How many people in work place based training and education have a teaching qualification? How many have fallen into training colleagues and juniors because it was part of the remit when they were promoted, or it "goes with the territory"? Is teaching something we can all do? Does it have to be especially taught? Does anybody really care?
I am not sure that we value teaching and training in this country to the extent that we should. In many of the professions the 'apprenticeship' model is alive and kicking purely because it requires little to no funding. Passing on one's professional knowledge, skills and judgement is an innate responsibility for any professional....isn't it?
These are rather deep questions, for which there is no hard and fast answer. However, in compulsory education, the healthcare services, public sector such as police and paramedic work, as well as in many other areas of professional life, the funding for and formal acknowledgement of dedicated training, teaching and mentoring, is almost non existent.
Pre service training is seen as all that is necessary for a teacher, a police officer and to an extent a doctor, to achieve the necessary "competencies" (Oh I hate that word!) to do their job. And this is where I suspect the problem lies. Competency based careers are just that - jobs. I would argue that professional careers require much more time and thought and dialogue than the mere ticking of lists and provision of "evidence" to show that one is competent (which now means 'just good enough!') A professional surgeon, lawyer, teacher, police officer, paramedic, nurse (I could go on) require more than just a degree in their subject or even a subsequent qualification in their vocational area. Professional expertise in all these areas takes time, requires guidance and mentoring, on the job coaching and reflection, and a dedicated commitment to development. Without the input of a more experienced other (a coach, teacher, mentor, trainer) this will not happen.
So back to my original question: How many people who find themsleves in this role, have the necessary skills, underpinning knowledge and natural aptitude to fulfil it? If everyone can be a teacher because they have been taught, can everyone be a doctor because they have been ill?
Increasingly I hear the lament from everyone around me that things are no longer working. Apart from the fact that policemen are getting younger (!) is there some truth in the complaints regarding a lowering of standards and attitude? If we are to do anything to counter this in professional life, we need to invest in those who are responsible for guiding the next generation, by educating them to think for themselves, and forget about ticking boxes.
If you have had teaching thrust upon you, I urge you to demand some support in this role. Most workplace based trainers are successful in what they do and many manage to communicate their skills, to a degree, to their trainees. But in a workplace that demands investment in health and safety, equality and diversity, and other such "rights", where are the rights of those who maintain the quality of the next generation?
Saturday 16 May 2009
Monday 4 May 2009
http://www.med-ed-online.org/pdf/Res00279.pdf
This may be of interest - a study reported on Medical Education Online, about reflective practice in medical students in the Netherlands. Bedtime reading for me tonight!
This may be of interest - a study reported on Medical Education Online, about reflective practice in medical students in the Netherlands. Bedtime reading for me tonight!
Sunday 3 May 2009
Reflective Practice -- guidance for trainees and students
Reflective Practice - How to write a reflective piece - guidance for trainees and students
As part of any learning experience, you may be asked to or to choose to keep a reflective practice log . This can be done in electronic form or on paper, as you see fit.
Many learners are often advised to include pieces of reflective writing in their portfolio or record of learning during a course. These will maximise your potential for learning from practice, record your thoughts, beliefs and actions and build upon the learning activities you undertake both in class, in a peer group setting, on line and with your mentor as well as at organised study events and in your everyday practice. Reflective practice acts as the cement which holds together the building bricks of formal learning activities and everyday practical work.
You can complete a reflective piece whenever you like but a useful way to engage in reflection on practice is to be incident led. As a time consuming exercise, reflective writing is not something you can formally do every day. It is however, something that can be carried out following an event of note. This may be:
Ÿ a particularly difficult event or procedure,
Ÿ an emotional patient or client encounter,
Ÿ a successful personal intervention,
Ÿ a challenging case or situation
Ÿ A difficult part of the course you are following
Ÿ A particularly useful encounter with a colleague or mentor
Reflection on practice does not have to focus only on practical or clinical events; remember that many learning programmes are made up of Knowledge, Skills, and Reflection. All aspects of learning should be reflected upon.
So what is reflective practice?
Reflective practice is not new; as a concept it has been used to underpin adult and professional learning for over two decades. The cultivation of the capacity to reflect on, and in action has become an important feature of courses and professional training programmes in many disciplines.
You need to ensure that you understand what you are learning and in understanding, that you develop the skills to retain and develop your understanding, to transfer it to different contexts, pass it on to others and take control of your own professional development in order to gain the most you can from all of your practical and learning experiences.
Reflective practice is related to Experiential Learning. That is to say that having an experience is an important part of learning but that having an experience is not the same as understanding its meaning. We know that repeated practice is the best way to improve technical and vocational proficiency but if we do not understand the theory behind the practice we will take much longer to reach the level of competence required, if at all. We may need to go beyond that to achieve excellence. We also need to remember that practice may not make perfect - it may make permanent but if it is not correct practice it will become dangerous in its permanence.
There are two different uses of Reflective Practice:
Ÿ Reflection on Practice
Ÿ Reflection in Practice
Reflection on practice is a retrospective activity, free from the urgency and the pressures of the immediate situation. It can be maximised by feedback and ideas from others and is usually the first stage of our development of reflection as a habit. Engaging in formal reflection from time to time not only deepens understanding and learning but also develops an internal ability to reflect in practice.
Reflection in practice is a hands on approach to thinking on your feet. It can take place during the action with a “where do we go from here?” question. This can be very useful in the full range of professional practices encountered in a career in dentistry. Reflection in practice develops over time after considerable experience of reflecting on practice.
