Module - Reflective Practice for clinicians

I recently wrote an e module for clinicians in reflective practice for the London Deanery Professional Support Unit. This module combines information about reflection for those looking to learn more about it, with a walk through hands on approach to doing reflection.

Access the page link below and click on the pdf picture of the module on the right of the page to go to the whole module.

http://www.londondeanery.ac.uk/professional-development/professional-support-unit/learning-development-and-personal-effectiveness-resources/reflective-writing-skills

Do let me know what you think of it.

Reflective Practice - some examples

Having worked recently on an e learning module on Reflective Practice, and with some superb trainee doctors in producing pieces of reflective writing, I wanted to share some of those with you.

There are three pieces of writing demonstrating the DEBRIEF guide for writing up reflections on clinical practice. I want to thank the trainees involved for their hard work and for being willing to share these pieces in various quarters.

Reflection 1:Massive haematemesis

Situation-ITU resident on night shift.

The case (Describe what happened)

We had a fifty one year old gentleman with NASH who had presented with haematemesis on our ITU outreach list. He had presented on the Friday with a litre of haematemesis witnessed in A&E. There was no gastro on call over the weekend so he was waiting for his scope on Monday. Soon after starting my night shift, I was asked by the med reg to come and see him as he had just had another episode of haematemesis of about 1L.

When I got there, he had just been reviewed by the surgical registrar and looked unwell. As I went to examine him, he vomited again- about 1.5L over my shoes and on to the floor. I asked for help, assessed what kind of IV access he had and squeezed the bag of blood that was up. A nurse soon arrived and the surgical reg. I asked them to fast bleep the anaesthetist on call and someone went to look for a Sengstaken-Blackemore tube.

The SB tube was put down which stopped the bleeding and more blood was ordered. The plan was to take the patient to theatre and do an OGD. I left the patient with the surgical registrar and the anaesthetists and went back to the unit. They would contact me if there was any deterioration and we made a bed available for the patient post-theatre.

A few hours later, I was called by the medical registrar on call to say that they were in the process of trying to get the patient transferred to the tertiary centre Liver ITU. The SB tube balloon had been pulled out and the surgeons on call could not band varices and there were no gastroenterologists available. I went back to the ward to assess the situation.

The patient now had an arterial line and a CVP line. The SB tube was back in place. The patient was still receiving blood and blood products. I spoke to the tertiary centre  and they accepted the patient for transfer. It was decided that the patient should be intubated for transfer and that it was best to do this on the ward rather than transferring him up to the unit first. The surgical registrar, medical registrar, anaesthetic SHO and registrar and the ITU consultant (over the phone) were all involved in this decision.

There was delay in intubation so that after the SB tube had been removed, the patient vomited blood again and then arrested (PEA). It was a difficult intubation but successful and the SB tube was then re-sited. The patient received 3 cycles of CPR with adrenalin and atropine with return of spontaneous circulation. The initial BP was 100 systolic. The patient’s daughter arrived soon after the start of the resuscitation but did not stay for long to observe.

The situation was again discussed with the tertiary centre  and consultants at home (anaesthetic, medical, ITU) and with the staff present (anaesthetists, surgical reg, medical reg, site managers, nurses) and it was felt that although the patient was unstable, transfer to a unit with staff to do oesophageal banding was the only option that offered some chance of survival. There were conflicting opinions about this but this was the consensus that was reached.

The patient however was not able to maintain his BP, despite boluses of adrenalin and ongoing transfusion. The BP was barely maintained at 70 systolic. The situation was re-assessed and it was decided that transfer was no longer an option. The family had not yet been spoken to. I was nominated to speak to family, with the medical registrar.

The family (wife, daughter, son) understood that the situation was serious and that we had tried to get the patient stable enough for transfer to a specialist unit but that this had not been possible. They wanted active treatment but understood that this was likely to be futile. I explained that the patient could either be brought up to ITU for ongoing support but that the outcome was likely to be poor. The alternative was to keep the patient comfortable on the ward. The family decided that they wanted the patient to be kept comfortable on the ward.

The situation was then again discussed with the members of staff present and with consultants over the phone. The consensus was that treatment should be stopped and the patient kept on the ward. He died soon thereafter with his family at the bedside.

My evaluation (E)

Things that went well: good communication between different members of staff, good decision making process, patient’s best interests always foremost, dignified death at the end.

Areas for improvement: awareness of ward nursing staff of seriousness of situation, hospital logistics (availability of SB tube), delay in intubation, out of hours gastroenterology availability.

Feelings (Bring out feelings, values, beliefs, assumptions etc)

This case left me with a feeling of slight unease; whilst I knew we had done all we could – and we had facilitated a clam and dignified death at the end of the process, I just felt like we could have been slicker in our management. I was frustrated by the nursing staff who did not seem to grasp how ill the patient was. I could feel myself getting angry with the lack of availability of the equipment and the out of hours gastro cover system. I felt like I was doing my very best for this patient but around me the staff and the hospital infrastructure were taking it all at a much more casual pace. We work hard and intensively and when that is not matched by the system or other colleagues it can be infuriating.

Review (Review in light of previous experience; how would someone else have acted?)
 

I have treated patients with similar problems before and have also been with patients at the end of their life. I think the reason this case affected me was because I felt overpowered not just by the inevitability of the patient’s death, but also by the small inefficiencies of the hospital system.

Identify learning points (I)

Communication between everyone involved in case is vital - staff present but also other centres and consultants over the phone, consensus in decision making is important and not easy, but sometimes we cannot always offer patients the care they need or we would like to offer.

Establish follow up actions (E)

The equipment issue is something I can do something about so I intend to do process mapping on such essential pieces of kit, and ensure that there is a system in place to have all kit kept fully stocked and up to date for future cases.

Further reading/ study: STEP Case of the month: http://estepcore.rcseng.ac.uk/secure/cotm/view_case_html?case_id=55

Feedback (Feedback on actions)

I have spoken to my consultant about the equipment project and he suggested I could submit the results as a Quality improvement Project to the next QIP conference the Deanery run.

