Teachingandlearningintheclinicalcontext

Author: DrLindaHutchinsonMBBS,MRCP,DCH,MSc DirectorofEducationandWorkforceDevelopment UniversityHospitalLewisham London Thispaperwasfirstwrittenin2003aspartofaprojectledbytheLondon Deanerytoprovideawebbasedlearningresourcetosupportthe educationaldevelopmentofclinicalteachers.ItwasrevisedbyJudy McKimmin2007withtheintroductionoftheDeanerysnewwebbased learningpackageforclinicalteachers.Eachofthepapersprovidesa summaryandbackgroundreadingonacoretopicinclinicaleducation. Aims Thispaper: Providessomeideasofhowtomakethemostofclinicalscenarios whenteachingstudentsortrainees Raisesawarenessoftherelevanceoftheoriesoflearningandteaching toclinicalcontexts Enablesyoutoidentifyaspectsofyoureverydayworkwhichcanbe usedasevidenceforCPD Learningoutcomes Afterstudyingthispaper,youwillbeableto: Identifyopportunitiesforteachingandenablinglearningineveryday clinicalpractice ApplysomeofthemajortheoriesoflearningandteachingfromHigher Educationandhealthcarecontextstoyourownteachingpractice Developareflectiveapproachtoteachingandlearningwhichyoucan utiliseinyourowncontinuingprofessionaldevelopment Content Introduction Educationaltheories: Behaviourtheory Cognitivetheory Humanismandadultlearningtheory Situatedcognitionandthetransferoflearning Applicationoflearningtheories

Thispaperprovidesanoverviewofteachingandlearningintheclinical context,considerstheoryandpractice.Itprovidesanoverviewofsome educationaltheories,explainshowthesehaveimpactedonteaching practiceandoffersideasforputtingtheoryintopracticeintheclinical contextwithaviewtocreatinggoodsituationsforlearning. ThereisacomplementarypaperFacilitatinglearning:Teachingand learningmethodswhichfocusesonthetoolsofthetrade:lookingat someofthemainteachingandlearningmethodsthatclinicalteachers mightuse. Introduction Healthcarehasasmanycontextsasyoucouldwishtofind.Teaching andlearningcouldbehappeninginafranticemergencyunit,ina childrensclinic,inaprimarycarefacility,inadentistsurgery,on outreachnursingvisits,inacommunitypharmacyandonandonandon. Itisdifficulttocomeupwithrulesofteachingthatwillfitallpossible situations. Maybethebestapproachwouldbetolookatsomegeneralprinciplesfor learning,arangeoftheoriesandapproachesthatcanbepickedand mixedtosuitthegivensituation.Thereisnotarightorwrongwayto teachortolearn.ToparaphraseMichaelErautsrecentcommentsonthe generalisabilityofresearch,insteadoftalkingaboutrightandwrong,we couldtalkabouttheconditionsunderwhichagivenapproachismost likelytowork(2002). Iflearningistheacquisitionofnewknowledge,skillsorattitudes,then teachingisprovidingtheopportunityforthattohappen.Educational theoristshavetriedtodescribetheprocessesbywhichlearningoccurs. Educationaltheories Behaviourtheory EducationaltheoryasweknowitstartedwithPavlovandhiscolleagues. Whetherusingdogs,pigeon,rats,or,unbelievabletoconsidernow,young children,theyworkedontheideathatifyourepeatedthesamestimulus enoughtimesandgaveanegativereinforcement(eg.electricshock)or positivereinforcement(eg.food)forincorrectandcorrectaction, eventuallyyoursubjectwouldlearn.Thisisknownasbehaviour theory.Beforewedismissitcompletely,acoupleofthingsoriginating frombehaviourtheorystillstandtoday.Firstlyreinforcementor punishmentandrewardcontinueinuse,althoughitismorepolitically correcttocallthemfeedback,andtousepositiveratherthannegative approaches. Secondly,breakingtasksdownintosmallsteps.Whentheratwas taughttonegotiateamazetogetthefood,smallbitsofthemazewere learntbeforegoingontothenextbitandfinallythewholemaze.We

teachclinicalskillsbybreakingthemdownintosteps,andeachstepand thewholerehearsed.

