2020) Resilience in action: leading for resilience in response to COVID-19 BMJ Leader Published Online First: 27 May 2020. doi: 10.1136/leader-2020-000260
Botelho, M., Gao, X., & Bhuyan, S. Y. (2018). An analysis of clinical transition stresses experienced by dental students: A qualitative methods approach. European Journal of Dental Education, 22(3), e564-e572.
Coakley, N., O’Leary, P. and Bennett, D. (2019), ‘Waiting in the wings’; Lived experience at the threshold of clinical practice. Medical Education, 53: 698-709. doi:10.1111/medu.13899
Gordon L, Jindal-Snape D, Morrison J, et al. Multiple and multidimensional transitions from trainee to trained doctor: a qualitative longitudinal study in the UK. BMJ Open 2017;7:e018583. doi: 10.1136/bmjopen-2017-018583
GMC (2015). Promoting Excellence: Standards for Medical Education and Training. https://www.gmc-uk.org/-/media/documents/Promoting_excellence_standards_for_medical_education_and_training_0715.pdf_61939165.pdf.
GMC (2016). Medical professionalism matters. Report and recommendations. General Medical Council https://www.gmc-uk.org/-/media/documents/mpm-report_pdf-68646225.pdf
Gruppen, L., Irby, D., Durning, S. and Maggio, L., (2018). Interventions Designed to Improve the Learning Environment in the Health Professions: A Scoping Review. MedEdPublish, 7(3). https://doi.org/10.15694/mep.2018.0000211.1
Haden, N. K., Andrieu, S. C., Chadwick, D. G., Chmar, J. E., Cole, J. R., George, M. C., … & Meyerowitz, C. (2006). The dental education environment. Journal of Dental Education, 70(12), 1265-1270.
Harden, R., (2018). Ten key features of the future medical school—not an impossible dream. Medical Teacher, 40(10), pp.1010-1015. DOI: 10.1080/0142159X.2018.1498613
Henzi, D., Davis, E., Jasinevicius, R., & Hendricson, W. (2007). In the students’ own words: what are the strengths and weaknesses of the dental school curriculum?. Journal of Dental Education, 71(5), 632-645.
Roff, S. (2005). The Dundee Ready Educational Environment Measure (DREEM)—a generic instrument for measuring students’ perceptions of undergraduate health professions curricula. Medical teacher, 27(4), 322-325.
Serrano, C. M., Botelho, M. G., Wesselink, P. R., & Vervoorn, J. M. (2018). Challenges in the transition to clinical training in dentistry: an ADEE special interest group initial report. European Journal of Dental Education, 22(3), e451-e457.
Stormon, N., Ford, P. J., & Eley, D. S. (2019). DREEM‐ing of dentistry: Students’ perception of the academic learning environment in Australia. European journal of dental education, 23(1), 35-41.
Coakley, N., O’Leary, P. and Bennett, D. (2019), ‘Waiting in the wings’; Lived experience at the threshold of clinical practice. Medical Education, 53: 698-709. doi:10.1111/medu.13899
Fenwick, T. (2014). Sociomateriality in medical practice and learning: attuning to what matters. Med Educ, 48(1), DOI:44-52 10.1111/medu.12295
GMC (2019).Caring for doctors Caring for patients. https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf
The Quality Assurance Agency for Higher Education (2017) Enhancement Themes; Transitions. https://www.enhancementthemes.ac.uk/completed-enhancement-themes/student-transitions/transition-skills-and-strategies
Larsen, D. (2019). Expanding the definition of learning: From self to social to system. Medical Education, 53(6), 539-542.
Week 9
1. Aims and Learning Objectives
In Week 9, we aim to help you understand the concept of clinical reasoning and its significance within medical education. This will lead you to reflect on how you could teach and help your learners to understand the applicability of clinical reasoning and to enhance their competence and achieve excellence in their practice. Finally, you will examine how you could incorporate clinical reasoning within your curriculum.
Specific objectives
By the end of this week you should be able to:
Appraise the concept and significance of clinical reasoning within medical education.
Critically analyse and evaluate your teaching practice to recognise transmission of understanding, concept and usability of clinical reasoning within your learner’s context.
