Medical educational theory in practice

Key points.

• •Aims, objectives, and outcomes represent hierarchical statements about the content of an educational encounter. They lend structure and clarity to both learner and educator.
• •Learners exhibit different learning styles and preferences, and educators should design their teaching to cater for a diverse audience.
• •Educators should be aware of the ‘hidden curriculum’, and act as good role models at all times.
• •Constructive feedback can be offered at the end of any educational encounter, and is mandatory when completing a workplace-based assessment.
• •Quality feedback guides the reflective process and can be delivered using a variety of models.

Learning objectives.

By reading this article, you should be able to:

• •Discuss establishing aims, outcomes, and objectives for an educational session.
• •Introduce adult educational theory into your practice.
• •Cater for different learning styles and preferences.
• •Illustrate different methods of delivering feedback.

Teaching, training, supporting, and assessing colleagues are duties of a doctor, but historically, doctors have received little formal training in how to teach.¹ Recently, a wealth of resources have become available; many universities offer formal qualifications in medical education, and the Royal College of Anaesthetists (RCoA) run the ‘Anaesthetists as Educators’ (AaE) programme, which offers a series of courses designed to improve teaching skills.

Teaching in any setting, be it in a classroom or in the operating theatre, requires planning. This may be as short as 5 min discussing expectations with trainees before a list, or hours of preparation for a workshop.

Distinguishing between aims, outcomes, and objectives

The first consideration is the aim of the session. This is a general statement of intent; for example, the aim of this article is to improve readers' understanding of medical education. Trainees themselves will often specify aims, particularly in operating theatre-based training. It is useful to establish this early to ensure that the expectations of the learner and the teacher align.

Objectives are more specific statements about what the teaching will deliver. For example, the objectives here are to: (i) discuss establishing aims, outcomes, and objectives for an educational session; (ii) introduce adult educational theory into your practice; (iii) cater for different learning styles and preferences; and (iv) illustrate different methods of delivering feedback.

Outcomes are more specific still, and the distinction between objectives and outcomes can be a source of confusion. We draw the distinction between them by considering objectives as statements of the topics that will be taught, but outcomes as those specific things that can be measured to ensure the objectives have been achieved. An example can be seen in Box 1.

Box 1. List of aims, objectives, and outcomes for a hypothetical small-group training session designed for novice anaesthetists on the subject of breathing circuits.

When designing such sessions, we tend to group learning outcomes under the relevant objectives, and have followed that convention here. Note the increasing specificity of the statements as one moves from aims, through objectives, and finally to outcomes.
Aim:	To introduce different types of anaesthetic breathing circuits
Objectives:
(i)	To introduce the circle breathing system
(ii)	To illustrate different types of Mapleson circuits
(iii)	To demonstrate the clinical use of commonly encountered breathing circuits
Outcomes:
(i)	To introduce the circle breathing system
(a)	List the components of a circle breathing circuit.
(b)	Draw a diagram of a circle breathing system.
(c)	Describe the function of the soda-lime canister in a circle system.
(ii)	To illustrate different types of Mapleson circuits
(a)	Draw a diagram of the six Mapleson circuits (A–F).
(iii)	To demonstrate the clinical use of commonly encountered breathing circuits
(a)	Describe why circle systems are most commonly found in theatre.
(b)	Explain why the Mapleson D system requires a much higher fresh gas flow than a circle system.
(c)	Explain why the Mapleson F system is commonly used when anaesthetising small children.

Alt-text: Box 1

Arguably, the learning outcomes are the most relevant to the trainee. The statements describe exactly what new knowledge or skills they will acquire by the end of the encounter. Having read this article, for instance, we expect that readers will be able to describe four learning styles; to explain matching teaching methods to learner preferences to maximise engagement; to be able to define terms such as ‘aims’, ‘objectives’, and ‘outcomes’ as they are used in a teaching context; and to list four feedback models.

Setting outcomes determines the focus of the training and clarifies the ‘take-home’ messages for the learner. They offer transparency because the trainees know which aspects of their knowledge, skills, or attitudes are being observed. This helps set ground rules by giving the educator permission to observe or probe trainee performance, and offer relevant feedback.

Outcomes should use specific, measurable verbs. The attainment of outcomes, therefore, enables the success of a training session to be measured. Verbs, such as ‘understand’ or ‘know’, are often written in learning outcomes, but are not necessarily best practice because it is impossible to directly measure ‘understanding’. It would be better to select ‘describe <condition>’ or ‘analyse <treatment option>’. This specificity then allows the trainer and trainee to make some assessment to determine if their learning objectives were met.

