The HETV “Pretenders and bluffers‟ guide” on Theories of Learning for Educational Supervisors

This short booklet is intended to offer some small insights into how people learn, and provide an aide memoir for some of the educational theory we hear mentioned by others and struggle to recall exactly what it is all about. There is no intention that it will provide anything more than a flavour of current thinking around learning. It is primarily intended for those involved in postgraduate medical training roles, but there may be material of value to those in other healthcare education roles. For those who want to gain an in-depth understanding of medical education in the UK today, there are a number of certificate, diploma and masters‟ programmes. There is more information at the end of this booklet on local programmes. For the day to day framework for postgraduate education, your „mandatory‟ training ( both the HETV endorsed online material and the one day workshop, along with NHS Core elearning Equal Opportunities and Diversity module), plus reference to HETV policies and guidance on the website will stand you in good stead. In addition, the latest version of the Gold Guide (v5, published May 2014) and our Field Guide for Supervisors will help you, as an educator, navigate a safe passage. Etymology A „bluffer‟ is an American English word used by poker players to describe some players. Its origins are probably Dutch, the verb bluffen or verbluffen meaning „to brag or mislead‟. The most infamous Pretenders of all were not the 1970-80s rock band, but James Edward Francis Stuart, the „Old Pretender‟ and his son Charles Edward Stuart, otherwise known as Bonnie Prince Charlie. James was the son of James II and his second wife, Mary of Modena, and was raised a Catholic which disbarred him from the succession to the British throne. That did not stop either of them from trying, unsuccessfully,to claim the crown from both George I in 1715 and George II in 1745.

How do we learn? Psychologists are still unsure how we learn, and why humans retain some facts or materials better than other, perhaps similar, information. Humans have the capacity to retain some material in their short-term memory, but this may be for a matter of seconds, let alone hours or days, and also the ability to retain other material in their long term memories. How we learn has been studied extensively by Honey and Mumford in Leicester, who devised a system of four learning styles: Activist Theorist Pragmatist Reflector Most of us have a dominant preference. A basic understanding might help to explain why some trainees excel in certain situations but can struggle in others, and why sometimes we gel better with one trainee but not another. Activist Activists learn by doing.

They need to „get their hands dirty‟. They are open minded in their learning, have no bias and get fully involved in new learning experiences

They prefer brainstorming, problem solving, getting „stuck in‟, group discussions, competitions and role play

Theorist Theorists like to know the thinking behind the actions. Models, concepts and facts need to be present for them to engage in the learning process. They like to analyse and build their own logical concepts and theories

They prefer models, statistics, stories, background information

Pragmatist Pragmatists like to be able to put their learning into practice. They are willing to experiment, try new ideas, theories and techniques and see if they work

They need time to think about how to apply learning in real situations, like problem solving, discussion with others and enjoy case studies

Reflector Reflectors learn by observing and thinking about what they have seen. They often sit on the sidelines as viewing is preferred to doing. They are able to synthesise many different viewpoints to make sense of something.

They like self analysis, quizzes, questionnaires, observing activity in others, coaching, getting and giving feedback

It is possible for anyone to do a validated assessment online at www.peterhoney.com for £10-20.

How do we build ‘learning’? Recall of something simple is almost 100% if done soon after the initial exposure to the idea. However, behavioural psychologists suggest that longer term ability to remember depends on both the frequency and „recency‟ of recall. Children have been traditionally taught using „rote learning‟, examples of which are to recite the alphabet, or the times tables. This type of learning does not require the child to understand why H follows G, or why 7x8 =56. Children will, as they mature, be able to move from rote learning to a cognitive style, which requires them to be able to understand a concept inside a framework, and build on it. Thus, with 7x8 =56, they can begin to see that if there are 56 apples to be shared equally amongst eight children, each would receive seven. This will later develop into an ability to link material (old and new) which is known as constructivism.

old

old

old

old

old new

new

new new

old

old

old

old

old

new new

Adults learn by self direction, which requires them to take responsibility and accountability for identifying their learning needs, formulating goals, finding resources and implementing learning strategies. This brings us to Bloom’s taxonomy

At the bottom of the pyramid, little thinking is required, and learning is „by rote‟. At the top of the pyramid, there is higher cognitive demand on the learner, who needs to think harder, make sense of the material presented and relate it to their existing knowledge. Adults have an awareness of the Aristotelian saying, „the more you know, the more you know you don‟t know‟. This is insight. Another model to consider is that of Burch’s ‘Four Stages of Learning’, first described in the 1970s.

