findresearcher.sdu.dk:8443 · web viewword count (must be within 10% of the specified word count)...

CME, University of Dundee Cover page v1.1, January 2016 SS AD

Student name: Corrie Myburgh

Assignment name (e.g. formative,

summative)

Summative assessment- Learning and

Teaching in Medical Education

Word count (must be within 10% of the specified word count)

3631

Assessment criteria Student evaluation

Content (e.g. critically

reflects on theories and

principles, synthesises

theory and practice,

identifies own learning

needs, includes appendices

where relevant)

Style, format and

language (e.g. structure,

coherence, flow, formatting,

use of language)

Sources and references

(e.g. accuracy of

referencing, integration of

appropriate literature)

Additional comments /

queries

1


Part A

Cognitive Load Theory- a brief description

In Cognitive Load Theory (CLT), expertise develops through a process of acquisition and

storage of complex, automated schema in long-term memory (LTM) (Sweller, 1994). In order

to achieve this state, short-term (STM) and working memory (WM) is utilized to create

simple, controlled schema, then amalgamated, transferred and stored in LTM (Fraser, Ayres,

& Sweller, 2015; Sweller, 1994). WM is fast acting, but limited in both storage capacity and

the complexity of information it can manage. Therefore, if the cognitive load (CL) required to

acquire a particular skill outstrips the capacity of WM, learning is inhibited/slowed (van

Merrienboer & Sweller, 2010; Young, Van Merrienboer, Durning, & Ten Cate, 2014). CL

consists of three elements, these being: intrinsic cognitive load (ICL), germane cognitive load

(GCL) and extrinsic cognitive load (ECL) (Debue & van de Leemput, 2014). With regards to

the first element, certain tasks carry a higher ICL than others; they are simply more

complicated, because their element interactivity is high. ICL is therefore something of a

constant. GCL is closely linked to ICL and thought of as a mental resource used for the

acquisition and automation of schemata. Due to their inter-relatedness, debate currently

remains over whether a distinction between the first two elements should be made (Debue &

van de Leemput, 2014). The final element ECL, relates to loading of WM from sources not

integral to learning (schemata acquisition or automation). This element is essentially a waste

of mental working capacity and is to be limited as much as possible (Sweller, 1994). The

various elements and organization of CLT are illustrated in figure 1, below.

From a research perspective, ECL is arguably the most modifiable of the three CL elements.

More specifically, whereas ICL and GLC can be managed or perhaps optimized, ECL can

theoretically be eliminated (van Merrienboer & Sweller, 2010). For this reason it is perhaps

also the most interesting from a daily teaching and learning practice point of view, because

mode of presentation and instructional format are under the teaching facilitator’s direct

control (Mann, 2010; van Merrienboer & Sweller, 2010). With all teaching and learning

factors remaining equal, optimizing these should tangibly benefit students struggling with

high ICL tasks.

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Figure 1: Infogram illustrating the key tenets of cognitive load theory (Adapted from (van Merrienboer

& Sweller, 2010) )

A key principle applicable to my teaching practice

Avoiding split attention phenomena, is a particularly relevant strategy for limiting ECL in

medical education (Fraser et al., 2015). One way of diverting learner attention is presenting

material in an unnecessary complicated manner. Thus, in an attempt to ensure the

construction of simple, integrated and robust learning documents (Nicol, 2007), a principle

relevant to pre-instruction video material might state the following:

Create pre-instruction video material, which integrates all relevant information into a

single document file.

A contextually relevant example

In a teaching module devoted to the soft tissue management skills, it is necessary for students

to acquire appropriate psychomotor skills in order to evaluate skeletal muscle structures for

clinically relevant myofascial trigger points. However, I have observed that several learners 3


struggle with this process, because they tend to focus on identifying anatomical

landmarks/activating muscles. Although they are provided with podcasts to be viewed before

classes, these do not include techniques for clearly identifying relevant muscular structures. A

document, which contains all the appropriate focus areas, would allow the learner to

assimilate relevant pre-requisite information before the psychomotor skills training is

introduced.