In 1956, a taxonomy of such verbs was created, and grouped by the type of knowledge or skills they access.² This allowed for a classification of learning objectives into areas, such as ‘knowledge’, ‘comprehension’, ‘application’, ‘analysis’, ‘synthesis’, and ‘evaluation’ according to the depth of knowledge the learner is expected to achieve. This list has been refined several times since, and an example is provided in Figure 1. Next to each heading is grouped a series of measurable verbs that can be used to specify objectives appropriate to each level. Simple factual recall, for example, represents the most basic form of learning. This may be appropriate for new topics or inexperienced trainees, but as expertise is gained a deeper level of understanding is required. Advanced learners should be able to synthesise knowledge and build links between concepts already learned.

Fig 1.

Bloom's taxonomy is a means of structuring learning objectives according to the depth of knowledge required. Remembering facts about a topic represents the lowest level of knowledge; the ability to create something using knowledge requires the highest levels of attainment.

There are many opportunities to set learning outcomes. Educational supervisors are well placed to set high-level outcomes relevant to an entire clinical attachment. It is sensible to set at least one specific objective at the start of each training list in the operating theatre that can be revisited at the end of the day. Anaesthetists may also have formal teaching responsibilities, for example delivering local teaching programmes for trainees preparing for Fellowship examinations or teaching on external courses. In many cases, learning outcomes are constrained by a training curriculum, but in each situation, specifying objectives can help both learner and trainer.

Knowing your audience

A key feature of adult learners is that they value autonomy and take responsibility for their learning.³ In a time-pressured workplace, the personal relevance of learning must be obvious if trainees are to engage with it. It is particularly beneficial if learning outcomes can be integrated into their normal working day.⁴ Some of these are highlighted in Kolb's learning cycle (Fig. 2), which considers the importance of reflecting on experiences to developing new understanding.⁵ Clinical supervisors need to be able to facilitate and guide that reflective process and establish a safe environment for the learners, one in which they can freely contribute.⁶

Fig 2.

Kolb's learning cycle (central disc) and Honey and Mumford's learning styles (outer boxes). Kolb visualised learning as stemming from reflecting on an experience, using that reflection to find ways to modify an approach, and then testing the new approach. This then generated a new experience that could feed back into the cycle. Honey and Mumford described a series of stereotyped learning styles that learners tend to adopt, which approximate to different steps in Kolb's cycle.

External factors also have motivational effects; for example, professional examinations are likely to dominate a trainee's agenda for substantial periods of time. It is therefore important that educators recognise and respond to trainees' needs, rather than encounters being overly teacher focused.

Learners tend to gravitate towards preferred methods of acquiring information, or ‘learning styles’. One of the most popular methods of quantifying this is the 80-item Honey and Mumford questionnaire.⁷ This identifies four learning styles: activist, pragmatist, reflector, and theorist. These styles approximate to steps in Kolb's cycle (Fig. 2).

Few learners fall exclusively into a single category, but many exhibit stronger preferences for one or two styles. Although learners adopt non-preferred learning styles at times, understanding these preferences is useful for the educator to assess whether a teaching style is appropriate to the audience. This questionnaire is also administered routinely to delegates attending the RCoA AaE programme to encourage them to reflect on their own teaching and learning practices.

When designing teaching encounters, people tend to favour learning styles to which they respond personally, but this risks narrowing methods of delivery and may reduce the impact for sections of the audience. Knowledge of trainees' preferences affords the educators a valuable and objective opportunity to appraise the variety of teaching methods they use.

These insights can be applied at many levels; educational supervisors can use this knowledge to tailor their recommendations for training opportunities, and course designers can reflect on programme content to ensure relevance for diverse audiences.

At the individual level, learning styles can assist in operating theatre settings. Consider the example of introducing a trainee to a new item of equipment; typically, the activist learner will simply want to experiment with the device, exploring functions and limits. The pragmatist will desire an understanding of the advantages the new device has over the old, but will not want a lengthy open-ended discussion about it. The theorist learner may want to understand fully the underlying principles, and how the device fits into guidelines or processes, but the reflector may wish to observe its use and be given time to consider before taking an opportunity to use it themselves. Tailoring the delivery of teaching maximises engagement by avoiding boredom or discomfort.

In addition to preferred methods of learning, people also express preferences on the format of teaching materials. Fleming's visual, aural, reading or write, and kinaesthetic system is one way of thinking about these tendencies.⁸ Fleming postulates that some learners prefer visual materials (photographs, diagrams, or graphs), others auditory items (lectures, podcasts, or group discussions), and some will prefer to read (textbooks, manuals, or journal articles). Finally, some learners prefer kinaesthetic means (simulation, supervised practice, or experience). These are also not absolutes, but do reinforce the value of providing a range of materials and methods when designing educational encounters.