Critically reflect on your own experiences and examine opportunities to incorporate clinical reasoning within your curriculum/ faculty/ context.
The study guide contains a variety of short presentations, texts, reading and thinking/ reflection points. There are also several formative tasks which are presented to help consolidate your understanding.
*Please see: Additional Resources: Clinical Reasoning – Theory, for detailed theoretical understanding of this topic.
2. Clinical Reasoning in a Nutshell
Clinical reasoning can be regarded as an intersection which strongly links dental knowledge and dental practice, hence forms an integral part of clinical teaching (Linsen et al., 2018). There are many definitions of clinical reasoning, from the simplest to extended versions (refer Additional Resource: Clinical Reasoning). Whatever the definitions maybe, it aims to include an individual’s ability of integrating and applying various types of knowledge, weighing evidence, critically evaluating and reflecting upon the process used to arrive at a diagnosis (Linn et al., 2012). This highlights the requirement of binding of knowledge and also the level of experience. This is more easily said than done.
How do we now as clinical educators translate these to our learners? Clinical reasoning is complex, situation specific, built up through experience, usually implicit and based on automatic processes of pattern recognition (Delany et al., 2014). Yet we aim for our learners to become successful dental problem solvers and develop strategies to assess their required competencies.
“Helping students and trainees develop clinical reasoning is not easy. Clinical reasoning is invisible and often subconscious. There is no gold standard for defining, teaching or assessing reasoning.” (Durning et al., 2013)
3. Clinical Reasoning – From Clinical Educators to Learners
Eva. K. W (2004) revisits the context of clinical reasoning through the lens of knowledge and underlying psychological mechanisms or key capabilities such as cognitive, emotional, social, metacognition and reflexivity (refer Additional Resource: Clinical Reasoning). However, debates the importance of cognitive process and the combination of both analytical and non-analytical clinical reasoning that is required for more comprehensive approach to clinical teaching.
Figure 1: A combined model of clinical reasoning. Each type of processing interacts with both the mental representation of the case being presented and the hypotheses raised, but to different degrees depending on the context (Eva, 2004).
Providing students with an array of strategies help students to flexibly adapt as the situation demands.
Task
Read the article below and make notes on the implications for clinical teachers.
Eva K. W. (2005). What every teacher needs to know about clinical reasoning. Medical education, 39(1), 98–106.
Please access this article through the Reading List.
Learning to Reason in Practice
Figure 2: Workplace-based model of learning (Ajjawi and Higgs, 2008)
There are strategies that can help the learning of clinical reasoning. Now let us look at clinical reasoning using a workplace-based model of learning that Ajjawi developed in their PhD.
Using interpretive approaches including observation of the workplace, multiple interviews and reflective activities Ajjawi identified how clinicians learn to make decisions in the work‐place. Using this model as a basis for the rest of the chapter each of the four themes are identified here, plus a final fifth theme on assessment, will be considered.
5. Part 1: Deliberate Practice and Feedback
To advance towards expertise, the learner must:
practice on improvement of a specific aspect of performance for a well-defined task
receive immediate, detailed feedback on performance to guide improvement
have multiple, purposeful opportunities for repeated practice of the same or similar tasks.
Thus, deliberate practice supports purposefully designed practice with multiple similar patient situations, coupled with meaningful feedback, to promote positive modification of future practice (Jessee. M. A., 2018).
Please refer Week 6 which explores this concept in more detail.
6. Part 2: Articulation of Clinical Reasoning
These are quotes from participants (practicing physiotherapists) in a PhD study (Ajjawi & Higgs 2012) – how do they accord with your experiences of clinical reasoning? What are the implications in terms of teaching and learning?
I think of the outcome and then basically stop myself and think: ‘Hang on, how did I get there? OK, what are the factors? What are the movement factors? What are the Communication of clinical reasoning medical factors?’ And then I try to identify as many of those and then try to verbalise what my thought process was. (N1 interview 1)
Reasoning as someone experienced, is something that you do fairly automatically. It’s not something specifically that you think about; but when you’re actually teaching someone to reason then you need to break it down into the basics and build it up from the basics, for them to achieve your level of reasoning. (MS3 interview 3)
The principles are the same whether you are discussing a case, observing a video of a consult or you are in real time with a patient. The skill in developing clinical reasoning capability is in unpacking their (and your) thinking.
