Diversity of learning & teaching

Sustainability in clinical skills teaching Sanjin Bajgoric, Joseph Appiah and Valerie Wass, Keele University, Keele, Staffordshire, UK Clifford Shelton, Lancaster Medical School, Lancaster, UK

SUMMARY Background: The deleterious effects of climate change mean that environmental sustainability is increasingly becoming a moral and economic necessity. Consequently, clinicians will increasingly be called upon to manage the effects of health care on climate change, and they must therefore do as much as is practically possible to limit the negative effects of their practice on the environment. As medical educators we have the opportunity not only to reduce the environmental impact of our own clinical practice, but also that of

those who we teach, through innovation. Such novelty can be explored during student-selected components (SSCs). Context: The project, entitled ‘Can we introduce sustainability to clinical skills teaching?’ was led by two third-year medical students during their SSC periods. New ways to make existing skills more sustainable were explored by surveying existing practice in the workplace, analysing selected skills in a lab-based setting and through discussions with sustainability champions. Innovation: Cannulation and intravenous (IV) antibiotic

preparation were chosen by the students as prototype skills. These skills were observed by the students in the workplace and adapted by them to appease the ‘triple bottom line’ of sustainability: environmental, social and economic factors were addressed. The revised skills were taught by the students to their peers in a sustainably conscious fashion. Implications: Provided that such innovations in sustainable skills teaching are deemed appropriate by clinical skills directors, such methods could be adopted across medical schools and expanded to cover a wider range of skills.

Clinicians will increasingly be called upon to manage effects of health care on climate change

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Sustainability involves the careful management of resources

INTRODUCTION

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ustainability involves the careful management of resources and care of the world to be passed on to future generations.1 A well-known model for sustainability, the ‘triple bottom line’ highlights the interaction between environmental, economic and social responsibility.2 More recently, ideas have evolved to suggest that the relationship between these components is hierarchical, given that economics is a construct of society and society relies on the environment to exist.3 Figure 1. Standard cannulation equipment showing unnecessary additional materials - a less sustainable option

The idea of sustainability in health care has arisen from the moral imperative for all practitioners to be mindful of the health of the public, in addition to that of their patients. The UK National Health Service (NHS) contributes to a quarter of all public health emissions, which has prompted the UK government to introduce an 80 per cent carbon reduction target, to be achieved by 2050, ensuring that this target is ingrained not only on paper, but also in the minds of health care staff.4 The ‘five Rs’ of Hutchins and White’s adapted waste hierarchy model describes the various ways in which one can act more sustainably: reducing, recycling, reusing, rethinking and researching.5 These principles can also be explored and applied during the teaching of clinical skills. The health belief model, although initially being developed to describe behavioural change in accessing health services, provides a useful framework for considering the approach of an individual or an organisation to sustainability.6 It can be used to highlight the barriers to changing attitudes towards sustainability in health care professionals. These include:

immaterial benefits, low perceived control and the supposed costs of taking action. At our institution, sustainability is taught as a component of all degree courses. This project formed part of the process of identifying areas for the integration of sustainability teaching in the medical curriculum. Sustainable ideas taught during the teaching of clinical skills during medical school can be implemented in the practice of future clinicians.

DESCRIPTION A student-led medical education SSC (student-selected component) was undertaken by two medical students with a shared interest in sustainability in health care (S.B. and J.A.). Supervision was provided by a professor of medical education (V.W.) and a clinical teaching fellow (C.S.) with an interest in sustainable health care. Supervision meetings were held on a weekly basis where learning objectives were set by the students and supervisors for each of the 4 weeks of the SSC period. Initially, a literature review was undertaken by S.B. and J.A.,

supported by C.S. and V.W. The purpose of this was to provide a grounding in the literature regarding sustainability in health care, educational theory relevant to skills teaching and attitudinal change. Subsequent discussion between S.B. and J.A. and the university’s sustainability lead provided insights into the feasibility of the project and illuminated further sources of information for their literature review. Existing practice in the hospital environment was then observed by S.B. and J.A., and each skill was evaluated against the five Rs of the adapted waste hierarchy model.5 Particular emphasis was placed on evaluating the methods that health professionals were already using to reduce the waste material generated by each skill. The students also met with clinical skills teachers in a lab-based setting where, through an iterative process, they were able to gain insight into further areas where their skills could be adapted for more sustainable teaching. The clinical skills teachers were also able to supply a cost breakdown of the relevant disposable materials, in order that S.B. and J.A. could calculate

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the financial savings that would be possible with a reduced use of materials (Boxes 1 and 2). Such innovation to create a new, more sustainable skill represented the ‘rethinking’ component of the model.5 Once the new version of each skill had been developed, S.B. and J.A. were individually recorded performing the skill using the Scotia Medical Observation and Training System (Scotia, Edinburgh, UK), in order to produce an educational resource. Throughout this process V.W., C.S. and the clinical skills teachers provided support and feedback. In addition to the submission of a written report, the assessment of this SSC involved the observation of S.B. and J.A. teaching a small group of fellow year–3 students to perform their sustainable versions of a clinical skill, using their video resources and face-to-face teaching methods. The session used an adaptation of Peyton’s model, whereby the learners were first shown a video of the skill, and then the teachers performed and explained the skill, before the learners performed the skill themselves.7 Feedback on the teaching was provided by the learners, V.W., C.S. and other teaching staff. In the written report, S.B. and J.A. reflected on their experiences of designing the session, carrying it out and receiving feedback.

RECOMMENDATIONS The synergy of environmental, cost and time savings, with the introduction of sustainability in the fashion described in this report, could have far-reaching effects. The precedent set in teaching sustainability in clinical skills should be expanded to encompass other skills commonly performed in the workplace and within clinical education centres. Encouragingly,

Box 1. Reduction in the materials used during cannulation Skill • Cannulation. Main changes made • Exclusion of excess paper material in cannulation pack (Figures 1 & 2).

Evidence suggests that sustainability teaching would be embraced by medical students

• The theoretical exclusion of local anaesthetic (LA) raised the controversial question of whether it was fair to withhold the use of LA in the name of sustainability. It was decided that the exclusion of LA from cannulation procedures using

Sustainability in clinical skills teaching.

The deleterious effects of climate change mean that environmental sustainability is increasingly becoming a moral and economic necessity. Consequently...
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