 Reflection 2: A&E

Describe events

During a night shift on call I was in theatre with a locum SpR assisting with a laparoscopic appendicectomy. The trauma bleep went off and it was announced that the call was a code red - meaning that there was an unstable patient. I left theatre and went to A&E. On arriving in resus, I found the rest of the trauma team (A&E consultant, orthopaedic SpR and nurses) with a 19yr old male who was intubated and ventilated, who had been transferred from another Hospital, following stabs to the left arm, chest, buttock and thigh. He had a systolic blood pressure of 60 and a tachycardia of 152 bpm and the A&E consultant asked me to insert a chest drain, which I did. As I had missed the primary survey (because I was in theatre), and the patient was unstable I reviewed it for myself and then suggested that a stab check was done - on removing the left arm bandage I noticed that the patient was exsanguinating from a lacerated brachial artery, and he had blood going through a cannulae distal to this in his left forearm which was why he was not responding to fluids. I applied a pressure dressing and asked the A&E consultant to call the surgical Trauma Consultant on call and ask him to attend. The consultant was there in 20 minutes and a tourniquet was applied and the patient went for a CT angiogram and then straight to theatre.

Evaluation

On reflection, I think the team worked well and quickly together once we had realised what the problem was. There was clear communication between each member of the team and life threatening issues were dealt with quickly and efficiently, even though we only had limited staff available.

Bring out emotions etc; Review in light of previous experience

Given my previous experience of trauma I quickly knew that the patient was unwell and I realised that if we didn't quickly find the cause for the hypotension he would arrest and would need a clamshell thoracotomy, which I had never performed alone before and without the support of my SpR or consultant this would have been terrifying. I was aware of how afraid I was about the possibility of having to do a thoracotomy if the patient arrested.

Identify learning points

I learnt the importance of reviewing the primary survey if the patient remains unstable and as in this case it was easily reversible with re-siting the cannulae into a different arm. I am also glad that I did not hesitate to call in my consultant as the patient went straight from A&E to theatre for repair of his brachial artery to save his left arm. Also, I found that being in such a stressful situation as a junior SHO can be emotionally quite challenging and I continued to replay the sequence of events over again in my mind to see if there was anything I could have done differently. I realise now that if that had been necessary I could have called upon the A&E consultant.

Establish follow up actions

Following the incident, I reflected with my consultant and the A&E consultant and suggestions for improvement included applying a tourniquet earlier to the left arm, rather than a pressure dressing. I had considered this at the time, but I was not sure why I hesitated. Next time, if I think of applying a tourniquet I will just put one on and make a note of the time of application. I think that discussing the case with consultants and colleagues afterwards helped me to feel more confident and identified important learning points. The follow day I did some reading about thoracotomies.

Feedback on those actions

I intend to follow up this learning by linking this case to a future case which either covers similar clinical ground or in which there is the question of calling for senior help.

 

Reflection 3: Paediatric patient

Case (D)

A failed kidney transplant patient, he had spent large part of his life in and out of hospital even though he was only seven. He knew all about doctors and nurses, blood tests and operations. He did not like being in hospital and he did not like being told what to do.

On the morning in question, I needed to take a blood sample from him. I introduced myself as I had not met him before. He looked at me suspiciously and told me he wanted to eat his lunch first. I thought this was a reasonable request and said I would come back.

When I came back he said he did not want his blood taken. I explained why it had to be done. There then followed every excuse he could think of as to why he should not have his blood taken then. He wanted to play some more first. He wanted his mum to have her blood taken first. He wanted another doctor to do it. He wanted to go to the toilet first. I dealt with each argument but he became more and more distressed. He swore and shouted and cried and tried running away.His mother said we should go ahead. The minute the needle touched his skin, he was quiet. He stopped crying and calmly watched the blood enter the specimen tube.

I asked him why he had been so distressed. He said he had to make a fuss ‘so that I would be careful’. I said I could understand his logic but that perhaps in future he did not need to make quite so much fuss.
 

I thought I dealt with this situation well by letting the patient eat his lunch and coming back later and I was glad that I asked him why he had been so distressed, because I learned something from that. However, I could feel myself getting angry with him and only just managed to control that. (Evaluation)

I was very busy that shift and could have done without this, but something made me curious about this child’s behavior. I have to say I admired him in a way for his strategy. (B)

When I thought back over this case later that evening, I recalled talking to a parent of a sick child a few months ago and she said how much she hated her powerlessness. She said she felt as though she and her daughter were victims in the machinery of the healthcare system. That comment stayed with me, and I wondered today if this child’s behaviour over the blood sample was driven by the need to exert some power over what was being done to him. (R)

I realized that we would do well to remember how vulnerable patients feel, and that we need to earn our patient’s trust and it is often best to tread carefully at the start. (I)

When I am working with patients in future, I will endeavour to give them as much choice as possible over their care, even down to when I take their blood. (Establish Actions) I would like to look at the patient feedback forms and see whether there is scope to ask them about choices in their care. (F)

Pendleton Plus goes international

Following the presentation and workshop on Pendleton Plus in the European ATLS meeting in Berlin in April, Pendleton Plus will be used in the 9th edition ATLS manual from early 2013. It is already being successfully used in a number of European countries and feedback has been positive. Users report liking the flexibility it gives to explore performance more deeply.

Pendleton Plus

Facilitating analytical feedback and reflection

A year ago I wrote about the debate surrounding Pendleton’s Rules for feedback and gave my view on why a structured approach is important.

A year down the line and I have amended Pendleton to reflect the good use I see it put to on a regular basis. My changes to the original address the concerns raised when critics of Pendleton discuss the framework:

Criticisms of Pendleton’s Rules:

* Pendleton's Rules often lead to narration of events: "I introduced myself, I introduced the topic, I asked a question...." (The 'what') and can omit to consider the analysis and application (the 'why' and the 'how') of the episode and the implications for future practice;
* Pendleton's Rules can leave learners unsure as to the quality of their teaching episode - was it good, poor, catastrophic - due to the 'balanced' feedback. Candidates want to (and need to) know how well they did.
* People struggle to give constructive feedback, or if they do, they either say what was sub optimal or how it can be improved, but not always both of those things.

