Learning useful skills in a clinical environment


"For the things we must learn before we do them, we learn by doing" (Aristotle). Everyone undergoes the stage of learning by doing. The more you practice, the better you get at the duty. But, what about the first time you learn a skill? And if you were to instruct a sensible skill, what approach do you adopt to make it an efficient teaching experience?

I work in a modern teaching medical center in the Country wide Health Service as a older registrar. The NHS provides a challenging work environment, a host for learning and instructing, and importantly, a location for healthcare pros to constantly adapt to the evolving changes in practice. Historically, health care education has revolved around lectures, circumstance based debate, bedside coaching and demo. Whereas copy of knowledge could be aided by lectures or case-based discussions, transfer of practical skills has been progressively more difficult, especially in an time where time is of substance. From teacher's point of view, it is vital to pass on essential information and skill to the learner, and to be able to do this; he/she might use various pedagogical methods or products to help make the most of the teaching experience. Transfer of knowledge and information from the tutor to the learner not only resides within the teacher and instructing techniques, but is also intrinsic to the learner himself. In this assignment, I am going to explore some of the teaching theories and practices needed to achieve skills in professional medical environment, which have been reflected in my teaching techniques.

Learning useful skills

Practical skills in medication vary from simple to very complex strategies. Traditionally, medical skills learning have been an apprenticeship, where most of the practical methods are learnt on patients in a clinical environment. From personal experience, learning a sensible skill was predicated on the basic principle of 'see one, do one, and teach one'. Infact, I learnt my first eyesight block using the same concept. It is a known fact that clinical experience is the precious metal standard for medical learning. However, in the 21st century, no one (trainee, trainer, or the individual) should be posted to the risks of experimental learning.

Theories of learning styles had been submit since early on 1900s. Kolb (1984) coined the word 'Experiential learning' which he referred to as 'learning by means of reflection on whatever we are doing'. Kolb considered learning as knowledge created through change of experience. He advised that new knowledge, skills and attitudes are achieved through interaction amongst four modes of experiential learning. 1) Cement experience 2) reflective observation 3) abstract conceptualisation and 4) dynamic experimentation. Honey and Mumford (1982) put forward an identical theory on learning through 1) Having an event (activist) 2) looking at the knowledge (reflector) 3) concluding from the experience (theorist) and 4) planning another steps (pragmatist). Applying these learning styles to sensible skills, every learner will go through all these styles predicated on the circumstances and the experience. For example, my first attention block engaged 1) watching the teacher perform an eyeball block on a patient, as he taught me the various steps (theorist), 2) supervise me doing an vision block (activist). 3) Having had the experience, I experienced the steps of the procedure and compared it to the typical techniques mentioned in the textbooks (representation) and made a few changes to my technique. 4) I needed to apply it for a length of time in order to perform eye blocks with ease and anticipate the next steps or package with any troubles I encounter (pragmatist). This might be true for my experience; conversely learners might favor one of these learning styles much better than the other. Theorists might want to know every part of detail before they embark on a practical skill, where as an activist might get perturbed by a lengthy justification and would actually reap the benefits of executing the skill. If we consider each one of these learning styles to be related to one another and building a vicious routine, every learner will go through all the periods of learning styles, however the preferred style might vary plus they might move in one style to some other based on the circumstances. Laurillard (1993) explains a four-pillared construction for the teacher-learner process. This involves a complex connection between your teacher's principles and constructed learning environment on the main one hands, and the student's concepts and specific actions on the other. She recognises the value of the student's own experience in the knowledge of academic ideas and techniques. Laurillard argues that the pedagogical strategies should encompass four main activities - debate, adaptation, relationship and reflection. Each one of these theories do connect with a learner needing to gain sensible skills in a medical environment. However from a teacher's point of view, recognising different learning styles in students and catering to the different needs of the learners is a difficult task.

