Adult Education

Adult education is an exciting challenge for the author of this assignment and would be ideal to help explore ways of structuring training and help prepare him to discover best practice to assist in his future role as a GP trainer. The first part of this essay looks into the ways and methods of managing education while the second part looks into the planning for all stages of learning for a specific topic. Learner Selected The learner selected by the author is a Specialist Trainee in General Practice which would be termed as a ST trainee in this essay.

This is a medically qualified individual who has had significant medical training and has few years left before qualifying has a general practitioner. The ST trainee (learner) is placed in a learning environment which would facilitate the acquisition of knowledge skills and attitude which would prepare him or her to practice independently. To achieve this education has to be managed appropriately to ensure appropriate use of resources to achieve the best outcomes.

The ST trainee could have a varied background social and economic, varying personality, learning styles and attitude might have different training and skills based on pervious work experience in hospital medicine and might have specific disabilities that would need to be considered when looking at managing their education. So flexibility and adapting the learning environment to suit the trainee is important. Management is defined as sum total of actions which involves getting people together to accomplish desired goals and objectives.

Management comprises planning, organiszing, staffing, leading or directing, and controlling an organization (a group of one or more people or entities) or effort for the purpose of accomplishing a goal. http://en. wikipedia. org/wiki/Management Bolam (1999 page 194) defined educational management as ‘an executive function for carrying out agreed policy’ He differentiates management from educational leadership which has as its core the responsibility for policy formulation and where appropriate organizational transformation (page 194).

Sapre (2002, p102) states that ‘Management is a set of activities directed towards efficient and effective utilization of organizational resource to achieve organizational goals’ (all this in Leading and managing people in education By Tony Bush, David Middlewood page 3) Ways and Methods of Managing Education Managing education could be achieved by looking at the function requirements for education. According to Bennt et al (1992 p. 5) this would include – marketing, finacial, personnel and production.

In the case of a ST trainee in a GP practice- Marketing- The manager could create avenues of marketing the advantages of the ST to the staff and patients- in a sense so that that they are aware of his role and contribution to the practice so that he gets to settle in and feels part of the collective. Financial -He or she could then look at resources available for learning (time, money, training aids, and patient’s experiences and contact) to make sure that they are maximised and are efficient and cause minimal disruption in the practice.

There would be need to develop innovative ways of sourcing extra funding to support the training if required Personnel-The manager should also ensure that the right people are the ones actually teaching (fitness to train), that the right processes for learning are instituted, that there is a learning environment at the surgery, that the ST has support at all times and that potential conflicts in personality and learning styles clashes are avoided. It is also important to consider how the different needs the trainee might have might be met by the diversity of strengths in the team structure.

For example practice manager for financial topics, GP lead for clinical issues, reception staff for interpersonal skills etc. Production- The ST trainee makes progress which is monitored, recorded and regular assessment points are set up to review progress and give feedback on how to improve performance. It is vital to appreciate the needs of the trainee and be flexible and adapt ‘production’ process to accommodate trainees with specific challenges for example disability or the odd difficult trainee with personal or health needs.

Another way of managing would be an unstructured approach were planning could be made in advance but then more flexibility could be made so as to adapt the education constantly to the trainee’s needs. According to Mintzberg (Mintzberg, 1990 cited in Kidd et al, 1997. p. 64) primary care management is more like keeping a ship afloat in a constantly threatening sea. Managing for performance One method of managing education is by setting tasks and using the accomplishment of these tasks as evidence of learning. The accomplishment of a task or activity’ as described by Riches (1997 p. 17) makes a straightforward requirement of the ST, either the task is completed or not. For example ST trainee is supposed to have certain number of entries in their electronic portfolio per week – one could set a target of 5 a week. The challenge with this is that all five might be poor quality and the training would have been successful with this goal. On the other hand you could have a trainee who has only 3-4 entries and they might show insight and reflection which shows learning is occurring.

Riches (1997) outline four problems with this form of management. -Reliability over time –very good performance may be observed during the evaluation period but this might not be typical -Reliability of performance observation – different criteria of different observers may produce difference performance ratings – The criteria being assessed for performance might be too limited to enable valid judgements to be made -performance is likely to be affected by context or ‘situational variables’ (Adapted from Riches 1997 p. 17)

Another way of managing education is through the concept of leadership and management Leadership is an interactive process that has several similarities to management. They both involve influence, working with people in groups and effective corporate goal achievement. “Management is about seeking order and stability; leadership is about seeking adaptive and constructive change” Northouse P. G. (2007). Bennis and Nanus (1985) maintained that; to manage means to accomplish activities and master routines whereas to lead means to influence others and create visions for change.