I have heard from those who had used a less structured approach to feedback, that whilst this can be done extremely well, is not done well by up to 50% of the learner group.  (anecdotal, not evidence based using RCT!)

The challenge is how to introduce analysis and evaluation in a simple, structured format that even the most reluctant facilitator of feedback can confidently tackle.

The product of extensive discussions and some pre piloting is presented here – ‘Pendleton Plus’ retains the principles of Pendleton's Rules (the learner self evaluates first; positives are usually discussed first) but has a couple of slight changes:

Pendleton Plus:

1. Insight: Coach Ask: “How do you think that went?” (to find out the level of insight of the learner)

Headline: Coach Tell: “I thought that was excellent | very good | good| OK | slightly problematic | problematic – let’s go back through what you did and look at each part, as this can be improved”

2. What went well: Coach Ask: “Let’s look at what you think went well?” Add “why” and “how did you do that?” questions where relevant to promote analysis
3. What to improve: Coach Ask:  “Let’s look at what you want to improve or develop.” Add “why” and “how would you do that?” questions where relevant to promote analysis
4. Action Plan: Coach Ask:  “What will you do to take this forward?”

Step 1 is to briefly ascertain the insight of the learner and a simple headline evaluation from the facilitator:
So the facilitators asks the learner in one word to sum up how they felt they did. It is important here not to let them delve head first into regurgitating the narrative of their episode, or to metaphorically beat themselves around the head in anguish. This is a quick stock check, to enable them to give a gut feeling, and for you to add your gut feeling, before the real analysis starts.

Step 2 asks the Pendleton initial question or 'what did you think worked well?' But the difference here is that where often the facilitator would previously listen to the retelling of the teaching story, then provide their own (often second) teaching story, this time the facilitator prompts the learner with 'why?' and 'how' questions - 'why did that question bring them to life like that?' 'How did you move them onto that point?' In this way Pendleton steps 1 and 2 (learner positives, trainer positives) should be covered in one stage, with the facilitator questioning, prompting and if necessary making observations to develop learner understanding of what went well, why and how they achieved that.

Step 3 does the same but with the areas for development. Again, analysis should be encouraged through the use of questions and observations: 'why do you think they fell silent at that point?’  'I noticed you looked uncomfortable then - why do you think that was?' Development for future would extend this conversation using 'how' questions: 'how would you deal with a silence like that in future?' 'How would you avoid...?'

Step 4 ought to be a quick resume of follow up actions from the learner of 1-2 points they did well and 1-2 points they intend to address.

Having piloted this I was surprised to see the ease with which people picked it up. The benefit of the familiarity with the original Pendleton clearly helped, as did the clear structure. I was concerned with the possibility that this would take longer to do than the previous system but this was not the case at all. In fact, many feedback sessions were a little briefer as they cut out the time consuming narration. As long as the group understood the principles involved, they seemed to have no trouble at all.

A useful paper I am sure you will all recognise which supports the principles of Pendleton Plus and may be useful to have on hand if anyone asks for further information is  Cantillon P, Sargeant J: Giving Feedback in Clinical Settings BMJ 2008;337:a1961 doi:10.1136/bmj.a1961

Do let me know of your experiences in using Pendleton Plus.

Pendleton's rules

At the recent ATLS National Day and the Europen meeting of ATLS Educators there were discussions about other courses trying out different approaches to feedback. It seems as though Pendleton's rules for feedback http://www.gp-training.net/training/educational_theory/feedback/pendleton.htm are falling out of favour.

I was asked why this may be the case, and my personal view is that it is not the Pendleton framework which is at fault, but the struggle many people have to either understand the point of Pendleton, or to conduct a developmental conversation that is both specific, based on behavioural evidence and sufficiently constructive.

I have discussed various forms of feedback on here previously (see DEBRIEF), but wanted to make out a case for the use of Pendleton's rules.

For me the benefit of Pendleton is that it reaches all stages of learning, from the competent to the incompetent, and from that which we are aware of to that which we are not aware of.

As I have written before, learning is a matter of developing both competence and conscious awareness. We progress from a state of not knowing that we do not know or cannot do (unconscious incompetence) through the stage of being aware of what we do not know or cannot do (conscious incompetence) to one of knowing what we know and can do (conscious competence) to the final stage of knowing what we know and doing what we do but not being always aware of that (unconscious competence.)

If this is the case, and this learning curve describes the rudimentary stages we progress through when learning a new skill or behaviour, then feedback needs to access each of these stages of learning.

Pendleton's rules map onto these stages of learning beautifully:

1. Asking "What went well with that?" accesses the conscious competence quadrant and focuses the learner's mind on practice that needs to be repeated in future. This question also allows for the teacher to assess the levels of insight the learner displays, in their self evaluation.

2. Providing further discussion of what went well led by the teacher, develops the good practice and may access the areas of strength which the learner has no awareness of (unconsciously competent.)

3. Asking the learner what they were less pleased with and what could be developed further, also checks insight levels, and accesses the consciously incompetent areas of practice.

4. Finally, discussing with the learner what the teacher feels needs to be developed (with an action plan to do so) accesses the unconsciously incompetent quadrant.

Pendleton offers a framework within which we can discuss all aspects of the learning curve, including those areas of competence and incompetence known and unknown to the learner. What we need to do within each of the four questions advocated by Pendleton is to be specific about the strengths and areas for development, not shy away from being honest in our descriptions of the behaviours we have observed. And we must always encourage further actions which develop the weaker areas.

Proof it can be done!

A great new article from a trainee who was victim to the curriculum changes from BST to ISCP.

