Online Approaches to Reflective Learning – initial studies

Isobel Braidman, Maria Regan, Simon Wallis, Caroline Boggis and Tim

Dornan

University of Manchester Medical School

Manchester Medical School Teaching and Learning

• PBL driven from years 1 - 5

• Emphasises participant – led learning

• Introduced contact with patients at both community and hospital level, clinical and communication skills to years 1 and 2 (Phase 1)

• Issues of professional identity and development raised earlier

Phase 1 Personal and Professional Development Portfolios

PHASE 1

Years 1 and 2

GMC’s Good Medical Practice

Portfolio group discussions

Supported by tutor facilitator

Students are familiar with…..

• Group facilitation techniques

• Face to face discussion of professional issues

• Framework of reflective learning for personal and professional development

Challenges to portfolios inYears 3 - 5

>450 students per year

Located in hospital sites spread over North West England

Each has its own specific timetable

But a common University of Manchester portfolio had to be delivered

Overview of portfolio in years 3 - 5

GMC’s Good Medical Practice

PHASE 1

Phase 1 + Extra sections (research, governance)

PHASE 2

Work place learning

Medlea Portfolio On line discussions through WebCTSupport: Students, Student

Facilitators, Clinical Mentors, Hospital Deans/Portfolio Leads

Phase 2 Personal and Professional Development Portfolio

GMC’s Good Medical Practice

+ Extra sections (research, governance)

appropriate for work place learning

On line discussions through WebCT

+Supported by peer facilitators from same year as students

Online reflective learning discussions

• Text based discussion encourages more reflection

• Interchanges are asynchronous - allows time to assimilate arguments of others and relate them to learner’s own experiences

• Important in the context of work place clinical learning

• Contrast with face to face which promotes more “new ideas”/thought showering

Newman et al (1997). Journal of the American Society for Information Science 48:484 -

496. Garrison (1997). Open Learning 12:3 - 11.

Online reflective learning communities

• How to turn groups of individuals exchanging information into communities of reflective learners?

• Require framework for the group’s activities, so that the group can focus their interactions

• Necessitates understanding how such groups develop

• Community of Enquiry Model

Community of Enquiry Model

Cognitive presence Social presence

Tutor presence

Defines content

Defines milieu of discourse

Establishes structure and process

Supports discourse

LEARNING LEARNING EXPERIENCEEXPERIENCE

Importance of student facilitators

• Volunteering to take responsibility for the learning of their peers

• Taking responsibility is important marker for professional development

• Important group to follow as a cohort

On line reflective discussions

Advertised for student facilitators

in Year 3

>60 responded received training in

facilitation techniques

Year 3 divided into 63 groups of 8

students, each with facilitator

Web CT page established

Web Page

Discussions

Prompts and Links

• Should there be a common health professional code? (Nursing and Midwifery Code of Conduct and Ethics http://www.nmc-uk.org/aFramedisplay.aspx?documentID=201 )

• Should medical students make a declaration or take an oath?• When do you think medical students should adopt a professional

code?• Should this apply in your private life?• How will you protect yourself and your colleagues from the

“hidden curriculum”? http://bmj.bmjjournals.com/cgi/reprint/329/7469/770

• How do doctors maintain professional behaviours when society is unsympathetic? http://www.webster.edu/~woolflm/nazidocsandothers.html

First reflective exercise: What is appropriate professional behaviour for

Year 3 medical students Prompts for discussion, web links and resources to

stimulate thinking accessed through Web page

What happened?

Facilitator calls first face to face meeting of group, to decide balance of on line and face to

face meetings and other ground rules

End point of exercise – each group reaches consensus over code of conduct and these are

pooled; students show evidence of participation by downloading contributions

Research Questions

• What was the extent of Web page usage?

• How did group members interact online with each other and with student facilitators?

• Did these discussion exhibit critical thinking?

• What was the content of the interactions?

• Did the student facilitators fulfil their role?

Methods

• Mixed Method approach used• Web postings for quality of interactions

analysed by Community of Enquiry Model (Garrison et al) for cognitive, social and tutor presence

• 5 groups randomly sampled from each hospital sector (n=20)

• Focus groups both students and facilitators• Individual semi-structured interviews• Completion of questionnaire

Community of Enquiry Template 1

Cognitive presence

No of triggers

Resolution

‘To start off the discussion I thought I would pick a couple of questions on our discussion list’

Exploration

Integration

‘Who is responsible for formal training….? For example are nurses learning to use equipment trained by other staff members……?’

