Supporting health students in the workplace

Module 2: Learning Styles / Adult Learning Principles

Objectives

• To understand adult learning principles
• Knowledge of how to appropriately situate learning for the adult learner using the Clinical Reasoning Cycle
• Identify your own learning style and understand how this may influence comprehension
• Understand emotional intelligence and how this impacts on interactions

The Adult Learner:

Adult learning theory is based on the understanding that adults are:

• autonomous and self-directed;
• have accumulated a foundation of life experiences and knowledge;
• goal and relevancy-orientated;
• practical;
• need to be shown respect.

The experiential learning cycle helps inform this theory. An adult will have an experience; think about it; identify the learning needs for the future; plan what needs to be undertaken; and apply new learning in practice. Good feedback will help the learner to establish the links between these steps. As a clinical supervisor / preceptor, it will be helpful to understand how and why adults learn.

Think of how, what and why you learn.

Traits of Adult Learners

 

1. Self-direction
2. Practice and results orientated
3. Less open minded
4. Slower learning but more integrative knowledge
5. Use personal experience as a resource
6. Motivation
7. Multi-level responsibilities
8. High Expectations

(Knowles, 2011)

1. Create useful and relevant learning experiences based on the age group and interests of your learners
2. Facilitate exploration
3. Build community and integrate social media
4. A voice behind the video is not enough
5. Challenge through games
6. Use humor
7. Chunk information
8. Add suspense
9. Accommodate individual interests and career goals
10. Stimulate your learners
11. Let learning occur through mistakes
12. Make it visually-compelling
13. Get Emotional
14. Get examples of their workplace
15. Be respectful to them 
16. Ask for feedback
17. Present the benefits of undertaking the course

(Knowles, 2011)

Clinical reasoning cycle

Clinical reasoning is a cognitive and metacognitive process that involves elements of critical thinking (thinking like a health professional). It is a cognitive process that manifests into an action. There are five categories of critical thinking: prioritization and delegation, problem recognition, clinical decision making, clinicalimplementation, and reflection (Bittner, Gravlin, MacDonald, & Bourgeois, 2017).

Clinical reasoning is a way clinicians can think about the issues they encounter in clinical practice (Levett-Jones et al., 2010).  These skills can be taught to health professions and have been shown to improve once students are made aware of their own understanding of the way that they interpret and conceptualize the decision making process and apply this to a clinical setting (Grubbs, 2017).

(Levett-Jones et al, 2009) Source

Clinical reasoning (CR) is based on what expert/experienced practitioners do automatically or instinctively (tacit knowledge). They engage in CR multiple times for each patient in their care. CR offers learners a model and explanation of what may seem tacit and implicit. Poor CR skills result in failure to collect cues and therefore failure to take action. CR is an educational model that has the potential to enhance your learner’s skills. It also provides a language that supervisors / preceptors can use to facilitate discussion and reflection on case based learning and simulation. It is a language to assist the novice to learn from experiences in practice.

Five rights of clinical reasoning

The effective use of the clinical reasoning cycle is directly linked to the ability to:

• Collect the right clues
• Take the right action
• For the right patient
• At the right time
• For the right reason              (Levett-Jones et al., 2009)

 

Ten Top Tips for the Teaching Supervisor

 

