REVIEW URRENT C OPINION
Teaching laryngeal endoscopy skills to speech and language therapists: applying learning theory to optimize practical skills mastery H. Fiona Robinson and Reg Dennick
Purpose of review This review was carried out to highlight relevant learning theory and its application to the teaching of endoscopic skills to speech and language therapists (SLTs). This article explains the most relevant models from Constructivist, Experiential and Humanistic Learning Theory, a combination that has been described as Constructive Experience, and describes the relevance and the benefits of applying educational frameworks in course design. This approach has been formally used to design and deliver practical skills teaching in medicine. Recent findings SLTs carry out endoscopic evaluation of the larynx (EEL) to provide information for evaluation and rehabilitation of voice and swallowing disorders. These are essential procedures in ear, nose and throat, voice and swallowing specialist centres. Training in endoscopy skills for SLTs working in the ear, nose and throat specialist centres in the United Kingdom has traditionally been provided external to the local clinic environment as 1 or 2-day courses. In one survey in the United Kingdom, 79% of SLTs reported that they did not acquire the depth of skill required to carry out EEL autonomously after attending such courses. Course development to teach practical skills should be underpinned by educational theory. Summary One EEL course in the United Kingdom is described, wherein sessions are interactive and experiential, promoting deep learning, constructive feedback and reflection, enriched by the completion of logs and portfolios. From course evaluations, all the learners met the learning objectives, developing and applying skills to become confident endoscopists in autonomous clinical practice. Keywords education, endoscopy, experiential, learning theory, voice
INTRODUCTION Speech and language therapists (SLTs) carry out endoscopic evaluation of the larynx (EEL) to provide information for evaluation and rehabilitation of voice and swallowing disorders. For swallowing disorders, the term used is fibre-optic endoscopic evaluation of the swallow. This is an essential procedure in the ear, nose and throat (ENT), voice and swallowing specialist centres. Formal training for EEL is usually provided as external 1 or 2-day courses in the United Kingdom. However, in a survey of 111 major ENT SLT departments in the United Kingdom [1], 79% of SLTs reported that they did not acquire the depth of skill required to carry out EEL autonomously after attending such courses; 62% had only limited access to ongoing and timely expert SLT supervision as they developed competence in differential diagnosis
and recruitment for therapy, and progress patients through rehabilitation [1]. Courses teaching practical skills should be underpinned by educational theory [2]. In this article, we aim to demonstrate how a variety of relevant and useful educational theories can be used to underpin the educational methodologies used to maximize learning.
Department of Ear, Nose and Throat, University Hospitals NHS Trust, Nottingham, UK. Correspondence to H. Fiona Robinson, MSc, FRCSLT, Advanced Speech and Language Therapy Practitioner, Department of Ear, Nose and Throat, University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK. Tel: +44 0115 9249924 x67741; e-mail: [email protected]; [email protected] Curr Opin Otolaryngol Head Neck Surg 2015, 23:197–201 DOI:10.1097/MOO.0000000000000163
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Speech therapy and rehabilitation
KEY POINTS Optimum teaching of practical skills combines elements of Constructivist, Experiential and Humanistic learning models. Combining these elements enables students to modify their existing knowledge and build their knowledge and skill towards autonomous practice. Courses that are learner centred with practical sessions based on a competency framework and taught within a formal protocol provide clarity and direction. Sessions that are interactive and experiential provide benefits of deep learning. Local supervision, constructive feedback and reflection, enriched by the completion of logs and portfolios, are elements that enable students to become confident endoscopists in autonomous clinical practice. These principles are already applicable to the teaching of practical skills in medicine.