According to Bennis and Nanus “Managers are people who do things right and leaders are people who do the right thing” (p. 221) The trainee has a set period of time to spend in the practice and has been given the task of accomplishing certain educational milestones by the deanery and the Royal College of General practitioners who accredited that he or she is fit for purpose. The trainer has been given the responsibility of supporting and guiding the trainee to enable him accomplishes the tasks that have been laid out. The trainer could accomplish this by making sure that the entire process is ‘managed’.

Management tends to be trainer centred, inflexible and stifling and makes it difficult to adapt changes quickly. On the other hand a Leadership style approach of achieving education would be the use of innovation and somewhat radical thinking to help the trainee acquire the learning he requires Another method of managing education is through facilitation The term management implies teacher- centred control of the parameters of learning but a learner- centred facilitator, with a wider horizon may be more appropriate in an adult education environment.

The use of facilitating education rather than managing education may have been a more appropriate title. ‘Facilitation is about helping and enabling, rather than telling and persuading’ (Cross et al 2006, p 92). In a sense it is about providing a catalyst to a spiral of learning where learning issues can be revisited when necessary, with increasing understanding and knowledge on each occasion. Bruner (1960), cited in Dellow, 2007) suggested structure of: analyzing needs, defining outcomes, identifying strategies and planning assessment.

Cross et al (1996) also concluded that fostering collaboration, promoting empowerment and troubleshooting were important. Schon suggested that propositional knowledge ( knowing that, knowing about/something) is of limited value to the emerging professional without professional artistry ‘where professional deal with the unique, the unanticipated, the uncertain, the value conflicts and indeterminate conditions of every day practice for which there is no text book response (Schon, 1983, 1987 cited in McGill and Brockbank 2006, p. 4) Here Schon identifies the challenging of learning for Professional Occupations where judgment based on data gathered is important and their might be multiple solutions to the same problem and training an individual to identify the ideal solution required more important than just ‘book knowledge’ The facilitator should also aim to strike a balance between teaching the ‘right way’ of thinking or doing something and increasing the choice. This could require discipline from facilitators who might be highly proficient at their own job and have developed skills adapted to their personal working environment.

The ‘right way’ of doing something depends on a complex interaction between the people involved and the environment. The style that one clinician has developed might not be transferable to an individual learner. However an awareness of different styles could be a useful addition to the learners ‘tool box’. What the student does to learn is more important than what the teacher does to teach’ (Minton 2005, p2) The facilitation of significant learning rests upon certain attitudinal qualities which exist in the personal relationship between the facilitator and the learner ( Roger 1983, cited in Wallace , 2005, p 16).

Carl Rogers (1983 cited in Hinchcliff, 2006, p. 70), also suggested a framework for effective teaching -establish a climate of trust -awareness of individual learning needs -the importance of student motivation in the learning process -exposure to a wide range of experiences -acting as a resource Managing education through apprenticeship model approach Another way of managing education is through apprenticeship. This occurs in a lot of occupation especially trades where certain skills need to be learnt. The ‘master’ or trainer sets good example and shows the ‘apprentice’ or ST how to be a GP.

The ST trainee learns by observation and emulating observed behaviour and attitudes. The limitations of this is that if you have a bad trainer then the trainee will learn bad attitudes, might be restricted because of lack of choice and does not promote adult styled learning because it is trainer centred. However if the trainee is able to reflect on observed behaviour from different trainers, compares them and chooses useful behaviour or choice of managing condition, discards the not so ideal and identifies why it would not be ideal this might be an invaluable way of learning.

ST trainees for example could learn how to consult by watching different trainers and observing how they communicate with patient and appreciating which works best in certain circumstances. Plan an aspect or topic of a learning programme which covers all stages of learning for an individual learner of this group a) Using a variety of teaching methods making clear which components can be facilitated by generic educational skills and which need craft knowledge The aspect of learning that the author has chosen for the learner in this group would be the General Practice Consultation.