Teaching in the operating theatre

The curriculum for anaesthesia notes that ‘anaesthesia is a craft specialty and much of the education and training is acquired through experiential learning and reflective practice with trainers’.⁹ Teaching in the workplace provides the majority of educational opportunities available to trainees. The AaE course ‘Teaching and Training in the Workplace’ is particularly relevant to anaesthetists who regularly supervise colleagues in the operating theatre.

To maximise the educational value of such teaching, some structure is useful. As suggested previously, spending a few moments before a list begins negotiating with trainees what the learning outcomes for that day should be allows the trainers to focus their attention. Involving the trainee in this process should also improve personal relevance (and motivation). In a sense, this becomes an ‘educational-WHO’ which might include the following: what stage is the trainee at? What are their current educational aims? What are the specific outcomes that this encounter can deliver? Are there any WPBA forms the trainee wishes to complete? Similarly, lists can conclude with a debriefing reflecting on whether objectives were met, reviewing ongoing needs, and planning specific future learning.

These briefings and debriefings can support workplace-based assessment (WPBA) forms. Completing WPBA for trainees can sometimes feel a bureaucratic burden, but this need not impede delivery of useful learning experiences. Moving beyond a ‘box-ticking’ exercise, there can be value in WPBA use depending on how both trainee and trainer interact via the paperwork. Best practice recommends that WPBA be completed contemporaneously, and an agreement should be reached about what assessments will be performed prospectively as part of the brief. Agreeing to complete a form retrospectively is suboptimal; an advance agreement allows the trainer to think about assessment criteria and focus on relevant areas. It also gives the trainer permission to scrutinise the trainee's performance and implies an agreement to enter into a feedback discussion at the end of the session. This process can embed the WPBA form into Kolb's learning cycle by using it as a trigger to reflect on performance. It is important to choose an appropriate WPBA for the educational event (Table 1).

Table 1.

List of workplace-based assessment tools (WPBA). It is important to choose the most appropriate tool for the educational event requiring assessment.

WPBA title	Abbreviation	Representative example(s)
Direct Observation of Procedural Skills	DOPS	Used during clinical sessions; best for assessment of single, well-defined procedure, such as insertion of a spinal anaesthetic, or fibreoptic tracheal intubation; allows the trainer and trainee to focus on one specific aspect of anaesthetic practice
Anaesthesia Clinical Evaluation Exercise	A-CEX	Used during clinical sessions; best for assessment of a single clinical episode, such as caring for a patient undergoing a total knee replacement under a regional anaesthetic; feedback might touch on specific technical skills, but places them more in context, allowing trainer and trainee to take a more holistic view of a case
Anaesthesia List Management Assessment Tool	ALMAT	Used during clinical sessions; best for assessment of the trainee's management of a whole theatre session, so takes a broader view than either DOPS or A-CEX; whilst aspects of clinical care will come in to ALMAT feedback, it is likely the trainer and trainee will focus on the managerial role of the anaesthetist and the logistics of safely maintaining theatre throughput
Multi-Source Feedback	MSF	Used away from clinical sessions; best for assessment of the trainee's teamworking skills, attitudes, and place in the multidisciplinary team; allows the trainer and trainee to reflect on their Johari window
Case-based Discussion	CbD	Used away from clinical sessions; the discussion can be a retrospective review of a case, or a hypothetical presentation; best for the trainer to probe the trainee's decision-making process, judgement, or knowledge around a specific condition; allows the trainer and trainee to reflect on their performance, and to consider alternative strategies

One of the more challenging sections of most WPBA forms deals with planning for future learning and development. Educational supervisors, college tutors, and annual review of competence progression panellists will be familiar with the generic phrases ‘more experience’ and ‘more practice’. Whilst it is undoubtedly true that most trainees will need more exposure to techniques on which they are assessed, stock phrases such as this miss an opportunity to guide learning.

For more impact, trainers should consider the recommendations about simple, measurable, achievable, relevant, and time-bound (SMART) objectives. Ideally, trainees should take responsibility for setting their own SMART objectives, perhaps guided by the supervisor.

Hidden curriculum

Trainees learn from every encounter, even when specific objectives have not been set. This still happens when the trainee is not consciously learning and the educator is not actively teaching.

An important element of workplace-based teaching is socialisation, particularly for those new to a specialty or clinical area. All workplaces have individualised cultural norms, for example, attitudes towards guidelines and protocols, methods of interacting with other members of the healthcare team, or risk tolerance. Much of the process by which new staff acclimatises occurs through a ‘hidden curriculum’.

