faculty development: clinical skill teaching dr reg dennick asst. director medical education...
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Faculty Development:
Clinical Skill Teaching
Dr Reg DennickAsst. Director Medical Education
University of Nottingham
Name of speaker
Outline of session
•Faculty development areas
•Teaching Practical skills
•Theories of skill acquisition
•Methods of skill teaching
•A practical exercise
Learning Outcomes
• List the range of Faculty Development areas. • Describe and explain the frameworks used for
understanding practical skill acquisition.• Outline the rationale for a practical skill teaching protocol.• Use a protocol for learning a practical skill• Reflect on the experience of learning a practical skill.
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Lecturing & presentation skillsSmall group teaching/facilitation
Problem Based Learning Bedside/clinical teaching
Informatics/CAL Curriculum design & evaluation
Management/leadership Assessment techniques
Educational theoryGiving feedback
Communication skillsSetting learning objectives
Assessing clinical skills: OSCEs, OSLERS etcMentoring/supervising
Professional development Assessing practical skills: DOPS, Mini-CEX etc
Simulation and simulators Teaching practical skills
Faculty Development: ‘Topics’
Teaching practical skills
How do you learn skills best?
Discuss with your partner
Example
This slide contained an image of two female lab technicians amongst lab equipment, taken
from unknown source, which requires copyright permission in order to reproduce it.
Theories/Frameworksof skill acquisition
• Simpson (1966)• Fits & Posner (1967)• Benner (1984)• Dreyfus (1986)• George & Dotto/RCS (2001)
Levels 1: PerceptionWhere the learner merely identifies the need to perform a particular skill in response to perceptual clues
Level 2: SetWhen the learner is ready to act. Levels 3: Guided responseWhen the skill is performed immediately after a demonstration.
Level 4: MechanismWhen the skill has started to become habitual. Level 5: Complex overt response Characterized by an accurate and efficient performance of the skill. Level 6: Adaptation When the skill has been so well internalized that it can be adapted for different contexts and situations Level 7: OriginationInvolves the creative development of new psychomotor skills.
Simpson 1966: The Psychomotor Domain
Cognitive phase - when the skill is being learned
Associative phase - when performance is becoming skilled
Autonomous phase - when the skill has become entirely automatic and can be carried out without thinking about it.
Fitts and Posner (1967): 3 phase model of skill acquisition
Dreyfus model of skill acquisition(Dreyfus & Dreyfus, 1986: “Mind over Machine”)
Level 1 Novice– Rigid adherence to taught rules or plans: ‘context-free elements’– Little situational perception
Level 2 Advanced Beginner– Situational perception growing but still limited
Level 3 Competent– Coping with crowdedness (pressure)– Now sees actions at least partially in terms of longer-term goals– Conscious deliberate planning and problem solving
Level 4 Proficient– See situations holistically– See what is most important in a situation– Uses intuition and ‘know-how’
Level 5 Expert– No longer predominantly relies on rules, guidelines or maxims– Intuitive grasp of situations based on deep tacit understanding– Analytic approaches used only in novel situation or when problems occur
“From Novice to Expert” (Benner (1984)
A framework for seeing how knowledge and attitudes are integrated with psychomotor skills in professional practice.
Progression from reliance on abstract principles and rule based behaviour to the increased use of actions based on personal experience.
• novice• advanced beginner• competent• proficient• expert
Summary of skill acquisition frameworks
Holistic
Contextual/Situational
Pattern recognition
Prioritisation
Flexibility
Decision making
Problem solving
Reflective
Intuition
Know-how
Tacit knowledge
Expertise
Unconscious
Skilled
Concrete
RulesProceduresProtocolsContext-freeInformation processingNo coherenceInflexibleAnalyticalAbstract
KNOWS
KNOWS HOW
SHOWS HOW
DOES
Com
pete
nce
Perf
orm
an
ce
MILLER’S TRIANGLE
Cog
nit
ive
Beh
avio
ura
l
Has knowledge about a skill but is not yet
practising it
Demonstrates basic competence
Knows how to do a skill and is practising
it
Is a competent and independent practitioner.
Performs in practice
Getting the balance right?
Theory Practice
Do you need to understand the theory of skill acquisition to teach a practical skill?
But how do we teach skills?
The prototype!
See oneDo one
Teach one
The RCS recommended skill teaching protocol
(As used on ACS, ATLS, IMPACT courses: George & Doto (2001))
• Conceptualisation phase• Visualization phase• Verbalization phase• Practice phase• Feedback phase• Skill mastery & autonomy phase
Conceptualisation phase Put the learning of the skill into cognitive and
attitudinal context.
Explain importance, relevance and usefulness (provides stimulation and motivation).
Describe skill's degree of difficulty and how much effort and practice might be required to achieve a specified level of competence.
Emphasise health and safety issues
Emphasise attitudinal, ethical and communication aspects.
Visualization phase Learners should be able to see the whole skill
carried out from start to finish by the expert in normal time without verbal explanation. (Is this always feasible?)
This enables the learner to start to construct an internal mental representation of the expected performance.
All participants should have a clear view of what is going on.
Verbalization phase (teacher) The skill should be demonstrated and explained
at the same time.
Break down the skill into its components.