Critical reflection

Tacit to critical reflection, is a retrospective, chronological focus. I would therefore argue that

my reflections on the future impact of this principle on my learners and myself, is highly

speculative. Nevertheless, in attempting to apply Gibbs’ reflective model generally and

specific to my particular medical education example (Forrest, 2008; McBrien, 2007), the

following points might be noteworthy:

1. I notice fewer students engaged in activities extraneous to the learning objective.

2. Fewer learners exhibit signs of frustration, because they are not getting on with the

‘job at hand’.

3. That the tutorial successes significantly outweigh challenges observed and that

consequently few changes need to be instituted.

4. That the learner cohort more rapidly takes up the core psychomotor skill.

Theory of Self-regulated Learning

In the quest to improve academic achievement (Gonzalez-Pienda, Fernandez, Bernardo,

Nunez, & Rosario, 2014), self-regulated learning (SRL) developed as a counterpoint to

focusing exclusively on mental ability in academic performance. A self-regulated learner

might be defined as a ‘master of his or her own learning process’ (Zimmerman, 2008). This

means that the individual can successfully employ self-directed processes and beliefs to

transform their mental abilities into academic performance skills (Gandomkar & Sandars,

2018; Zimmerman, 2001).

Several philosophical traditions and theoretical perspectives contribute to the theories of

SRL; these include among others phenomenology, social cognitive theory and constructivism

(Zimmerman, 2001). However, in all of these, focus is placed on personally initiated

4


strategies that might improve learning outcomes and environments. In turn, these typically

involve so-called metacognitive processes associated with learning environments, the person

themself and various behavioural influences (Zimmerman, 2008).

A key principle applicable to my teaching practice

It would appear that collaboration in group-work processes are optimized by a balanced

gender ratio (Takeda & Homberg, 2014). And furthermore that male only or male gender

exclusion groups result in higher incidences of reduced collaboration and underperformance

(Takeda & Homberg, 2014). With this in mind, a common-sense pedagogical strategy may

include the implementation of the following principle:

Create gender-neutral working groups by introducing measures that ensure

heterogeneity.

A contextually relevant example

In our post-graduate teaching environment, our general, historical practice has been to either

let learners in psychomotor skills modules self-select their working groups. This practice

appears to stem from the idea of treating the learner like a ‘grown-up’. What tends to occur

though is that classmates stick together throughout their training, often resulting in less than

desirable group gender heterogeneity. Experience has taught us that all male groups can be a

disruptive influence. As a result the teaching staff has started to select groups by using a

simple ad hoc numbering system. For example, each student is assigned a number from 1 to 3

and groups are formed according to number allocation. Once the groups have formed small

swops are then made to ensure gender neutrality. This practice has been effective in

eliminating all-male groups, but gender neutrality remains an issue.

Critical reflection

From a reflective point of view, the strategy of ‘artificially’ creating work groups does

perhaps not intuitively resonate in an environment where one engages senior students in

small groups. However, the teaching goal must be prioritized over the establishment of

friendly rapport (Forrest, 2008). Whilst the academic performance might not reflect the value

of this process directly, sub-optimal collaborative behaviors associated with male only or 5


male gender exception groups is thus avoided. In post-module student evaluation, a single

question can be included to take the temperature on this self-regulated learning strategy. It

has been suggested that we circumvent this entire problem, by pre-selecting gender neutral

work groups before the start of the module.

Part B

General description of the topic

My topic falls within a module entitled: ’Soft Tissue Treatment’, which focuses on manual

treatment of structures in the vicinity of the spinal column. The course is rated at 3 ECTS

points (80-90 hours) and includes formative supervision and a summative objective

structured clinical examination (OSCE). Students entering this module have successfully

completed courses in anatomy, patient observation and palpation, and movement palpation.

Their exposure to abnormal findings and diagnosis is, however, very limited at this point.

One of the selected interventions is called Dry Needling (DN) and it is around the

introductory lecture and practical session I have constructed a lesson plan. The intellectual,

academic and practical competencies are summarised in table1, below.

Competencies DescriptionIntellectual and Academic

Discuss the principles of DN Discuss and explain indications/contraindications for DN

Practical Apply achieved skills in anatomy and palpation in the examination of soft tissues and the use of soft tissue techniques

Independently perform DN

Table 1: Bologna Convention's division of competencies relevant to Dry Needling, adapted from (Davies, 2017).