The hidden curriculum describes behaviours and attitudes that are never formally taught or learned, but are nevertheless internalised through observation and experience. These factors are not explicitly communicated to trainees, thus staff (particularly senior clinicians and others in positions of authority) must be mindful to uphold high standards and act as strong role models. Tolerance of poor behaviour can contribute to inter-professional rivalries and conflict. In extreme cases this creates a culture of ‘normalised deviance’ where risky behaviours become such a usual part of team methods that members no longer notice poor practice.¹⁰

Trainers should therefore think about the training they deliver both overtly and implicitly. They must also give some thought to how training delivery impacts them personally. Teaching adds to workload, and safe delivery of clinical service remains the priority. In 1908, Yerkes and Dodson conducted an observation of learning effects in mice in varying conditions of stimulation.¹¹ Learning was poor when the mice were seldom stimulated because of boredom and disengagement. Conversely, at extreme levels of stimulation, the mice were preoccupied and unable to engage. They concluded that optimal performance occurred at middling levels of stimulation. Similar relationships occur in the workplace.¹² However, in this context, there is the added complexity that the trainer, usually the senior clinician present, has simultaneous responsibilities to deliver safe and effective care to the patient. The trainer should ensure that the learning objectives chosen are realistic and achievable given the complexity or expected difficulty of the clinical workload.

The trainer can also be vigilant for unexpected or unusual opportunities for teaching, sometimes known as ‘windfall learning’. Whilst there is value in structure and planning of teaching, this should not confine the trainer rigidly, and they should capitalise on situational factors relevant to the trainee. Most obviously, this might occur after a critical incident in the operating theatre where focus might reorientate to recognition and management of the event, but might also draw on organisational or managerial issues in the workplace.

Offering feedback

The primary aim of formative assessment is to facilitate the development of an individual, and in clinical settings can occur almost continuously.¹³ This contrasts with summative assessments, such as the FRCA examination, which measure individuals against a set standard, have an important pass/fail aspect, and usually occur as specified events.

Kolb's cycle highlights that in order for individuals to develop they must reflect on an experience and use that reflection to make changes. Two types of reflection can be highlighted: reflection in action and reflection on action.¹⁴ Reflection in action occurs in real time, during the activity in question. Reflection on action occurs later, when thinking back on an activity and its outcome. It is this reflection on action that is most amenable to constructive feedback.

Quality feedback is essential to facilitating the learning process, encouraging the trainees to reflect on aspects of their Johari window.¹⁵ The window is a tool developed by psychologists in 1955 as a method for visualising insight into individuals' behaviours and thoughts. It groups traits as open (known to ourselves and others), hidden (known only to ourselves), and blind spots (things known to others, but hidden from ourselves). A fourth section describes those unconscious biases or motivations unknown to both others and ourselves. Good quality debriefing can encourage reflection and self-appraisal, with the intention of shrinking blind spots.

Feedback can be formal or informal, and structured or unstructured, and the method used will depend on factors such as the topic to be debriefed, the relationship between the trainer and the trainee, and the purpose of the encounter.

Formal feedback is probably most frequently used in the appraisal of skills, either technical or non-technical. Often, this will occur in the context of WPBAs, but feedback can occur in a multitude of other settings around the workplace. Clinical activities offer frequent opportunities for informal feedback, and such feedback contributes to the hidden curriculum by subtly reinforcing or correcting behaviours and attitudes.

It is a hallmark of professionals that they seek feedback and use this to improve practice, and this need not be threatening, even when performance has been poor.¹⁶ Negotiating which behaviours or skills are open to discussion before a period of observation (as part of an educational-WHO) sets ‘rules of engagement’ and defines limits on topics available for discussion. In essence, one is forming a contract with the learner before starting the encounter, and this is important in establishing safety for the debriefing process.

The more experienced the recipients are, the more insight they are likely to have into their performance, and often the facilitator's role is to encourage trainees to debrief themselves. For less experienced trainees, the feedback process may be more involved. The educator must be alert to the hierarchy gradient that often exists between the trainer and the trainee, and encourage trainees to contribute to the process wherever possible.

Trainers should also be mindful of where and when they deliver feedback, particularly if it follows a stressful or difficult experience. Although it is usually desirable to offer feedback as close to the event as possible, this may not always be appropriate, such as after particularly traumatic clinical incidents. Whether feedback is delivered one to one or as part of a group needs to be decided. Where groups are present, deciding whether other members of the team are permitted to contribute is important and highly relevant to work in an operating theatre where the actions of the anaesthetist impact on a wide variety of team members. Before embarking on debriefing, the trainers need to consider their agenda and that of the trainee, choosing a limited number of maximum value topics to prevent feedback becoming rambling and poorly focused. Selecting topics in advance allows trainers to maintain relevance and defend against being sidetracked.