Reflective practice is not then, a bolt on extra to a learning programme. It is an integral and vital part of the learning process. Reflective practice is a way for us all to make sense of the different elements of learning and how they fit into training and good practice.
How do we write a reflective piece?
There are many ways to structure reflection on practice and learners will find preferred ways of doing this. However, to help you, here is our recommended approach for any situation.
Event - what happened? Go through the basics of the incident on which you wish to refelct, pulling out the facts as you saw them
Debrief - try to list the good elements of the event and the bad. Work out what you would do again and what you would wish to change. Isolate any emotions that may stand in the way of you revisiting the event again, and deal with them at this point.
Actions - set actions to intervene and amened the elements you were not so happy with and plan for those interventions
Review - look at the interventions and follow up actions and see how they made a difference to your practice.
This is similar to the original Reflective Practice cycle developed by Kolb (1984) in that it takes as its starting point an action or an event. This approach is unique in that it encourages us to examine our practice from three different perspectives - factual, emotional and theoretical before making changes for future use.
HOW DO I INCLUDE MY REFLECTIVE PIECES WITHOUT MAKING ME SOUND LIKE A TOTAL IDIOT?
Some of you have expressed concern about the “bearing my soul” aspect of reflective practice and it is true that there is a fine line between sharing experiences honestly and laying oneself open to criticism for doing so.
What we would suggest is that you do the whole reflective process for your own benefit, because it is only by being totally honest and open about it that you can learn properly from it. But when it comes to including that reflective piece in your portfolio, it may be an idea to edit it thus:
HEADLINE: What you have learned from this event
EVENT: 1-3 sentences about the event itself with some idea of the area you targeted from reflection
LEARNED: now you can spend longer on this area, discussing what it was you learned from the event and expressing this in developmental but positive terms
ACTION: This is where you identify the actions resulting from the reflection. They may be short, medium or long term and you can revisit them after you have implemented them to comment on their efficacy once used in practice.
Remember to always follow up with a review of your amended practice after you have implemented your actions. This completes the cycle of learning initiated from the original piece of reflection.
Good luck!
Surgical Training – a Spiral of Learning – Are you ready?
S Vig, H Allan, L Hadfield-Law, A Hollowood , M Deakin
S Vig, H Allan, L Hadfield-Law, A Hollowood , M Deakin
William Halsted was an innovator of surgical training in the early 20th century. Traditionally training was offered to the senior professors and Halsted wished to improve this, not change it and bring it round full circle but to take training and education to a higher level.
Halsted changed the focus of training to the house officer. House officers were given graduated responsibilities including supervised surgery within an apprenticeship model. Dependent on time served and large numbers of patients treated, the programme ensured that the resident surgeon would be skilled and experienced at the end of it.This concept of surgical training has continued to be used successfully but has recently had to evolve again with the implementation of MMC and EWTD.
Trainees no longer have access to a wealth of experience or time. Trainees need to understand the knowledge, skills, judgment and professionalism needed to become the Consultant Surgeon. They also now need to use every opportunity and patient encounter to learn.
Trainees have adapted and have embraced the Foundation Programme. Assessments and reflective practice have been key to developing education and training and are mandatory for the trainees. These trainees have now become the CT1s and 2s registered with Intercollegiate Surgical Curriculum Programme (ISCP). They are keen and enthusiastic and determined to succeed to become the next generation to influence surgery. Trainees are expected to lead their learning and ask for assessments to direct their learning needs. They are ready.
Are the trainers ready? Although some surgeons took part in the ‘Tools of the Trade’ training sessions which introduced the new workplace based assessments used in the Foundation Programme, many didn’t. Some surgeons took part in briefings associated with the implementation of the Intercollegiate Surgical Curriculum Programme (ISCP) which involved an introduction to the assessment methods, as well as the curriculum and the web site but many did not.
ISCP not only specifies a syllabus within a curriculum but also designated educational and mentoring responsibilities of the Assigned Educational Supervisor (AES), Clinical Supervisor, Trainer and Assessor. The College Training the Trainer course was updated to reflect the new curriculum and in particular the needs of the Clinical Supervisors as teacher and trainer, but what of the AES and Assessor?
Training and Assessment in Practice (TAIP) was developed, by surgeons and educators for the Raven Department of Education, to coincide with the implementation of the curriculum. TAIP developed a framework to clarify the usage of the new assessment tools.
From the first pilot, before implementation, participants were feeding back how helpful the course was in developing their understanding of workplace based assessment and where it fits into the process of supporting a trainee’s learning, including using assessments formatively to provide developmental feedback.
‘I particularly valued the video analyses and the scoring and the discussions that followed. Equally, I valued the trainer/trainee case scenario demonstrations – very very powerful.’ (Leeds Participant 2008)
“Assessment tools demystified…” said a participant on a recent Training and Assessment in Practice (TAIP) course held in the West Midlands.
‘the sessions looking at how to incorporate assessment tools into everyday practice and what exactly we are assessing will make the greatest difference to my practice.’ (Reading participant 2008)
The course does not just cover the new assessments but also covers the learning agreement, portfolio assessment and development and how to encourage the trainees learning experience drawing on the ISCP and utilising on-line forms. TAIP also encourages a quality assurance of the assessment process.
The interactive course, with faculty including a surgeon, an educator and trainee has had additional benefits to the consultants attending:
They are able to apply the same systematic approach to learning, recording evidence and building a portfolio for their own practice which is helpful in preparation for revalidation;
The programme provides evidence of the consultant’s continuing professional development (CPD). This is further enhanced if the surgeon becomes faculty on the programme.