Whatthebehaviouristsgaveus: Activityaidslearning Repetitionandpracticeaidslearning Smallstepsaidlearning Reinforcementaidslearning

Cognitivetheory
th Inthemiddleofthe20 centuryitbecamemoresophisticated,with cognitivetheory.Theageofradioandelectricalgoods,especiallythe computerwasinfluentialhere.Thetheoristsofthetimesaidwelearnby receivinginformation,processingit,storingitandretrievingita transmitterradiomodel.Teachersneededtoensureeachstepwas optimised.Reducingextraneousnoisetoallowthemainmessagetobe theonethatwasheardmakingsurepeoplewereattendingsothatthe messagewouldgetthrough.Processingtheinformationmeantrepeating it,usingit,tryinganumberofformats.Fromthiscomestheideaof givingapieceofinformation,thengettingaclassorgrouptowork throughexamples. Feedbackisanintegralpartofcognitivetheory, similartothereinforcementofbehaviourism.

Storinginformationforlaterretrievalisassistedbytheprocessing mentionedabove.Thenotionofsurface,strategicanddeeplearningis familiartomostpeople.Surfacelearningisstoringlotsofinformationin shorttermmemorytoregurgitateinanexaminationorimmediate setting.Strategiclearningallowsthesubjecttoignorethebitsthatare notanticipatedasrequired,andfocusonthosethatare.Againoften assessmentdriven,butevenintherealworld,ifyouattendalectureor presentationyouonlylistentothebitsthatyouthinkarerelevanttoyour lifeorworkandmakesensewithinit. Deeplearningisfacilitatedbybeingencouragedtounderstandthe background,thebasicelementsthatleadtothewholeconcept.It assumeslearningwillbebankedinlongtermmemorystoreasithasbeen learnt,examined,digested,reprocessed,understood. Surfacelearninghasabadreputation,deeplearningagoodoneand strategicisfrowneduponbutacknowledgedasasurvivaltactic.Yetallof usemployeachoftheseinoureverydaylife.Anddeeplearningisnotthe wholeanswer.Ionceknewhowtousecalculus.Ipractiseditina numberofways,knewthehistoryofitsdevelopmentanddiscovery,loved mathsanddidwellinexams.Mylearningcouldnothavebeendeeper, butithaslongbeeninaccessibleinthatlongtermmemorybank. Absolutelynochanceofrecallnow.Evendeeplearningneedsregularuse inordertokeepit.

Althoughpredominantlyconcentratingontheteaching,thecognitivistsdid acknowledgethatindividuallearnershaddifferentstyles.Anumberof inventoriesarenowavailabletoallowindividualorgrouplearningstyles tobequalified. Inthetablebelow,wecanseehowlearningprocessescanbelinkedto instructionaleventsthattheteachercanfacilitate.Thefirsttwocolumns showstagesfromGagnsinstructionsforlearningtakenfromThe ConditionsofLearningandTheoryofInstruction,1965. Thelastcolumngivespossibleexamplesrelatingtoclinicalteachingand learningsituations. LearningProcess AttentionAlertness Expectancy InstructionalEvent gainingattention Examples presentcasestudy, clinicalphotograph informinglearnerof explainoutlineof theobjective sessionandwhyit activatingmotivation mightbeimportant Stimulatingrecallof Reviewprevious priorknowledge session,orsettask thatallowsaudienceto shareexisting knowledge Presentingthestimulus Giveshorttalkonthe material maintopic Providinglearning Goovertopicinmore guidance detail,emphasisingthe mainmessages Elicitingperformance Setexercisesthat allowaudiencetogo overtheabove, workingthrough examples Providingfeedback Givefeedbackonthe assessingperformance exercisesabove Enhancingretention Summarisemain andtransfer pointsgivehandout withfurtherreading

