TEACHING METHODS: PRINCIPLES & PRACTICES

Yvonne Steinert, Ph.D.

Linda Snell, MD, MHPE, FRCPC, FACP McGill University How to reference this document:

Steinert. Y., Snell. L., Teaching Methods: Principles & Practice. Train-the-Trainer Program on Professionalism. 2009.

OBJECTIVES

• • • • •

By the end of this session, participants will be able to:

Outline general principles for teaching and learning professionalism Describe the key concepts of situated learning theory Identify principles of adult learning & instructional design Identify teaching methods/tools available in their settings Match teaching methods to objectives in their own settings

SESSION OUTLINE

• A Review of General Principles • An Overview of Situated Learning Theory • An Update on Principles of Adult Learning • Key Concepts of Instructional Design • An Overview of Teaching & Learning Methods • Completion of an Action Plan • Conclusion

THE CHALLENGE …

• How to impart knowledge of professionalism to students and residents • How to encourage the behaviors characteristic of the “good” physician...

WHAT IS NEEDED ?

1.

Cognitive base 2.

Experiential learning 3.

Role modeling 4.

Self-reflection 5.

Environment > teach it explicitly > provide opportunities on a regular basis > requires knowledge and self-awareness > provide opportunities through the curriculum > must be supportive of professional values

THE “BOTTOM LINE”

• • • Promote an integrated approach • Define core content & provide conceptual frameworks • Use multiple teaching & learning strategies • Enable experiential learning & reflection • • Link evaluation to teaching...

• Methods of instruction may vary with curricular design and place in the curriculum • . . .

• BUT …The principles of professionalism should not vary

FOR DISCUSSION

• How do you currently teach professionalism?

• What theoretical frameworks guide your thinking?

WHAT IS THEORY?

• Theories represent various aspects of reality in an understandable way.

• Theory simplifies reality by ignoring a large number of variables (like a map) and often stress the importance of certain variables by giving them special names or stressing their importance in words, figures or formulas. Adger, 2002

WHY THEORY?

• The particular theory we subscribe to is likely to dictate how we work.

• An awareness of theoretical frameworks will allow us to make informed choices about how we approach teaching and learning •

Without theoretical frameworks to guide our practice, there is a danger that there will be too much reliance on intuition or common sense.

There is nothing so practical as a good theory.

-

Lewin, 1951

SITUATED LEARNING THEORY

• Situated learning is based on the notion that knowledge is

contextually situated

and fundamentally influenced by the

activity, context, and culture

in which it is used.

• Brown et al, 1989

WHY SITUATED LEARNING?

• It is particularly appropriate to educating professions that are communities or cultures “joined by intricate, socially constructed webs of belief”... • It brings together the cognitive base and experiential learning needed to facilitate the acquisition of professionalism

SITUATED LEARNING

• Cognitive Apprenticeship – Modelling – Scaffolding – Coaching – Fading • Collaborative Learning • Reflection • Practice • Articulation

MODELLING

• The resident observes, then mimics, the teacher in the performance of a task. • Is most effective when teachers make the target processes visible, often by explicitly showing the resident what to do. • Enables residents to observe normally invisible processes and to begin to integrate

what

occurs with

why

it happens.

SCAFFOLDING

• Refers to the support teachers give residents in carrying out a task.

• Can range from almost doing the entire task to giving occasional hints as to what to do next.

• Supports and simplifies a task as much as necessary to enable residents to learn • Facilitates the transfer of what residents already know to the task at hand.

FADING

•

Fading

is the notion of slowly removing support... giving the learner more and more responsibility. • Fading is a critical step in the trajectory of becoming an independent practitioner.

COACHING

• Runs through the entire apprenticeship experience • Involves helping residents while they try to learn or perform a task • Includes directing learner attention, providing hints and feedback, structuring tasks, and providing additional challenges or problems • Helps residents to maximize use of their cognitive resources and knowledge...

COLLABORATIVE LEARNING

• Includes: – Collective problem-solving; – Displaying and identifying multiple roles; – Confronting ineffective strategies and misconceptions; – Developing collaborative work skills.

REFLECTION

•

Reflection IN Action:

while performing an act/role, analyze what is being done •

Reflection ON Action:

after performing the act/role, reflecting on the impact of the action on the patient and oneself • •

Reflection FOR Action:

reflecting on what has been learned for the future -Schön,1983; Lachman & Pawlina, 2006

PRACTICE

• Serves to test, refine, and extend skills into a web of increasing expertise – in a social context of collaboration and reflection.