This article shows how hard Rafay worked and what he has achieved. He is now deservedly in ST3 training in the specialty of his choice.

http://careers.bmj.com/careers/advice/view-article.html?id=20002902

DEBRIEF: A reflective tool for workplace based learning

Hayley Allan

Why do we sometimes act inconsistently? Our heart is pulling us in one direction and our head is insisting on another. What about that gut feeling we have? You know that niggling feeling in the middle of the night? The knowledge, deep down somewhere that what we are doing is not totally right?

Survival has always depended on gut feeling. Humans would long be extinct if they did not have the ability to instinctively know when something is wrong. How many times do we hear someone saying that they “just knew” something was wrong? Paediatricians know that if the mother is worried, they ought to be worried. The girl who was mugged outside the internal front door of her second floor flat, knew there was something not quite right.  What is this sixth sense we all have and why are we advised to ignore it at our peril?

Call it intuition, call it experience. (It will depend on where you were schooled. If in the arts or social sciences you may favour intuition as a term for this phenomenon. Medics and those who deal with the allegedly more concrete world would call it experience. )

Experience is a tremendous learning tool because it develops in us over time; it steadily drip feeds our psyche while we work. Experience builds up pattern recognition over time. It swells the coffers of our intellect, adding to the vault of events and feelings that our mind stockpiles over the years. It is a rich resource. Many people, especially those who learned their craft through trial and error, through experimentation and throughput of events, believe there is no other way to learn.

But what if that accumulation of experience could be fast tracked? What if, instead of laying down lots of fifty pence pieces in the bank vault (individually heavy and of low value) we put by the (admittedly less frequent) stash of ten pound notes we came across? Is there a way to take more learning from fewer learning experiences?

Learning from experience and developing metacognition

DEBRIEF is a tool that enables reflection to take place between a number of people or individually. It provides a structure for review of an event in an emotional, a cognitive and a practical way, thus addressing the psychosocial and practical elements of learning. It has been acknowledged that learning is facilitated or hampered by emotions (Boekaerts 1993, Goleman 1995) and that emotions drive learning and memory (Sylvester 1994.) Learning is not a purely cognitive process (Le Doux (1997) Gross (2008) Love & Goodsell (1996). Much has been said about the emotional impact of learning. If we agree that learning is based on experiences then we cannot deny that emotions will play a part in those experiences and how we process them. The DEBRIEF model, in the constructivist tradition, helps learners to “take responsibility for their own learning, to be autonomous thinkers, to develop integrated understandings of concepts and to pose – and seek to answer- important questions.” Brooks & Brooks (1993)

Friere (1970) argued that learning and education is transformed through praxis – that is “reflection and action upon the world in order to transform it.” Vygotsky (1978 ) identified a zone of proximal development – a gap in terms of experience between two people at different levels of performance which could be used to “scaffold” (Wood et al 1976) the learning for the less experienced of the two. Scaffolding works best when functioning in a situated context or a Community of Practice (Lave & Wenger 1991) and remains the most practically useful way for many in training to learn. DEBRIEF offers a simple structure for such scaffolding to follow, but can also develop in time into internal DEBRIEFing, or metacognition.

Where are the trainers? And how do I know what I don’t know?

In current workplaces, trainees rarely have a supervisor with them all the time; the luxury of a more expert person always being at the elbow of the novice to question and support them in their thinking and practice is but a dream. If medical training is to be ‘trainee driven’ ( ISCP 2010, RCPath 2011,RCP 2011 ) then learners have to recognise their own learning needs and seek out an expert with whom to discuss those needs. However many needs, or gaps in knowledge and uncertainty about practice, fall into the zone of ‘unconscious incompetence.’ How can we know what we do not know if we do not know it and do not know that we do not know it? Once we are consciously competent (that is we know what we don’t know) there is not a problem, but often this conscious awareness has to be raised by either experience or a supervisor. If the supervisors aren’t there, we return to the learning by mistakes method, which is no longer tenable in the twenty first century.

This is where gut feeling comes in.


Fig 1. The role of conscious awareness in the development of competence.

There is a halfway house between unconscious incompetence and conscious incompetence where gut feeling resides. It is a small space, barely perceptible to some, but it can be developed given practice and the right conditions. Gut feeling can alert the learner to an inconsistency, or a ‘perturbation’ (Piaget 1954, 1971) and it is then the role of the learner to pursue this. There are several ways to do this, and usually the educational response is to seek out a supervisor or mentor for a conversation such as a Case Based Discussion, or to reflect on the perturbation independently. Both approaches can have limited effect. A CBD may yield a sophisticated level of analysis, resulting in new levels of understanding for trainee and even for the trainer. Often however, the conversation becomes didactic and theoretical and the synthesis between knowledge and application can be lost. Independent reflection is a good habit to develop but if the gut feeling is not explored purposefully and systematically there will be no real development beyond the ever decreasing circles we can be trapped in when trying to work out ‘what went wrong.’

DEBRIEFing

Debriefing is a mixture of reflecting and teaching. Using a framework to discuss the gut feeling with a more experienced colleague can lead to unexpected revelations. Once the framework has been practised several times it can work without another person’s input. If the learner becomes accustomed to following the steps in the model, s/he can uncover information and understanding to which they did not have conscious access previously either with a peer or alone.


DEBRIEF model



Describe events as factually as possible

Evaluate what went well/to change next time

Bring out emotions/values/beliefs/assumptions that cloud judgement and development

Review and analyse in light of previous experience; what a colleague would have done

Identify lessons learned

Establish follow up actions

Feedback on actions


©Hayley Allan 2009


Fig 2 DEBRIEF model
 
How does DEBRIEF work?