RetrievaltoWorking Memory

SelectivePerception Encoding:Entryto LongTermMemory Storage Responding

Reinforcement CueingRetrieval

SeetheCurriculumdevelopmentpaper,Aimsandlearningoutcomes sectionformoreinformationonlearningandlearningstyles. Whatthecognitivistsgaveus:

Learningcomesfromunderstanding Organisationandstructureofteachingaidlearning Perceptualfeaturesneedattention Cognitivefeedbackaidslearning Individualdifferencesneedtobetakenintoaccount

Humanismandadultlearningtheory Bythe1970sand80stheindividualbecamemoreimportant.Carl Rogers,MalcolmKnowlesandotherssaidadultsaredifferenttochildren. Theyhaveexperiences,priorknowledge,personalities.Theywilllearnif weprovideasecure,motivationalenvironment,infact,theycannothelp butlearnasitisanaturalhumaninstinct.Theroleoftheteacheristo facilitatethelearning,nottobethefountainofallknowledge. MakeitajourneyofselfdiscoverysaidMaslow,albeittalkingabout psychologicaldevelopmentandhumanmotivation.

Letsreflect,holdupthemirrorsothatpeoplecanthinkabouttheir actionsandlearnfromandforthemselves,saidKolb.Lookatthe TeacherstoolboxitemLearningtheorieswhichprovidesmoreinformation abouttheoriesofhowpeoplelearnandwhatthismeansforteachers. Thestrongemphasisonreflectivepractice,somuchapartofnursing education,isbasedonthesepremises.Thereflectionthatisnecessaryto turnaneventintoaconcreteexperienceismorethanremembrance.Itis ananalysisusingastructuredprocesstoreviewtheknowledgeandskills usedduringtheeventand,probablymoreimportantly,anygapsand learningneedsthatwereidentified. Whatthehumanistsgaveus:

Learningisanaturalprocess Motivation,purposesandgoalsareimportant Socialsituationaffectslearning Choice,relevanceandresponsibilityaidlearning Anxietyandemotionaffectlearning

Situatedcognitionandthetransferoflearning Inaseminalpaperin1989Brownandcolleaguesquestionedtheideaof learningbeingtransferable.Youteachachildthe4timestable,heorshe

canreciteitfantastically,buttakethemtotheshopsandsayyouneed fourpacketsofsweetsat8peachandnothing.Ortheconversesituation: thechildwhohelpshisorherparentsintheshopatweekendsandcan multiplyuppricesbytheunitsofitemsinabox,numberofboxes,andso on,butputapencilandpaperinfrontofthemandaskthemtodothe sum,andtheystruggle.MypersonalexampleisthatIwenttothetalks onhowtomanagehaematuriainchildren,Ireadthebooks,I regurgitatedforexams,butcometheclinicandthechildinfrontofme andIhadtostartagain.OnceIhadseenafewchildrenpresentinglike thatitwaseasier.Thelearninghadtobesituatedinmylifecontextto haveanymeaningandtostick.Situatedcognitionhasmanyimplications fortransferringclassroombasedlearningintotherealworld.Andevenin theworkplace,knowingsomethinginonecontextmaynotmeanyou knowitinanother. Importantly,thismakesteachingandlearningintherealworldcontext themostmeaningfulevenifitisconstrainedbypracticalitiesandthe tensionsofdeliveringservice.Althoughtheapprenticeshipmodelisopen toabuse,itisintuitivelytherightmodelandshouldbethebasisofall healthcareprofessionseducation.Aswegetpushedfurtherintothe worldofsimulationsandmodels,itisworthrememberingthelimitations. Applicationoflearningtheories Enoughtheory. Howdoesthathelp? Ifinditusefultotakebitsofeachoftheaboveandconsiderhowwecan createagoodsituationforlearning.Regardlessoftheclinicalcontextany orallofthesecanbeadapted. Step1gettheenvironmentright(humanism/adultlearning) Regardlessofwhatyouwanttoteachandwhatthepersonwantstolearn, itisvitaltocreateapositivelearningenvironment.Themostimportant teachingtechniqueistheoneleastplannedrolemodelling.Asa teacher,youshouldmodelgoodbehaviour,clearboundaries,youshould motivateandenthusebyunderstandingthelearnersperspectives.This canbedifficultwhenyouknowtherearefactorsoutsideofyourcontrol thatwillpotentiallydemotivate,butateacherwhoprovidesan atmosphereofenquiry,freeofcondemnationorridiculeisagoodone whateverthecircumstances. Simplemeasuresmaybeneededopeningthewindowsinastuffyroom, stoppingforabreakwheneveryonestartstoflag,leavingtimeatthe beginningtofindoutwhatthestudentsexpectandwant,attheendfor finaldiscussionandquestions,allshowthatyouarethinkingofthe students. Othermeasuresshowthatyouvaluethem.Beinggenuinelyinterestedin theiraccounts,theirquestionsandthereasonsbehindthem,usingtheir experiencesandtheirpriorknowledgetobuildthesession.Certainly avoidanceofanxietyanddistressisessential. Step2whoarethelearners(cognitiveandhumanism)