From a deanery/Schools of Surgery perspective, the course provides evidence that their surgeons are meeting the ISCP requirements that AESs and Assessors are trained (No5 vol89 ISSN:1473-6357) and the PMETB standard 4 for trainers (http://www.pmetb.org.uk/fileadmin/user/QA/Assessment/PMETB_STANDARDS_FOR_TRAINERS_JAN_2008.pdf).
Recent developments in the programme include:
· greater cooperation between the Education Department and Schools of Surgery to deliver the programme locally. The benefits to surgeons are decreased costs both in terms of fees and travel and accommodation as well as time away from home (and the workplace)
· In response to feedback from participants and Schools of Surgery the programme has been modified so that the College is now able to offer a one day course tailored to the day to day needs of Trainers and Assessors.
For further information on TAIP please contact the Professional Development team: 020 7869 6350 or pdcourses@rcseng.ac.uk
Experience Based Learning
EXPERIENCE BASED LEARNING: Making the most of Surgical Training
Hayley Allan, Stella Vig
Introduction & Rationale
It is widely believed that it is impossible to train surgical trainees to CCT level in a mere 48 hour week; that trainees cannot gain sufficient exposure to surgical disease or carry out an acceptable number of procedures to gain the confidence and competence for CCT within the time now available. (Ann R Coll Surg Engl (Suppl) 2009;91:78-79)
EWTD is a reality and hospitals are already implementing strict controls to ensure its trainees do not exceed the hours they are allowed to work, resulting in a consultant led service which furthermore restricts training time and opportunity. (Ann R Coll Surg Engl (Suppl) 2009;91:70-71)
Traditional training in surgery followed the immersion method. Trainees were on site for most of the week and quickly saw a wide variety of cases. The apprenticeship model (Wenger 1999, Lave & Wenger 1991) is one of which the profession is proud; trainees learned their craft from the ‘master’, acting as assistant and developing through a sustained and protracted mentorship. Surgical ‘firms’ ensured that learning and training were cascaded down from the consultant to Consultant to Registrar to SHO and so on. One learned everything from very few teachers. The fear today is that one learns much less from a greater number of trainers. An alternative approach is sought.
Given that EWTD is something we cannot overturn in the immediate future, it is our responsibility as educators of tomorrow’s surgeons to find a way around this hurdle. We cannot change EWTD; ISCP and the newer training methods are here to stay for the short term at least, and the current trainees cannot afford to miss out. As their future patients, neither can we.
Experience Based Learning
The way forward is an Experience Based Learning curriculum. This takes as its central tenet the merits of apprenticeship learning and blends with that trainee responsibility for ‘training on the job; learning off the job.’ Trainees may only be allowed in the hospital for 48 hours a week but they – with our help – can ensure that they receive the best dedicated training by managing their practical and clinical skills on the job with supplementary learning off site. On the job learning needs to be in the clinical context – in theatre, on the wards and in out patients. This is what the ISCP takes as its classroom setting and this is where the EWT hours should be focused. The other areas of learning a trainee surgeon engages in, audit, presentations, research, journal clubs etc ought to be kept for their off the job time.
Hayley Allan, Stella Vig
Introduction & Rationale
It is widely believed that it is impossible to train surgical trainees to CCT level in a mere 48 hour week; that trainees cannot gain sufficient exposure to surgical disease or carry out an acceptable number of procedures to gain the confidence and competence for CCT within the time now available. (Ann R Coll Surg Engl (Suppl) 2009;91:78-79)
EWTD is a reality and hospitals are already implementing strict controls to ensure its trainees do not exceed the hours they are allowed to work, resulting in a consultant led service which furthermore restricts training time and opportunity. (Ann R Coll Surg Engl (Suppl) 2009;91:70-71)
Traditional training in surgery followed the immersion method. Trainees were on site for most of the week and quickly saw a wide variety of cases. The apprenticeship model (Wenger 1999, Lave & Wenger 1991) is one of which the profession is proud; trainees learned their craft from the ‘master’, acting as assistant and developing through a sustained and protracted mentorship. Surgical ‘firms’ ensured that learning and training were cascaded down from the consultant to Consultant to Registrar to SHO and so on. One learned everything from very few teachers. The fear today is that one learns much less from a greater number of trainers. An alternative approach is sought.
Given that EWTD is something we cannot overturn in the immediate future, it is our responsibility as educators of tomorrow’s surgeons to find a way around this hurdle. We cannot change EWTD; ISCP and the newer training methods are here to stay for the short term at least, and the current trainees cannot afford to miss out. As their future patients, neither can we.
Experience Based Learning
The way forward is an Experience Based Learning curriculum. This takes as its central tenet the merits of apprenticeship learning and blends with that trainee responsibility for ‘training on the job; learning off the job.’ Trainees may only be allowed in the hospital for 48 hours a week but they – with our help – can ensure that they receive the best dedicated training by managing their practical and clinical skills on the job with supplementary learning off site. On the job learning needs to be in the clinical context – in theatre, on the wards and in out patients. This is what the ISCP takes as its classroom setting and this is where the EWT hours should be focused. The other areas of learning a trainee surgeon engages in, audit, presentations, research, journal clubs etc ought to be kept for their off the job time.
DOING (on the job) leads to
LOOKING BACK (debrief/reflection)leads to
THINKING/LEARNING (off the job)leads to
LOOKING FORWARD (planning/preparation)leads to DOING....
Experience Based Learning Model (Allan & Vig 2009)
This model shows how training on the job and learning off the job are integrated to make meaningful connections between clinical practice and medical education. If trainees are encouraged to take away their experiences and learn from them, out of hospital working hours, following discussions of these experiences with a trainer, with relevant action planning to target future learning activities, then each clinical experience will take the trainee further than it would have done without such additional processing. In this way, the learning experiences on the job, although fewer in number, have greater impact qualitatively, upon trainee development.