6. Part 2: Articulation of Clinical Reasoning
6.1. Rethinking Cognitive Load Theory and Cognitive Overload
Cognitive load theory is concerned with the learning of complex tasks, in which learners are often overwhelmed by the number of interactive information elements that need to be processed simultaneously before meaningful learning can commence. The process has 3 main parts, Sensory Memory, Working Memory and Long-Term Memory. The sensory memory filters the information and passes to the working memory. The working memory processes the current information and stored as organised information in the long-term memory. (Paas, van Gog & Sweller, 2010; Brünken, Moreno & Plass, 2010)).
The working memory has a limited capacity and is seen as short term and finite whereas long-term memory is infinite. Knowledge is constantly processed and shunted to long-term memory as the learner is exposed to new knowledge. However, the learners can also extract previous knowledge from long-term memory in the event of encountering new material which reduces the cognitive load. Conversely, if the working memory is constantly processing new information and the learner is unable to fall back on the long-term memory due to insufficient subject knowledge, this results in Cognitive overload. (Byyny, 2016; Paas, van Gog & Sweller, 2010)
Breaking down subject content is one of the ways to reduce this gap between working memory and long-term memory or rather reducing cognitive load
6. Part 2: Articulation of Clinical Reasoning
6.2. Deconstruction of a Clinical Case Reflections
Here is an example of a particular framework (Table 1) to guide the deconstruction of a clinical case in a small group.
Table 1: Framework to guide deconstruction of a clinical case. Adapted from Crang-Svalenius & Stjernquist, 2005.
| Background facts | Main problems | Possible explanation (list all then prioritise) | Additional information/ information required | Expected effects | Ethical, legal, economical, psychosocial aspects |
| Prognosis if nothing is done | Suggested management measures (including referral) | Learning objectives
|
The categories shown here act as a prompt to scaffold the discussion and help the learner to prioritise different aspects of the case. Ajjawi used a similar sheet with physiotherapy students on clinical placement where in the first week of the placement they would fill one out after seeing a patient and then we would discuss their findings and importantly the underlying thinking together. Eventually students will internalise the framework. Feel free to change any of the categories as suitable to your context.
6. Part 2: Articulation of Clinical Reasoning
6.3. SNAPPS
This is an example of how the use of SNAPPS with medical students increased the articulation of clinical reasoning.
SNAPPS model (Wolpaw, Wolpaw & Papp, 2003) is an approach to case presentation that is advocated in the literature. The idea is that you teach the students how to present cases following this format at the beginning of the rotation then they just use this format for the rest of the placement.
The following video (2.58 mins) demonstrates the process of teaching SNAPPS to a learner:
Additional Reading
The following readings can be accessed through the Reading List.
This article below describes the SNAPPS model. (Optional Reading)
Wolpaw, T. M., Wolpaw, D. R., Papp, K. K. (2003). SNAPPS: A Learner-centered Model for Outpatient Education. Academic Medicine, 78 (9); p 893-898.
The article below shows that SNAPPS facilitates and enhances the expression of clinical diagnostic reasoning during case presentations. (Essential Reading)
Wolpaw T1, Papp KK, Bordage G. (2009). Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med ;84(4):517-24. doi: 10.1097/ACM.0b013e31819a8cbf.
The first ‘P’ in the acronym (probe) provides an opportunity for students to ask questions of the supervisor. The study below shows that when using SNAPPS students’ uncertainties about diagnostic reasoning were better able to be explored. (Optional Reading)
Wolpaw T1, Côté L, Papp KK, Bordage G. Student uncertainties drive teaching during case presentations: more so with SNAPPS. (2012) Acad Med. 2012 Sep;87(9):1210-7.
7. Part 3: Promoting Reflective Practice
Integration of reflective practice as a metacognitive learning activity within the curriculum, promotes students’ metacognition (refer Additional Resources: Clinical Reasoning Theory) by elucidating possible gaps in their learning approaches (Wessels, du Plessis, du Plessis & Bouman, 2019).
Structured reflection while practising with cases appears to foster the learning of clinical knowledge more effectively than the generation of immediate or differential diagnoses (Mamede et al., 2010; 2012).