1. Every little bit helps: Seize the teaching moment. Even if you don’t have the whole package worked out, it’s still worthwhile sharing what you can, as best you can.  Don’t have time to run through a process or procedure in full? Draw the learner’s attention to one key aspect of the task. No time for a complete debrief immediately after a difficult case?  Ask a few key questions to check the learner’s understanding of what occurred and give quick feedback. Follow up later when there is time.
2. Teach by guided questioning: Ask questions to discover the state of the clinician’s knowledge and understanding. Encourage independent thinking and problem-solving.  Effective questioning uncovers misunderstandings and reinforces and extends existing knowledge. Questions keep the learner engaged, “on their toes”, listening and thinking.
3. Invite the learner to set the agenda: Adult learners should be involved in decisions about the direction and content of learning. Your ultimate objective as a supervisor is to foster the learner’s ability to be a self-directed life-long learner.
4. Encourage questions: Questions from the learnershould always be treated with respect. You may be shocked at what you did not know, but on closer inspection, may discover that others are just keeping quiet. The three most important words in teaching and learning are “I don’t know’.
5. Focus the learner: Start any teaching session by setting up the importance of the session. Teaching is more effective if it is tailored to the learner’s interests, ambitions, and current level of knowledge and ability. Answer the question: why should they pay attention to what you are about to teach them?
6. Focus the learning: Don’t try to teach too much at once. Try not to repeat what is already known. Clinical situations are complex but limit the learning to the key aspects that form the learning edge of your audience’s knowledge base. Procedures and processes can be broken down into steps, not all of which have to be covered at once.
7. Encourage independent learning: Don’t try to teach everything – give enough information to start the learner on track, then ask them to complete the task themselves.  Set tasks that require the learner to act on the information you have provided. Keep learning open ended. Encourage the learner to seek other educational opportunities and report back on their learning.
8. Teach evidence-based practice: Build a life-long learning attitude in the learner. Even more important than knowing the current best answer to a clinical problem is having the skills to identify a clinical question, search the clinical literature, appraise the evidence and form an evidence-based plan.
9. Check the understanding of the learner: Have the learner actually understood what has been taught? Can they demonstrate clinical reasoning and put knowledge and skills into practice?  It not, perhaps revisit specific topics or skill areas until the learner feels confident and can show that they have learned.
10. Evaluate your own practice as a teacher: How well did the student learn from the information you provided? Every time you teach you have a chance to learn how to do it better (and more easily) next time. Try different methods and compare learner outcomes. Seek feedback from the learner. Compare notes with your peers.

Adapted from (HETI), April 2012

It is important for clinical supervisors / preceptors to use language that leads the learner through the journey of exploration. Here are some examples that may act as cues when questioning learners.

 

Creating an optimum learning environment

Physical Environment

Minimising distractions and taking into account the learner’s needs, such as regular breaks or finding a quiet place to talk, contributes to creating a supportive learning environment.

Motivation

The role of the facilitator is to motivate the learner both intrinsically and extrinsically. As learners are motivated by inclusion and consultation, the role of the facilitator is to establish a trusted relationship and communicating a passion for the subject in order to create an effective learning environment.

Safety

Learning requires a safe environment ensuring a physically safe place to work.  Learning can be emotionally and psychologically challenging and individuals need a place where they can be encouraged to question their own knowledge.  Facilitators have to create a safe learning environment that allows learning to take place.

Tips for setting up learning environments that facilitate learning

• Ensure regular breaks
• Avoid busy times
• Involve constructive feedback in the development of ground rules
• Provide constructive feedback on performance
• Involve learners in developing learning content
• Ensure that content is relevant to the learner’s needs: integrate it with the practice examples wherever possible

Special considerations for facilitating learning in clinical environments

• Ensure that patients/clients and families are comfortable and have given consent to having others present, such as students or other clinicians;
• Ensure that potential consequences for harm to the patient/client are discussed, managed and minimised;
• Ensure that the learner feels welcome and is physically and psychologically safe.

(HETI, May 2012)

With any new concept there are certain pitfalls that can occur. The following table outlines some of the more common Clinical Reasoning errors that may occur.

Clinical Reasoning Errors

Error	Definition
Anchoring	The tendency to lock onto salient features in the patient’s presentation too early in the clinical reasoning process, and failing to adjust this initial impression in the light of later information. Compounded by confirmation bias.
Ascertainment bias	When a practitioner’s thinking is shaped by prior assumptions and preconceptions, for example ageism, stigmatism and stereotyping
Confirmation bias	The tendency to look for confirming evidence to support a clinical diagnosis rather than look for disconfirming evidence to refute it, despite the later often being more persuasive and definitive.
Diagnostic momentum	Once labels are attached to patients they tend to become stickier and stickier. What started as a possibility gathers increasing momentum until it become definite and other possibilities are excluded.
Fundamental attribution error	The tendency to be judgemental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that may have been responsible. Psychiatric patients, those from minority groups and other marginalised groups tend to be at risk of this error.
Overconfidence bias	A tendency to believe we know more than we do. Overconfidence reflects a tendency to act on incomplete information, intuition or hunches. Too much faith is placed on opinion instead of carefully collected cues. This error may be augmented by anchoring
Premature closure	The tendency to apply premature closure to the decision making process, accepting a diagnosis before it has been fully verified. This error accounts for a high proportion of missed diagnosis.
Psych-out error	Psychiatric patients are particularly vulnerable to clinical reasoning errors, especially fundamental attribution errors. Co-morbid conditions may be overlooked or minimalised. A variant of this error occurs when medical conditions (such as hypoxia, delirium, electrolyte imbalance, head injuries etc.) as misdiagnosed as psychiatric conditions.
Unpacking principle	Failure to collect all the relevant cues in establishing a differential diagnosis may result in significant possibilities being missed. The more specific a description of an illness that is received, the more likely the event is judged to exist. If an inadequate patient history is taken unspecified possibilities may be discounted.