Unconscious incompetence

Conscious incompetence

Conscious competence

Unconscious competence It is possible to fall off any rung on this ladder if the learner overstretches themselves, or fails to update their knowledge over time, and they become unconsciously incompetent. This may be seen as an educational „snakes and ladders‟ game.

How many repetitions do we need to undertake to embed something in our long term memory? The Dreyfus and Dreyfus model of expertise considers that learners pass through a series of stages before becoming an expert. These are

Novice Rigid adherence to rules or plans. Little situational perception. No discretionary judgement

Advanced beginner

Guidelines for action based on attributes or aspects. Situational perception still limited. All attributes and aspects are treated separately and given equal importance

Competent Copes with multiple actions. Able to see actions at least partially as part of longer term goals. Conscious and deliberate planning of actions. Procedures standardized to blueprint.

Proficient Holistic view. Can identify the important facets in a situation. Can perceive deviations from the norm/ Decision making is less laboured

Expert No longer relies on rules or guidance. Intuitive grasp of the situation based on a deep and tacit understanding. Analytical in novel situations. Has a vision of what is possible.

Is there a difference between ‘Practice makes perfect’ or ‘Experience is simply having had multiple opportunities to do things the same way’? The brain is plastic and will rewire connections as it adapts to retain new knowledge. It will coordinate a complex set of actions involving motor function, visual and audio processing, verbal language skills to rewire and myelinate new connections. There are aphorisms suggesting 10,000 hours to become a virtuoso musician or ten years training to become a chess Grandmaster, but there is no absolute certainty as to how long an individual may need to practise a skill or procedure to become proficient, or expert. However, without effective feedback on performance, the brain will not rewire, as there is less possibility of new information being considered. Therefore neither aphorism suits a culture where lifelong learning is necessary. There is some emerging evidence that we become less competent as we age, with much data coming from screening procedures for continuing to hold a driving licence around the world. Clearly, society at present imagines some „golden period‟ between having no skills/ knowledge and the onset of the decline in performance, when an adult is deemed competent, and in medicine, this is the point at which the Certificate of Completion of Training is issued by the GMC. However, as not all postgraduate training programmes are of the same length, it is clear that the time spent in clinical training to become competent varies by specialty. There is a minimum „indicative time‟

for training in a given specialty, and a limit on the duration of a training time extension for any trainee.

Does our culture impact on teaching or learning? In short, yes it can. Culture is a complex concept, and has being likened by some to a Russian doll, with ever new surprises as the layers are opened up. Globalisation and the increasingly widespread use of the internet are beginning to blur boundaries between different groups, but even so, everyone is unique, with many cultural reference points impacting on their behaviours.

Whilst this section is by no means discursive, there are some broad brush portraits, described by Hofstede, which can offer some insights into how where we grew up, and received our undergraduate training, might impact on our approach to learning. He describes six dimensions: power distance, individualism, uncertainty avoidance, pragmatism, indulgence and masculinity which describe our cultural reference points, and how we interact as a society. According to Hofstede, Power distance is defined as the extent to which the less powerful members of institutions and organisations within a country expect and accept that power is distributed unequally.