Training on the Job
The assessment ‘tools of the trade’ facilitate this focus. Using feedback maximises learning and training opportunities on the job. Trainees ought to be getting feedback on their DOPs and PBAs at every possible opportunity in theatre. Scheduling one trainee observation into an Out Patient clinic every week, with ten minutes to teach through feedback, is not an impossible task. Ward rounds ought to be prepared for, used as (group) training opportunity and again subject to training feedback focused on the trainee(s) stage and needs. Admittedly it is difficult to organise given the time pressures, the Clinic appointment templates and the dearth of training lists in theatre, but there are still opportunities available.
The Apprenticeship system worked because surgeons integrated clinical and training commitments. However, for modern clinicians this may be something of a revelation; a recent consultant participant on a TAIP (Training and Assessment in Practice) course said that she had realised during the course that clinical and training commitments were not separate; that if she tried to meet them individually she failed. She said that she intended to integrate her clinical and training work in the future. Training on the job, using the ISCP tools as recommended by the TAIP course, ensures that trainees and trainers focus on the workplace based opportunities for learning that most of us worry will be eroded by EWTD.
Learning off the job
Learning off the job has always been a fact of life for the trainee surgeon, as it is for trainee nurses, teachers, lawyers, police officers and many more professional groups. When we embark on a career the training period and early years of that career will occupy more hours than those we are paid for. All surgeons want to succeed and most are prepared for the extra work that requires. Learning off the job is a reality for surgeons and there are many opportunities for them to continue to do so, leaving clinical and surgical development to be the focus of the time they are officially at work. Indeed learning does not stop at CCT. Lifelong learning has always been a part of a surgeon’s job and will continue to be.
As trainers, we need to consider how trainees can fit learning off the job into their already busy programme of surgical training. Naturally trainers see their main responsibility as on the job training, but an additional feature of a great surgical trainer, whether in 1909, 1959 or 2009 is that of mentorship. The ISCP has defined the responsibilities of those designated Programme Directors, Educational Supervisors and Clinical Supervisors, but it is those trainers who are able to structure the learning of their juniors to allow for observation, discussion, teaching and learning followed with brief feedback and action planning, who are distinguishing themselves with the trainees today. Ensuring that trainees receive support and development whilst engaging in clinical care, with immediate feedback and discussion and follow up activities to reinforce the learning, may well reduce the number of times a trainee has to do something before they are proficient at it. It could be that more overt and directed training proves to be more time efficient than some of the more covert ‘immersion’ methods previously used.
EBL – maximising the time available
Quantity is not a guarantee of competence. If it took ‘Bill’ 7 procedures to perfect his technique in 1983, because he was largely unsupervised, it may only take ‘Ben’ 2 or 3, because he has been well prepared with video footage, staged training, detailed feedback and follow up teaching using the DOPs and PBA forms. He may have had access to a wet lab to practise the particularly tricky part of the operation, and observed another surgeon doing the same procedure. He may well reach the same level of competence as ‘Bill’, only 4 or 5 procedures earlier.
EBL does not promote having the same experience 7 times; it focuses on what we can learn from each experience before the next one comes along so that we can change it for the better.
Professional learning and development in many spheres has been influenced over the last 15 years by the ideas of Wood, Bruner & Ross ( 1976 ) who rejected the traditional mode of see one, do one, or the “copy me” approach to training. Rather a trainer teaches through dialogue, providing “scaffolding” support structures to assist the trainee in their practical learning. As the trainee grows more proficient the support structures are reduced and trainees gain in confidence and autonomy. Many good trainers do this already; some do not.
Dialogue and Debrief
Dialogue on the job is not always possible. In theatre, scaffolding has been used by effective trainers for centuries, but on the wards and in clinic, due to patient presence, it is not possible for trainer and trainee to articulate their thoughts and actions whilst seeing a patient. For this reason the dialogue has to take place as soon after the episode as possible. The ISCP calls this dialogue assessment; TAIP refers to it as feedback. Traditionally such dialogue would happen informally in the mess or the pub. That trainers and trainees need to talk about what they do together to learn and train, is undeniable. How they do this and when they do it, is less clear.
Five minutes is all that is required to feedback to or to debrief a trainee if the learning episode has been structured and observed. Since Training the Trainers and the ATLS Instructor courses were developed 15 – 20 years ago, Pendleton’s rules (1984)have been used for debriefing trainees. There may be no better tool for evaluating simple, practical procedures but some of a surgeon’s work requires slightly more than the questions, “What went well?” and “what can be improved?”
To be of any educational value, debriefs need to be:
• Two way
• Open
• Specific
• Evidence based
• Behaviour focused
• Honest
• Developmental
• Supportive
A simple mnemonic can be used to debrief trainees meaningfully. Once they have accepted and understood the method they can use it reflexively to self evaluate too.
Describe events
Evaluate what went well/to change next time
Banish emotions that cloud judgement and development
Review and analyse in light of previous experience
Identify lessons learned
Evidence learning in portfolio
Follow up with action plan
All debriefs should start with a simple summary of what has happened. Trainees may view an event differently from their trainer and discrepancies need to be identified early.
Pendleton’s rules can be used initially to evaluate areas of good practice and areas requiring development. Deeper analysis is often necessary especially if a trainee does not understand why certain aspects were or were not effective.
If the event has produced any strong feelings in the trainee these should be elicited as they may have a bearing upon judgement and the ability to move forward.
