Communication Skills Week 5 PDF

Behaviourism as a Way of Learning  Behaviourism is a popular learning theory that when used in an educational context proposes that physical actions such as thinking, acting and feeling can be regarded as behaviours in a teaching and learning setting. Behaviourism propo...

Behaviourism as a Way of Learning  Behaviourism is a popular learning theory that when used in an educational context proposes that physical actions such as thinking, acting and feeling can be regarded as behaviours in a teaching and learning setting. Behaviourism proposes that ‘Learning should be understood and explained in terms of what is directly observable’ Behaviourism, and therefore transfer, understand and explain learning as something that is held in the mind of the individual learner, which is a container for knowledge and skills, and propose that knowledge is a type of ‘substance’ that can therefore be moved around The transfer metaphor is an important one in education, as it has been developed and influenced as it has evolved in the various schools of thought about learning, ranging from cognitive (mind‐centred) views of transfer and metacognition through to situated views (where learning takes place in a particular context or group)  These different understandings of transfer as the vehicle for moving knowledge around have variously described it as happening between tasks (behaviourism) – for example, where a learner is able to learn a task in the classroom and transfer it to the clinical workplace – or in the mind of the individual learner (cognitive learning theories), where knowledge is learned in the classroom, stored in the learner’s mind and then transferred to the clinical workplace through memory and recall. An important point here is that behaviourism through its belief in transfer accepts learning as being independent of any context, and this influential understanding of how learning is moved around has enabled the front loading of knowledge and skills education to the early years of the medical curriculum in many subjects. Learning by simulation – for example, learning by doing in a simulated setting by trying out situations and receiving feedback on performance – partially emerged from the behaviourism stable and partially from models of skills learning  reflection As part of ongoing educational research, learning theorists explored reflection as a tool for learning. An important milestone for reflection in medical education was Schon’s (1991) seminal work The Reflective Practitioner in which learning was categorised as something that happened in an authentic practice context, where learners could reflect upon their experiences and actions and learn from these. Reflection had an impact on medical education and became a significant way of learning and developing professional practice for doctors and students alike.  over 70% of UK medical schools (Hargie et al. 2010) the dominant conceptual framework for teaching and learning clinical communication is the colloquially named Calgary‐Cambridge model developed by Kurtz, Silverman and Draper in their seminal work Teaching and Learning Communication Skills in Medicine (Kurtz et al. 2005). This framework, amongst others, offers an integrated and evidence‐based guide that intentionally deconstructs clinical communication learning into a series of learned skills that are developed in simulated settings where students learn experientially to develop skills and competence through practise and feedback. This systematic method of learning has led Hargie et al. (2010) to conclude that ‘there is overwhelming evidence that, when used in a systematic, co‐ordinated and informed fashion, communication skills training is indeed an effective training medium’. However, in line with its behaviourist pedagogy, when simulation based, it relies on the transfer metaphor to allow learners to move their learning from classroom to clinical practice.  Situated learning pointed to a new direction in learning that acknowledged the context. In their influential book Situated Learning: Legitimate Peripheral Participation Lave and Wenger (1991) presented a theory of learning that outlined the processes a novice learner goes through to become a full member of a community of practice (Wenger 1998). They proposed that learning is dependent on the learning context and the social relations that take place within it. Learning is therefore something that takes place outside of the individual and happens within a network of social relations in the clinical context.  The literature gives a clear steer. Bligh and Bleakley (2006) suggest that learning by simulation alone can become ‘self‐referential’ and may result in a simulation of learning only and not of real‐life situations; for example, it can simulate a learning exercise that is not part of real life. They suggest that simulation is a good prelude to learning in the workplace, but that effective interaction between simulation and workplace learning can increase the power of both So, perhaps we should accept that simulation, with its behaviourist origins, works well as a preparation for working with real patients in real clinical situations, but should we also accept that formal clinical communication education should run throughout the undergraduate curriculum, and beyond, to scaffold students throughout their learning Situated and Work‐Based Learning  practical representation of this knowledge dissonance is given by Benbassat and Baumal (2008), who observe that in the early years of medical education students are taught clinical communication in the main by behavioural scientists, but that many clinical teachers who teach them in the clinical workplace are not expert in this field and therefore there is no continuity between these teaching domains for students. Evans et al. (2010) share this view and comment that in nurse education the lack of shared learning goals between teachers results in ‘Students having to learn within a disintegrated learning context in which opposing values of learning exist’. Theories of workplace learning have become popular in the last 20 years because of two important changes in society.. First, education is no longer seen as something that is confined to youth and the achievement of qualifications, as we now recognise that most adults in professions must be ‘lifelong’ learners who need to update their knowledge and skills on a regular basis throughout professional life.. Second, knowledge and skills are themselves constantly changing in a complex professional life and require the learner to adapt to rapid change in a flexible way. Given these societal drivers, the workplace becomes the natural place for learning that is context specific and deals with a high degree of situated knowledge they recommend that ‘an important step in improving