• Enables skills to become deeply rooted and “automatically” mobilized as needed.

ARTICULATION

• Includes two aspects: – The concept of articulating or separating out different component skills in order to learn them more effectively – Getting students to articulate their knowledge, reasoning, or problem-solving processes in a specific domain • Also helps to make learning – and reflection – visible

IN SUMMARY...

• Situated learning is based upon the idea that knowledge is

contextually situated

and fundamentally influenced by the

activity

,

context

and

culture

in which it is used. • In this model, teachers must assume the role of

coach

in addition to that of pedagogue – and they must act as

models

for performing tasks. • At the same time, students become

experts

and engage in reciprocal teaching, and the role of

apprentice

and

master

are shared.

INSTRUCTIONAL DESIGN

Topic Target Audience Participant Needs

Goals and Objectives Evaluation Content Teaching Methods and Aids

•

PRINCIPLES OF ADULT LEARNING

• Adults are independent.

• Adults come to learning situations with a variety of motivations and definite expectations about particular learning goals and teaching methods.

• Adults demonstrate different learning styles.

• Much of adult learning is “relearning” rather than new learning.

ADULT LEARNING (CONT’D)

• Adult learning often involves changes in attitudes as well as skills.

• Most adults prefer to learn through experience.

• Incentives for adult learning usually come from within the individual.

• • Feedback is usually more important than tests and evaluations.

IN SUMMARY…

• Create a climate of respect and “safety” • Encourage active participation – in design and implementation • Build on experience • Encourage collaborative inquiry • Empower participants – to carry out their learning plans....

LET’S TRY THIS OUT ...

TEACHING AND LEARNING METHODS

TEACHING AND LEARNING METHODS 1. Context 2. Different methods for different levels?

3. Strategies / methods 4. Do all roles have to be taught all the time?

5. What if resources are limited?

TEACHING AND LEARNING METHODS

1. Context

2. Different methods for different levels?

3. Strategies / methods 4. Do all roles have to be taught all the time?

5. What if resources are limited?

CONTEXT

• Standard of accreditation: – Curricular content broadly outlined – Expectation that assessment will occur • Little guidance re implementation: – Need to translate general into specific – Teaching methods that will be effective • For specialty • For level of resident

LEARNING ABOUT PROFESSIONALISM OCCURS…

• Teaching Rounds • Academic Half Days • Core Seminars • Journal Clubs • Conferences • Informal discussions • Self-directed contexts • … • Bedside • Wards • ER • Clinics • OR • Lab • …

TEACHING AND LEARNING METHODS

1. Context

2. Different methods for different levels?

3. Strategies / methods 4. Do all roles have to be taught all the time?

5. What if resources are limited?

ADAPT TO LEARNER LEVEL

Imparting core knowledge Promoting self-reflection, application

Medical student Preclinical Residency Clinical

Level of learner Increasing complexity  capacity to personalize Increasing reflection

TEACHING AND LEARNING METHODS

1. Context 2. Different methods for different levels?

3. Strategies / methods

4. Do all roles have to be taught all the time?

5. What if resources are limited?

‘Miller triangle’

does shows knows how knows

LEARNING PROFESSIONALISM GOALS

Knowledge acquisition Understanding Patterning Participation Application to practice Self-evaluation …

does shows knows how knows

Strategies for Teaching Professionalism

Report of the CanMEDS Working Groups – 2005

Strategies for Teaching Professionalism

Lectures Guided reflection & feedback Simulations Mentoring Team learning Workbooks Reading Role modeling Recognition, ceremonies Case discussion Role play Bedside learning Encounter cards Faculty Development Logbooks Patient stories Portfolios Narratives Group discussion Vignettes Experiential learning Web Video review

Teaching & Learning Methods

• Lectures, Interactive Lectures • Directed reading, Web-based learning • Small group discussions • Case discussions / Clinical vignettes • Critical Incidents • Simulation / Role Play / Video review • Experiential Learning • Encounter Cards • Role Modeling • Guided Reflection • Portfolios • Narratives Knowledge Acquisition Understanding Patterning Participation Application to practice Self evaluation

LECTURES, INTERACTIVE LECTURES

• Excellent for transmitting facts, core knowledge • Increasing interaction likely improves understanding and promotes ‘deeper’ learning • Efficient use of resources

READING, WEB-BASED

• Excellent for transmitting facts, core knowledge • Using workbooks with question guides, or interacting on-line may improve understanding • Efficient use of resources

GROUP DISCUSSIONS

VIGNETTES, CASE DISCUSSION

• Promote understanding and application to practice • Stimulate reflection, with guided questions • Cases or vignettes can be ‘paper’, video, Web - based

CASE VIGNETTE EXAMPLE

CASE

- A long-time patient of yours requests a note from you documenting a non-existent illness in order to recover cancellation penalties from the airlines on a nonrefundable ticket.

