Faculty Development:

Clinical Skill Teaching

Dr Reg DennickAsst. Director Medical Education

University of Nottingham

Name of speaker

Outline of session

•Faculty development areas

•Teaching Practical skills

•Theories of skill acquisition

•Methods of skill teaching

•A practical exercise

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.

Introduce secondary colours into your presentation

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Lecturing & presentation skillsSmall group teaching/facilitation

Problem Based Learning Bedside/clinical teaching

Informatics/CAL Curriculum design & evaluation

Management/leadership Assessment techniques

Educational theoryGiving feedback

Communication skillsSetting learning objectives

Assessing clinical skills: OSCEs, OSLERS etcMentoring/supervising

Professional development Assessing practical skills: DOPS, Mini-CEX etc

Simulation and simulators Teaching practical skills

Faculty Development: ‘Topics’

Teaching practical skills

How do you learn skills best?

Discuss with your partner

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.

Theories/Frameworksof skill acquisition

• Simpson (1966)• Fits & Posner (1967)• Benner (1984)• Dreyfus (1986)• George & Dotto/RCS (2001)

Levels 1: PerceptionWhere the learner merely identifies the need to perform a particular skill in response to perceptual clues

Level 2: SetWhen the learner is ready to act. Levels 3: Guided responseWhen the skill is performed immediately after a demonstration.

Level 4: MechanismWhen 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: OriginationInvolves the creative development of new psychomotor skills.

Simpson 1966: The Psychomotor Domain

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

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

“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

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

RulesProceduresProtocolsContext-freeInformation processingNo coherenceInflexibleAnalyticalAbstract

KNOWS

KNOWS HOW

SHOWS HOW

DOES

Com

pete

nce

Perf

orm

an

ce

MILLER’S TRIANGLE

Cog

nit

ive

Beh

avio

ura

l

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

Getting the balance right?

Theory Practice

Do you need to understand the theory of skill acquisition to teach a practical skill?

But how do we teach skills?

The prototype!

See oneDo one

Teach one

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

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.

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.

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.

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.

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.

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.

 

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!

Activity:

The Origami Shirt !!!

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?

Visualisation phase

Watch an origami shirt being made.

This will be done with no words

or commentary.

Make sure you have a clear view.

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 bottomShort axis left and right

Verbalisation phase

Fold so that the left axis aligns with the top axis

Verbalisation phase

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

Verbalisation phase

Fold the narrow strip over the triangle you have just formed.

Verbalisation phase

Press firmly along the crease.

Verbalisation phase

Carefully tear along the crease.Discard the larger piece of paper.

Verbalisation phase

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

Verbalisation phase

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

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.

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.

Verbalisation phase

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

Verbalisation phase

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

Verbalisation phase

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

Verbalisation phase

Make a line for the buttons.

Verbalisation phase

Draw in the buttons

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.

Visualisation phase II

Talk the teacher through the sequence

Practice phase

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

Feedback phaseThis 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.

Skill mastery

How much practice do you think you will need?

Skill autonomy

How could you develop the origami shirt?

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?

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?

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.

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

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.