The ST – trainee as part of their training need to learn how to consult in general practice to a high standard and to maintain and improve upon this throughout their career. Teaching Methods I will now discuss teaching methods that could be used to facilitate learning. Scaffolding Scaffolding Theory was first introduced in the late 1950s by Jerome Bruner a cognitive psychologist. As a teaching method the trainer provides a scaffold or structure for the ST to follow in order to achieve a task. This scaffold ould be a template, guideline or internet resources to help with decision making (for example Map of Medicine). Once that task is achieved, the next task is set and scaffolded again. A new task is set using the previous scaffolds; students can begin to learn on their own. As they become increasingly in control of their own learning, they can adapt the scaffolds to various situations. For the ST to learn about consultation- a simple algorithm could be made of how to start a consultation, introduction, data gathering, investigation and discussing management and safety netting.

This template could then be adapted by the ST to different consultations as appropriate and then used to facilitate learning by reflection and feedback. Praxis Praxis is Greek for action with reflection. The idea of learning while doing (working) learning is a widely recommended approach to teaching adults (P. 87, Vella). Donald Schon (1983) suggested that the capacity to reflect on action so as to engage in a process of continuous learning was one of the defining characteristics of professional practice.

He felt that the ‘battery model’ of charging trainees with knowledge while in training so that they could discharge that knowledge or skill while working independently was not ideas for professionals and that being able “think in action”, was more suitable for professionals in a fast-changing world. The ability to reflect might be innate in some ST trainees while in others there might be need for the trainer to encourage reflection. For example the ST trainee could look at complaints or complements following consultations – identify what went wrong or well and then use that as a learning point to improve future consultations.

Constructivism Constructivism is a contextualized approach to learning. The presentation of context is an important aspect of teaching adults. (ref. )(P. 54, Knowles) According to the constructivists, learners gain deep understanding when they act on new information with their present knowledge and resolve any discrepancies which arise. (P. 58, Cruikshank, et al. An example of this teaching method is the use of new knowledge described by Cruickshank et al P. 59 as ‘Discovery learning’ which is something new or might go against revious knowledge or experience that the trainee might have. According to (Dixon P. 23) adults appear to be strongly motivated to reduce this discomfort by modifying knowledge structures and, thus, engaging in learning. (P. 23, Dixon). The major beliefs about discovery learning according to Cruikshank et al (P. 59) Discovery learning is most useful for higher-order thinking and problem-solving. Instructors should regularly engage learners’ curiosity. Discovery learning activities should be done both independently and collaboratively.

Information is most meaningful when learners come to understanding on their own. When learners are given regular opportunities to discover knowledge for themselves, they learn how to learn. An ST trainee coming from hospital medicine might find that communication and consultation different in general practice when compared with previous learning. Using these differences and the effectiveness of the consultation models in general practice could further understanding of how to communicate effectively with patients.

Websites and Electronic Media Another teaching method is the use of the internet. There are different internet resources available which effectively teach on consultation. The RCGP on their website internet resources and DVDs which could enhance learning about how to consult according to their standard. The challenge is however making this easy to access, flexible to the level of learning and experience of the trainee and making it stimulating and rewarding experience for the trainee to continue to use.

Medical education has embraced digital teaching aids and there are now numerous websites that patient can acquire knowledge Group work According to Vygotsyk 1978 (page 84) students can learn better by collaborating and discussing concepts with peers than by constructing answers in isolation. The term zone of proximal development (ZPD) is the grey area between the things the learner can do alone and the things the learner can with help from a more knowledgeable person or peer group. The use of groups is an effective teaching method for learning communication.

The ST trainee could observe mock consultation with other colleagues and at the same time practice different consulting styles and techniques. Small groups of peers at the same level of career maturity create a social environment that motivates adult learners to persist. P. 2, Kerka. Group work can sometime be virtual. Increasing more group work and dialogue and learning can occur by internet groups – for example and online moodle group could be set up for How to consult in general practice for ST trainees in a deanery. ]Questioning Another teaching method is the use of questions.

Questions can allow students to interpret and incorporate facts into their experiences are especially helpful to adult learners (P. 22, Turoczy). In my opinion sometimes questions are better at facilitating learning than answers For example before a tutorial on communication one could ask paper based question prior to tutorial to help aid learning. The ST could then reflect later on after the tutorial and appreciate the knowledge or skill that has been acquired during the course of the tutorial. Explaining Another teaching method is explanation.