Please refer Week 5 which explores this concept in more detail.
7. Part 3: Promoting Reflective Practice
7.1. Promoting System 2 Analytical Thinking
Awareness of systems thinking, risk of cognitive errors and bias, cognitive forcing strategies, cognitive aides – many of these strategies aim to push clinical reasoning towards the more analytical end of the spectrum. Testing for one competing hypothesis is one of the best ways of protecting against cognitive biasing and premature closure on diagnosis. The essential reading by Cutrer et al, 2013 talks about the diagnostic pause/ timeout which aims to achieve a similar effect.
7. Part 3: Promoting Reflective Practice
7.2. Self-assessment and Self-monitoring
Self-assessment is often conceptualised as a personal, unguided reflection on performance for the purposes of generating an individually derived summary of one’s own level of knowledge, skill, and understanding in a particular area (Eva & Regehr, 2008). Self-monitoring is an aspect of self-assessment that enables clinicians to assess their own mental processes during clinical practice. It may contribute to quality of care that allows early recognition of cognitive biases, technical errors, and emotional reactions and may facilitate self-correction and development of therapeutic relationships. Self-assessment lies in two major domains—the integration of high-quality external and internal data (Epstein, Siegel & Silberman, 2008).
Examples of high-quality external data are:
Challenging cases
Morbidity
Feedback
Clinical audit
Examples of high-quality internal data are:
Mindfulness
Motivation
Diagnostic pause/ timeout
7. Part 3: Promoting Reflective Practice
7.3. Strategies to Consider
Some strategies for you to consider introducing into your team…
Simulation centre – a visit to a simulation centre for an away day
Use of video – recording practice with real patients and deconstructing it and having a conversation with the learner about the what and more importantly the why.
Critical event analysis
Audits
7. Part 3: Promoting Reflective Practice
7.4. Emotional Reactions
This figure represents a model of optimal cognitive reasoning in relation to emotional load.
Mindfulness
Moment-to-moment monitoring of thinking processes.
Linked to attitudes: patience, openness, trust, non-judging, acceptance and letting go
Evidence that improves mood, empathy, burnout (Krasner et al., 2009)
Theorised to reduce errors – but no empirical testing
Some research around stress and its influence on decision making in the simulated environment exists (LeBlanc, 2009). There is also research in nursing around distractions and clinical reasoning errors.
8. Part 4: Role Modelling
Clinical reasoning is considered the most important characteristic of a role model as well as enthusiasm and love for their work (Ambrozy et. al., 1997). Mirhaghi et al. in their comprehensive review of the literature to describe dimensions of role modelling found that it is contributed with clinical excellence, ethics and teaching skills. In addition, clinical excellence and competence also encompasses sound clinical reasoning (Cruess et al., 2008).
Let us revisit the role of a supervisor (Week 3) as an example:
Role models for good clinical reasoning – thinking out loud
Teaching on complex cases
Being explicit when teaching about clinical reasoning
Discuss decision making in uncertain situations
Feedback about learners decision making processes
Questioning students
Helping learners calibrate their decision making
Your role as an educational supervisor is to help develop structured educational opportunities whether that be in the workplace (e.g. BTE, observation and feedback) or in the classroom (case‐based learning) – see e.g. Audétat et al. 2012. However, it is also to ‘model the way’ by using your own clinical reasoning to explore your student’s clinical reasoning and help them learn from that. This is described by Neighoubr in his book ‘The Inner Apprentice (2012) who describes the necessity to adopt an ‘awareness centred’ approach to teaching through ‘noticing, realising and acknowledging’ what it is that your student is thinking. This is described in the next chapter.
8. Part 4: Role Modelling
8.1. Neighbour – How the inner apprentice learns
Neighbour’s learning process (reproduced below) highlights the importance of noticing your student’s MINIMAL CUES, realising this is a pivotal POINT OF KAIROS (point of learning) for them, acknowledging that through the use of AWARENESS RAISING QUESTIONS under conditions of SAFE INSECURITY.
Although it is probably not necessary to explore all the components in any great depth (most are self-explanatory) it is really the effectiveness of your use of Awareness Raising Questions that is key to enabling that in-depth clinical reasoning exploration. It can be useful to create your won list of ‘favourite’ most effective ways of probing and exploring and there are some suggestions as to how to create that list in the next Chapter.