Components that make up the topic

Pre-lecture theoretical- Podcast giving an overview of Myofascial Pain Syndrome and

Trigger Point interventions

Lecture (theoretical)- Power Point Presentation of mechanisms of action, indications,

contra-indications, side-effects and adverse events associated with DN interventions

Lecture (practical)- psychomotor skills training for DN and DN procedure performed

on lab. partners

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There are no pre-requisites per se for this topic. In it, we build on the general foundation of

anatomical knowledge and palpation skills, as well as specific knowledge of Myofascial Pain

Syndromes and palpation of skeletal muscle trigger points of the Trapezius muscle acquired

earlier in the module. It is therefore expected that the learner will already be able to:

Indepedently perform examination, diagnosis and management of Myofascial Triggerpoints of the Trapezius muscle.

Rationale for activities chosen and strategies for minimising potential problems

This is the only invasive intervention this group of students will use in their clinical practice

and it is also the first time they are exposed to it. Therefore, the pre-lecture preparation for

this session is extremely important, because extrinsic cognitive load has to be reduced as

much as possible (Fraser et al., 2015). Thus, by firstly focusing on the theoretic-clinical

components of the lesson and then on the acquisition of psychomotor skills, the learner’s

anxiety is reduced regarding important, but peripheral clinic-diagnostic issues (Nicol, 2007).

We are interested in the ‘how to’ and not the ‘why’. I would also argue that we here attempt

to split attention phenomena, as we give the learner freedom to focus on the technical skills

associated with DN (van Merrienboer & Sweller, 2010; Young et al., 2014).

As this lesson focuses on psychomotor skills, the plan is fashioned from Gagne’s

instructional design model (Khadjooi, Rostami, & Ishaq, 2011) and incorporates Peyton’s

four-step approach for the acquisition of complex psychomotor skills (Buscombe, 2013;

Gradl-Dietsch et al., 2016). The specific procedure rationale is as follows:

Step 1: Demonstrating the entire DN procedure serves as the finished product model;

allowing learners to create a cognitive framework, which they can then populate with detail

as we focus on the different elements of the DN procedure (Gradl-Dietsch et al., 2016;

Khadjooi et al., 2011).

Step 2 & 3: By performing the procedure firstly on a simulation doll, then on themselves and

then finally on laboratory partners, the learner has a greater opportunity to experience deep

learning (Gradl-Dietsch et al., 2016). As the learners both perform and articulate the task,

important cognitive strategies at play here include elaboration and serial positioning (Fraser

et al., 2015).

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Step 4: The teaching is rounded of by peer evaluation and formative assessment, which

encourages self-regulated learning and critical reflection is encouraged and in its entirety.

The lesson thus follows the full Kolb learning cycle (Miller et al., 2016).

Critical Reflection

Description

This is a challenging lesson to facilitate, for three reasons a) the students have no existing

cognitive framework relating to the topic, b) there is a limited time frame and c) the learner

cohort size fluctuates. As a result, the level of proficiency achievable for the learner in this

context is at best ‘competent’. I have to co-teachers, who mainly fulfil a back-up role in this

teaching.

Feelings

I feel pressure in this regard, because every learner must reach every learning outcome for

this session to simply be ‘adequate’, I would personally like to see him or her achieve a

higher degree of competency. Group size fluctuates between 15 and 25 students, and it is

noticeably easier to reach the learning objectives with a smaller group. Furthermore, I have

also observed that students want me, as the senior tutor, to observe them and lower numbers

makes individual attention more likely. This creates a feeling of guilt, that I am not providing

an optimal learning opportunity.

Evaluation

There is a heightened sense of anticipation and application from the learners as this is a

special intervention for them- the only invasive one they perform. Therefore, I am always

pleasantly surprised how rapidly the students respond to the cognitive challenge posed; as

they focus on the psychomotor skills training and move on to integrate these with their

clinical reasoning. I do, however, sense the students struggling to separate the psychomotor

skill from the clinical aspects as they tend to want to ‘find something’ to treat. Perhaps then

there is a higher level of element interactivity than what I perceive (van Merrienboer &

Sweller, 2010)?