Caring and Compassion

A sympathetic consciousness of another's distress together with a desire to alleviate it.

Insight Openness

Self-awareness; the ability to recognize and understand one's actions, motivations and emotions.

Willingness to hear, accept, and deal with the views of others without reserve or pretense.

Respect for the Healing Function Respect Patient Dignity & Autonomy Presence Competence

The ability to recognize, elicit and foster the power to heal inherent in each patient.

The commitment to respect and ensure subjective well being and sense of worth in others and recognizes the patient's personal freedom of choice and right to participate fully in his/her care.

To be fully present for a patient without distraction and to fully support and accompany the patient throughout care.

To master and keep current the knowledge and skills relevant to medical practice.

Commitment Confidentiality Autonomy Altruism Integrity and Honesty Morality and Ethical Conduct Trustworthiness

Being obligated or emotionally impelled to act in the best interest of the patient; a pledge given by way of the Hippocratic oath or its modern equivalent.

To not divulge patient information without just cause.

The physician’s freedom to make independent decisions in the best interest of the patient and for the good of society.

The unselfish regard for, or devotion to, the welfare of others; placing the needs of the patient before one's self interest.

An adherence to a code of moral values; incorruptibility.

To act for the public good; conformity to the ideals of right human conduct in dealings with patients, colleagues, and society.

Worthy of trust, reliable.

Responsibility to the Profession Self-Regulation Responsibility to Society

The commitment to maintain the integrity of the moral and collegial nature of the profession and to be accountable for one's conduct to the profession.

The privilege of setting the standards; being accountable for one's actions and conduct in medical practice and for the conduct of ones colleagues.

The obligation to use one's expertise for, and to be accountable to, society for those actions, both personal and of the profession, which relate to the public good.

Case #1 Case #2 Case #3 Case #4 Case #5

CRITICAL INCIDENTS

• A discussion, analysis and reflection on a ‘real life’ vignette, of excellent or poor professional behaviors. • Good to start reflection and self-evaluation

SIMULATION, ROLE PLAY, VIDEO REVIEW

• ‘Rehearsal in a safe environment’ • Patterning • Stimulates reflection, with guided questions

SIMULATION, ROLE PLAY: EXAMPLE

• Standardized patient communication sessions around ethical issues • Followed by feedback from SP, tutor-observer and peer-observers • Questions to guide reflection and improve skills

ENCOUNTER CARDS

• Stimulate self-evaluation • Stimulate reflection • Make the implicit explicit • Provide a framework

ENCOUNTER CARDS - EXAMPLE

• P-MEX • Mini-CEX • ER shift evaluation and feedback cards

| | | | | | Professionalism | Mini-Evaluation | Exercise | | | P-MEX | | | | | Evaluation Forms | | | Faculty of Medicine McGill University

PROFESSIONALISM MINI-EVALUATION EXERCISE Evaluator:_______________________________________ Student/Resident:________________________________ Level: (please check) 3rd yr 4th yr res 1 res 2 res 3 res 4 res 5 Setting Ward Clinic OR ER Classroom Other ► Please rate this student’s/ resident’s overall professional performance during THIS encounter:

UNacceptable BELow expectations MET expectations EXCeeded expectations

► Did you observe a critical event?

(comment required) no yes Listened actively to patient Showed interest in patient as a person Recognized and met patient needs Extended him/herself to meet patient needs Ensured continuity of patient care Advocated on behalf of a patient Demonstrated awareness of own limitations Admitted errors/omissions Solicited feedback Accepted feedback Maintained appropriate boundaries Maintained composure in a difficult situation Maintained appropriate appearance Was on time Completed tasks in a reliable fashion Addressed own gaps in knowledge / skills Was available to colleagues Demonstrated respect for colleagues Avoided derogatory language Maintained patient confidentiality Used health resources appropriately

Mini-CEX

EXPERIENTIAL LEARNING

• Includes • Learning from role models • Reflection and self evaluation • ‘Learning by doing’

EXPERIMENTIAL LEARNING – ROLE MODELING

• Major influence in the creation of a physician • Affects career choice • Part of the formal & informal curriculum • Patterning • Participation

ROLE MODELS: WHO ARE THEY?