This could take the form of lecturing or didactic teaching. This is becoming less used because in my opinion it does not usually enhance deeper or retained learning. The ST could attend a course on consultation and then practice aspects learnt Demonstrating and modelling Demonstrations are done to provide an opportunity to learn new exploration and visual learning tasks from a different perspective. A ST could learn about consultation by sitting in with an experienced GP and then modelling his consultation to the experienced GPs standards. ) Integrating assessment and curriculum planning c) Ensuring the effectiveness of learning Perhaps the most important factor that adults bring to their learning is experience. Rogers (2002 p 9) suggest that the expectations and the agendas that adult student learners brings are equally important and that these are partially formed by information about the learning programme supplied by the teaches. Discussion about the management of education of a GP speciality registrar cannot take place without reference to the MRCGP curriculum that has been compulsory since September 2007.

This curriculum contains a syllabus of core knowledge referred to as a knowledge base. The RCGP- GP curriculum describes the various teaching methods and the role of the teacher (Teaching, mentoring and Clinical Supervision, 2007 p 9). The didactic approach is telling to pass on knowledge eg. This is measles. The Socratic approach involves helping the learner to become aware of the limits of his or her knowledge or implicit values and beliefs through asking awareness-raising questions. Eg ‘Why do you think that gentleman always rings for a visit on a Friday?

Heuristic teaching methods aims to encourage discovery learning. This respects the autonomy of the learner, a key component of learning theory, in which learning from experience is promoted, eg I agree, you could ring him first to decide whether a home visit is really necessary. Reflective practice fits well with the Counselling styles of teaching which the teacher’s role is to promote the exploration of feelings; self discovery and the examination of implicit assumptions e. g what options were available to you when managing that consultation?

Counselling interventions are particularly useful in mentorship and clinical supervision. I will now discuss about integrating assessment and curriculum planning Assessment is ‘whenever one person in some kind of interaction, direct or indirect, with another is conscious of obtaining and interpreting information about the knowledge and understanding or abilities and attitudes of this other person’ (Rowntree, 1987, cited in Day, 2002, p viii. ). The purpose of assessment is to determine -determine if learning objective have been met support trainee learning -certification and judgement of competency -development and evaluation of teaching programme -understanding of learning process -predicting future performance (Adapted from Amin and Khoo, 2004; Newble, 1998) Assessment is often divided into formative and summative categories,summative being assessment at the end of training to see if the trainee has met a set standard (grading tool) and formative a continous record of learning attained during the course of the training (educational diagnostic tool).

Educational researcher Robert Stake explains the difference between formative and summative assessment with the following analogy ‘when the cook tastes the soup, that’s formative’. Curriculum is the set of courses, and their content, offered at a school or university- Oxford dictionary. Curriculum is prescriptive, and is based on a more general syllabus which merely specifies what topics must be understood and to what level to achieve a particular grade or standard. ‘In educational terms, a syllabus is not the same as a curriculum- a curriculum encompasses all the complex factors that contribute to a complex educational programme.

A syllabus is simply concerned with specifying a list of items that can be learned, taught or assessed (Riley et al, 2007, p15) According to the RCGP with regards the General Practice Consultation the aspects that needs to be covered include understanding the context which the consultation happens, understanding the structure of consultations, and attain good professional attitudes http://www. rcgp-curriculum. org. uk/extras/curriculum/statementDetails. aspx? id=2 Integrating assessment into curriculum planning has been done carefully by the RCGP for ST trainees.

The assessments have been integrated into the planning for the curriculum to aid learning and as well help assess if the trainee has met the set standards of independent practitioner status. Since August 2007 there is a single training and assessment system for UK trained doctors wishing to obtain a CCT (Certificate of Completion of Training) in General Practice. Satisfactory completion of the scheme is an essential requirement for entry to the General Medical Council’s GP Register and for membership of the Royal College of General Practitioners.

The MRCGP is an integrated assessment programme that includes three components: Applied Knowledge Test (AKT) Clinical Skills Assessment (CSA) Workplace-Based Assessment (WPBA) The WPBA tools are: ?Case-based Discussion ?Consultation Observation Tool (in primary care only) ?Multi-Source Feedback ?Patient Satisfaction Questionnaire (in primary care only) ? Direct Observation of Procedural Skills (in hospital posts) ? Clinical Evaluation Exercise (Mini-CEX) (in hospital posts) ? Clinical Supervisors Report (in hospital posts

Each of these is independent and tests different skills but together they cover the curriculum for specialty training for general practice. Evidence for the workplace-based assessment is collected in the eportfolio of each ST. For the WPBA, the use of the tools does not involve pass/fail assessments; the judgement may be one of insufficient or inadequate evidence, particularly in the early stages of training, but this simply points to the need for further training. At regular points during training all the evidence available from the trainee is reviewed and a judgement is made about progress through each area of professional competence.

