- Negotiating skills
- Learning styles
- Needs analysis
- Planning learning
- Educational resourcing
- Evaluating learning
Learning is a life long process that has several phases. Most notably a childhood phase. where the teacher's agenda dominates and the adult phase, where the learner is more actively involved. In professional education, the new recruit has often to submit to another phase of teacher dominated education, and this can affect their learning pattern for the rest of the professional life. One of the roles of the postgraduate teacher is to help the learner to assume a more active and responsible role in his or her learning.
The learning of the qualified professional has to satisfy the following broad aims:
- to maintain and consolidate knowledge and skills
- to acquire new appropriate knowledge and skills
- to develop areas of new interest
- to facilitate the process of contributing to new knowledge and skills
The fields within which these general aims will apply will be:
- clinical medicine
- business management
- public health
- health service administration and planning
- science and research
He or she is an adult learner with the characteristics of which are laid out below:
(Knowles M (1984) The Adult Learner – A neglected species, Houston Gulf)
- respond best to a non-threatening learning environment where there is a good teacher/learner relationship.
- want to assess themselves against a relevant standard to determine educational needs.
- want to select their own learning experiences - self directing.
- prefer a problem orientated patient based approach to learning.
- want to apply their knowledge and skills immediately.
- want to know how they are progressing.
- want to contribute from their own knowledge and skills to help others to learn.
In order to help the individual learner, the mentor will be involved in some of the processes:
- Negotiating skills
- Learning styles
- Needs analysis
- Planning learning
- Educational resourcing
- Evaluating learning
The mentor will meet learners who appreciate their need in a general sense, but who cannot define the details and see the value of this approach. Helping this process is to open a negotiation between the learner and himself, facilitated by the mentor.
Seeing the value of this approach
Start simply by using examples from everyday general practice. Examples from your own practice experience are appreciated. For example:
A patient discharged from hospital on the latest ACE inhibitor. What is this drug, what are its indications and problems? How do I know it is working? Should I be using it in others?
These are the sort of questions that arise from a single common incident in practice. Here are examples of need. some of which can be easily solved, others will take more effort.
Build up gradually by taking the example to pieces and developing them.
We all know how to look up drugs in the BNF and/or Mims, but how helpful are they for the newer preparations? There is the community or hospital pharmacist who is always willing to advise, send details from independent reputable sources and even come along to talk to an interested group. Are you the only one who doesn't know?
Are there any recent reviews on the subject? The local librarian at the PGC can help. There maybe a video tutorial on the management of heart failure with ACE inhibitors, a diploma in general medicine therapeutics and so on.
The main point is to show how real educational needs and their solution can be drawn from everyday practice, and can open out more fields. Once the local librarian is consulted, she will be a recognised resource and probably used again. Showing the application of this way to learning can open the concept of the method as well as demonstrating how the detail of learning needs can be defined.
The process of reflective learning
All practice based learning relies heavily on the concepts articulated by Schoen.
The expert practitioner uses knowledge and skills influenced by attitudes to solve problems in the work place, this is her ZONE OF MASTERY. This solving process is automatic, routine and intuitive - it requires little critical thinking. This is the area of KNOWLEDGE IN ACTION.
When the facts or features do not fit the usual pattern then a SURPRISE is said to occur. The larger the field of mastery the less surprises occur. The less surprises occur means that the practitioner needs to be extra sensitive to recognise them.
REFLECTION IN ACTION is where
- the surprise is recognised.
- the problem is reviewed.
- alternative hypotheses are raised, which might lead to research
- further information is sought
- from the patient / client
- from the body of professional knowledge
- information systems
The problem is then solved with the new information (the gathering of more or new knowledge does not necessarily mean new learning)
REFLECTION ON ACTION is where the surprise and its resolution are reviewed. This then leads onto new learning. This process often raises more questions which require further information from the body of professional knowledge or by doing research or self inquiry -audit; both of which will add into the pool of knowledge. skills and attitudes that make up the zone of mastery.
LEARNING OUTCOMES that also add to the zone of mastery are:
- new practice
- discontinuing out-moded practice
- continuing professional education
- reinforcement of established effective practice.
Schoen D A (1983) The Reflective Practitioner, (1983) Basic Books Inc.