Next the trainee should be encouraged to review the event in light of previous experiences of a similar nature. Is there a pattern emerging? (BMJ 2008;336;827-30)
Trainee is then asked to review the debrief and to summarise lessons learned from the incident and the conversation.
Follow up area 1: evidence of learning from the event to be documented in the Portfolio
Follow up area 2: future actions to be implemented and reviewed.
Future Actions
On most of the ISCP assessment tools, there is a box for “Agreed actions.” Often documented actions include ‘reading’ and ‘practice’. Whilst both are excellent sources of future learning and development, without trainer involvement in these actions, there is a risk of bad practice being reinforced rather than a change in practice as the outcome. Agreed actions have to complete a learning loop.
Event - Debrief - Actions - Review
Learning Loop (Allan & Vig 2009)
Without a review of the agreed actions, the trainee does not know if he or she has benefitted from the debrief and action plan, and the trainer is not aware of whether the trainee has in fact learned from the original event and the following debrief. Assessment is not a linear process; it needs to revisit and review the original training interventions to see whether those interventions have had the desired impact on learning. Suggested actions include:
Read x and teach the medical students. Put in your portfolio the teaching notes and student evaluations.
Practise x in the skills lab with (a registrar). Next time we are in theatre you will show me how to do this and we will fill in a relevant assessment form.
Conclusion
Experience Based Learning proposes a ‘training on the job, learning off the job’ model for surgical training, whereby trainees use as their curriculum setting the workplace contexts of theatre, ward and out-patients clinic. Supplementary activities such as audit, research, teaching and presentations are conducted outside of the EWT week. Trainers continue to train as they have always done, on the job, ensuring that debrief and follow up review of agreed actions is carried out. In this way, the requirement for trainees to learn from their mistakes without the guidance of an experienced expert, is reduced and so too are the numbers of procedures they have to do. Experience Based Learning provides trainees with experiences from which to learn, whilst under the apprenticeship guidance of their trainer consultants. Workload can be shared, once the trainee has mastered the relevant skills and knowledge to undertake the work required. Every experience has a training purpose, and each experience is utilised to this end. The appeal of the old apprenticeship model was the relationship built between trainer and trainee; effective debrief and review will provide this too.
Birchley D, Ann R Coll Surg Engl (Suppl) 2009;91:70-71
Black D, Ann R Coll Surg Engl (Suppl) 2009;91:78-79
Driessen E, van Tartwijk J, Dornan T (2008) TEACHING ROUNDS The Self Critical Doctor; helping students become more reflective. BMJ 2008;336:827 – 30
Lave J, Wenger E, 1991 Situated Learning: Legitimate Peripheral Participation. Cambridge University Press
D Pendleton et al, The Consultation: an Approach to Learning and Teaching, 1984
Wenger E, 1999 Communities of Practice: Learning, Meaning, Identity. Cambridge University Press
Wood D, Bruner JS, Ross G, 1976 The Role of Tutoring in Problem Solving in The Journal of Psychology & Psychiatry 17.
TAIP – Training and Assessment In Practice http://www.rcseng.ac.uk/education/courses/TAIP_.html/
Developing reflective writing among trainees
This is something I wrote to encourage trainers to use reflection with their trainees, and to guide them to encourage trainees to use a structured approach to reflection in completing their portfolios
Reflective practice is an essential component of the Portfolio for all trainees today. The ISCP requires it as do other forms of training and education both at undergraduate and postgraduate level. However, very few syllabuses or training programmes define exactly what it is; fewer still give any advice on how to do it – or for supervisors and trainers, how to teach it. This paper will give trainees a greater understanding of how to approach their reflective practice, and trainers a framework for encouraging and developing the practice among their juniors.
What is it?
“Reflection is vital for learning from clinical experiences” (Driessen et al, BMJ 2008 336)
To many people "experience" means "making the same mistakes with increasing confidence over an impressive number of years" (O’Donnell, 1997). The “impressive number of years” that surgeons spent in training previously has now gone and in the era of EWTD and ISCP, trainees cannot afford to make the same mistake twice. One way of addressing this is to encourage and develop the use of reflection in all trainee doctors.
Defining reflection
When we say that trainees need to be more reflective, what we mean is that they need to let future behaviour be guided by systematic and critical analysis of past actions and beliefs and the assumptions that underlie them. (Dewey, 1933)
Why use it?
All doctors in the UK are now required to make reflection a critical foundation of their lifelong learning (GMC 2000). Research evidence from nursing, (Jarvis in Nurse Educ 1992) and teaching (Korthagen et al, 2001) suggests that reflection can help students learn from their experiences.
How do we do it?
“Students do not generally adopt reflective learning habits spontaneously, so teachers must help them” (Driessen et al, BMJ 2008 336)
Most trainees do not really know how to reflect effectively on their practice. They may be aware that something has not gone particularly well; for Dewey, reflection was stimulated by an event that aroused a state of doubt, perplexity and uncertainty that often leads to the individual searching for the possible explanations or solutions. (Dewey, 1933) Trainees are less keen to reflect on practice that has gone well, although it is useful for them to do this from time to time to ensure they understand why it went well in order to replicate the good practice. Most of us want to improve the poor practice and this is where much of reflection is centred.
Supervisors and trainers need to stimulate students to assess and analyse their actions and devise alternative actions. To do this they need to provide a safe learning environment, give honest feedback and ask the right questions. The skill of the trainer is to listen well and ask open questions
Approaches to stimulating reflection in trainees
1. After conducting an assessment tool (mini CEX, CbD, DOP, PBA)
- Ask the trainee what they felt their strengths were in that activity.