DEBRIEF is more than reflection. It is a series of questions asked of the learner which promote recall of the events, evaluation of his or her role in the events, and a psychological review of the impact of the events on the learner’s sense of wellbeing, before addressing the cognitive impact and reviewing the account for previous similarities of behaviour. Often perturbations (Piaget 1954, 1971) occur because we repeat behaviour which is a function of emotional or psychological triggers from past experiences. It is only when learners can look back in a safe environment, knowing that whilst they may have made mistakes they also had a positive effect on some of the events concerning them, that they are free to own those mistakes. Emotions can block cognitive development and progress and so the examining of the feelings, beliefs, assumptions or motives behind the learner’s actions is often a pivotal point at which the individual unblocks that repetitive behaviour or identifies the gut feeling causing the perturbation. Being able to move onto action planning as a result of the identification of what has been learned is a positive and valuable way for the learner to move on from the event.

How does DEBRIEF differ from regular reflection?

Reflection often follows the Learning cycle of Kolb (1984) but rarely bridges the gap between the action and reflection stages or between reflection and theory stages. Most learners are not able to make those large transitions alone without additional structure.

Fig 3 Kolb’s reflective practice cycle

Fig 4 Kolb’s cycle with DEBRIEF added

DEBRIEF provides a step wise structure to enable the learner to progress through each of Kolb’s learning points, but looking in turn at the behavioural, psychological and cognitive elements of the practice. By following these steps when reviewing an experience the learner is not only processing the experience itself, but is also developing metacognition which will enable further reflection on future experiences.

Building on Pendleton

Many trainers use Pendleton’s rules in discussing performance with trainees. Pendleton’s central tenets are learner comments preceding trainer’s comments, and positive features preceding developmental areas. This is included in the second step of the DEBRIEF model in order to review the actions taken and behaviour used. Without the emotional and cognitive areas of the experience being looked at too, the feedback can remain formulaic and focused on the surface actions rather than the motives or thinking underlying them.

The impact of DEBRIEF on learning

DEBRIEFing makes learners feel in control of their work; by instigating the process and by learning from an honest DEBRIEF, a trainee can relate to the strengths and areas for development within their practice, can understand the psychological impact of events and is able to access theoretical, emotional and practical developmental strategies to change that work for the better. Ownership of learning, especially in the workplace is a fundamental driver for progress. DEBRIEFing using this structure is a versatile process. A Case Based Discussion can easily turn into a DEBRIEF session as can using Pendleton’s rules for feedback. A learner can seek out a supervisor, more experienced colleague or a peer and discuss the event using the model outlined here. Alternatively the model can be applied to the event independently, using honest self disclosure to explore the issues and impact.

Conclusion

In a postgraduate medical training world where the pressure upon the trainers to teach has never been greater, but the time for teaching has never been more limited, the DEBRIEF model equips learners to structure and guide their own learning, utilising their supervisors, senior colleagues, peers and their own reflections to make sense of their daily experiences. Learning by pattern recognition is no longer tenable; smaller numbers of experiences carry greater pressure on trainees to learn and develop. DEBRIEF offers a comprehensive model for them to do this.


Bibliography

Boekaerts M (1993) Being concerned with well being and with learning Educational Psychologist 32(3) 137 - 151
Brooks JG & Brooks MG (1993) In search of understanding: the case for constructivist classrooms. Alexandria VA, Association for Supervision & Curriculum Development
Friere P (1970). Pedagogy of the oppressed. New York: Continuum
Goleman D (1995) Emotional Intelligence New York Bantam books
Gross M et al (2008) Emotions and feelings in learning process: Understanding emotional learning experiences of Postgraduate students ESREA Life History & Biography Network conference, Canterbury Christ Church university, UK http://tallinn.academia.edu/MarinGross/Papers/253692/Emotions_and_Feelings_In_Learning_Process_Understanding_Emotional_Learning_Experiences_of_Postgraduate_Students
ISCP 2010 https://www.iscp.ac.uk/home/principles_intro.aspx
Lave J, Wenger E (1991). Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.
Le Doux J (1997) The Emotional Brain: the mysterious underpinnings of emotional life New York Simon & Schuster
Love PG & Goodsell A (1996) Enhancing Student Learning: Intellectual, Social and Emotional Integration by Love. ASHE-ERIC Higher Education Report series 95-4, (Volume 24-4), http://www.ntlf.com/html/lib/bib/95-4dig.htm
Kolb D A (1984) Experiential Learning: Experience as the source of learning and development. Prentice-Hall.
RCP 2011 http://www.jrcptb.org.uk/assessment/Pages/Workplace-Based-Assessment.aspx
RCPath 2011 http://www.rcpath.org/resources/pdf/definitions_of_assessment_tools__ar.pdf
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Wood, D. J., Bruner, J. S., & Ross, G. (1976). The role of tutoring in problem solving. Journal of Child Psychiatry and Psychology, 17(2), 89-100.

Supporting medical trainees - a new course

BEST (Building Excellence in Specialty Training) is a new course I am running on behalf of several Deaneries around the UK, to explore much needed ways for trainees to gain access to opportunities for learning on the job.

With the advent of the latest report on training under the European Working Time Directive,(EWTD) http://www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20Version.pdf by Professor Sir John Temple, which highlights the need for dedicated training and support for junior doctors, BEST addresses one of the shortfalls in the new WBA (Workplace Based Assessment)and competence based training system.

The Training and Assessment in Practice (TAiP) course that I wrote and have delivered for the last 3 years on behalf of the Royal College of Surgeons of England has seen over a thousand consultants demystified as to what the WBAs are and how they complement existing good training practice. However there has been no such provision for trainees. Many are still using the WBAs incorrectly as retrospective, virtual scoring forms rather than face to face engagement and training tools. They struggle to identify their Educational Supervisor and to gain meaningful Learning Agreements from them. Even when trainees understand the formative and developmental nature of the WBAs, they are often working with trainers who are enculturated into a summative, secretive pass/fail mentality because that is all they have known during their own training.

BEST is available to equip trainees with the skills they need to manage their own training, to access the appropriate opportunities and to engage their trainers within a system they are mandated to use.