nation

region

ethnicity

religion

gender

family

education

profession

specialty

organisation

generation

Individualism is the degree of interdependence a society maintains among its members. It has to do with whether people´s self-image is defined in terms of “I” or “We”. Uncertainty avoidance is the extent to which the members of a culture feel threatened by ambiguous or unknown situations and have created beliefs and institutions that try to avoid these Pragmatism : how every society has to maintain some links with its own past while dealing with the challenges of the present and future Indulgence is defined as the extent to which people try to control their desires and impulses, based on the way they were raised Masculinity is described as what motivates people, wanting to be the best (masculine) or liking what you do (feminine). What may surprise some is that even neighbouring countries may not share similar perspectives on these six dimensions, such as India and her neighbours Pakistan and Bangladesh, or the UK and the Irish Republic.

http://geert-hofstede.com/united-kingdom.html

In the UK, at present, postgraduate medical training is seen as ‘adult directed learning’ with emphasis on it being autonomous and self directed. Independent thought is encouraged, alongside critical thinking. It is expected that the adult learner will question the teacher and explore alternative solutions to clinical problems. However, in much of Africa and on the Indian sub-continent, the education culture is more didactic and trainees value their senior colleagues‟ opinions highly. Questioning them can be seen as disrespectful, yet that is exactly what a case-based discussion might lead to, or a reflective essay should describe. The results of not appreciating these influences on learning behaviours may be that a trainee becomes uncertain around what is „best practice‟, and becomes demotivated as they struggle to „shine‟ in some learning situations and withdraw. Do different groups within the healthcare workforce share the same values, and might this have an impact on how we learn, or do? As we move towards a more integrated healthcare workforce, with nurses, midwives, health scientists and therapists sharing workshops, lectures and in simulation settings, there are other challenges as we seldom really understand the professional frameworks which have shaped the expectations of these colleagues. A recent survey (2013) carried out in the UK by the Chartered institute of Personnel and Development, alongside the Healthcare People Management Association, explored why different groups of staff had chosen their profession or organisation. Perhaps not surprisingly doctors were the group least likely to be doing their job by „accident‟, and were most likely to have entered medicine as a vocation, but also were the group least attracted by the salary on offer! Thus, other groups may have different motivation for being in their current roles, and this may also shape their approach to learning.

Where do healthcare workers learn? The simple answer is „everywhere‟, but not every learning opportunity is formally recorded as such, and there is no trail, electronic or paper-based, for

most of this. Learning does not happen in isolation, nor only at specific moments in the week. Didactic teaching has a role, but it is not the exclusive modality in adult learning. Opportunities for learning will include (this is not exhaustive):

From patients, carers and relatives

From colleagues (junior, senior, peer) in any healthcare role

On ward rounds (whether following a senior colleague, or leading it )

In multi-disciplinary case meetings

In clinics

In theatres / endoscopy suites etc

„Low‟ or „high‟ fidelity simulations

Journal clubs

Attendance at morbidity and mortality case review meetings

Structured workshops / study days organised by the schools / specialties and Royal Colleges

From online material, such as eLearning for Health, the NHS Leadership Academy programmes such as the Edward Jenner programme in Clinical leadership, the BMJ etc

Over the last ten years or so, in the UK, the advent of „structured training‟ for doctors, and defined curriculae have described a programme of knowledge and skill acquisition considered by the Medical Royal Colleges and the GMC to define a „trained specialist‟. Dentists and other healthcare professionals have also witnessed movement in this direction more recently. There has been a risk that both trainer and trainee have come to see the completion of the curriculum requirements, and evidence being collated into a portfolio, as a series of hoops to jump through, or hurdles, once cleared, mean that competence has been achieved. This has been seen in programmes where many assessments were seen by one or both parties as only summative, and not formative. Multisource feedback done at the end of a placement, might be a particular example of a „missed opportunity‟ as the next round of feedback will almost always come from a different group of people working in a different service. Feedback No-one should ask for formal feedback on the execution a technical skill, or element of a consultation after the event has been completed, although there has been a tendency on both parties to do this, especially if it went rather better than expected. The advent of Supervised Learning Events (SLEs) in Foundation Programmes, and more recently the introduction of SLEs in Core and Specialty programmes goes some way to address this issue. Feedback can be difficult to both give and receive on some occasions: the SCARF model described by Rock (2008 and 2012) can be useful to understand why trainees respond in certain ways to particular situations. S status, or relative importance C certainty, or ability to predict the future A autonomy, or perception of being able to control events R relatedness, or sense of safety with others, „friend or foe‟? F fairness, or perception of fairness in exchanges with others