Schoen D A (198) Education the Reflective Practitioner, .Jossev-B ass Ltd. LS'BN 1-55542-220-9
Learning is a characteristic of our species. We all learn, some better than others, some faster than others. The way in which we learn can vary. Kolb defined four main styles of learning: (Experiential Learning Prentice Hall 1984)
- Concrete experience - feeling - having the experience
- Reflective observation - watching - reviewing the experience
- Abstract conceptualisation - thinking - concluding from the experience
- Active experimentation - doing - planning the next stage
These four styles also form the points on the circumference of the learning cycle.
The Kolb model of learning sets the styles round the perimeter of a circle. The process of learning is complete if the learner passes through all the styles.
The complete learner possesses the ability to pass through all the stages with equal facility, but most people have a preferred learning style. The style is preferred or dominant not exclusive. We each enter the circle at the point of our own preference and move according to our needs and circumstances. In some instances, the learner just learns in the one style and sees no need to move. In medicine, this would be difficult, but not impossible.
The work and publications of Peter Honey and Alan Mumford have produced a method of exploring the individual's learning style. (The Manual of Learning Styles, P Honey an A Mumford, P Honey Publications, Maidenhead 1992). The questionnaire published in the manual enables the learner to determine their learning style, compare their results with the accumulated results of many thousands, and explore their preferred ways of learning. When describing the styles they use the terms activist, reflector, theorist and pragmatist, corresponding with Kolb's concrete experience, reflective observation, abstract conceptualisation and active experimentation.
Completing the learning style questionnaire enables the learner to select the method most suited to their preferred style. It will also enable them to make the most of that style, and from the basis of success, develop their other styles.
For effective learning to occur, a learner needs to feel comfortable with the method, a personalised plan with the method tailored to the preferred style is likely to achieve this.
The elegance of this model is in its easy adaptation to the problem solving process often used by health care professionals.
Defining learning needs can be difficult, often because we have been educated in the system of always being right and justifying ourselves. The underlying philosophy of defining learning needs is that of the error model, where errors or omissions are not only permitted. but their recognition encouraged and celebrated. In this model, the teacher is the factor that enables the learner to recognise and act on the errors. In medicine, error equates to tragedy and even death. Whilst this can be the case, it is probably a failure to recognise small errors that results in a major error.
The error does not have to be a wrong action, it may be an omission. It is possible to view a referral from general practice as a failure to cope, or an inability to do something. This might be appropriate in the area of major surgery or cardiac investigation, but in some other instances we refer because of a lack of knowledge or skill. Analysis of referral letters often discloses such areas of need. This can be either a personal, practice or other group activity,
PUNs and DENs'
A tool for identifying your learning needs.
(Adapted with kind permission of Richard Eve, GP Tutor, Taunton)
PUNs = Patients' Unmet Needs.
DENs = Doctors' Educational Needs.
This exercise should be carried out over a week in the surgery. The first stage is to recognise the PUNs that arise during your consultations. The question the GP must ask himself after each consultation is "WAS I EQUIPPED TO MEET THE PATIENTS NEEDS?" or "COULD I HAVE DONE BETTER?". In this way an area will be identified that would benefit from further learning or development. These areas for learning should be grouped into
- Knowledge (clinical).
- Knowledge (non-clinical).
- Skill or Attitude.
Record each PUN in a log showing date, patient age. sex and ID, description of the PUN and the group it falls into.
The second stage. which is done later when there is time to reflect, is to define the DEN that arises, or to meet the PUN by other means such as delegation or practice management. Record this in the final column of the log and if it is a DEN use the group classification to decide how it could be fulfilled. This might be by simply asking a colleague, looking it up, or it may need further study, training by attachment to an expert, small group discussion or other forms of learning. You now have a list of personal learning needs which can be compiled along with those derived from other sources and prioritised with the help of your mentor.
Here are some examples of spotting PUNs and defining DENs:
- A patient is seen with a peptic ulcer, has heard of triple therapy and wants it. You prescribe but wonder if you have given the best prescription — there seem to be several different regimens promoted and should you have insisted on gastroscopy first, or is there a reliable test for the presence of Helicobacter. Here is a Clinical Knowledge PUN and the corresponding DEN is to learn more about triple therapy.
- At times patients' needs may not be fully met because, for example. you are unable to tell them the times when the Special Clinic is open, don't know who is the best surgeon for referral with impotence, don t know whether they can have free prescriptions. This Non-clinical knowledge PUN is best met by asking, delegation or ensuring that information resources are easily available within the practice.
