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Faculty Development: Clinical Skill Teaching Dr Reg Dennick Asst. Director Medical Education University of Nottingham.

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Presentation on theme: "Faculty Development: Clinical Skill Teaching Dr Reg Dennick Asst. Director Medical Education University of Nottingham."— Presentation transcript:

1 Faculty Development: Clinical Skill Teaching Dr Reg Dennick Asst. Director Medical Education University of Nottingham

2 Name of speaker Outline of session Faculty development areas Teaching Practical skills Theories of skill acquisition Methods of skill teaching A practical exercise

3 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.


5 Introduce secondary colours into your presentation Insert body text here… Lecturing & presentation skills Small group teaching/facilitation Problem Based Learning Bedside/clinical teaching Informatics/CAL Curriculum design & evaluation Management/leadership Assessment techniques Educational theory Giving feedback Communication skills Setting learning objectives Assessing clinical skills: OSCEs, OSLERS etc Mentoring/supervising Professional development Assessing practical skills: DOPS, Mini-CEX etc Simulation and simulators Teaching practical skills Faculty Development: ‘Topics’

6 Teaching practical skills

7 How do you learn skills best? Discuss with your partner

8 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.

9 Theories/Frameworks of skill acquisition Simpson (1966) Fits & Posner (1967) Benner (1984) Dreyfus (1986) George & Dotto/RCS (2001)

10 Levels 1: Perception Where the learner merely identifies the need to perform a particular skill in response to perceptual clues Level 2: Set When the learner is ready to act. Levels 3: Guided response When the skill is performed immediately after a demonstration. Level 4: Mechanism When 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: Origination Involves the creative development of new psychomotor skills. Simpson 1966: The Psychomotor Domain

11 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

12 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

13 “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

14 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 Rules Procedures Protocols Context-free Information processing No coherence Inflexible Analytical Abstract

15 KNOWS KNOWS HOW SHOWS HOW DOES Competen ce Performance MILLER’S TRIANGLE Cognitive Behavioural 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

16 Getting the balance right? TheoryPractice Do you need to understand the theory of skill acquisition to teach a practical skill?

17 But how do we teach skills?

18 The prototype! See one Do one Teach one

19 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

20 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.

21 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.

22 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.

23 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.

24 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.

25 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.

26 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!

27 Activity: The Origami Shirt !!!

28 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?

29 Visualisation phase Watch an origami shirt being made. This will be done with no words or commentary. Make sure you have a clear view.

30 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 bottom Short axis left and right

31 Verbalisation phase Fold so that the left axis aligns with the top axis

32 Verbalisation phase Press hard on the fold and crease firmly. The top left corner angle should be bisected.

33 Verbalisation phase Fold the narrow strip over the triangle you have just formed.

34 Verbalisation phase Press firmly along the crease.

35 Verbalisation phase Carefully tear along the crease. Discard the larger piece of paper.

36 Verbalisation phase Make a fold about 3 to 5mm from the end. This will form the collar of the shirt.

37 Verbalisation phase Fold the piece of paper in half, along its long axis. Press firmly to crease the paper. Refold in the opposite direction.

38 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.

39 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.

40 Verbalisation phase Do the same for the other side. You should now see the collar taking shape.

41 Verbalisation phase Bring the rear portion of the paper to the front. Tuck the end under the collar.

42 Verbalisation phase Press the shirt into shape, making sure that the crease down the front faces outwards.

43 Verbalisation phase Make a line for the buttons.

44 Verbalisation phase Draw in the buttons

45 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.

46 Visualisation phase II Talk the teacher through the sequence

47 Practice phase Now, have a go at making an origami shirt. And while you are doing it, we shall enter the…. Feedback phase This 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.

48 Skill mastery How much practice do you think you will need?

49 Skill autonomy How could you develop the origami shirt?

50 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?

51 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?

52 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.

53 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

54 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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