- experience and example working in a teaching practice
- teaching from the Trainer, Partners and other members of the practice team
- the other education resources and opportunities available in the practice
Why a training practice?
Learners are heavily influenced by their environment as well as anything the Trainer may attempt to put across. If the environment and the teaching produce mixed messages then the overall effectiveness of the teaching is diminished. When the tension is between do what I say and do what we do the latter is the more powerful message.
For Trainees to get the maximum benefit from their training therefore, it is important that the training practice provides a high standard of care and is efficiently organised. These features exemplify and reinforce the messages of good practice that the Trainee receives from other sources such as reading or day release courses.
Doing a job well should not be regarded as elitist. Trainees need to see General Practice conducted and managed in an exemplary way. Effective training for General Practice should equip the Trainees to cope with all types of practice regardless of social or economic circumstance.
The training practice as a learning resource
For a Trainee to get the best out of training, a wide range of methods and resources should be developed. This is impossible for Trainers to provide on their own as the range of knowledge, skills and attitudes needed is enormous and cannot be encompassed by one individual. In a training practice each Partner has different expertise as do the Practice Nurses and Health Visitors. Many aspects of practice management and the organisation are best taught by Practice Managers and administrative staff.
Becoming a Training Practice is not a once and for all transformation but a maturation and continual evolution influenced by many factors. These include, national and regional criteria, individual Trainees, local trainers group, courses and reading. The most important factor however is the motivation of the doctors and members of the practice.
Good practice and good teaching?
The development of a practice requires both the promotion of good practice and the fostering of a good learning environment. This involves consideration of various aspects of the practice:
Trainees need space. They need a consulting room and another room at least for reflective time and reading. A room is also required within the practice for meetings, computers, equipment, the team and teaching.
A training practice has additional equipment needs, eg, video recorders and other audio visual equipment for practice clinical meetings.
It should be possible for Trainees to refer regularly to current information, especially that relating to General Practice and to read in depth about specific subjects they might need to study. The Library needs to be wider and better catalogued than that of a conventional practice. It should contain books in general on teaching and learning General Practice and if teamwork is to truly to be encouraged, training practices should include literature from the fields of Nursing, Health Visiting and Practice Management as well as medicine.
- records and computers
Clear, ordered records are essential for good clinical care. Every patient is unknown to a new Trainee who needs key information quickly. Good records are also central for screening, audit, prescribing and chronic disease management. Computerised records can be an essential teaching aid.
Trainees learn from their environment which includes the people of the practice. At a minimal level the other Partners are a model for the Trainees and support for the training which includes adequate time for learning and teaching. The Trainee after the first 1-2 months in the practice creates space for the other members in the practice by taking a share in the clinical load, hence it should not be difficult for the Partners to allow time not only for the Trainer and Trainee to have tutorials but for learning outside the practice, reflection and individual work. Ideally all Partners should be actively involved in teaching the Trainee.
If all the Partners do not see themselves as teachers then the Trainee can miss out. Partners need to recognise the strengths and weaknesses in themselves and the others so the Trainee can benefit from these. If the Partners are teaching, even in a limited capacity, the principles of effective teaching and learning are shared.
- staff and teamwork
Different health professionals and staff within a practice need to work together with common aims to develop a team. A training practice must not only have a strong and effective team but the essential parts of the team need to be overt. Trainees need to see and understand what makes teams work and this may not be immediately obvious. Trainees need to attend practice meetings, subsequently discuss the process of the meeting with the Trainer. The Trainee can receive many learning experiences from involvement in the day-to-day working of the practice.
Part of team working which promotes development and enhances learning involves the team learning together. The practice can do a wide variety of things to encourage joint learning:
- have team meetings with a visiting expert to discuss a subject, eg., the local Obstetrician to discuss ante natal care
- involve all team members in the development of a joint protocol for the care of a patient group, eg., the elderly, terminally ill, asthmatics, etc.