Various tools are available for structuring feedback. These can provide mechanisms for exploring how trainees frame clinical situations and allow instructors to understand their reasoning. This is important because their frame of reference may differ from that of the observer. Should the trainer disagree with a trainee's course of action, it is particularly important to understand why decisions made sense to the trainee at the time. Professionals will seldom seek to deliberately make errors, thus it is risky for the trainer to make assumptions about why the trainee acted a certain way—this can be perceived as judgemental. It is much more appropriate to explore decision-making processes with the trainees, questioning and probing their thoughts whilst allowing them to verbalise their reasoning.

Some examples of feedback tools and their advantages and disadvantages are presented as follows. There is no single best method of offering feedback, but it is essential in all methods that trainee involvement is maximised, and that feedback remains non-judgemental and open.

• (i)Advocacy enquiry: This involves the trainer making an objective statement about observed events (advocacy) and asking the trainees to elaborate on their thought processes at the time (inquiry). By making a factual statement about observations and by asking the trainees to describe their internal processes, it offers an opportunity to explore the trainees' mental models. This technique is often incorporated into other debriefing strategies, including debriefing with good judgement and debriefing as a learning conversation.16, 17 These techniques are flexible and non-judgemental, but have been criticised for being overly instructor focused.¹⁸
• (ii)Pendleton's rules: Using this technique (or the similar ‘sandwich technique’), the instructor and trainee comment on a positive aspect of their performance, followed by a weaker area, finishing on a positive.¹⁹ This method is straightforward, but criticised for being inflexible, and can be artificial particularly when faced with debriefing a very strong or very weak performance.
• (iii)SET-GO: This is a structured debriefing system, based on asking what the trainees saw, what else they encountered, what they thought, what their goals are, and what they offer to achieve the goals.²⁰ This can work well but, as with Pendleton's rules, an intention to stick to a prescribed format can be restrictive.
• (iv)Chicago model: This six-step method involves (a) review of the trainee's objectives, (b) interim feedback from the instructor, (c) self-assessment by the trainee, (d) behaviourally focused feedback with (e) specific examples, and (f) specific strategies for improvement.²¹ Steps (d) and (e) incorporate aspects of advocacy inquiry, meaning this can also be used to access the trainee's thought processes. The more complex format of the feedback can be a little cumbersome.

Whichever model is chosen, it is crucial that the trainer maintains credibility. At a very basic level, this means honesty and fairness. If a performance was exemplary, there is little to be gained by nitpicking out of some sense that there must always be an opportunity for development. Similarly, if a performance was very poor, then it is usually better to acknowledge this early and examine it promptly in the debriefing, rather than artificially extracting what few positives there might be. Professionals generally have insight, and ignoring ‘elephants in the room’ dents the credibility of the debriefer, distracts the learners as they wait for the ‘other shoe to drop’, and contributes little or nothing to the quality of the educational experience.

Conclusions

It need not be complicated to maximise value from educational encounters, but spending time on planning an activity will make the event more efficient. By performing a short educational-WHO at the start of an operating list to specify learning outcomes can help focus the trainer and the trainee, set ground rules, and simplify the delivery of feedback. This can also improve the impact of WPBAs.

Consideration of the different learning styles and preferences of trainees in the operating theatre during a unit of training or a period of educational supervision can help broaden the appeal of teaching, and thus, ensure maximum engagement.

Acknowledgements

The authors gratefully acknowledge the assistance of Dr Sean Williamson, who kindly reviewed a draft of this manuscript for his comments and suggestions.

Declaration of interest

PG teaches on the Royal College of Anaesthetists 'Teaching and Training in the Workplace' and 'Anaesthetic Non-technical Skills' courses.

MCQs

The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education.

Biographies

Paul Greig BScMedSci (Hons) DPhil PGCME MAcadMEd FRCA is a consultant anaesthetist at Guy's and St Thomas' NHS Foundation Trust in London. He gained his DPhil at the University of Oxford, and is an academic visitor at the Nuffield Department of Clinical Neurosciences. He has extensive experience of simulation teaching, and teaches on the Anaesthetists as Educators programme of the Royal College of Anaesthetists.

Julie Darbyshire MA MSc is a researcher at the University of Oxford where she also manages the critical care research programme. Her research interests focus on the patient experiences of research and healthcare. Her DPhil has explored noise and disturbances in the intensive care unit. She has created a training programme for staff that was designed to simulate the patient experience of intensive care.

Matrix codes: 1H02; 2H01; 3J02