This paper explains the most relevant models from Constructivist, Experiential and Humanistic Learning Theory, a combination that has been described as Constructive Experience [3]. The article also describes the relevance and the benefits of applying educational frameworks in course design [4 ]. To improve training in this specialist area, the Nottingham EEL course was designed to provide participants with enriched learning towards autonomous practice. The course comprises 4 days (two sessions of 2 days) of teaching over 6 months and one ‘virtual’ day within the student’s home clinical environment with their local mentor. The EEL course is learner centred, respecting learners and acknowledging and building on their prior knowledge [5]. It also implements humanistic theories of learning from Carl Rogers’ client-centred approach [6] and Abraham Maslow’s self-actualization principle [7]. The precourse questionnaire enquired about specific skills and knowledge factors and the curriculum was designed to build on prior knowledge and tailored to the students’ areas of need. This ensured a relevant and learner-centred approach for the students. All the students were UK-based qualified postgraduate SLTs with more than 5 years of experience working in the surgical ENT speciality. None had competence in endoscopy skills, with all students describing themselves as novice endoscopists. &
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Learning objectives for the practical course were made explicit in the precourse information. By the end of the course, participants will (1) be able to carry out rigid and flexible endoscopic examination. (2) be competent in collecting good-quality images using a standard examination protocol. (3) be able to interpret images to understand phonatory behaviours and identify common laryngeal pathologies and inform management. Mental readiness for new concepts was created by provision of a precourse pack including academic literature, the Royal College of Speech and Language Therapists (RCSLT) Competencies Framework for Endsocopy [8] and clinical articles including anatomy and physiology refresher sheets. Flawed and outdated aspects of the students’ previous knowledge or skills were rectified and correct knowledge reinforced on the course – for example mislabelling anatomy or poor technical skill in the scoping procedure. To activate prior learning on the first day, the students completed a quiz covering anatomical and procedural areas. The results were kept by the individual student and not shared with the group, as its purpose was to identify the individual’s knowledge gaps. The quiz was repeated after the course to demonstrate that specific learning had taken place. Kolb [9] indicated that learning is the process whereby knowledge is created through the transformation of experience. Experiential Learning Theory provides a mechanism for how learning takes place. The EEL course mixes theoretical and experiential sessions with reflection and selfcritiquing. Students completed logbooks of numbers of procedures undertaken, a reflective diary and a portfolio of learning outcomes. The RSCLT Competency Framework [8] directed the outputs of the course and provided information about students’ levels and rates of progress. The students also studied protocol documents, for example setting up equipment, and laryngeal evaluation protocols for each procedure that they conducted, to ensure that they were working and evaluating logically and recording the visual parameters appropriately. They accessed the theoretical and practical experiences that they needed as part of the more formal curriculum. This approach has elements of Kolb’s Experiential Learning Cycle by providing simultaneous and concurrent opportunities for concrete experience, reflection and assimilation to build skills and knowledge. Bandura [10] emphasized the importance of role models, Volume 23 Number 3 June 2015
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Teaching laryngeal endoscopy skills to speech and language therapists Robinson and Dennick
and Vygotsky [11] stressed the importance of the social context of cognitive development. The didactic sessions had a maximum of eight students, with the practical skills teaching in pairs, taught by three expert SLT endoscopists and one ENT surgeon. Volunteers were used as simulated patients to maximize and standardize the experiences for students. In addition, the students themselves carried out their practical skills training sessions using each other and volunteered as patients in a simulated situation. Gibbs Reflective Cycle [12] enabled the students to embed reflection into the course and hence to develop their professional ‘reflective practice’, as ¨ n [13]. described by Scho Miller [14] described the development of clinical skills, competence and performance for clinical assessment in a pyramidal framework, subsequently known as Miller’s Triangle. Using this model, the expectation was that by the end of the 6 months course, students would build up their knowledge and skill, from knowing about EEL and its applications, through acquiring and retaining motor skills (being able to perform EEL), and finally becoming competent and independent endoscopists. These models of learning theory underpin practical skills teaching in medicine. We followed the Royal College of Surgeons practical skill teaching protocol which is both didactic and experiential, combining motor