On a more practical note, the needles are extremely thin, making it difficult for more than 5

students to observe. This reduces the overall efficacy of the ‘complete procedure

8


demonstration’, as the learners tend to jostle for the best vantage point. This may be a

significant source of external cognitive load detracting from effective learning (Young et al.,

2014).

Analysis

I would argue that the lesson uses classroom and online (blended teaching) strategies

constructively to achieve the learning objectives (Hsu, Hsieh, & J., 2014). However, at its

core, this lesson is about competency (van der Vleuten, 2015) and therefore it would be

prudent to focus more on this aspect, as competencies and objectives are complimentary, yet

different. Specifically, we may construct a competency framework and then re-consider

which teaching and learning strategies are a best fit in relation to framework (GMC-UK,

2018). Furthermore, this session could be re-positioned earlier in the module and then re-

visited later. In this way a more timeous formative assessment and feedback can be offered

and more skills repetition will be possible (Nicol, 2007).

Conclusion

Generally speaking, the learning objectives for this teaching are met. Indirect evidence of for

this is that there have never been adverse events during the teaching and DN use has

maintained its position as a popular intervention among practitioners. However, I believe that

better use of experiential learning can contribute significantly to this teaching.

Action Plan

Pre-teaching learning- students could be tasked with completing a checklist whilst

observing a practitioner performing dry needling in the field.

Demonstration- a head camera could be purchased, so that the students can focus on

the big screens we have available, rather than trying to cram into a small space.

Co-teachers- I could provide them with an item list of criteria to look for as they

observe the students working.

A competency framework can be constructed for this intervention. The relevant

competencies for this lesson can then be focused upon

Suggest repositioning this lesson earlier in the module to create natural opportunities

for serial positioning, elaboration and repetition strategies.

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Part C

Description

‘Learning and Teaching in Medical Education’ is the first core module in the certificate of

medical education. This twelve week course is constructed to facilitate my fulfilling 5

objectives, these being to:

Compare and contrast the major pedagogic theories and principles of Learning and Teaching Apply educational theories to develop a pedagogically robust lesson plan contextualised to my

own environment Critically reflect on my own developmental needs as teachers Critically appraise evaluation tools in the educational environment Critically engage with feedback dialogue

The course has one formative and one summative evaluation, both in the form of written

assignments.

Feelings

Initially, I felt overwhelmed by the module; week 3 in particular was very densely packed

with learning theories. And I quickly became aware of my relative ignorance of what I would

term ‘formal teaching practice’, despite being a career academic. Moreover, keeping to the

weekly lesson plan initially created anxiety, as I had to integrate ‘homework’ into a full

schedule.

However, once I had developed the habit of blocking off time to follow the lessons and had

completed the formative assessment, I started to relax into the module. Highlights of the

module were: operationalizing critically reflective thinking, the teaching theories themselves,

discovering and constructing evidence-driven teaching principle and creating a structured

lesson plan. For me, the least engaging part of the module was the use of evaluation tools.

Evaluation

In evaluating the course objectives, I shall use a simple 3-star rating system based purely on

my own judgement (✪✪✪= objective definitely achieved, ✪✪= objective achieved, ✪ =

objective marginally achieved, = objective not achieved)

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Course objective 1

The introduction to key theories was extremely useful for me. I chose to explore CLT and

self-regulated learning further, as the former is teacher-focused (Sweller, 1994), where as the

latter appeared more learner-focused (Gandomkar & Sandars, 2018). Social learning theories

also resonated with me as, along with the two previously mentioned frameworks, they form

an interesting ‘triangulated’ view of teaching and learning at the individual, group and

community level (Mann, 2010).

Despite my exposure to and engagement with the literature, large gaps in my teaching and

learning theory knowledge remain. Several salient questions remain in relation to these gap

areas. Examples of these include:

Within cognitivism (memory), how can I more effectively apply strategies like

elaboration, deep processing and chunking (Kitamura et al., 2017)?

When do behaviouristic teaching strategies becomes an obstruction for reflection and

critical thinking, especially when clinical competencies are being developed (van der

Vleuten, 2015)?