How the Inner Apprentice learns
Unfamiliar circumstances generate
a need for MUTATIVE INFORMATION.
This need results in a disquieting state of
COGNITIVE DISSONANCE,
which is felt subjectively, and which is also
indicated by behavioural MINIMAL CUES
detectable by an attuned and perceptive trainer.
At the pivotal POINT OF KAIROS,
the learner’s Inner Apprentice
attempts to reduce cognitive dissonance,
either
by discounting the mutative information,
or
(helped by AWARENESS-RAISING QUESTIONING,
and under conditions of SAFE INSECURITY)
by restructuring the knowledge store,
including its beliefs and values,
i.e. learning.
Repertoire-enhancing learning
produces a sense of
COGNITIVE RESONANCE,
and in extreme cases, a powerful EPIPHANY,
which also have learner-specific minimal cures?
The legacy of cognitive resonance is
an educational EXPANSION SPACE,
hierarchically organises,
into which the learner grows and develops
as the TRAJECTORY OF APPRENTICESHIP unfolds.
Neighbour (2012) The Inner Apprentice. Figure 6.1 p 116. Kluwer
8. Part 4: Role Modelling
8.2. Awareness-Raising Questions
The example below of an approach to generating ARQ’s is based on a tutorial on a GP consultation and so is laid out under the heading that relates to the key areas of the consultation under consideration. However, a more comprehensive approach to creating your own list might be to develop examples of questions under the categories of ‘What’, ‘Where’, ‘When’, ‘How’, or even at times ‘Who’ but it’s important NOT to ask a direct ‘Why’ question as this often leads to a defensive response. As you can see from the example below indirect questions are also useful.
(Opening gambit, curtain-raiser)
Tell me your thoughts about …
I noticed you said …
(Speech censoring)
Hold on, could you please tell me more about …
I’m wondering what you meant by …
That sounds interesting …
Could you go into a bit more detail?
Could you explain why you …
(Value-laden language)
That’s an interesting word – tell me why you said …
It sounds as if you might have some strong feelings about …
(Internal search)
What were you thinking just then?
I had the impression you might have been remembering something just then
(Micro-emotions)
I think you were feeling some … just then. Could you tell me about it?
It seems that makes you feel a bit …
(Silence)
What are you thinking or feeling right now?
(Gently repeat some of the student’s significant words)
Has what we’ve been talking about reminded you of anything else?
As we’re talking are you having any fresh thoughts?
Let me tell you what I’m thinking or feeling at the moment
Neighbour, 2012
9. Part 5: Re-Engineering Assessment (and Feedback)
Re‐engineering assessment is about explicitly assessing and providing feedback on clinical reasoning. Refer Week 3 for a rethink on feedback.
9. Part 5: Re-Engineering Assessment (and Feedback)
9.1. Script Concordance Tests (SCTs)
Script Concordance tests are the current gold standard in written tests that assess cognitive reasoning. The script concordance test (SCT), based on cognitive psychology script theory, is a tool of clinical – reasoning assessment that may be used to evaluate a candidate’s approach to ill-defined problems encountered in practice (Lubarsky et al., 2013)
SCTs are:
a test for diagnostic or management reasoning
based on experienced doctor opinion
pioneered by Charlin et al, 2000
Currently SCT is the most promising written test for clinical reasoning. SCTs are challenging to write and to develop a scoring schema. Many articles have been published about SCTs. Please see the optional reading section for this week, in the reading list.
Additional Reading
Charlin et al. (2000) The script concordance test: A tool to assess the reflective clinician. Teaching and Learning in Medicine 12(4); 189-195.
Lubarsky, S., Dory, V., Duggan, P., Gagnon, R. & Charlin, B. (2013) Script concordance testing: From theory to practice: AMEE Guide No. 75, Medical Teacher, 35:3, 184-193
Please access these readings through the Reading List under Optional Reading.
10. How Can You Promote Clinical Reasoning Within Your Practice?
Task
Read and Reflect
Read the article below which reviews the process of clinical reasoning and provides the teacher with a framework to teach clinical reasoning to students and junior doctors.