- Add your own view of the strengths
- Ask the trainee where they think they could develop
- Ensure you shape the area(s) for development to make them meaningful and not too many
- Finally ensure that there are agreed actions for the trainee to follow up in order to learn from and then demonstrate development in this area.
Example:
After a Mini CEX in clinic, you and your trainee identify together the strengths of professionalism and appearance, rapport with a patient and organisation of encounter. In need of development was the history taking. You discuss the areas of weakness here and agree that he will shadow you in clinic next week, recording your history taking approach. He will then teach this to the F1s the following week and do a follow up mini CEX the week following that.
This is the most helpful way you can encourage reflection in a trainee especially early in their specialty training career. Encourage them to document their development too, with evidence in this case of the records he makes of your history taking, and the evaluations he receives from the F1 teaching the following week. When he has received his next mini CEX form he can put all of these pieces of evidence together to show that he has learned from this period of time.
2. LISA model for reflecting
- List - basic elements of practice, situation, problem
- Identify - assumptions, beliefs, feelings, rules, motives etc underlying practice and your approach to it
- See - with other practice? Possible alternatives? Comparative merits
similarities and drawbacks?
- Act - plan and then implement a new approach.
LISA is the framework used in the TAIP manual and provides a basic approach to Reflecting on practice from which to begin a reflective conversation with a trainee. In a simpler, but similar manner to Dewey’s 5 stage approach (Dewey 1933) LISA looks at the facts of the event or problem, the assumptions or beliefs or feelings that resulted from it and may stop the learner from accessing further learning or activity, the cognitive progress made from the reflection – looking at thought processes and other comparable practice and the patterns between them, before finally deciding upon an alternative action plan to implement. Like most reflective practice this is influenced by Schon (1987).
3. ALAC: (Driessen 2008)
Element of reflection - How to support reflective learning
- Action
Help trainees choose experiences that support and develop their learning
- Looking back
Separate performance from person (a mistake does not mean the person is a failure); be trustworthy and honest; acknowledge and make success explicit; provide feedback; encourage trainees to obtain information and evidence from various sources and put it into their portfolio
- Analysis
Focus on the trainee’s own role in the success or failure; encourage trainee to take the perspective of others; ask ‘why’ questions; ‘confronting’ questions; ‘generalising’ questions; point out inconsistencies in trainee’s analysis; help them generalise between experiences
- Creating alternative actions
Ask trainees to suggest options for change; encourage them to formulate plans and check these are in line with analysis; help them to focus on SMART objectives for learning
SMART: Make sure your actions are:
- Specific
- Measurable
- Achievable
- Relevant
- Timely
Advice for trainees in reflecting on their practice
The benefits of regular reflective writing
Reflective writing provides an opportunity for us to think critically about what we do and why. It provides
· a record of events and results and our reactions to them,
· data on which to base reflective discussion,
· opportunity for us to challenge ourselves and what we do and to look at doing it differently and better,
· impetus to take action that is informed and planned,
· an opportunity to view our clinical practice objectively and not see all problems as personal inadequacy,
· increased confidence through increased insight
· Basic documentation to support future entries in our portfolio and for job applications etc.
(http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm)
Peer reflection
Engaging in open and collaborative discussion about work with a peer is a process that can enable us to become more reflective doctors. You can use any of the models advocated above if you and your peer are reasonably confident and experienced in challenging one another in reviewing an event. If you are new to this you may wish to reflect with a supervisor first until you become more confident.
Using the LISA framework
A helpful way of understanding the process of reflection described by Stephen Brookfield (1995) describes the process of hunting out our assumptions and critically examining them. Ask yourself what are the assumptions behind your practice and then try to develop a contrary argument. You now have two sides of an argument to evaluate. This is engaging in personal critical reflection.
Keeping a journal
The journal is parallel to the field book or laboratory notes of the scientist. We not only record what happened or what was observed but in addition we can record a tentative hypothesis or the development of new understanding, we can use our writing to make a new sense of phenomena. Reflective writing has the potential to provide us with a systematic approach to our development as a reflective, critical and constructive learner. Our journal can provide an opportunity to make explicit our position on a range of issues of personal significance.
Your journal could be structured:-
· as a personal learning journey, tracking and documenting an evolving understanding of your clinical practice and learning
· a critical reflection on a clinical encounter you have witnessed between a colleague or your registrar or consultant supervisor
Ideas for getting started on reflective writing:
1. Use a checklist
· What is the current problem or issue? Describe the context
· What additional information would be useful?
· How is it related to other issues?
· Who or what could help?
· What are my assumptions? How can I test them?
· What can I do to create a change? Be as adventurous as you can
· What are the possible outcomes of these?
· What action will I take? Why?
· List the outcomes you hope to achieve.
· Reflection on the actual outcome What worked well?
· What could I do differently next time?
2. Focus on a critical incident that took place in your clinical practice.
· Describe the incident as objectively as possible.
· What were the assumptions that you were operating with?
· Is there another way to see this event?
· How would your patients explain this event?
· How do the two explanations compare?
· What could you do differently?
3.And from time to time...
· What has using this journal confirmed that I already know about my learning and how I affect that?
· What do I need to do to improve the quality of what I do?
· What might I do instead of what I do now?
· What innovation could I introduce?
· What professional development activities should I be seeking?
For more information on reflective practice see:
Ballantyne, R & Packer, J; (1995)Making Connections: Using Student Journals as a Teaching/Learning Aid, HERDSA ACT.
Boud, D; Keogh, R; & Walker, D, (1995) Reflection: Turning Experience into Learning, Kogan Page, London.