Training at Foundation stage and beyond in Core and Specialty training programmes is now built around the use of Portfolios to document evidence of competence and progression. Use of the new Assessment tools (Mini CEX, CBD, DOPs, PBA and a range of 360° feedback) is here to stay and the BEST course will:

• Develop understanding of the assessment tools and how best to use them in everyday practice;
• Show how to manage the Learning Agreement;
• Identify immediate learning needs;
• Consider how to get the best out of trainers;
• Identify ways to ensure trainer observation sessions;
• Use the tools to gain training rather than assessment;
• Manage the reception of feedback from your trainer;
• Agree ways to action plan further learning;
• Identify the appropriate people to ask to conduct your 360° feedback;
• Agree follow up activities to show progress after your 360° feedback;
• Support the development of simple approaches to structure reflective writing;
• Develop and improve a piece of your reflective writing;
• Identify the use and value of a portfolio;
• Discuss ways to add quality to your portfolio;

Sessions are delivered using live demonstrations for candidates to discuss, group work and paired work.

By the end of the course you will have:

• Prepared a PDP
• Drawn up an action plan
• Managed your feedback from a trainer
• Identified follow up activities from an assessment tool
• Improved a piece of reflective writing
• Received advice on your portfolio

Please email me for further details. There are a variety of ways that BEST can be accessed.

Hayleyallan@tiscali.co.uk

Who needs Learning Outcomes?

I was working this week on a new course with another educationalist. When it came to the Learning Outcomes she, knowing my position on them (that they are great to put in at the end of the programme but no use at all when designing learning events) said, "Let's not start with the LOs...."

Hurrah! said I, and we began to design our session using key messages and activities to achieve those messages. What a joy!

I rummaged through my archives to find a copy of this article that speaks for itself. I wish to reiterate that LOs are great to put in a course programme so that learners see what they are going to get out of the day. But to start off with them when planning learning? Only if you are a businessman.....!

Who needs learning objectives?
Posted by Charles Jennings in Strategy, The training cycle on Tue, 28/07/2009 - 08:42
• This article looks at the case against creating learning objectives
• It explores how learners are often discouraged by box-ticking and how trainers need to implement better systems at helping learners retain information
• Charles Jennings cites examples of how effective learning can be achieved without the use of learning objectives

How many times have you embarked on some formal learning, whether in a classroom or through an elearning or blended course, and the first thing you’re presented with is a list of rather bland learning objectives? This begs the question, are lists for losers? Charles Jennings considers the evidence.

1. At the end of this course you will be able to tie your shoelaces in a double bow
2. At the end of this course you will be able to use a blender to make a tasty fish milkshake
3. At the end of this course you will be able to make gold out of base metal
4. and so on...

Apart from being some of the most de-motivating writing any of us have ever read, lists of learning objectives are the worst possible way to create an environment for learning. In fact, they are often the first barrier to real learning. Why so?

Two basic problems
I see two basic underlying problems with learning objectives. Firstly, many training and development specialists continue to apply a model of learning objectives that was developed more than half a century ago in a context that they don’t really understand. It’s a model that was ‘of its time’ and, although some of the principles still apply, certainly isn’t as relevant in the 21st century as it was in the mid-1900s, even accepting the view that formal learning still has a place in developing people.

Secondly, many training and development specialists are learning obsessed rather than performance obsessed. Their focus is on delivering content and assessing its retention by learners – on ensuring learners ‘learn’ rather than enabling people to ‘do’. Giving fish rather than fishing rods.

"There’s a strong argument that proof of achievement of learning objectives as commonly assessed at the end of the learning event doesn’t even measure learning."
Subsequently their learning objectives tend to be built around a set of post-course assessments. Even then, the way in which the ‘learning’ is assessed is often so poor that it only measures short-term memory retention rather than real learning and behaviour change.

A nod to Bloom
Back in 1956 when Benjamin Bloom and his committee members developed a taxonomy of learning objectives they were working in a very different world than we live in today. Reductionism and codification were the dominant mindsets. The standard approach to teaching at the time (and it was ‘teaching’ rather than ‘learning’) was to design courses and programmes so that students should take the same time to reach a specified level of mastery.
It was a crude approach where the hares won and the tortoises lost. Bloom was kicking against this with his taxonomy. The three learning domains of Bloom’s Taxonomy (cognitive, affective and psychomotor) were, in some way, an attempt to overlay some of the complexity of the learning process on what was seen at the time as a rather deterministic and mechanistic endeavour. Bloom was, underneath it all, a progressive. A former student once described him as "embracing the idea that education as a process was an effort to realize human potential, indeed, even more, it was an effort designed to make potential possible. Education was an exercise in optimism." (Elliot W. Eisner in the UNSECO Quarterly Review of Comparative Education 2000).

Bloom himself saw beyond learning objectives as simply a means to an end. He was convinced that environment and experience were very powerful factors influencing human performance. It’s worth noting that his last book published just six years before he died in 1999 was ‘The Home Environment and Social Learning’. He certainly wasn’t hung up on learning objectives. Bloom’s view of learning was the need to focus on target attainment rather than the ‘race to the finish post’ as was common in the 1950s. It was, in reality, a belief of learning as an enabler. At the time Bloom was addressing an important issue through his learning objectives, today that battle has been won.

Learning objectives and improved performance
So why, 50 years on, do we still have this slavish adherence to presenting learning objectives at the outset of courses in some mechanistic manner, and often skewed to the cognitive domain? It’s often ignorance, and sometimes simply a desire to make the life of the trainer easier, I’m afraid. And sometimes it’s just marketing. Learning objectives are really only useful for the people designing the learning. If used well they can form a helpful framework for instructional designers. However, they should be kept well away from learners or course recipients. If a course is well-designed and targeted to meet a defined performance gap, a list of learning objectives serves absolutely no purpose other than to dull the enthusiasm of those embarking on a course of study.