and deep learning with activities from behaviourist theories – such as repetition and practice, feedback, role modelling and instructional sequences and reward [15]. It comprises six elements as follows: (1) Conceptualization – To put the practical training into cognitive context, the students discussed the rationale for EEL in SLT practice as a method for contributing to differential diagnosis, rehabilitation and the improvement of quality outcomes. Professional and health and safety protocols were presented. Students discussed ethical issues such as consent, the use of topical anaesthesia and how to manage unexpected findings, for example previously undiagnosed carcinoma of the larynx. (2) Visualization – A short video of the procedure was viewed and left for reference in the tutorial room. In pairs – novice endoscopist SLT with a novice assisting SLT – the students observed the expert SLTs demonstrating the procedure in real time using a volunteer as a patient. (3) Verbalization – The expert SLT repeated the examination, breaking the skill down into its components and talking it through. The
students followed a procedural template to track the activity and for use later in their own practice and were encouraged to ask questions for clarification. (4) Practice phase – This was a crucial phase and could be repeated as often as required. Dewey [16] stressed the importance of the learner’s active involvement in the learning process and Kolb [9] referred to this as ‘concrete experience’ in his experiential learning cycle. Each student handled the flexible laryngoscopes to become familiar with technical elements, such as lens focus, light balance and control of the tip of the endoscope, in preparation for passing the scope transnasally. The novice endoscopist then passed the flexible scope via the nares and manoeuvred the tip into position above the larynx of the volunteer, the novice assisting SLT taking notes and observing the comfort of the volunteer. During this phase, the expert SLT provided constructive feedback, initially as comments or supportive redirection, for example demonstrating how to manoeuvre the endoscope to provide a panoramic sweep of the laryngeal and pharyngeal structures. Building from this, the novice endoscopist was then directed to look at finer levels of detail, such as achieving a view of the laryngeal anterior commissure and asking the volunteer to carry out a series of diagnostic probe activities to assess vocal cord function. The novice assisting SLT completed the procedure feedback template to share with the novice endoscopist, supporting self-reflection and discussion, and contribute to their portfolio. Each pair of students changed roles and during the whole course they also had the opportunity to work with different partners and supervisors, enriching their experience and promoting deep learning, and accommodate individual learning and teaching styles. (5) Skill mastery – Each student had the opportunity to carry out the EEL on 10 occasions during the first 2 days of the course. Crucially, when students returned to their own clinical environments in between the teaching sessions, they were required to allocate time to consolidate and build their skills. Evidence of this activity away from the course was provided in the form of logs and portfolio documentation. (6) Skill autonomy – Deliberate practice with repetitions is necessary to become an expert [17]. Indeed, the RCSLT competency framework [8] requires that the SLT endoscopist carries out 35 successful endoscopy procedures before autonomous independent practice can commence. This takes the form of five procedures
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as assistant endoscopist, 10 procedures as the endoscopist under supervision with assistance and 20 procedures autonomously under supervision. The total number of procedures undertaken on the course and in between was very relevant to the participants in their transition to autonomous endoscopist.
RESULTS The precourse questionnaire was repeated after the course and all students reported that they had made good improvements in their knowledge and understanding. Observations by the supervisors showed that each student had achieved the learning objectives of the course. They reported that the use of reflective logs and clinical diaries had promoted consolidation of theory and knowledge. Each student had begun to provide an EEL service within their own clinical setting with reported benefits in both patient management and multidisciplinary working.
DISCUSSION Students expressed that moving from theoretical frameworks into applying practical skills was the most stressful aspect. Cognitive dissonance may result in the student actively avoiding these situations [18] and the students acknowledged that this was a barrier to progression. However, on this course, the teaching team was vigilant for these elements and the dissonance in itself was a motivator. Dewey [19] wrote that the most powerful learning occurs when the student is dealing with uncertainty. Through receiving personalized tuition, one-to-one tutorials and supervision sessions, students worked towards consonance and reported this approach to be one of the most useful and powerful aspects of the teaching. Mezirow’s theory of transformative learning [20], describing the social process of constructing a new interpretation of one’s experience, underpinned the teaching, allowing students to critically reflect on their own and each other’s performance and emerging skills. The collaborative style was enhanced with the addition of external expert SLTs contributing to the final day of the teaching, which was interpretation of images and treatment planning. Maslow’s hierarchy of needs [7] importantly stated that in order for people to achieve their full potential, their basic needs must be fulfilled (physiological needs such as hunger, thirst and warmth, safety needs such as physical and psychological safety including shelter, and social or 200