For the ST, it is important to appreciate the level and experience that the trainees has because that would allow the trainer to be able to appreciate how frequently to introduce interventions and support if trainee is not showing satisfactory progress. Difficulties sometimes encountered by STs with regards Consultation varies from socio-cultural and language difficulties and sometimes personality leanings. It is therefore important to make the learner aware of the requirements for the training, understanding of the assessments involved and regular set periods to review set goals.

The WBPA offers assessments from different assessors and comparing assessments performed by independent people (triangulation of assessment) is useful to avoid collusion between learner and facilitator. Assessment needs to be a shared responsibility. Documentation is essential to provide evidence to all parties concerned. Naturally occurring evidence (NOE) including critical incident reflections and thank you letters from patients c) ensuring the effectiveness of learning. (20%) Effectiveness is defined by the Oxford Dictionary as the degree to which something is successful in producing a desired result.

According to Riley et al (2005, P 17) General Practitioners learn in 4 ways: experiential, self directed, needs based and problem- based learning. Experiential learning is the process of making meaning from direct experience, in self-directed learning (SDL), the individual takes the initiative and the responsibility for what occurs, while needs based learning has to do with learning as needs arise and problem based learning provides the problems first for the learner and allows him to find solutions and the learner could then identify potential learning needs.

I feel using these forms of techniques to establish learning would be ideal to teaching communication. MBTI for trainer and trainee Honey mumford Using assessment to improve effectiveness of learning Life long self directed learning constantly reflecting learning/best practice Accurate assessment will determine if the learning objective that the ST actually does what he knows to do in an appropriate way. Miller, (1990) illustrates the difference between spectrums of knowledge to performance ‘Effectiveness of learning is different from assessing the progress of learner (assessment)’. Newell- Jones, 2007). It may be measured by observing how the learner’s performance changes (a workplace-based assessment). This contrasts with formalised learning that aims to measure whether learning has been achieved rather than it is put into practice. Beginning : Identify needs and resources available Middle: review progress , identify good performance or underperformance and review the plan END assess overall performance and evaluate learning Known to ST and to others (Public area)Not known to ST and to others (Unknown area) Known to others but not to ST hidden area)Known to ST but not to others (Private area) THE JOHARI WINDOW Luft and Ingham observed that there are aspects of our personality that we’re open about, and other elements that we keep to ourselves. At the same time, there are things that others see in us that we’re not aware of. As a result, you can draw up a four-box grid. It was initially used to describe aspect of ones personality but recent interpretation has been to look at is also as clinical skill ( embracing knowledge, skills and attitudes) that a trainee might have. . The public area contains things that are openly known and talked about – and which may be seen as strengths or weaknesses. This is the self that ST chooses to share with others 2. The hidden area contains things that the trainer and the team observe that ST does not know about. Again, they could be positive or negative behaviours, and will affect the way the team acts towards the trainee. 3. The unknown area contains things that nobody knows about the ST – including ST.

This may be because we’ve never exposed those areas of our personality or knowledge, or because they’re buried deep in the subconscious. 4. The private area contains aspects of our self that we know about and keep hidden from others. Fig 1 – Miller’s pyramid of clinical competence

References Vella, Jane. (1994)Learning to Listen, Learning to Teach: The Power of Dialogue in Educating Adults San Francisco: Jossey-Bass, Inc. SCHON D A (1983) The Reflective Practitioner: how professionals think in action London: Temple Smith Knowles, Malcolm. (1980). The Modern Practice of Adult Education: From Pedagogy to Andragogy. New Jersey: Cambridge/Prentice Hall Regents. Cruikshank, Donald R. , Deborah L. Bainer, Kim K. Metcalf. (1995). The Act of Teaching. New York: McGraw-Hill, Inc. Kerka, Sandra, Adult Learner Retention Revisited. ERIC: http://ericacve. org/docs/retain. htm, 1995. Vygotsky, L. S. (1978). Mind and society: The development of higher psychological processes. Cambridge, MA: Harvard University Press. Turoczy, Cheryl, Question Well to Teach Well. Adult Learning, Vol. 8, #5 & 6, p. 22.

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