Linn, A., Khaw, C., Kildea, H. & Tonkin, A. (2012). Clinical Reasoning – A guide to improving teaching and practice. Australian Family Physician, 41(1); 18-20.
Please access this reading through the Reading List under Essential Reading.
Think how you would teach clinical reasoning within your own context.
(Please spend 2 hours on this task)
11. Activity 9.1
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45661
After completing this activity please return to this resource.
12. Take-Home Messages
Principles
Think about your own clinical reasoning and learn to break things down
Teach models of clinical reasoning, susceptibility to cognitive errors, and forcing strategies to avoid them
Raise awareness of and critically reflect on factors that influence decision making
Facilitate learning from experiences
Help sharpen perceptual skills
Reflection, thinking, planning
Provide feedback based on observation
Critical thinking rather than knowledge-focus
Help trainees develop rules and recognise patterns, encourage them to make links to similar situations, compare and contrast – be explicit
Avoid focussing on knowledge alone
Force consideration of alternative possibilities
Important to model values, attitudes, behaviour and thinking
Some evidence for teaching metacognitive/reflective strategies
Recognise conditions that compromise decision making (e.g. stress, fatigue, distractions)
Learning from peers, educators, supervisors through explicit practice reflection, discussion and feedback of CR is essential
Notice that the principles link in with the capabilities mention in the previous chapter in relation to the cognitive, metacognitive, social and emotional capabilities.
12. Take-Home Messages
12.1. Don’t forget good educational principles
Create a positive learning environment
Set realistic and clear expectations
Build on prior knowledge and experiences
Provide supported participation
Provide time for reflection on experience
Consider follow-up learning tasks
Give (and take) feedback regularly
A combination of knowing about clinical reasoning (Additional Resources: Clinical Reasoning – Theory), the evidence (presented here) and the educational theory (presented throughout this programme with some principles summarised here) is crucial in order to develop structured opportunities for developing clinical reasoning and dealing with difficulties in clinical reasoning (Audétat et al 2012).
13. Activity 9.2
You should now complete this activity, which you can access using the link below:
https://pgmed.dundee.ac.uk/mod/forum/view.php?id=45662
14. References
Ajjawi, R., & Higgs, J. (2012). Core components of communication of clinical reasoning: a qualitative study with experienced Australian physiotherapists. Advances in Health Sciences Education, 17(1), 107-11B.
Ajjawi, R., & Higgs, J. (2008). Learning to reason: A journey of professional socialisation. Advances in Health Sciences Education, 13(2), 133-150.
Ajjawi, R., Thistlethwaite, J., Aslani, P., & Cooling, N. (2010). What are the perceived learning needs of Australian general practice registrars for quality prescribing? SMC Medical Education, IC(I), 92.
Ambrozy, D. M., Irby, D. M., Bowen, J. L., Burack, J. H., Carline, J. D., & Stritter, F. T. (1997). Role models’ perceptions of themselves and their influence on students’ specialty choices. Academic medicine: journal of the Association of American Medical Colleges, 72(12), 1119–1121. https://doi.org/10.1097/00001888-199712000-00028
Atkinson, K., Ajjawi, R., & Cooling, N. (2011). Promoting clinical reasoning in general practice trainees: role of the clinical teacher. The Clinical Teacher, 8(3), 176-180.
Audétat, M.-C., Dory, V., Nendaz, M., Vanpee, D., Pestiaux, D., Junod Perron, N., & Charlin, B. (2012). What is so difficult about managing clinical reasoning difficulties? Medical Education, 46(2), 216-227.
Brünken, R., Moreno, R., & Plass, J. L. (2010). Cognitive Load Theory: Historical Development and Relation to Other Theories. Cognitive Load Theory. Cambridge University Press.
Brünken, R., Moreno, R., & Plass, J. L. (2010). Cognitive Load Theory: Recent Theoretical Advances. Cognitive Load Theory. Cambridge University Press.
Byyny R. L. (2016). Information and cognitive overload: How much is too much?. The Pharos of Alpha Omega Alpha-Honor Medical Society. Alpha Omega Alpha, 79(4), 2–7.
Charlin et al. (2CCC) The script concordance test: A tool to assess the reflective clinician. Teaching and Learning in Medicine 12(4); 189-195.