What any learner, and their manager, wants to know is whether on-the-job performance has been improved through some formal learning intervention. In other words, whether the experiences that the employee had during formal training has resulted in changed behaviour and performance in the workplace. Achievement of learning objectives is not evidence of this. The ability to pass a test or demonstrate a skill in a classroom setting is not the same as being able to do so in workplace conditions. I suppose the notable exception is where the classroom conditions mirror exactly, or almost exactly, the workplace – such as training pilots in a flight simulator. Still, I don’t imagine any one of us would take kindly to flying in a plane with a pilot who has only proved his or her performance in a simulator and hasn’t a modicum of experience in the air, unless there isn’t an alternative.

"Learning objectives are really only useful for the people designing the learning."
In fact there’s a strong argument that proof of achievement of learning objectives as commonly assessed – at the end of the learning event – doesn’t even measure learning. Sometimes the time lag between end-of-course testing and attempting to put the learning into action is such that the ‘learning’ is lost from short-term memory. At other times the work environment is less ‘controlled’ than the learning environment and the added variables mean performance improvement simply doesn’t occur. Most of us have seen situations where people return bright-eyed and bushy-tailed from a training course with plans to do things differently – time management, project management and people management training are good cases-in-point - only to revert to the old ways as soon as the day-to-day pressures of the working environment kick back in.

Measuring performance
If you are going to assess the impact of a course on individual participants’ performance in the workplace you need to forget about learning objectives for doing the job. Remember, learning objectives may be useful to help you create a logical design, but that’s all they’re useful for. When you get to measuring transfer of learning to the workplace you need to engage with the people who are in a position to observe behaviour and performance and those who are in a position to measure outputs. This usually means the manager and the team member who is responsible for maintaining performance metrics for the business or team – the balanced scorecard metrics or similar.

This approach requires training and development managers and instructional designers to engage with business managers and agree on strategies for measuring the impact of the learning before the learning design phase even starts. A good way to do this is to roll it into early engagement with business managers in defining the performance problem to be solved, whose performance needs improving and whether training is likely to help solve the problem (which is usually ‘no’, but sometimes ‘yes’).
In most cases performance change can’t be measured immediately following the training if it is to be meaningful. Take the case of transactional work - data entry or call centre operatives for instance – where the proof that training has led to improved performance requires data taken over a period of time, and not just on the first day or two back in the workplace. All this requires more thought and effort than writing a few overarching learning objectives (even if in well-formed behavioural format) and then developing assessments to ‘test’ whether they’ve been achieved or not. And it requires different skills of the training and development team.

Charles Jennings was chief learning officer at Reuters and Thomson Reuters. He now works as an independent consultant on learning and performance. Details of Charles consultancy work and his blog can be found on his website www.duntroon.com

Reflective Practice - here is how to do it!

http://www.rcog.org.uk/files/rcog-corp/uploaded-files/ED-Reflective-Prac.pdf

This excellent pdf from the Royal Colleg of Obstetrics and Gynaecology has everything you need to know about writing up your reflections in medical training.

Article in BMJ for medical trainees

http://careers.bmj.com/careers/advice/view-article.html?id=20001007

This article published in the BMJ this week gives a good overview of the structure of training and the role of the trainee and trainer in negotiating access to training opportunities.

With The Royal College of Surgeons in England, I have worked with over a thousand consultants and senior trainers to establish understanding of the Workplace Based Assessment Tools and their place in Medical and Surgical postgraduate training.

In partnership with some forward thinking Deaneries, we are now offering such courses for Trainees. BEST (Building Excellence in Specialty Training), is a one day course for all Foundation and Core (or ST 1 and 2) trainees who wish to master the approaches needed to get the best out of their training and their trainers.

Cognitive Apprenticeships

While researching for a course I am writing I found this article on the web which I thought was most interesting. Despite it being about school classrooms - and American ones at that! - it offers a great example of how we can develop active apprenticeships in our more constrained educational environments. I shall certainly be looking at how I can incorporate the key elements of this work into my new course.

http://projects.coe.uga.edu/epltt/index.php?title=Cognitive_Apprenticeship

Early Adopter, Early Cynic, Blind Complier or Blind Rebel? How do you react to training courses?

Surgeons' reactions to training, assessment and management courses is understandably at a low ebb. With the PMETB trainer requirements deadline earlier this year, many consultants found themselves mandated to attend a range of courses in Educational Supervision; Clinical supervision; Training the Trainers; WBA tools; Assessment and Appraisal; Equality and Diversity; Trainees in Difficulty; or 'Manual Fire Bucket Assessment Handling' as one surgeon referred to the homogenised mass of courses he had to take.

Disparity in content, delivery and quality of these courses has led to a lowest common denominator perception among participant groups. Think of the worst course you have ever attended, multiply it by ten and you have the level of underwhelming expectation with which most groups greet their latest day out of clinical practice.

In little over three years there have been well over a thousand participants (estimates at time of press number over 1200) through the Royal College of Surgeons of England Training & Assessment in Practice (TAiP) course. Such numbers enable perception analysis to be carried out regarding the differing reactions from participants, to the course. Four predominant types emerged:

• Early Adopter
• Early Cynic
• Blind Complier
• Blind Rebel

TAiP was developed by an educator and a group of surgeons to support consultants in the use of the ISCP, a new training and assessment programme developed by the Intercollegiate Surgical body in response to MMC (modernising Medical Careers) and the advent of the EWTD (European Working Time Directive.) Although TAiP contains strategies to support consultants in using the new WBA (Workplace Based Assessment) tools, many participants see the course as an imposition.

The aim of the TAiP course is to give everyone the information they need to use the ISCP system in accordance with good training practices. This requires understanding of the system and a willingness to use it.

In analysing the different responses to the course, it became clear that these two predominant factors are central to a person's response. The first of these concerns capability; that is whether the surgeon comes to the course with either an understanding of ISCP or the capability to develop an understanding within the day. The second factor relates to attitude; does the surgeon have the willingness to work with the system? Some participants have an attitude of open mindedness, or compliance with suggested new approaches. Others have greater resistance to any suggestion of change and are determined not to comply with whatever is suggested. This attitude is very often pre determined by factors outside the area of responsibility of the group facilitators.