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interpersonal needs such as belonging to a group). The course was taught in comfortable tutorial and clinical rooms with ample refreshments and breaks, providing effective teaching and learning conditions. The small group environment provided a common sense of purpose and direction with the students building trust and with flexibility to change the curriculum if required. Students were nervous of handling the scopes, particularly the very experienced therapists who described feeling vulnerable in exposing their lack of skill. Students were given constructive feedback to provide formative assessment [4 ]. Effective feedback offers insight into students’ actions and their consequences. Constructive feedback produces significantly better outcomes [21]. Two widely accepted models of feedback in clinical education, Pendleton’s rules and agenda-led outcomes based analysis are described in Chowdhury and Kalu [22] and we followed a structured and constructive approach in the course. Rogers [6] stressed the importance of the teacher–student relationship, with teachers being facilitators rather than didactic transmitters of information [3]. In addition, however, supervision from an expert SLT was integral to successful outcome of the training. Vygotsky [11] described the ‘zone of proximal development’, where the teacher acts as the scaffold to move the student from their existing level of skill to a higher level. Furthermore, to promote continued theoretical learning and mastery of the practical endoscopy skills in an experiential learning cycle, supervisors local to the students were sourced. Identification of the local multidisciplinary team and a local mentor was a prerequisite of acceptance on the course, and this supervision was vital during the course of the training and for ensuring continuing development of competence in practical and interpretation skills. The didactic and practical sessions were interactive which according to the principles of constructivism promotes deep learning. Marton and Saljo [23] explored how students approached learning and demonstrated their deep and surface learning styles. Entwistle [24] suggests that surface learning such as copying can be transformed by interactivity into deep learning, demonstrating understanding and finally transformation of skills and knowledge. Maslow [7] and Rogers [6] emphasized the theory of ‘self-actualization’: that people wish to become the best that they can be and to fulfil their potential and achieve independence. The course design allowed students to continue their practical and theoretical development as &
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Teaching laryngeal endoscopy skills to speech and language therapists Robinson and Dennick
self-directed learners and produce action plans for their future development. The time between the taught elements enabled contextualization and integration of the new skill into local clinical practice. Social constructivism describes communities of practice as valuable in supporting each learner’s engagement, and students were encouraged to join their local multiprofessional communities of practice, such as the RCSLT Special Interest Group in ENT and local and external multidisciplinary learning events, for example conferences and research groups. This would allow for mapping their experiences onto others experiences and to engage in action planning for further experiences, a crucial element of Experiential Learning Theory. A progression model to promote breadth, depth, utility and proficiency of clinical practice is an area of interest in planning the next EEL course [25], providing a framework for continuing professional development, with prospective application of educational theory promoting effective learning [2].
CONCLUSION Applying learning theory to optimize skills mastery has transformed the development and outcomes of one practical skills course for SLTs. Using our understanding of learning theory to other practical skills course design, for example endoscopic evaluation of swallowing and videofluoroscopic evaluation of swallowing, may provide the same benefits. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Slade S. A survey of endoscopy use by speech and language therapists. Proceedings of the British Academic Conference Otorhinolaryngology; 2009; Liverpool. 2. Sadideen H, Kneebone R. Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning? Am J Surg 2012; 204:396–401. 3. Dennick RG. Theories of learning – constructive experience. In: Mathieson D, editor. An introduction to the study of education, 3rd ed. London: Routledge; 2008. 4. Dennick RG. Twelve tips for incorporating educational theory into teaching & practices. Med Teach 2012; 34:618–624. This article describes a group of learning theories that are fundamentally related and which can provide guidance on a range of teaching and learning practices. Common educational theories can be combined to provide practical tips for teachers and facilitators. 