Constructivism and sensible skills

Knowledge and skills are developed by interaction between the learner and environment. This explains constructivistic theory by Paiget wherein he attempts to explain the way the learners attain knowledge (Paiget 1985). Paiget put forward the concept of accommodation and assimilation. Accommodation is the process of experiencing a mental construction of the way the external world works. Assimilation is an activity of incorporating new experience into already existing construction, which is the internal mental model of the external world. By constantly interacting with the external world, knowledge is assimilated on the pre-existing framework. This knowledge gathered will form a basis for future conversation with the exterior world so that such relationships are filled up with fewer failures. For example, while learning a useful process, by learning a fresh approach you are creating a framework as to the way the approach works. With repeated practice and experience, you might assimilate new knowledge on to the existing framework in so doing improving your skills and performance, which means that your future tasks have fewer failures. Schunk (2004) explains three different kinds of constructivism - endogenous (learning by relationships between structures in the external world), exogenous (learning by relationships between cognitive set ups) and dialectical (constructions not entirely based on external or internal environments). Constructivists emphasise that knowledge is not received only from exterior resources, but is produced, often by contact with exterior stimuli, from specific understanding. Out of this knowledge bottom part, and the changes caused within it by constantly evolving experience, stems understanding of the earth. Most constructivistic theories are based on 'learning by doing' or 'hands-on problem resolving' strategies. Learners gain knowledge by experimentation, and the teacher's responsibility is to examine that the knowledge and skill moved are those which they had meant. Errors are destined to happen and it is up to the tutor to correct them, re-direct and participate student in productive discussion to be able to promote transfer of knowledge (DeVries 2004). In the event the principle of constructivism were to apply straight to the teaching of sensible skills in a clinical environment, it could be good for the trainee based on the skills gained by energetic experimentation, nevertheless, you cannot overlook the dangers enforced on the patients, especially if the trainee is a beginner. Such is the discussion against constructivism especially with regards to novice students who do not possess a mental style of how to perform a particular job (Sweller 1999, Kirschner, Sweller, and Clark, 2006). Jonassen (1997) proposed that all novices ought to be taught in well-designed, well-structured learning conditions. Kirschner and collegues (2006) considered constructivistic way as an unguided approach to instruction. However, instructing useful skills in a medical environment, even in a well-designed led system will not completely eliminate the dangers imposed on patients.

Constructive position, as referred to by Biggs (Biggs, 2006) presents a relationship of constructivism and instructional design. It entails using contructivism as a framework to guide decision making at all phases in instructional design. The learner brings with him a build up of knowledge, beliefs and assumptions, which new information is assimilated which varieties a basis for future learning. The learner is clearly aware of what the targets and goals are. The educator contributes to the procedure by alignment between your learning activities and learning effects, and also provides opinions to the learner predicated on the assessment criteria. Constructive alignment provides a different attitude on the coaching process and signifies a symbiotic romantic relationship between the learner and the educator in order to get the best from the learning experience. This will form a good foundation for teaching functional methods where there are place goals and targets to be achieved in a scientific setting, however the question of patient safeness is of key concern.

Aids to teaching practical skills

Many students feel very troubled about learning sensible skills in a medical environment. The existence of an individual sets them into a hard position, as they have to interact with the patient as well as concentrating on learning the abilities. Teaching practical skills requires exact instructions to the learner in order to perform the skill. Using the evolution of it over the last two decades, instructing and learning techniques reach new levels. Historically educating useful skills has mainly experienced lectures and live demo of the skill. While using arrival of technology, both lectures and demonstration can be found as videos and internationally via Internet. Videos form a useful tool specifically for teaching functional skills, as it web links both audio and aesthetic information to supply the learner with a multisensory experience (Hampton, 2002). There is no uncertainty that functional skills are best gained by dynamic experimentation. A lot of the practical skills are actually applied on mannequins or simulators. Rehearsing clinical skills on a mannequin or a human being patient simulator provides a realistic healthcare situation, without worries of causing any injury to a real patient. However, simulation should augment medical practice, rather than replace it (Rauen, 2001). For the novice, skills should first be attempted in a secure environment such as on mannequins or simulation centre, and then employed until such time as they or their instructors feel they can be competent to execute the abilities on real patients. This could be supervised by the trainer and may be combined up with assessments prior to the student performs the skills on patients. Issenberg (1999) recommended that such evaluation should be predicated on the level of competency of the trainee or learner. 'One may have no skill, some skill, or complete mastery. Therefore, when coaching or testing an art, the level of suitable mastery must be defined based on working out level. ' Simulation technology has been shown to be a highly effective educational tool that is well accepted by students and brings about significant improvements in skills training and proficiency. Integrating it and simulation along with regular assessments form an excellent platform for coaching functional skills in a scientific environment.