future doctors’ communication skills is to integrate communication teaching into every clinical course’. We have already seen a definition of workplace learning in chapter 28 that defines it as about the relationship that exists between the individual learner and the group processes that are situated in the workplace. Workplace learning looks at how the individual, social and cultural processes of working affect learning in the workplace context  Workplace learning theories offer medical educators a rich conceptualisation of how learning takes place in the authentic and complex clinical workplace (Brown 2012). Many divergent workplace learning theories exist, and it would not be possible to precis them in this short chapter. However, against this rich backdrop the theoretical construct of ‘recontextualisation’ stands out as an interesting and practical way to examine the changing nature of knowledge itself and therefore how it is learned.. Developed by Evans, Guile and Harris (2008), this framework aims to inject ‘Fresh thinking’ into the challenge of integrating theory and practice in work based learning. Recontextualisation moves beyond the behaviourist metaphor of transfer to suggest that knowledge and concepts change as they are made teachable and become learnable by students who will make sense of them and eventually apply them to their practice  suggest that ‘the knowledge transfer problem in work‐based learning programmes can be better understood when thinking breaks free of the transfer metaphor and is reframed according to a process model framework for recontextualisation’.. This theoretical framework suggests that the process of recontextualisation is a whole body response to learning that changes learners as individuals, as well as the context (workplace) within which they operate and ultimately the knowledge itself. It links the individual learner with the context and the group within which he or she learns, as learning is not independent of the learner, or of the context, or of the culture in which learning takes place, but requires all three to be complete. To understand how knowledge is shaped and changed, four kinds of recontextualisation are important in this framework  Content Recontextualisation – knowledge in the programme design environment – i.e. medical school teachers identify codified knowledge from its primary disciplinary sources (e.g. from books, publications and literature) and select it for inclusion in the Clinical Communication curriculum. They decide what it is important for students to learn and how much of it should be included in the curriculum. Clinical Communication knowledge is therefore selected and adapted for use in the medical school. Pedagogic Recontextualisation ‐ knowledge in the teaching and facilitation environment, i.e. the codified knowledge that has been selected is contextualised to the curriculum and medical school teachers design teaching methods to deliver it to students, e.g. they decide how and where it will be taught and learned in the curriculum. The Calgary‐Cambridge guide has also been formative to this process, which in most medical schools involves systematic experiential learning and simulation as the pedagogy of choice.  Workplace Recontextualisation – knowledge in the workplace environment, i.e. students learn situated knowledge from clinical teachers by a mixture of modelling, mentorship, observation, teaching and feedback in the clinical workplace. Clinical placements facilitate students to recontextualise and modify their Clinical Communication knowledge, attitudes and skills (learned in part in the simulated, medical school environment) into the authentic clinical workplace, mediated by workplace culture and practices. Learner Recontextualisation – what learners make of these processes, i.e. how medical students formulate personal strategies to bring together all forms of learned knowledge, skills and attitudes and recontextualise them to create new Clinical Communication knowledge, skills and insights into the workplace and assimilate these into their emergent clinical practice and professional identity.  To support the recontextualisation framework, Evans et al. (2008) propose that seven ‘Principles of Recontextualisation’ are needed in order that chains can be forged between the domains of recontextualisation that can bring together and connect Knowledge Partnerships and links must exist between medical school and the clinical workplace. These links are important to allow recontextualisation to take place. Partnership allows ‘cultural synchronicity’ between medical school and clinical workplace. Gradual release of knowledge and responsibility must flow from medical school and clinical workplace teachers to students. Medical students progress through a curriculum in cl inical communication that starts with theory and simulation and moves to prac tise with real patients in the clinical workplace under the supervision of clinical teachers, therefore becoming increasingly complex as the range of tasks the s tudents are asked to perform becomes more sophisticated.  Learning conversations must take place between teachers and students. Learning conversations are those that are facilitated by teachers who recognise the knowledge a s student has acquired and who then question them about this to develop that knowledge. Medical students must utilise workplace clinical resources. Being able to make use of clinical workplace resources is an important learning tool for students. Students must be able to access hospital intranet facilities, patient records, test results, clinical equipment and clinical protocols during clinical placements. Sharing clinical communication problems between medical school and clinical workplace. When a clinical communication problem is encountered in the clinical work place or in the medical school classroom, how is it resolved? Cross‐fertilisation between these two domains would be an excellent way to develop and share practice.  Senior doctors act as knowledge brokers for students. Senior doctors from the clinical workplace bring real‐world perspectives to learning that can bridge medical school and clinical workplace and provide authenticity. Shared and integrated accreditation of students must exist. In medicine shared accreditation between medical school and vocational licensing body, for example, the General Medical Council in the UK, has already been achieved and is important  The quest for developing excellent clinical communication does not end at qualification, and we know already the impact that qualified doctors have on the education of medical students. It is there fore logical to extend this kind of education into the postgraduate domain to provide a continuum of development that follows the principles of lifelong professional learn ing for doctors.