5. Ausubel DP. Educational psychology: a cognitive view. New York: Holt, Reinhart and Winston; 1968. 6. Rogers C. Freedom to learn for the 80’s. Columbus, OH: Charles Merrill Publishing Company; 1983. 7. Maslow AH. Toward a psychology of being. New York: Van Nostrand Reinhold; 1968. 8. Carding PN, Jones S, Morton V, et al. Speech and language therapy endoscopy for voice disordered patients. Royal College of Speech and Language Therapists position paper; 2008. 9. Kolb DA. Experiential learning. Englewood Cliffs, NJ: Prentice Hall; 1984. 10. Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice Hall; 1977. 11. Wertsch JV. Vygotsky and the social formation of mind. Cambridge, MA: Harvard University Press; 1985. 12. Gibbs G. Learning by doing: a guide to teaching and learning methods. Oxford: Further Education Unit; 1988. 13. Scho¨n D. The reflective practitioner: how professionals think in practice. New York: Basic Books; 1983. 14. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (Suppl 9):S63–S67. 15. George JH, Doto FX. A simple five-step method for teaching clinical skills. Fam Med 2001; 33:577–578. 16. Dewey J. Logic: the theory of enquiry. New York: Holt; 1938. 17. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79 (Suppl):S70–S78. 18. Festinger L. A theory of cognitive dissonance. Stanford, CA: Stanford University Press; 1957. 19. Dewey J. Experience and education. New York: Collier Books; 1963: 69. 20. Mezirow J. Transformative dimensions of adult learning. Jossey-Bass: San Francisco, CA; 1991. 21. Black P, Williams PD. Assessment and classroom teaching. Assess Edu 1998; 5:7–73. 22. Chowdhury RR, Kalu G. Learning to give feedback in medical education. Obstet Gynaecol 2004; 6:243–247. 23. Marton F, Saljo R. Approaches to learning. In: Marton F, Hounsell D, Entwistle N, editors. The experience of learning: implications for teaching and studying in higher education, 3rd Internet ed. Edinburgh: University of Edinburgh Centre for Teaching, Learning and Assessment; 2005. pp. 39–58. 24. Entwistle N. Styles of learning and teaching. London: David Fulton; 1988. 25. Harden RM. Learning outcomes as a tool to assess progression. Med Teach 2007; 29:678–682.
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Teaching laryngeal endoscopy skills to speech and language therapists: applying learning theory to optimize practical skills mastery H. Fiona Robinson and Reg Dennick
Purpose of review This review was carried out to highlight relevant learning theory and its application to the teaching of endoscopic skills to speech and language therapists (SLTs). This article explains the most relevant models from Constructivist, Experiential and Humanistic Learning Theory, a combination that has been described as Constructive Experience, and describes the relevance and the benefits of applying educational frameworks in course design. This approach has been formally used to design and deliver practical skills teaching in medicine. Recent findings SLTs carry out endoscopic evaluation of the larynx (EEL) to provide information for evaluation and rehabilitation of voice and swallowing disorders. These are essential procedures in ear, nose and throat, voice and swallowing specialist centres. Training in endoscopy skills for SLTs working in the ear, nose and throat specialist centres in the United Kingdom has traditionally been provided external to the local clinic environment as 1 or 2-day courses. In one survey in the United Kingdom, 79% of SLTs reported that they did not acquire the depth of skill required to carry out EEL autonomously after attending such courses. Course development to teach practical skills should be underpinned by educational theory. Summary One EEL course in the United Kingdom is described, wherein sessions are interactive and experiential, promoting deep learning, constructive feedback and reflection, enriched by the completion of logs and portfolios. From course evaluations, all the learners met the learning objectives, developing and applying skills to become confident endoscopists in autonomous clinical practice. Keywords education, endoscopy, experiential, learning theory, voice
INTRODUCTION Speech and language therapists (SLTs) carry out endoscopic evaluation of the larynx (EEL) to provide information for evaluation and rehabilitation of voice and swallowing disorders. For swallowing disorders, the term used is fibre-optic endoscopic evaluation of the swallow. This is an essential procedure in the ear, nose and throat (ENT), voice and swallowing specialist centres. Formal training for EEL is usually provided as external 1 or 2-day courses in the United Kingdom. However, in a survey of 111 major ENT SLT departments in the United Kingdom [1], 79% of SLTs reported that they did not acquire the depth of skill required to carry out EEL autonomously after attending such courses; 62% had only limited access to ongoing and timely expert SLT supervision as they developed competence in differential diagnosis
and recruitment for therapy, and progress patients through rehabilitation [1]. Courses teaching practical skills should be underpinned by educational theory [2]. In this article, we aim to demonstrate how a variety of relevant and useful educational theories can be used to underpin the educational methodologies used to maximize learning.