Brookfield S. (1995) On Becoming a Critically Reflective Teacher, Jossey Bass, San Francisco.
http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm
Dewey J. How we think: a restatement of the relation between reflective thinking to the education process. Boston: Heath, 1933Driessen E, van Tartwijk J, Dornan T The self critical doctor: helping students become more reflective. BMJ 2008 336:0
General medical Council. Revalidating doctors: ensuring standards, securing the future. London: GMC, 2000
Jarvis P. Reflective Practice and nursing. Nurse Educ 1992; 12; 174 – 81
Korthagen FAJ, Kessels J, Koster B, Lagerwerf B, Wubbels T. linking theory and Practice: the pedagogy of realistic teacher education. Mahwah, NY: Lawrence Erlbaum Associates, 2001
O’Donnell M. A sceptic’s medical dictionary. Oxford: Blackwell BMJ books, 1997
Schon, D; (1987) Educating the Reflective Practitioner; Jossey Bass, San Francisco.
Reflective practice is an essential component of the Portfolio for all trainees today. The ISCP requires it as do other forms of training and education both at undergraduate and postgraduate level. However, very few syllabuses or training programmes define exactly what it is; fewer still give any advice on how to do it – or for supervisors and trainers, how to teach it. This paper will give trainees a greater understanding of how to approach their reflective practice, and trainers a framework for encouraging and developing the practice among their juniors.
What is it?
“Reflection is vital for learning from clinical experiences” (Driessen et al, BMJ 2008 336)
To many people "experience" means "making the same mistakes with increasing confidence over an impressive number of years" (O’Donnell, 1997). The “impressive number of years” that surgeons spent in training previously has now gone and in the era of EWTD and ISCP, trainees cannot afford to make the same mistake twice. One way of addressing this is to encourage and develop the use of reflection in all trainee doctors.
Defining reflection
When we say that trainees need to be more reflective, what we mean is that they need to let future behaviour be guided by systematic and critical analysis of past actions and beliefs and the assumptions that underlie them. (Dewey, 1933)
Why use it?
All doctors in the UK are now required to make reflection a critical foundation of their lifelong learning (GMC 2000). Research evidence from nursing, (Jarvis in Nurse Educ 1992) and teaching (Korthagen et al, 2001) suggests that reflection can help students learn from their experiences.
How do we do it?
“Students do not generally adopt reflective learning habits spontaneously, so teachers must help them” (Driessen et al, BMJ 2008 336)
Most trainees do not really know how to reflect effectively on their practice. They may be aware that something has not gone particularly well; for Dewey, reflection was stimulated by an event that aroused a state of doubt, perplexity and uncertainty that often leads to the individual searching for the possible explanations or solutions. (Dewey, 1933) Trainees are less keen to reflect on practice that has gone well, although it is useful for them to do this from time to time to ensure they understand why it went well in order to replicate the good practice. Most of us want to improve the poor practice and this is where much of reflection is centred.
Supervisors and trainers need to stimulate students to assess and analyse their actions and devise alternative actions. To do this they need to provide a safe learning environment, give honest feedback and ask the right questions. The skill of the trainer is to listen well and ask open questions
Approaches to stimulating reflection in trainees
1. After conducting an assessment tool (mini CEX, CbD, DOP, PBA)
- Ask the trainee what they felt their strengths were in that activity.
- Add your own view of the strengths
- Ask the trainee where they think they could develop
- Ensure you shape the area(s) for development to make them meaningful and not too many
- Finally ensure that there are agreed actions for the trainee to follow up in order to learn from and then demonstrate development in this area.
Example:
After a Mini CEX in clinic, you and your trainee identify together the strengths of professionalism and appearance, rapport with a patient and organisation of encounter. In need of development was the history taking. You discuss the areas of weakness here and agree that he will shadow you in clinic next week, recording your history taking approach. He will then teach this to the F1s the following week and do a follow up mini CEX the week following that.
This is the most helpful way you can encourage reflection in a trainee especially early in their specialty training career. Encourage them to document their development too, with evidence in this case of the records he makes of your history taking, and the evaluations he receives from the F1 teaching the following week. When he has received his next mini CEX form he can put all of these pieces of evidence together to show that he has learned from this period of time.
2. LISA model for reflecting
- List - basic elements of practice, situation, problem
- Identify - assumptions, beliefs, feelings, rules, motives etc underlying practice and your approach to it
- See - with other practice? Possible alternatives? Comparative merits
similarities and drawbacks?
- Act - plan and then implement a new approach.
LISA is the framework used in the TAIP manual and provides a basic approach to Reflecting on practice from which to begin a reflective conversation with a trainee. In a simpler, but similar manner to Dewey’s 5 stage approach (Dewey 1933) LISA looks at the facts of the event or problem, the assumptions or beliefs or feelings that resulted from it and may stop the learner from accessing further learning or activity, the cognitive progress made from the reflection – looking at thought processes and other comparable practice and the patterns between them, before finally deciding upon an alternative action plan to implement. Like most reflective practice this is influenced by Schon (1987).
