Online Approaches to Reflective Learning initial studies

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Online Approaches to Reflective Learning
initial studies

• Isobel Braidman, Maria Regan, Simon Wallis,
  Caroline Boggis and Tim Dornan
• University of Manchester Medical School

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Personal and Professional Development in
Manchester place in curriculum
PBL
Body and Disease
People Health and Illness
PBL
Doctors in Society
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Overview of portfolio
PHASE 1
PHASE 2 Work place learning
Phase 1 Extra sections (research, governance)
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Phase 1 Personal and Professional Development
Portfolios
PHASE 1 Years 1 and 2
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Students are familiar with..

• Group facilitation techniques
• Face to face discussion of professional issues
• Framework of reflective learning for personal and
  professional development

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Challenges to portfolios inYears 3 - 5

• gt450 students per year
• Located in hospital sites spread over North West
  England
• Each has its own specific timetable
• But a common University of Manchester timetable
  had to be delivered

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Phase 2 Personal and Professional Development
Portfolio

• Virtual Managed Learning Environment (bespoke for
  our course)
• Horus workplace learning technologies,
  attainment of intended learning outcomes
• specifications enriched through systems analysis
  approach
• reflective learning
• teacher development
• integrating assessment
• learning management in workplaces
• transfer to other healthcare professions

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Phase 2 Personal and Professional Development
Portfolio

Supported by peer facilitators from same year as
students
On line discussions through WebCT
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On line reflective discussions
Advertised for student facilitators in Year 3
lt 60 responded received training in facilitation
techniques
Year 3 divided into 63 groups of 8 students, each
with facilitator
Web CT page established
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Web Page
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Discussions
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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?do
  cumentID201 )
• 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.bmjjourna
  ls.com/cgi/reprint/329/7469/770
• How do doctors maintain professional behaviours
  when society is unsympathetic? http//www.webster.
  edu/woolflm/nazidocsandothers.html

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What happened?
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
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
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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?

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Methods

• Mixed Method approach used
• Analysis of web postings for quality of
  interactions by Community of Enquiry Model
  (Garrison et al)
• Focus groups both students and facilitators
• Individual semi-structured interviews
• Completion of questionnaire

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Results Use of web page

• Online discussions used vigorously from November
  June
• All 63 groups have participated
• gt3,300 messages posted

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Quality of Interactions

• 5 groups randomly sampled from each hospital
  sector (n20)
• Interaction analysed by community of enquiry
  model (Garrison et al )
• Assessed level of cognitive and social presence

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Analysis of message interactions
Cognitive Presence in Messages
CTE (No of triggers)
3
CE (Exploration)
37
CI (Integration)
37
51
CR (Resolution)
51
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Analysis of message interactions
Social Presence in Messages
SEE (Emotional)
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35
SOC (Open)
SGC (Group cohesiveness)
39
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Example of facilitator interaction with group - 1
Message no. 1737Branch from no. 1660 Posted by
(MMMP3EJS) on Thursday, March 1, 2007
556pm Subject Re Relationships with
patients Hi 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?
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Example of facilitator interaction with group - 2
Message no. 739Branch from no. 602 Posted by
(mmmp4as4) on Sunday, January 28, 2007
120pm Subject Re Dating Ex-patients I think
the group has discussed some interesting points
around the ethics of this issue. Having looked at
some of the literature on the subject and not
wanting to repeat you guys Im just going to say
that aside from it being un-professional, the
risks that this involves, especially in the
future where the relationship may not last needs
to be sized up. In an age of fitness to
practice boards and doctors being disciplined,
you must question whether it will really be worth
following your emotions. I think that despite the
GMC looking at every case of misconduct
individually, the argument for the relationship
being unethical on the basis of transference,
autonomy and consent will be an easier one to
make, compared to the argument in the doctors
defence. Interestingly a study done by Gartrell,
Physician-patient sexual contact. Prevalence and
problems, showed that students/doctors who
werent taught about non-professional
relationships were more likely to partake in one
in the future, so were already benefiting from
the hidden-curriculum!
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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.

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Reflective Content

• I sometimes feel like I am out of my depth on
  the wards and it would be useful to have some
  guidelines to abide by.
• Sometimes what they (patients) say really
  affects me emotionally. Is it OK to let them see
  that their pain causes me pain, and stay to talk
  even if I'm getting a bit teary myself?

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Reflective content

• Message no. 1801Branch from no. 1800
• Posted by (mbchfsb9) on Friday, March 9, 2007
  453pm
• Subject Re Relationships with patients
• I met a lady recently who had terrible headaches
  and had been kept awake all night due to snoring
  by the lady in the next bed and was also finding
  it difficult to rest during the day because of
  the light. When I asked about her sleep, she
  broke down into tears and told me she couldnt
  take it anymore. I suggested to her to tell the
  nurse so that they could maybe do something to
  help. But the lady was very against the idea,
  saying that she was just being selfish. I
  sympathised with her and reassured her, saying
  that she needs her sleep and that she needed to
  look after herself. She agreed to let me talk to
  the nurse. When I spoke to the nurse, the nurse
  was surprised, as the lady had not moaned at all.
  I managed to arrange for her to get a damp cloth
  to go over her eyes and the nurse said that she
  would find some sunglasses or eye mask for her. I
  asked also if it would be possible to move the
  snoring lady, and fortunately she was just about
  to be moved onto another ward. I went back to the
  lady and told her what the nurse had said, and
  she seemed really grateful. Sometimes as a
  student, I feel a bit useless as all I can do
  really is learn from others and not do anything
  actively, but when situations like that happen, I
  really feel as if I make a difference.

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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 youve
got a busy timetable, its 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.
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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

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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