Download SOME ADULT LEARNING THEORY

TEACHING CLINICAL SKILLS
The process of gaining knowledge and skills can be likened to a
journey with several stages to pass through on the way from
being unskilled to skilled. Theoretical models
1)
Awareness
First there is the awareness of the existence of a knowledge or skill – this awareness
may be raised by self-recognition of a gap in knowledge or through interaction with
others. A teacher should be able to help a learner recognise their needs and identify how
these should be met. This would often follow the experiential learning cycle.
2) Acquisition
The acquisition of new knowledge or skills can be done in a number of ways and this
should suit the learning style of the learner whilst always remembering that patient care
comes first. Thus for example learning could be achieved informally through colleagues,
during tutorial time, in discussion in small groups, through e-learning or by a formal
teaching course.
3) Development
The trainee then develops their knowledge and ability to perform the skill. This requires 4
R words which help develop a cycle of learning. Reflection, Rehearsal, Repetition
and Review.
The teacher can support this by encouraging the learner to reflect upon what they are
doing, providing the opportunities for rehearsal and repetition and regularly reviewing
progress.
But remember that Practice does not make perfect – makes permanent. Only perfect
practice makes perfect performance. One description of this calls this Deliberate
practice. This is activity that's explicitly intended to improve performance that reaches
for objectives just beyond one's level of competence, provides feedback on results and
involves high levels of repetition
4) Mastery
Eventually the teacher’s review concludes that the learner has mastered the skill and is
able to do this independently. They should also have reached a stage where they can
teach others. It should be remembered that once a skill is learnt it will become rusty and
potentially dangerous if there is not ongoing practice and repetition.
5) Adaptability
Once we have learnt one skill it then becomes possible to adapt it to other skills. For
example once we can take a blood sample it becomes easier to learn how to gain
intravenous access for a drip.
A second but parallel model of the journey from novice to expert is depicted in
The Conscious-competence framework which consists of four stages.
1)
UI - The person is unaware of the existence of the skill and therefore of its
relevance to the role they are performing. This typically is true of new learners but
there is a danger that established doctors remain unaware of changes in practice
whilst thinking they are competent.
2)
CI - The person becomes aware of the existence of the skill and how it could be
used to enhance their knowledge and improve their working practice. They then
aim to acquire that skill.
3)
CC - The person acquires the skill and reaches a level where they are comfortable
performing the skill and can perform it consistently to a reasonable standard.
Because it requires concentration of thought this can lead to a rather robotic
performance or loss of focus if other things happen. At times this means that there
can be a temporary loss of competence when working under pressure or having to
multitask.
4)
UC - The person has acquired a level of performance that enables them to perform
the skill with little mental effort, it has become second nature and often intuitive.
The person who has reached this stage is not necessarily the best teacher of a skill
as they no longer need to think about the actions they are performing and therefore
may have difficulty in articulating all the aspects of the skill to a novice.
The diagram shows the movement of this journey as the learner follows the red arrows.
The green arrow identifies the need of the teacher to reflect back to be able to teach at
the right stage for the learner.
Competence
Conscious
Incompetence
CC: the person achieves CI: the person becomes
'conscious competence' in aware of the existence
a skill when they can
and relevance of the skill
perform it reliably at will
and aims to acquire it
UC: the skill becomes so
UI: the person is not
Unconscious practiced that it enters the aware that they have a
unconscious parts of the particular deficiency in
brain - it becomes 'second
the area concerned
nature'
The most effective teacher should be in the zone of the learner and once awareness has
been raised this would typically be in CI in early learners and CC in those who are more
established. The teacher should think through the processes involved in performing the
skill and articulate this comprehensively and accurately to a trainee.
UI may be the domain of the poor performer in that their skills are lacking but they may
not be aware of this.
CI may be the domain of the trainee in that they know they need to acquire skills in
certain areas and are actively pursuing this.
CC may be the domain of most interaction between the learner and teacher as the
former seeks mastery.
The ability to reflect back is an important skill and has been explained with the term
reflective competence - a step beyond unconscious competence and looking at how
the teacher’s unconscious competence developed and understanding the theories and
models and beliefs that informed and maintained that competence.
The problem for many teachers is doing this effectively.
PRACTICAL APPLICATION
This provides some background to the theory of learning a skill and I will now detail a
learning exercise where skills teaching can be demonstrated using the 4 step approach.
If this is being done on a course I would ask participants to bring a non medical skill –
like tying a knot, fitting a camera battery or making a paper napkin for example – which
they can teach in less than 2 minutes.
I would usually tie this in with a session looking at feedback skills so that participants can
work in trios with all playing the part of teacher, learner who then gives feedback to the
teacher and observer who gives feedback on the feedback.
The 4 step approach
1)
2)
3)
4)
Trainer demonstrates – no commentary
Trainer demonstrates – with commentary
Trainer demonstrates – trainee commentates
Trainee demonstrates – trainee commentates
At the start it is worth checking what experience the learner already has of the skill or
similar skills.
Allow time for questions and check how the learner is getting on throughout.
Get the learner positioned so they can see easily and from the correct angle. (For
example side by side rather than facing one another)
Allow time at the end to summarise and decide what the learner should do next.
Demonstrating with no commentary allows a learner to concentrate fully on observing
the task and this will be particularly important to visual learners.
Many teachers find it difficult to remember this stage.
Teachers who teach with Unconscious Competence sometimes run through this very
quickly and make it appear very easy which can put a learner off.
Also when they move to Stage 2 they can find it difficult to articulate what they are doing.
However adding a commentary breaks down the process for the learner and letting them
commentate acts as repetition before they move on to the task of both doing and
commenting on what they are doing. This allows 4 stages of repetition and the first stage
towards the learner reaching mastery.
This is adapted from an article, from the Medical Journal of Australia which gives more
detail and references.
Teaching on the run tips 5: teaching a skill (MJAVolume181 Number 6 20 September 2004)
Fiona R Lake and Jeffrey M Hamdorf
Lack of time is a common difficulty for teachers and the following
comes from part of an article providing suggestions for teaching
when time is limited. The full article is in BMJ 2008; 336:384-7
In particular we focus on the One Minute Preceptor model
(OMP) as an effective and efficient way of using cases to learn.
To achieve this combined caring and teaching goal in a time efficient manner, clinical
teachers use various strategies to (a) identify the needs of each individual learner, (b)
teach according to these specific needs, and (c) provide feedback on performance. This
three step teaching process can be adapted to the environment in which the teaching is
taking place.
Step 1: Identify the learner’s needs
The time saving rule of thumb is: target, and then teach. If the teacher can quickly
determine what an individual learner needs to know, then he or she can focus any
teaching on those needs, thus saving time by not teaching what the learner already
knows or is not ready for. To assess the learner’s level of knowledge quickly, the teacher
needs only two tools: good questions and the ability to listen and observe.
Ask questions
Questions are the teacher’s primary diagnostic tool, can precede or follow the learner’s
encounter with the patient, and can guide the choice of teaching methods. Questions
asked before a patient encounter can help the teacher to ascertain the learner’s
experience with the problem at hand—for example, "have you had a chance before to do
investigations in an elderly patient with sudden onset of mental status changes?" or "do
you already have a differential diagnosis in mind?" Questions that follow the learner’s
presentation of patient findings can guide the teacher’s decisions about what and how to
teach—for example, "What do you think we should do next?"
Conduct a two-minute observation
This time efficient strategy allows the teacher to observe the learner’s performance
instead of making inferences about the ability of the learner from the case presentation
alone. The two-minute observation model, which is like an epidemiologist’s sampling
technique, involves the teacher slipping in and out of the patient encounter without
intervening, in order to gather more direct information about the learner’s needs for
guidance, direction, feedback, or enrichment. Both teacher and learner should agree on
the patient encounter that will be used and the aspect of the interaction that will be
targeted for the quick observation—such as establishing patient rapport, history taking,
physical examination, or patient education. Four elements are needed for this to work
effectively:


The teacher must be sure that the learner knows that the observation is for
teaching purposes and understands how the observation will work;
The learner will need to explain the process to the patient so that the teacher can
enter and leave the room without disrupting the encounter;


Whenever in the room, the teacher needs to be outside the patient’s visual field
and refrain from participating in any manner;
Time will be needed for discussion afterwards, to focus on what was done well,
what can be improved, and what type of independent study might be useful.
Step 2: Teach rapidly the "one-minute preceptor" model
The most widely known and researched teaching method is the "one-minute preceptor
model," (the one-minute teaching model).This method involves identifying the needs of
each individual learner, teaching, and providing feedback by using a five step approach:





Get a commitment about what the learner thinks is going on with the patient;
Probe for underlying reasoning or alternative explanations;
Teach a general principle;
Provide positive feedback about what the learner did right;
Correct any errors by making suggestions for improvement.
Box 1 gives an example of the model in use.
Research on the one-minute preceptor model has found strong satisfaction with the
model by learners and teachers and generally improved learners’ ratings of their faculty
and resident teaching after they were observed and given feedback on the basis of the
model.
Box 1 Example of the one-minute preceptor model
The following dialogue took place after a learner’s case presentation of a 3 year old
boy who complained of earache.
Get a commitment
Teacher: "What do you think is going on?"
Learner: "I think he has an upper respiratory tract infection, probably an
acute bacterial otitis media."
Probe for supporting evidence
Teacher: "What led you to that conclusion?"
Learner: "He has a history of repeated acute otitis media and currently has
a fever and a painful right ear. In addition, I believe his right ear is red and
less mobile."
Teacher: "What would you like to do for him?"
Learner: "First, I would like you to confirm my findings. If you agree, then we
should give him some antibiotics. As he doesn’t have any allergies to
medications and was successfully treated with amoxicillin in the past, I think
amoxicillin is a reasonable choice."
Teach a general principle
Teacher: "It does sound like otitis media. The key features of otitis media in
the history are upper respiratory tract symptoms followed by ear pain and
increasing fever and irritability. He is also at risk as he has had prior
episodes of acute otitis media. In the physical examination, I look for the
appearance of the ear drum—including any erythema, opacification, and
distortion of landmarks with bulging or retraction. Sometimes there will be
purulent discharge in the external canal if the tympanic membrane has
perforated. This child would seem to fit these criteria." The teacher
concludes: "With the lack of allergies, amoxicillin is a logical choice for an
antibiotic. I’ll be glad to confirm your ear examination findings. Let’s go and
see the patient."
Reinforce what was done well
Teacher: "You did a good job of putting the history and physical
examination findings together into a coherent whole.
Correct errors and/or make recommendations for improvement
Teacher: "You might check the Cochrane Collaboration for an evidence
based review on otitis media."
Step 3: Provide feedback
Feedback is one of the most underused yet powerful instructional strategies available
and can take less than a minute, and several of the above models build feedback into
the sequence. Feedback provides the learner with a description of their strengths and
recommendations for improvement. The key to feedback is going beyond praise to
specific descriptive comments about a learner’s performance. It can also serve as an
opportunity to promote self reflection and independent study.