Threat Reward Learning unlikely Learning possible These colour coded examples below suggest situations where one element of the SCARF model is invoked S Outcome 3 given, trainee perception of their status may be seen to be lowered C Lack of clear training plan or PDP removes certainty A Trainee told they will be working in a specific place may render them „helpless‟ R Issues with the relationship between trainer and trainee F Not being included in complaint response to PALS could undermine perception of fairness S Recognition of completion of a good audit, QIP C Well structured induction appraisal and clear goal setting mapped to trainee‟s curriculum A Trainee involvement in roster co-ordination R Clear understanding F being involved in discussions around redesign of service delivery at departmental level through local Trainee Forum Feedback is best delivered using examples of the recently observed behaviours to illustrate the points you need to make. Ideally, these should be used for both reinforcing excellence if seen, as well as to modify and improve mediocre performance. Formative assessment Formative learning and assessment is the tool to monitor how the trainee acquires and develops a particular skill set. It is part of the SLE. It requires observation by the trainer, and constructive feedback on one or more elements of the work observed. It should help the learner identify their strengths, and areas which are weaker. It also allows trainers to address specific areas of concern quickly, and minimise poor / dangerous behaviours continuing. Summative assessment Summative reviews occur at the end of a period of training or study, and are similar in many ways to an exam or test. The trainer has a series of benchmarked standards against which the trainee is assessed. On occasion, a summative assessment may lead to further formative learning being advised. The Educational Supervisor review to write the „end of year‟ report prior to ARCP is such an example in postgraduate training.

What makes a good teacher? A good teacher should be able to help their student learn, and this goes beyond the simple transmission of information. Shuell suggested the teacher‟s fundamental task is to get students to engage in learning activities that are likely to result in their achieving those outcomes. What the student does is more important in determining what is learnt than what the teacher does. The wheel below shows the broad categories expected of a good teacher: (adapted from Harden and Crosby, AMEE guide no 20)

Supporting learners to develop their practice. In the NHS, staff are expected to have an annual appraisal, and for doctors, the content of the appraisal portfolio is described by the principles of Good Medical Practice, as defined by the GMC, most recently in 2013. These are

1. Knowledge, skills and performance 2. Safety and quality 3. Communication, partnership and team working 4. Maintaining trust

For doctors in training programmes, the summative review with the Educational Supervisor and the ARCP process combine to form the assessment of the „benchmarkable‟ knowledge (as exemplified by passing exams, and from case based discussions) or skills (technical assessments against a specialty defined standard) ,audit and quality improvement projects etc. The measurement of performance, communication, partnership, team working and maintaining trust comes in part from the 360 degree feedback,

facilitator

role model

information provider

resource developer

planner

assessor

and clinical governance / complaints/ compliments and SUI investigations. The ARCP panel will appraise the evidence and issue a training outcome with suggestions for the next phase of training. All doctors are expected to write an annual personal development plan, and some, particularly those where specific areas of concern are identified, will also need a personal improvement plan. The latter invariably requires input from the Educational Supervisor and Director of Medical Education at the employing Trust, and usually includes supportive input from a coach in the HETV Professional Support Unit (formerly CDU). However, professional development should not be a „once a year activity‟, and reflection (see below) is an integral tool in modern practice. Personal Development Plans

1. What do I want to achieve? 2. How am I going to do this? 3. How long will it take me to achieve this goal? 4. What are the hallmarks of achieving this target? 5. If I don‟t achieve it, why was that?