Adapted from Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine. 78(8), 1-6.

Learning styles

Many people recognise that each person prefers different learning styles and techniques. Learning styles group common ways that people learn. Some people may find that they have a dominant style of learning, with far less use of the other styles. Others may find that they use different styles in different circumstances. There is no right mix. Nor are your styles fixed. You can develop ability in less dominant styles, as well as further develop styles that you already use well.  (www.learning-styles-online.com, 2018) 

Using multiple learning styles and multiple intelligences for learning is a relatively new approach. This approach is one that educators have only recently started to recognise. Traditional schooling used mainly linguistic and logical teaching methods. It also used a limited range of learning and teaching techniques (www.learning-styles-online.com, 2018).

By recognising and understanding your own learning styles, you can use techniques better suited to you. This improves the speed and quality of your learning.

THE SEVEN LEARNING STYLES   (http://www.learning-styles-online.com/overview/)

• Visual (spatial): You prefer using pictures, images, and spatial understanding.
• Aural (auditory-musical): You prefer using sound and music.
• Verbal (linguistic): You prefer using words, both in speech and writing.
• Physical (kinesthetic): You prefer using your body, hands and sense of touch.
• Logical (mathematical): You prefer using logic, reasoning and systems.
• Social (interpersonal): You prefer to learn in groups or with other people.
• Solitary (intrapersonal): You prefer to work alone and use self-study

Source

Tip: To consolidate learning, have a student present a patient case study to the unit or another staff member to help reinforce knowledge!

Common Problems in Student Learning Experiences

These are some of the more common problems that you may encounter as a clinical supervisor / preceptor:

1. Lack of learner focus:         
   • The learner attempts to do too many things at one time - the result can be failure to make a useful amount of progress in any one area
   • Focus may be reduced by lack of logical progression and limited grouping of related activities
2. Loss of learning opportunities:
   • Many opportunities may be difficult to use effectively
   • Sometimes productivity can conflict  with learning needs
   • Expectations may be unrealistic and sometimes do not reflect the amount of preparation, orientation and support provided
   • Some important events occur unexpectedly
3. Mistakes:
   • Reflect on how you feel when you make mistakes
   • Mistakes can happen
   • The pressure not to make mistakes is immense
4. Supervised practice:
• Supervised practice can be an intimidating experience
• Few of us are truly at ease when someone is looking over our shoulder
• Find ways to help without interfering (unless the actions have the potential to cause harm)

Tip: To consolidate learning, have a student present a patient case study to the unit or another health professional to help reinforce knowledge

Emotional intelligence

Salovey & Mayer (1990, p. 189) define ‘Emotional Intelligence’ as "the subset of social intelligence that involves the ability to monitor one's own and others' feelings and emotions to discriminate among them and to use this information to guide one's thinking and actions".

‘The emotionally intelligent workplace’ developed the idea of a culture of an appropriate level of emotion intelligence to support the atmosphere within a business (Goleman & Cherniss, 2001).

Emotional Intelligence is the integration of thought and feeling; between cognition and emotion. Goleman discussed four domains: Self-awareness; self-management; social awareness; and relationship management (Goleman, 2001). Having a higher awareness of these principles assists people to be more effective in the work place. Cherniss and Goleman’s book ‘The Emotionally Intelligent Workplace’ (2001) is available on Google Books:

The Emotionally Intelligent Workplace