‘Another example [of relations with patients] that I encounter during my attachment…… is when a dietician of a diabetic clinic is trying to advise patients to loose some weight …...’

‘You have to gain the patients trust. …you can do this are by acting professionally and being polite and considerate…., gaining their trust and then maintaining …the trust initially and not abuse it’.

Community of Enquiry Template 2

Social Presence

Emotional

Open

Group Cohesiveness

‘….all the extra things linked with competitiveness like trying to look good in front of consultants, which I know I do, I’m only human!’

‘I agree with what X and X said about being sensitive and empathising with patients’.

‘I don’t think it is possible to regulate the relationships between doctors and their ex-patients, but if anyone else agrees or disagrees, let me know’.

Community of Enquiry Template 3

Tutor presence Organisational

(management)

Clarification

Discourse, consensus, sharing

‘We also need to include evidence in our portfolio of our participation i.e. print off parts of our internet discussions so everyone needs to get involved.’

‘Under ‘Mystudies’ you can click straight onto WebCT or you can also click onto Year 3 portfolio, this takes you to the WebCT home page’.

I would agree with everyone that when defining an ex patient you should consider what he/she was treated for……Would a sensible suggestion be if you meet someone and recognise him/her…. you should give serious thought to any relationships?

Results – Use of web page

• Online discussions used vigorously from November – June

• All 63 groups have participated

• >3,300 messages posted

Hourly Usage of WebCT during March 2007

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour

No

of

Hit

s

Analysis of message interactions

Cognitive Presence in Messages

37%

51%

9%3% CTE (No of triggers)

CE (Exploration)

CI (Integration)

CR (Resolution)51%

37%

Analysis of message interactions

39%

35% 26%

Social Presence in Messages

SEE (Emotional)

SOC (Open)

SGC (Group cohesiveness)

Analysis of message interactions

Tutor Presence in messages

18%

34%

48%Organisational(Management)

Clarification

Discourse, consensus, sharing

Example of facilitator interaction with group - 1

Message no. 1737[Branch from no. 1660]Posted by (MMMP3EJS) on Thursday, March 1, 2007 5:56pmSubject: Re: Relationships with patientsHi everyone!I think the points you have been discussing are all very true and very important to remember each time we speak with a patient. I too have noticed how patients will speak openly and in long detail about their illnesses and current problems with us as medical students and then as you mentioned, decide not to tell the Dr in order not to "waste their time" or bother them too much. A good point was made when X mentioned the importance of our role in passing this information on to the Dr in charge of the patient's care. I once spoke to a patient at my GP practice ready to present her history to the Dr, she gave her consent to speak with me and went on to explain that her husband was seriously ill and had been transferred to a hospital in another part of the country. I explained that I would be able to go in to the consultation with her and help to explain her situation if she liked. I think the fact that I could transfer this information to the GP and accompany her was a comfort. It is also interesting that X mentioned the importance of avoiding giving false reassurance to patients. Sometimes, if not careful, this could be an easy way out of a difficult conversation. How has everyone else dealt with some of the situations come across when patients are looking for reassurance in your answers?

Reflective Content

• ‘Has anyone ever considered just how much of a difference we can make to a patient just by sitting and talking to them? I can appreciate that the doctors and nurses are generally too busy to have time just to sit and chat with patients, so I think that since we have this opportunity as medical students then we should make the most of it.’

• ‘This incident touched me quite a lot personally, because I'd just had first hand experience in my personal

life with people suffering from HIV/AIDS.’

Student Reaction

From preliminary analysis of structured interviews

‘I think is good and anything that encourages people to write more I think is good, and I think that you can use it anytime, anywhere is definitely a benefit, and especially if you’ve got a busy timetable, it’s much easier to fit in fifteen minutes of an evening to write a reply to someone than it is to try and meet up with someone and so, yeah, I think it should continue’.

Summary and Conclusions

• Initial observations indicate that the online discussion facility used by almost all Year 3 students, despite being widely dispersed

• It is possible to support this with student facilitators, drawn from the same year.

• We also provided reflective learning by this means

• Community of Enquiry Analysis showed interactions in some groups became more sophisticated over time

Challenges

• Role of student facilitator requires clarification for the students

• Does downloading evidence of participation in online discussions for the purposes of portfolio review/appraisal, influence the nature of these discussions?

• Student Facilitators felt that discussions required a focus and requested further exercises

• Further activity provided “How to become a safe prescriber?”

• On line reflective discussions facilitated by students is now being rolled out to Year 4