• ...Individuals admired for their ways of being and acting as professionals.

•

Côté & Leclère: Acad Med, 2000

• Role models “must first attempt to reflect core attributes of physicians.” •

Skeff: NEJM,1998

CHARACTERISTICS OF ROLE MODELS

Positive Negative

Clinical Competence

knowledge, skill, reasoning communication

Teaching Skills

explicit about what is modeled, makes time for teaching respects students’ needs, feedback, encourages reflection

Personal Qualities

compassionate, caring, honesty and integrity, enthusiastic, interpersonal skills, commitment to excellence, collegial Cruess, Cruess, Steinert BMJ 2008

STRATEGIES TO IMPROVE ROLE MODELING

• • Demonstrate clinical competence • Protect time for teaching • • Demonstrate a positive attitude • • Implement a student-centered approach • Facilitate reflection • Encourage dialogue • Be aware of the importance • of role modeling • • Be explicit about what is being modeled (when • possible) • • Participate in faculty development • • Work to improve the institutional culture

Cruess, Cruess, Steinert BMJ 2008

EXPERIENTIAL LEARNING – GUIDED REFLECTION

• Reflection: purposeful thought provoked by learner’s unease when they recognize that their understanding is incomplete

Dewey, 1933

• Participation • Application to practice: – hands-on, supervised patient care – mentoring

Linking Reflection ACTIVE OBSERVATION OF ROLE MODEL • Making the Unconscious Conscious & Role Modeling UNCONSCIOUS INCORPORATION OF OBSERVED BEHAVIORS REFLECTION & ABSTRACTION ACTIVE EXPLORATION OF AFFECT AND VALUES Translating Insights into Principles and Action GENERALIZATION & BEHAVIOR CHANGE

After Epstein et al, 1998

PORTFOLIOS

• A collection of documents or other media where reflection, professional attitudes & behaviors are expressed • Stimulate reflection • Stimulate self-evaluation • Need for review ?

PORTFOLIOS: EXAMPLES

• Might contain: – Personal notes, reflections, ‘diary’ – Letters to self or others – Case report examples – Evaluations – Letters from patients, supervisors – Logs – Professional roles in organizations – Professionalism education sessions attended, – Professionalism awards –

NARRATIVES

• Narrative competence – the ability to absorb, interpret and act on the stories and plights of others •

R Charron

• Stimulate reflection, with guided questions • Stimulate self-evaluation

NARRATIVES: EXAMPLES

Use stories about patients & about own professional development as a means of learning … • • •

“When I was a resident ….” “I experienced this today in clinic …”

•

“Let me tell you about a student I had …” “I cared for a patient who had experienced…”

LET’S USE WHAT WE HAVE JUST LEARNED

TEACHING AND LEARNING METHODS

1. Context 2. Different methods for different levels?

3. Strategies / methods

4. Do all roles have to be taught all the time?

5. What if resources are limited?

DO ALL ROLES HAVE TO BE TAUGH ALL THE TIME?

THE ‘SLIDING SCALE’ OF CANMEDS

• Not for every rotation • Not for every objective • Sometimes one size does not fit all, so identify – where the competency is

best

taught, and – where it is

least

appropriate to be taught • Have a rationale for why you teach it

TEACHING AND LEARNING METHODS

1. Context 2. Different methods for different levels?

3. Strategies / methods 4. Do all roles have to be taught all the time?

5. What if resources are limited?

WHEN RESOURCES ARE LIMITED…

• • • • Adopt Adapt Create Share • Don’t forget the learning environment

CONSIDER ALL TEACHERS …

• Faculty • Residents • Other health professionals • Patients

THE LEARNING ENVIRONMENT

• Be aware of & address professionalism barriers • Time • Context • Competing activities • … • Support, recognize & reward good professionalism: • Ceremonies • • Awards

KEY MESSAGES

• • • • Remember the goal of the teaching Identify opportunities for teaching within your own context/setting Match teaching method/tool to context & objective No single method can do it all • • • • It is unnecessary to teach all roles all the time Include other health professionals Tie teaching to assessment Positively affect the learning environment

The greatest difficulty in life is to make knowledge effective, to convert it into practical wisdom.

• Sir William Osler

ACTION PLAN

• Take a few minutes to reflect on this half-day, and complete the relevant section of the action plan