PDPs should be drafted using the „SMART‟ acronym, goals / challenges being specific, measurable, achievable, realistic and time limited/ defined. Performance Improvement Plans

1. Describe why the PIP is needed 2. Identify the problem which needs to be addressed 3. Explain what must happen and what will be measured as the outcome 4. What help is available? 5. What is the timescale to complete the PIP? 6. What are the consequences if the PIP fails?

Reflection Brew, in 1993, summed up the value of reflection with this quote: „Too often we close up possibilities by not looking enough‟. Reflection has been described by Gibbs (1988) as a cycle, shown below, and some similarities with Kolb‟s learning cycle:

description of the event

feelings and thoughts about

the event

evaluation: good and bad

parts

analysis

conclusion: what else could

I have done?

action plan: how could/ should it be done differently next time?

Reflective essays are increasingly expected after critical incidents have been reported, and as a personal review after a complaint. They should however, be used in positive situations, and after learning events, even if in a shortened, listed format.

References 1. Gold Guide v5 2014. A reference guide to postgraduate specialty

training in the UK. General Medical Council

2. Honey, P. & Mumford, A. (1982) Manual of Learning Styles London: P

Honey

3. Noel Burch from Gordon International Training 1970s

4. Dreyfus, S E (1981) Four models v human situational understanding:

inherent limitations on the modelling of business expertise USAF Office

of Scientific Research, ref F49620-79-C-0063;

5. Dreyfus, H L & Dreyfus, S E (1984) "Putting computers in their proper

place: analysis versus intuition in the classroom," in D Sloan (ed) The

computer in education: a critical perspective Columbia NY, Teachers'

College Press.

6. Hofstede, Geert (1983). "Culture's Consequences: International

Differences in Work-Related Values". Administrative Science Quarterly

(Johnson Graduate School of Management, Cornell University) 28 (4):

625–629.

7. Shuell TJ (1986) Cognitive conceptions of learning, in Review of

Educational research, 56, 411-436

8. Rock D and Cox C SCARF in 2012: updating the social neuroscience

of collaborating with others. NeuroLeadership Journal, 4

http://www.davidrock.net/files/09_SCARF_in_2012_US.pdf

9. Harden RM and Crosby J, 2000, AMEE Gide no 20, The good teacher

is more than a lecturer- twelve roles of the teacher, Medical Teacher,

22, 4,.

10. Brew, A 1993 Unlearning through experience. in Boud D, Cohen R.

Using experience for Learning Walker D (editors), SRHE/ Open

University Press, Buckingham

11. Gibbs G (1988) Learning by Doing: A guide to teaching and learning

methods. Further Education Unit. Oxford Polytechnic: Oxford.

Further personal development as an educator

There are a limited number of subsidised places each year for the postgraduate certificate programme at Oxford Brookes University in Clinical Education. Enquiries should be directed to the administrators in the HETV School of General Practice in the first instance for more information on the programme. The programme is intended for both medically or dentally qualified health professionals in primary and secondary care. It should go without saying that HETV expect participation in planning, delivering and evaluating training from staff who participate in this programme, during and after the certificate is under study.

Suggested titles for further reading Your Brain at Work by David Rock. Published by Harpers Business, 2009, ISBN 978-0-06-177129-3 How to Teach Continuing Medical Education by Mike Davis and Kirsty Forrest. Published by Wiley-Blackwell, 2008, ISBN 976-1-4051-5398-0 Teaching Today by Geoff Petty. Published by Nelson Thomas, 2004. ISBN 0-7487-8525-6 Medical Teacher, the journal of the Association for Medical Education in Europe (AMEE) Organisations for Educators There is no obligation to join any of the organisations listed below, but an awareness of their existence may be of value. AMEE (Association for Medical Education in Europe) BEME Collaboration (Best Evidence Medical Education) AoME (Academy of Medical Educators) ASME (Association for the Study of Medical Educators) primarily for doctors practising in the UK and Ireland WFME (World Federation for Medical Education)