My rating: ✪✪✪

Course objective 2

Similar to the teaching theories, ‘lesson planning’ is a large domain and delving into each of

the 15 or more teaching methods would require more than the week allocated. Contextually,

much of my teaching involves psychomotor skills training both Peyton’s steps and Gagne’s

procedural hierarchy were valuable additions to my toolkit in relation to creating better

structure in my teaching as well as improving competency acquisition among my students

(Gradl-Dietsch et al., 2016; Khadjooi et al., 2011).

It was also during this module that I started are reflective journal (Myburgh, 2018), which I

have used on several occasions as part of my critical reflections in relation to lesson planning

(I shall elaborate on this under point 5, below).

On a purely practical note, this objective followed the summative assignment and I was slow

to engage with the week’s activities, due to the mental fatigue of completing the summative

assignment by the due date.

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My rating: ✪✪✪

Course objective 3

Critical reflection is a practice I have periodically flirted with, but never adopted wholesale as

part of my teaching habits. Perhaps then, it should not be a surprise that I found this

component of the module difficult to launch into. However, making an effort to keeping an

online reflective journal has helped me to identify areas of teaching interest as well as

specific gaps in my teaching practice. Some of these include:

Continue routine use and integration of the reflective cycle.

Develop a practice of constructively using evaluation tools.

Gain more exposure to integrating multiple lesson plans into coherent pedagogically sound

teaching modules.

My rating: ✪✪

Course objective 4

In order to address this objective, the course material progresses rapidly through two

extensive frameworks, one centered on the educational environment and the other on the

student/trainee needs in the educational environment (Hutchinson, 2003; Millheim, 2012).

From this platform, several instruments are introduced and via a padlet platform, comparisons

are drawn between the DREEM, PHEEM and NSS survey instruments.

Using the s padlet response as a benchmark to view my development with respect to

evaluation tools, I would argue that I met this objective. However, in reaching the objective,

I feel that I did not spend enough time on the two interesting frameworks, which one would

be very likely to use as a rationale for choosing a particular evaluation tool.

As a result, I currently do not yet feel fully confident in my appreciation of how to critically

appraise evaluation tools for my teaching practice.

My rating: ✪

Course objective 5

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Critically engaging with feedback dialogue occurred during the summative tutor assignment

feedback and peer-feedback in the lesson plan segment. In the case of the former, I received

constructive critique on minor referencing issues relating to an illustration I included.

However, perhaps more importantly I also received clear confirmation that I was on the right

track. With regards to the latter, after not receiving any feedback initially, I then received

very constructive peer-feedback, which made me aware that I had not used the Gagne rubric

and as some of the hierarchy domains were not populated. I was able to correct this issue in

my subsequent lesson plan.

I did, however, not have an opportunity to engage in a deeper feedback dialogue in this

module.

My rating: ✪✪

Analysis

The choice of focusing on both a cognitivist (Sweller, 1994) and constructivist theory

(Gandomkar & Sandars, 2018) was based upon my own curiosity, yet somewhat arbitrary.

The implication being that the exploration of these pedagogical approaches did not consider

theoretical issues relating to my lesson plan. And although, provided an almost textbook

example of how Peyton’s four step approach effectively facilitates deep learning, it would

have created better continuity if I had focused on theoretical issues relating to psychomotor

skills trainin specifically, before constructing the lesson plan.

For me, ritical reflection is a constant theme throughout this module and I was proided with

both methods (reflective journaling, padlets) and modes (Gagne’s reflective cycle) to engage

and maintain this practice.

Closely associated with the reflection is feedback, which one might argue forms part of the

the same iterative process. I encountered both tutor and peer feedback, both of which were

useful in generating better output.

I experienced the most insecurity around the evaluation, as do not feel competent in

employing evaluation tools in my own teachin practice.

Conclusion

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In conclusion and based on my own judgement, I achieved the objectives of this module. I

did, however, achieve the outcomes to a greatest degree with respect to theoretical principles

and to a lesser degree in relation to evaluation instruments.