Cruess, S. R., Cruess, R. L., & Steinert, Y. (2008). Role modelling–making the most of a powerful teaching strategy. BMJ (Clinical research ed.), 336(7646), 718–721. https://doi.org/10.1136/bmj.39503.757847.BE
Cutrer, W. B., Sullivan, W. M., & Fleming, A. E. (2013). Educational Strategies for Improving Clinical Reasoning. Current Problems in Pediatric and Adolescent Health Care, 43B), 248-257
Delany, C., Golding, C. (2014). Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC Med Educ 14, 20. https://doi.org/10.1186/1472-6920-14-20
Epstein, R. M., Siegel, D. J., & Silberman, J. (2008). Self-Monitoring in Clinical Practice: A Challenge for Medical Educators. The Journal of Continuing Education in the Health Professions 28(1), 5-13.
Eva K. W. (2005). What every teacher needs to know about clinical reasoning. Medical education, 39(1), 98–106. https://doi.org/10.1111/j.1365-2929.2004.01972.x
Eva, K. W., & Regehr, G. (2008). “I’ll never play professional football” and other fallacies of self-assessment. The Journal of Continuing Education in the Health Professions, 28(1), 14-1B.
Gagnon. N., Bernier. C., Houde. S., & Xhignesse. M. (2020). Teaching and learning clinical reasoning: a teacher’s toolbox to meet different learning needs. British Journal of Hospital Medicine, 81(3), 1-8.
Jessee. M. A. (2018). Pursuing Improvement in Clinical Reasoning: The Integrated Clinical Education Theory. Journal of Nursing Education, 57(1), 7-13.
Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, et al. (200B) Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.
LeBlanc V. R. (2009). The effects of acute stress on performance: implications for health professions education. Academic medicine: journal of the Association of American Medical Colleges, 84(10 Suppl), S25–S33. https://doi.org/10.1097/ACM.0b013e3181b37b8f
Linn. A., Khaw. C., Kildea. H. & Tonkin. A. (2012). Clinical reasoning. A guide to improving teaching and practice. Aust Fam Physician, 41:18–20.
Linsen. A., Elshout. G., Pols. D., Zwaan. L. & Mamede. S. (2018). Education in Clinical Reasoning: An Experimental Study on Strategies to Foster Novice Medical Students’ Engagement in Learning Activities. Health Professions Education, 4(2), 86–96.
Lubarsky, S., Dory, V., Duggan, P., Gagnon, R. & Charlin, B. (2013) Script concordance testing: From theory to practice: AMEE Guide No. 75, Medical Teacher, 35:3, 184-193, DOI:10.3109/0142159X.2013.760036
Mamede, S., Schmidt, H. G., Rikers, R., Penaforte, J. C., & Coelho-Filho, J. M. (2007). Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning. Medical Education, 41(12), 1185-1192.
Mamede, S., van Gag, T., van den Berge, K., Rikers, R. M., Van Saase, J. L., Van Guldener, C., et al. (2010). Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA, 304(11), 1198-1203.
Mamede, S., van Gag, T., Maura, A. S., de Faria, R., Peixoto, J. M., Rikers, R., et al. (2012). Reflection as a strategy to foster medical students’ acquisition of diagnostic competence. Medical Education, 46(5), 464-472.
Mirhaghi1, A., Moonaghi, H. K., Sharafi, S., Zeydi, A. E. (2015). Role Modelling: A Precious Heritage in
Medical Education. Scientific Journal of the Faculty of Medicine in Nis, 32(1): 31 – 42.
Paas, F., van Gog, T. & Sweller, J. (2010). Cognitive Load Theory: New Conceptualizations, Specifications, and Integrated Research Perspectives. Educ Psychol Rev 22, 115–121. https://doi.org/10.1007/s10648-010-9133-8
Scott, l. A. (200B). Errors in clinical reasoning: causes and remedial strategies. BMJ, 338, b186C
Wessels, Q., du Plessis, A., du Plessis, A. & Bouman, D. (2019). The use of reflective practice to promote pharmacy students’ metacognition in a foundation anatomy course. Anatomy Journal of Africa, 8(1): 1474 – 1481.