- Persistent tennis elbow /rotator cuff/plantar fasciitis presents which would benefit from injection. You don't feel confident to do it and have to temporise/refer/use less effective NSAID. Skill PUN may be met by delegation to partner who does injections for the practice or by fulfilling your own DEN by arranging appropriate training.
- Young man presents with 'can't cope anxiety' and tearfulness. Has been bullied at work and his job is at risk. You recognise your irritation with him, want to say 'stop being wet, pull your socks up etc.' and desire to end the consultation instead of focusing on his problem. The patient still has a PUN and perhaps you have an Attitude DEN that needs addressing. It may be that discussion of the problems of dealing with 'wet men' in a small group where others might acknowledge this difficulty also, would enable you to manage such people better and thereby alter your feelings about them.
CRITICAL OR SIGNIFICANT EVENT recording is a way to highlight areas of inadequacy, either in practice systems or personal knowledge and. or. skills. Practice meetings to discuss these events are ways to pinpoint learning needs for the group, as well as the individual.
In all these it is helpful to define the needs by discussing the area, or topics, with another person such as a mentor. A very helpful step is to translate the learning needs into a list of objectives.
Before moving into the solutions it is pertinent to remember the work of Maslow, who defined a hierarchy of needs that should be satisfied before effective learning can occur. He states that the needs must be attended to in their hierarchical order. They are:
- Physiological - to be fed and watered
- Safety - freedom from excessive anxiety
- Social - the need to be loved and cared for, respected as a person
- Self-esteem - skills mastered. recognition by others
- Self-fulfilment - personal achievement, freedom to take responsibility, be creative and develop
Maslow A (1954,) Motivation and Personality, Harper New York
Experience from training in general practice shows the value of considering all these areas. Failure to gain professional self-esteem often has its roots in social upset or excessive physiological stress. It is probably true for principals in practice and has manifested itself of late in the crises produced by complaints against GPs. It is important to recognise, and value, the pastoral element of mentoring. In this way. the mentor can encourage the mentee to acknowledge personal influences on development, and by acknowledging them to see how they can be addressed as part of the total professional learning plan.
This is the exercise where the learner, initially with help from the mentor. will put the how to the what. Thus the need to write the list. Each learning need or objective can be allocated a method to achieve it. The method will depend upon the individuals learning style, the topic, resources and the time available.
The resulting document will become the index to the personalised learning plan or portfolio.
To continue the example from before
|What are ACE inhibitors?||Ask district pharmacist to practice meeting|
|What are the indications for their use?||Meeting at PCG with cardiologist (theorist)|
|To learn modern concepts of heart failure||Latest review article (theorist)
Distance learning package (reflector)
|To find out what is happening in practice||Audit of practice activity
Invite audit facilitator to a meeting
The most important part of this document is the when column. This provides the internal discipline for the learning process.
Assessment and evaluation are words that present difficulty both in meaning as well as content. They carry with them highly charged feelings which need to be defused. In the context of portfolio, or planned learning, they represent the learners own evaluation of both the method chosen, as well as the effectiveness. An important part of the process of understanding assessment is the expression of the persons understanding of the word(s) and the feelings attached to it.
Assessment is about how much a person has learned.
Evaluation is about how the learning was delivered.
At the simplest level, assessment is the testing of the objective:
|Objective:||I will be able to describe the indications for prescribing an ACE inhibitor|
|Assessment:||What are the indications for prescribing an ACE
|Method:||Demonstrate from case note that ACE inhibitors have been used in these ways.|
A more general approach acknowledges the contribution to learning of other factors such as ceneral satisfaction with the environment, the process and the content. The learner and the teacher both contribute to the evaluation.
|Did you achieve your objective? YES/NO
My objectives were totally achieved - 0 - 0 - 0 - 0 - 0 - 0 - 0 - 0 - I did not achieve any of my objectives.
The concept of the portfolio learning method is that the learner evaluates his own learning as he progresses through the plan. and that the portfolio can be evaluated by his mentor or any other appropriate external person. It clearly demands motivation, honesty and the acceptance that learning is a continuing process.
(RCGP Occasional Paper 63) Portfolio Based Learning in General Practice (1993).