Be aware of cognitive and manipulative problems novices might face.
Novices should be encouraged to articulate and describe the processes occurring thereby adding to their internal mental representation.
Verbalisation phase (student)• Ask students to guide the facilitator through the
skill instructing him or her in what to do at each stage.
• The facilitator may question the students again and ensure that they understand the process and are giving clear and accurate instructions.
Practice phase Novice practises the skill.
Feedback phase This very important component of psychomotor
skills teaching relies on the skills of the facilitator to give help and guidance to novices.
Again it is here that the ability to empathize with learners and to get into their ‘mind-set’ is essential.
Feedback should reward positive actions.
Skill mastery This phase occurs after much practice and allows
the learner to demonstrate to the facilitator that they have achieved a specific level of required competence.
Skill autonomy This phase constitutes independent practice and
means that the learner can routinely perform the skill without error in real-life contexts.
Summary of skill teaching protocol
Conceptualisation
Visualisation
Verbalisation (teacher)
Verbalisation (learner)
Practice
Feedback
Mastery
Can be combined
Autonomy (Expertise)
Images
Video
Simulator
Use it or lose it!
Activity:
The Origami Shirt !!!
Conceptualisation
•What is the importance of the origami shirt?•How relevant and useful is it?•How hard is it to do?•What are the health and safety precautions when handling and folding paper?
•Should I wear ear protectors? Or goggles? What about protective gloves?
•What are the ethics of making origami shirts?•What is the right attitude to making origami shirts?
Visualisation phase
Watch an origami shirt being made.
This will be done with no words
or commentary.
Make sure you have a clear view.
Verbalisation phase I (plus a little bit of additional
visualisation)
All together now…Take a sheet of 60-120gm-2 A4 paper.Long axis top and bottomShort axis left and right
Verbalisation phase
Fold so that the left axis aligns with the top axis
Verbalisation phase
Press hard on the fold and crease firmly.The top left corner angle should be bisected.
Verbalisation phase
Fold the narrow strip over the triangle you have just formed.
Verbalisation phase
Press firmly along the crease.
Verbalisation phase
Carefully tear along the crease.Discard the larger piece of paper.
Verbalisation phase
Make a fold about 3 to 5mm from the end.This will form the collar of the shirt.
Verbalisation phase
Fold the piece of paper in half, along its long axis.Press firmly to crease the paper.Refold in the opposite direction.
Verbalisation phase
Fold the paper in half so that the end away from the collar just slips under the collar.Press hard on the fold to make a crease.
Verbalisation phase
Turn piece over.Fold the collar inwards to make a triangle with an apex as close to the fold as you can manage.Press firmly to make a crease.
Verbalisation phase
Do the same for the other side.You should now see the collar taking shape.
Verbalisation phase
Bring the rear portion of the paper to the front.Tuck the end under the collar.
Verbalisation phase
Press the shirt into shape, making sure that the crease down the front faces outwards.
Verbalisation phase
Make a line for the buttons.
Verbalisation phase
Draw in the buttons
Verbalisation phase
Bend the shirt slightly along the long axis so that it will stand up.Admire your skill.Accept the praise and admiration of friends and colleagues.
Visualisation phase II
Talk the teacher through the sequence
Practice phase
Now, have a go at making an origami shirt.And while you are doing it, we shall enter the….
Feedback phaseThis is ad hoc feedback on the trainee’s progress in actually carrying out
the task, offering advice and comment as the execution of the task progresses. It is formative, rather than summative.
Skill mastery
How much practice do you think you will need?
Skill autonomy
How could you develop the origami shirt?
On the origami shirt exercise…
How was it for you?What are the advantages and disadvantages of this particular
protocol?How might you adapt it for use in your own professional area?
Feedback in the context of skills teaching
What does it mean to give feedback in the context of skills teaching?
Examples of good feedback?Examples of bad feedback?Rules for feedback?
Mastery Learning and 4/10: How to become an expert (Ericsson, 2006)
• Geniuses/Experts are made not born (?)– Supportive environments– Important mentors– High investment of effort
‘The more I practise the luckier I get’• High IQ not a predictor• 4/10 rule: to become an expert you practise/work
4hrs/day for 10 years.
References
Benner, P (1984) From Novice to expert: Excellence and power in clinical nursing. London : Addison Wesley.
Dreyfus, HL and Dreyfus, SE (1986) Mind over Machine. Free press. New York
Ericsson, A (2006) The Cambridge Handbook of Expertise and Expert Performance. CUP. Cambridge
Fitts, P and Posner, M (1967) Human Performance. Belmont, California: Brooks/Cole Publishing Company
George, JH., Doto, FX. (2001) A simple five-step method for teaching clinical skills. Family Medicine 33, 577-8
Miller G E. (1990) The assessment of clinical skills/competence/performance. Acad. Med. 65:563-7
Simpson JS. (1966) The classification of educational objectives: psychomotor domain. Office of Education Project No. 5-85-104. Urbana, IL: University of Illinois
Learning Outcomes
• List the range of Faculty Development areas. • Describe and explain the frameworks used for
understanding practical skill acquisition.• Outline the rationale for a practical skill teaching protocol.• Use a protocol for learning a practical skill• Reflect on the experience of learning a practical skill.
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