Need for assessing practical skills

Most clinical professionals believe that evaluation sorts an important part of carrying on medical education and also boosts performance by motivating the learners. Love and colleagues (Love, 1989) designed a randomised control trial to evaluate teaching psychomotor skills in medical. Second year medical students were randomly assigned to either a control group, which was self-directed, or even to an experimental group, that was taught specialized medical skills in a laboratory. He found statistically significant improvement in the performance of the experimental group in the target structured professional medical examinations (OSCE). He concluded that the action of assessment may enhance the performance by giving a motivation for learning the skill. Brown (2008) and co-workers recently did a big analysis in New Zealand affecting 3496 students based on the student's conceptions of assessment and their links to effects, and deducted that students who get pregnant assessment as a way of taking responsibility will illustrate increased educational outcomes. He also proposed that professors who take responsibility for assessment may be more effective classroom experts. Teachers assessing useful skills must be clear about the criteria being used for diagnosis and really should provide regular reviews about the performance of the college student. Outcome-based assessment provides significant and useful reviews to the trainer regarding student achievement, assessment, and the quality of the education.

Practising specialized medical skills

Does practice make perfect? It is an acknowledged fact that with experience, skills and performance improve. Historically, the fact that participating in enough practice, regardless of the structure of practice, causes maximal performance has always been debated. Bryan and Harter (1899) examined skill acquisition in telegraphic language and found that after great amount of practice, skill acquisition plateaus. However, such skills could reach above the plateau by restructuring and re-organisation. Fitts and Posner (1967) proposed that 'Primary performance is mediated by sequential processes, which with additional practice are changed into an individual direct (automatic) retrieval of the right response from storage' (Fitts and Posner, 1967). Bloom (Bloom, 1986) advised that with regular practice of particular skills and sub-skills, you can find development of automaticity. It is quite clear from these theories that practicing skills does help in enhancing performance, however training skills without composition leads to a plateau in performance. Making use of Biggs theory (Biggs, 1996) of constructive alignment, if the professors were to provide a definitive composition and regular evaluation, practicing specialized medical skills would improve performance. Gagne (Gagne, 1962) discussed the importance of definitive composition and advice in bettering performance of functional skills quoting a good example of gunnery in armed forces training. Any useful skill should bring together both theory and practice, it is not only having the ability to take action, but also about understanding the explanation that underpins the action. Peyton (1998) described a greatly advocated model for teaching scientific skills in a simulated environment. It really is known as the 'four stage approach' predicated on the velocity of performance, explaining every step of an art and repetition of the task. He advised that the students must be given constructive reviews and allowed time for reflection and practice of the skills to ensure learning takes place. Having read many of the articles which stress on the value of proper framework in practicing an art, I have to trust Ericsson (1993) and conclude that 'How expert one becomes at a skill has more to do with how one tactics than with basically performing an art a large quantity of times'.


Confucius, a well know Chinese philosopher quoted 'I listen to and I neglect. I see and I remember. I do and I understand'. There is absolutely no substitute to doing specialized medical skills, and such skills should be based on sound knowledge to be able to get mastery over performance (Gomez and Gomez, 1987). With conflicting viewpoints regarding ideas of learning and coaching, the traditional role of your tutor as a person delivering information to the learners has been questioned. From a teacher's perspective, the emphasis is to coordinate and transfer valuable information, as well concerning encourage novel thinking to be able to help in learning (Rogers, 1967). Mastery over a skill is only attained by repeated practice, so the facilitator must definitely provide precise training and regular responses to the learner as to what constitutes a minimal standard of practice to be able to ensure the safety of the patient in a scientific environment. This will demand the learners to keep an open up and active brain, as well as be encouraged and self-evaluative to make their own inferences from the experiment (Linderman, 1925). With innovations in It and simulators, exercising specialized medical skills has been made trouble-free with no real harm to the patients, especially for beginner students. However, not all practical skills can be employed on simulators. Knowles, Holton and Swanson, 1998, explained learning as an activity of 'becoming' pitched against a procedure for being 'molded'. 'Shaped' suggests moulding to a pre-defined standard, structure or idea, whereas 'becoming' signifies a process of reflecting on the knowledge gained to be able to instigate growth of knowledge and skill. From my knowledge of learning sensible skills, learners are subjected to both being 'formed' and 'becoming'. There can be an initial phase of transference of knowledge and skill from the educator to the learner (designed), and with repeated practice and experience, there is certainly internalization of knowledge and skills wherein the learner critically examines his skills to be able to improve performance (becoming). Every learner is shaped as a beginner and with repetition and experience, 'becomes' a master of the skill.

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