Understanding these patterns of behaviour can assist the facilitators to relate appropriately to each participant and to manage the course in slightly different ways, according to the group make up. By examining the four permutations of the aforementioned factors we can see that each response type presents its own challenges to the facilitators.

• Early Adopter - high capability, high compliance
• Early Cynic - high capability, low compliance
• Blind Complier - low capability, high compliance
• Blind Rebel - low capability, low compliance


The Early Adopters in a group have both high levels of compliance and capability. They are often keen to make sense of a new system and to find ways to implement change. They are not afraid to be seen to be different and for this reason often occupy positions of leadership. Early adopters do bring their own challenges to the group facilitators. Whilst their open mindedness means they are willing to look at new perspectives, their high levels of capability require the facilitators to have a sophisticated grasp of the issues and perspectives, the knowledge frameworks and the medical settings within which the participants work. If facilitators demonstrate credibility, considerable levels of knowledge and understanding, and harness the inventiveness of the group to a common goal, even making them think they have developed original ideas, the early adopters will react overwhelmingly positively to the course.

The second group are called Early Cynics because their lack of compliance means that they often announce their cynicism at the start of the course. They can initially appear to be very challenging to the facilitators but by asking about their cynicism it is easy to tell whether it is informed or not. Early Cynics can be the most rewarding of all participants due to their high levels of capability. If their cynicism is ill informed, they are not Early Cynics at all, but fall into the fourth category, Blind Rebels. There are some Early Cynics who have high capability but who are so fearful of change that their high level of non compliance reduces them to the fourth category too. But real Early Cynics have high levels of capability; their ideas are often persuasive and they are quick to grasp new information. It is their intelligence that will triumph over their non compliance and result in a positive response to the course at the end. For course facilitators Early Cynics present two challenges. Their aggression at the start of the course can be disruptive and hold up progress. If they are given a limited space to air their views, this will “park” their scepticism. And then, in a similar way to the early adopters, the Early Cynics require facilitators who are knowledgeable and who also demonstrate persuasive, informed argument. (Cynicism with poor levels of understanding is not cynicism but rebellion. For this reason the only true cynics are those who know what it is they do not believe in.)

The third group of respondents appear to be relatively easy members of the group initially. Called Blind Compliers they are characterized by their apparently high levels of compliance and low levels of understanding. They ask few questions and appear to be absorbing what is being said. However, without careful handling this group can easily leave with little more than they came. Their compliance means they are not likely to question the frameworks being presented, but unless all the details of the course, including acronyms, roles, responsibilities and relationships are spelled out to them, they let much of the new perspectives wash over their heads. Whilst they may present little by way of attitudinal challenge to the facilitators, the faculty must check that Blind Compliers are following, understanding and integrating what they are exposed to on the course into clinical practice. A course can become a one way didactic session never really getting beyond the basics of the course content, if there are lots of Blind Compliers in a group, so facilitators must ensure that these learners are made to think for themselves too. If the overall group has a mixture of Blind Compliers, Early Adopters and Early Cynics, it challenges the facilitators to cover the basics in a simple way but also to extend the complexity of the arguments for those with higher capability and understanding, as already discussed.

The final group is probably the most challenging but they often have the greatest need for the course. With Blind Rebels both their compliance and their capability are low. Most often they have attended the course because they have been forced to do so, either as a result of an appraisal action or because there have been threats associated with non attendance. This group have developed a stance of non compliance as a result of their lack of understanding or willingness to engage in new ideas, and see courses as threats to their professional standing. They will argue fiercely against any proposed change, finding a range of people to blame for the changes they see as having been externally imposed. The difference between this group and the Early Cynics is that the Blind Rebels do not have the capability to argue with any degree of information or logical reasoning. Indeed, the more vociferous they become the more the rest of the group begin to disengage with them. This group of participants can be very disruptive as they can raise a comment or an objection to every point made. The challenge for the faculty is to maintain composure in the face of often rather offensive behavior and to remember that this group need as careful instruction as the Blind Compliers. It would be encouraging to think that information would assist the Blind Rebels to overcome their non compliance but for many in this group it is often not enough. For those who are determined to destroy the course, it may be necessary to respond to their ill informed arguments somewhat aggressively, highlighting where they are misinformed and emphasizing that both information and a change in attitude would indeed help them to overcome their grievances. Often it is only their self instigated isolation from the rest of the group that finally reduces them to silence. Frequently they have to be allowed to hang themselves with their own petards, necessitating a group attack on their disruptive behaviour.

In an unrelated field but one which may be interesting to compare, we can see that similar findings have been discussed with regard to the responses of people to new technology. The Everett Rogers Diffusion of innovations theory - for any given product category, shows five categories of product adopters:

o Innovators – venturesome, educated, multiple info sources;
o Early adopters – social leaders, popular, educated;
o Early majority – deliberate, many informal social contacts;
o Late majority – sceptical, traditional, lower socio-economic status;
o Laggards – neighbours and friends are main info sources, fear of debt.

However this pattern is a linear one, describing types of people within a range of demographic factors, including social background, psychological make up, educational history, personality and popularity, economic situation, social influences and fears. In the paradigm used with surgeon responders to courses I look simply at the responses relating to two factors – those of compliance and capability.

For those of us involved in education and training, this paradigm provides us with an interesting perspective on the challenges facing us in any group of participants in a course group. A surgeon cohort group should not usually be perceived as a mixed ability group in the usual definition of the term. All consultant groups must surely share a similar level of intelligence and motivation to have achieved the position of consultant. But new initiatives coupled with the disenchantment surrounding the many changes we have seen in the last five years, mean that attitude to change as well as engagement with it result in a mixed ability reaction to training courses.

For course facilitators, such groups can be very challenging for a variety of reasons. Understanding the factors behind the behaviours of surgeons attending such courses can help faculty to respond appropriately to each type of participant, ensuring maximum success and minimum disruption for each course group.