Thisisnotanexcusetostereotypemedicalstudentsorthenursing students,butfindingoutwhattheyknow,whattheirexperiencesare,etc. Thereisnotoftenenoughtimefordetailedresearchbeforeateaching sessionandwecanallrecalltimeswhenwethoughtweweretoteachone groupanditturnedouttobeagroupatadifferentlevel. Step3whatdoyouwantthemtoknow/dobytheendandtowhat level?(behaviouralandcognitive) Herearethegoodoldobjectives.Itgetsboringtorepeat(andtodo,lets behonest)buttimespentongettingtheaimsright,withorwithoutthe studentsinput,allowsthecorrectselectionofteachingmethods.Isita rotebasedtask,eg.basiclifesupport,thatneedsadrill,needsbreaking downintosmallsteps,repeating,repeating,repeating.Orisitanethical awarenesswithnorightorwronganswersthatrequiresexploration throughdiscussion,allowingstudentstogeneratetheirownviewpoints basedontheirpreviousexperiences.Eventhoughpotentiallyextreme, andcertainlymoretimeconsumingthanaonewaylecture,itallowsthe wholegrouptoseethebreadthofviewsandaccommodatedifferencesin opinion. Step47prepare,prepare,prepare,prepare(behaviouralandcognitive mostly,butalsohumanism) IfIhadsixhourstochopdownatree,Idspendthefirstfourhourssharpeningtheaxe AbrahamLincoln

Thetensionbetweendeliveringtheserviceandteachingisalwaysevident, andwhentheformerisunderpressurethelatterisforgotten.Asking busycliniciansfromwhateverprofessiontoteach,takestudents, supervisetrainees,etcisdifficultenough,suggestingtheythenspend timepreparingeachdayresultsinlaughter.

Step8Feedbackandreflection(all) Notjustgivingfeedbacktothestudentsandallowingthemtoreflecton theirlearning,butalsofeedbackandreflectiononyourroleasateacher. Whatdidyouasateacherlearnfromthis? Gothroughtheevaluationresults,askacolleaguetoobserveand commentonyourteaching.Evenagoodteachercangetbetter.

Activity Considerarecentteachingsessionwhereyouwerealearner. Whataspectsoftheabovetheoriesdoyourecognise? Couldthesessionhavebeenbetterifconsiderationhadbeengivento theoreticalconcepts? Considerarecentteachingsessionwhereyouwereateacher. Whataspectsoftheabovetheoriesdoyourecognise? Couldthesessionhavebeenbetterifconsiderationhadbeengivento theoreticalconcepts?

References Eraut,M.(2002).LearninginHealthandSocialCare,1,15. Gagne,RM.(1986)Theconditionsoflearningandtheoryofinstruction. th 4 edition,Holt,RhinehartandWinston,NewYork Furtherreading Dent,JAandHarden,RM(2001)Apracticalguideformedicalteachers. ChurchillLivingstone,London Welsh,I.AndSwann,C.(2002)Partnersinlearning:aguidetosupport andassessinnurseeducation.RadcliffeMedicalPress,Abingdon.