- create a practice journal club with all members bringing interesting articles from their disciplines, literature for others to discuss
- form practice quality circles with each group setting their own criteria and levels of achievement in different areas
- have joint tutorials in which, for example, the Trainer, Health Visitor and Trainee discuss topics of mutual interest
- if the Health Visitor is a field work teacher or the District Nurse is a practical work teacher, it is possible to encourage the students to study issues together
- develop joint projects with team members, eg., review access to the practice with a receptionist group, plan a health education programme for the Mother and Toddler Group with the Health Visitor
- management systems
Teamwork is important but other activities also contribute to the efficient functioning of the practice. Most practices have a system for repeat prescribing, receiving home visit requests, out of hours work, without which it would be impossible for the practice to function. Often these systems are written down in an office procedure book. Other clinical and organisational systems at work in the practice are less obvious and are rarely written down, eg., communication channels or networks within the surgery. Leadership too is an important factor in change and long-term planning and the various leadership styles need to be discussed between Trainee and Trainer.
For good practice systems of organisational and clinical management need to be developed and perfected to help all the members of the practice members to work efficiently. In a Teaching Practice these systems need not only to function but to be overt and available so that the Trainee can understand how they are formed, how they work (well or badly) and how they can be improved.
- audit and quality assurance
A measurement by the practice of its standard of care, comparison of the achieved standards with an agreed protocol and making changes to deal with any deficiencies is an essential feature of good practice. It is difficult, if not impossible, to practice a high standard if one is not prepared to measure those standards and compare them with others. A Training Practice is striving for quality and the audit of clinical care is essential. Trainees will learn to measure the quality of their work as part of normal practice and establish patterns of behaviour that will endure for the whole of their professional careers.
- projects and research
It is difficult for a Trainee to see research and projects as valuable if similar activities are not being undertaken by the Trainer or other Partners. It is important, therefore, that members of the practice feel these activities are important and part of normal practice.
Patients in the practice are probably the Trainees greatest learning resource. A Trainer can manipulate the Trainees case mix. There are significant organisational factors involved with training, eg., frequent change, perception and understanding of what a Trainee is and does, etc.
- the learning environment
Honey & Mumford (1986) describe four types of learning style:
- Activist style. Learning comes best from your experiences, active involvement and work and people.
- Reflective style. Learning comes best when a student is able to stand back and think and review carefully the task in an unhurried way.
- Pragmatist style. Learning is maximised when the theory and the job are obviously linked; where the task is practical and there is a chance to try out the techniques.
- Theorist style. A student learns best from being offered and using a theoretical model, can question and analyse the task and deal in terms of concepts.
The awareness of a Trainees preferred learning style can be useful for a Trainer to encourage initial learning and enthusiasm for a subject. For example,in a teamwork exercise:
- The theorist might wish to start by reading Effective Team Building by John Adair (1986).
- The reflective would learn more by observing teamwork and discussing it.
- The activist might start with a joint audit project with the Health Visitors.
- The pragmatist might benefit from discussion about cases where teamwork has played a major part.
The Trainer must not confuse learning style with personality and must appreciate that learning style is not fixed. Indeed, the Trainers role should be to help Trainees to be aware of their own learning styles and develop a wider range of styles to facilitate learning later on in their career. There are four recognised teaching styles.
- Authoritarian - tell and sell. The teacher makes a point and does not encourage questions because they will question his authority. This style is probably only good for conveying facts (but so is reading).
- Socratic - question and answer. The teacher always asks and the learner always answers, each answer triggering the next question. Information is only provided when the learner demonstrates an area of ignorance.
- Heuristic - find out yourself. Encouragement of learning by doing.
- Counselling - understand what is behind it. This is a less directive style than the others with the aim that the learner should understand the interactions that are taking place between him and the material being learned. Under this, ideally, Trainers should be able to use different styles for different situations. It is, however, difficult to move from one style to another. Trainers must be aware of their own strengths and weaknesses.
- The practice and its members are powerful influences on learning.
- Learners need a wide variety of experiences and approaches.
- Involvement of Partners and other team members in the teaching takes careful planning.
- The practice should provide a high standard of care and Trainees need to understand how this comes about.
- Trainees need to think about their own approach to practice in some detail.
- Time and space must be created for the Trainee.
- Roles, protocols and practices relating to teamwork must be open and shared.
- Regular audit should be undertaken.
- Records and libraries should be of a high standard.
- Trainers need to use Trainers Groups and courses, and the literature of general practice to develop continually their approach to teaching.