Action Plan

Developmentally speaking, this module points towards the following salient issues for me:

Developing a more complete accessible typology of teaching and learning theories

Exploring the literature and practice of psychomotor skills training in greater depth

Exploring the literature and practice of teaching environment evaluation in greater

depth

Continue, expand and integrate my reflective journal into a normal part of my

teaching practice

Consider a future module that focuses on evaluation in teaching

References

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Appendix: Gagne Lesson Plan Template

Session title: Introduction to dry needling of Myofascial Trigger points

Student / trainee level: 3rd year Bachelor

Level Activity

1 Gaining

attention

Welcome group.

Introduce new tutors if relevant.

‘I hope you have all had the time to watch the introductory podcast on

myofascial pain syndromes and dry needling?

‘Did you all have a chance to visit the website that explains the differences

between acupuncture and dry needling?’

2 Informing

learner of

objectives

‘Our mission is to familiarize you with the procedure of trigger point dry

needling and to train the psychomotor skills necessary for safely and

effectively administering the intervention.’

This is end the learning objectives are:

1. Describe the procedure of dry needling and discuss patient safety

factors

2. Observe a typical skeletal muscle dry needling protocol

3. Practice the dry needling procedure, giving specific attention to key

psychomotor skills.

3 Stimulate recall

of prior learning

In your work groups, please take 5 minutes to discuss:

1. ‘What were some of the most interesting differences between

acupuncture and dry needling for you?

2. ‘Do the differences in the needle designs make sense to you?’

(Plenum feedback from each group)

4 Presenting

stimulus

Demonstrates a complete dry needling protocol.

‘I will now demonstrate a typical dry needling procedure for you, to give

you an overview of how it is likely to be carried out in clinical practice.

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You can either come closer and watch me or follow on the big screen.’

Power Point Presentation highlighting intervention action, side-effects and

adverse events.

5 Providing

learning

guidance

Now that you have seen the entire process and consider the side-effects and

potential risks, lets break it down shall we?

1. Make sure you have all the equipment ready, that is needle, alcohol swab, used needle receptacle, cotton ball and tweezers.

2. The latex glove is on your non-needling hand ‘the one you can prick by accident’

3. Wipe the skin and allow the alcohol to evaporate (45second is enough)

4. Whilst waiting for the alcohol, open the blister pack and ready the needle.

5. Place the needle, still in its guiding tube, onto the correct area and appy firm pressure to the tube- there should be 3.5 mm of the needle handle protruding from the top of the guiding tube.

6. Tap the needle handle firmly to drive it through the skin in one, quick motion.

7. Elicite appropriate twitch responses from the skeletal muscle8. Remove the needle and apply pressure with the alcohol swab9. If a bleed is evident, apply strong pressure with the cotton ball for

45-60 seconds.10. Place only the used needle in the sharps bin11. Discard the plastic tube, blister pack and triangular stopper.

6 Eliciting

performance

1. Simulation- In pairs, please now perform the procedure on the

simulation dolls. Remember the sharp tap when inserting the

needles!

2. Self-needling exercise. Now its time to needle yourselves.

Remember here you must focus on the feedback from the needle.

3. Live controlled procedure- Please break up into your smaller

groups now and move to your tutors. Perform the procedure on

your lab. buddy. Remember- no seated patients!

7 Providing

feedback

Main group plenary discussion and comments from group tutors.

‘It is important that you all appreciate that the needling procedure has

technical components, but also a skills component. The skill part is the most

difficult. Things like a smooth routine, getting the needle through the

dermal layers, not causing heamatomas will all enhance patient experiences,

reduce side-effects and ultimately optimize effectiveness.’

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Remember to practice, practice, practice

8 Assessing

performance

Peer evaluation of procedure and formative feedback and

‘Please remember by next week, I want to see the needling procedure

uploaded along with your peer feedback.’

9 Enhancing

retention and

transferRe-consider whether learning objectives- have we achieved them?

In summary then:

1. Do you know why our dry needles look the way they do and how to use them?

2. Are you becoming aware of the small details that you need to be good at to perform the procedure?

3. Are you clear about the importance of patient safety and how to establish safe treatment parameters?

Make sure that all educational materials are accessible.

Solicit feedback of teaching: ‘Please comment on the dry needling

procedure blog so that I can optimize the teaching for next time. Anything

you are unsure about- please comment.’

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