3. ALAC: (Driessen 2008)
Element of reflection - How to support reflective learning
- Action
Help trainees choose experiences that support and develop their learning
- Looking back
Separate performance from person (a mistake does not mean the person is a failure); be trustworthy and honest; acknowledge and make success explicit; provide feedback; encourage trainees to obtain information and evidence from various sources and put it into their portfolio
- Analysis
Focus on the trainee’s own role in the success or failure; encourage trainee to take the perspective of others; ask ‘why’ questions; ‘confronting’ questions; ‘generalising’ questions; point out inconsistencies in trainee’s analysis; help them generalise between experiences
- Creating alternative actions
Ask trainees to suggest options for change; encourage them to formulate plans and check these are in line with analysis; help them to focus on SMART objectives for learning
SMART: Make sure your actions are:
- Specific
- Measurable
- Achievable
- Relevant
- Timely
Advice for trainees in reflecting on their practice
The benefits of regular reflective writing
Reflective writing provides an opportunity for us to think critically about what we do and why. It provides
· a record of events and results and our reactions to them,
· data on which to base reflective discussion,
· opportunity for us to challenge ourselves and what we do and to look at doing it differently and better,
· impetus to take action that is informed and planned,
· an opportunity to view our clinical practice objectively and not see all problems as personal inadequacy,
· increased confidence through increased insight
· Basic documentation to support future entries in our portfolio and for job applications etc.
(http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm)
Peer reflection
Engaging in open and collaborative discussion about work with a peer is a process that can enable us to become more reflective doctors. You can use any of the models advocated above if you and your peer are reasonably confident and experienced in challenging one another in reviewing an event. If you are new to this you may wish to reflect with a supervisor first until you become more confident.
Using the LISA framework
A helpful way of understanding the process of reflection described by Stephen Brookfield (1995) describes the process of hunting out our assumptions and critically examining them. Ask yourself what are the assumptions behind your practice and then try to develop a contrary argument. You now have two sides of an argument to evaluate. This is engaging in personal critical reflection.
Keeping a journal
The journal is parallel to the field book or laboratory notes of the scientist. We not only record what happened or what was observed but in addition we can record a tentative hypothesis or the development of new understanding, we can use our writing to make a new sense of phenomena. Reflective writing has the potential to provide us with a systematic approach to our development as a reflective, critical and constructive learner. Our journal can provide an opportunity to make explicit our position on a range of issues of personal significance.
Your journal could be structured:-
· as a personal learning journey, tracking and documenting an evolving understanding of your clinical practice and learning
· a critical reflection on a clinical encounter you have witnessed between a colleague or your registrar or consultant supervisor
Ideas for getting started on reflective writing:
1. Use a checklist
· What is the current problem or issue? Describe the context
· What additional information would be useful?
· How is it related to other issues?
· Who or what could help?
· What are my assumptions? How can I test them?
· What can I do to create a change? Be as adventurous as you can
· What are the possible outcomes of these?
· What action will I take? Why?
· List the outcomes you hope to achieve.
· Reflection on the actual outcome What worked well?
· What could I do differently next time?
2. Focus on a critical incident that took place in your clinical practice.
· Describe the incident as objectively as possible.
· What were the assumptions that you were operating with?
· Is there another way to see this event?
· How would your patients explain this event?
· How do the two explanations compare?
· What could you do differently?
3.And from time to time...
· What has using this journal confirmed that I already know about my learning and how I affect that?
· What do I need to do to improve the quality of what I do?
· What might I do instead of what I do now?
· What innovation could I introduce?
· What professional development activities should I be seeking?
For more information on reflective practice see:
Ballantyne, R & Packer, J; (1995)Making Connections: Using Student Journals as a Teaching/Learning Aid, HERDSA ACT.
Boud, D; Keogh, R; & Walker, D, (1995) Reflection: Turning Experience into Learning, Kogan Page, London.
Brookfield S. (1995) On Becoming a Critically Reflective Teacher, Jossey Bass, San Francisco.
http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm
Dewey J. How we think: a restatement of the relation between reflective thinking to the education process. Boston: Heath, 1933Driessen E, van Tartwijk J, Dornan T The self critical doctor: helping students become more reflective. BMJ 2008 336:0
General medical Council. Revalidating doctors: ensuring standards, securing the future. London: GMC, 2000
Jarvis P. Reflective Practice and nursing. Nurse Educ 1992; 12; 174 – 81
Korthagen FAJ, Kessels J, Koster B, Lagerwerf B, Wubbels T. linking theory and Practice: the pedagogy of realistic teacher education. Mahwah, NY: Lawrence Erlbaum Associates, 2001
O’Donnell M. A sceptic’s medical dictionary. Oxford: Blackwell BMJ books, 1997
Schon, D; (1987) Educating the Reflective Practitioner; Jossey Bass, San Francisco.
Hello
This is a site for anyone who is involved in or interested in educating trainers. I do not use these terms lightly. In a 'training' focused world, my mission is to educate through training. In medicine and surgery, my main place of work, there is much talk of training and little consideration of education. I see this as a dangerous distinction; to train someone we show them how to be like us - a useful first step in their development - but we must go further than that and educate them to think for themselves. This is time consuming and onerous and it is not surprising that the quick fix of training is more attractive in today's NHS and elsewhere.
I intend to post up here some of the materials I have written for my work, to share with anyone who is interested. And please, share your views on here, add your own thoughts. I look forward to "talking" to you.
Best Wishes
Hayley
This is a site for anyone who is involved in or interested in educating trainers. I do not use these terms lightly. In a 'training' focused world, my mission is to educate through training. In medicine and surgery, my main place of work, there is much talk of training and little consideration of education. I see this as a dangerous distinction; to train someone we show them how to be like us - a useful first step in their development - but we must go further than that and educate them to think for themselves. This is time consuming and onerous and it is not surprising that the quick fix of training is more attractive in today's NHS and elsewhere.
I intend to post up here some of the materials I have written for my work, to share with anyone who is interested. And please, share your views on here, add your own thoughts. I look forward to "talking" to you.
Best Wishes
Hayley
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