Department of Ear, Nose and Throat, University Hospitals NHS Trust, Nottingham, UK. Correspondence to H. Fiona Robinson, MSc, FRCSLT, Advanced Speech and Language Therapy Practitioner, Department of Ear, Nose and Throat, University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK. Tel: +44 0115 9249924 x67741; e-mail: [email protected]; [email protected] Curr Opin Otolaryngol Head Neck Surg 2015, 23:197–201 DOI:10.1097/MOO.0000000000000163
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Speech therapy and rehabilitation
KEY POINTS Optimum teaching of practical skills combines elements of Constructivist, Experiential and Humanistic learning models. Combining these elements enables students to modify their existing knowledge and build their knowledge and skill towards autonomous practice. Courses that are learner centred with practical sessions based on a competency framework and taught within a formal protocol provide clarity and direction. Sessions that are interactive and experiential provide benefits of deep learning. Local supervision, constructive feedback and reflection, enriched by the completion of logs and portfolios, are elements that enable students to become confident endoscopists in autonomous clinical practice. These principles are already applicable to the teaching of practical skills in medicine.
This paper explains the most relevant models from Constructivist, Experiential and Humanistic Learning Theory, a combination that has been described as Constructive Experience [3]. The article also describes the relevance and the benefits of applying educational frameworks in course design [4 ]. To improve training in this specialist area, the Nottingham EEL course was designed to provide participants with enriched learning towards autonomous practice. The course comprises 4 days (two sessions of 2 days) of teaching over 6 months and one ‘virtual’ day within the student’s home clinical environment with their local mentor. The EEL course is learner centred, respecting learners and acknowledging and building on their prior knowledge [5]. It also implements humanistic theories of learning from Carl Rogers’ client-centred approach [6] and Abraham Maslow’s self-actualization principle [7]. The precourse questionnaire enquired about specific skills and knowledge factors and the curriculum was designed to build on prior knowledge and tailored to the students’ areas of need. This ensured a relevant and learner-centred approach for the students. All the students were UK-based qualified postgraduate SLTs with more than 5 years of experience working in the surgical ENT speciality. None had competence in endoscopy skills, with all students describing themselves as novice endoscopists. &
198
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Learning objectives for the practical course were made explicit in the precourse information. By the end of the course, participants will (1) be able to carry out rigid and flexible endoscopic examination. (2) be competent in collecting good-quality images using a standard examination protocol. (3) be able to interpret images to understand phonatory behaviours and identify common laryngeal pathologies and inform management. Mental readiness for new concepts was created by provision of a precourse pack including academic literature, the Royal College of Speech and Language Therapists (RCSLT) Competencies Framework for Endsocopy [8] and clinical articles including anatomy and physiology refresher sheets. Flawed and outdated aspects of the students’ previous knowledge or skills were rectified and correct knowledge reinforced on the course – for example mislabelling anatomy or poor technical skill in the scoping procedure. To activate prior learning on the first day, the students completed a quiz covering anatomical and procedural areas. The results were kept by the individual student and not shared with the group, as its purpose was to identify the individual’s knowledge gaps. The quiz was repeated after the course to demonstrate that specific learning had taken place. Kolb [9] indicated that learning is the process whereby knowledge is created through the transformation of experience. Experiential Learning Theory provides a mechanism for how learning takes place. The EEL course mixes theoretical and experiential sessions with reflection and selfcritiquing. Students completed logbooks of numbers of procedures undertaken, a reflective diary and a portfolio of learning outcomes. The RSCLT Competency Framework [8] directed the outputs of the course and provided information about students’ levels and rates of progress. The students also studied protocol documents, for example setting up equipment, and laryngeal evaluation protocols for each procedure that they conducted, to ensure that they were working and evaluating logically and recording the visual parameters appropriately. They accessed the theoretical and practical experiences that they needed as part of the more formal curriculum. This approach has elements of Kolb’s Experiential Learning Cycle by providing simultaneous and concurrent opportunities for concrete experience, reflection and assimilation to build skills and knowledge. Bandura [10] emphasized the importance of role models, Volume 23 Number 3 June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Teaching laryngeal endoscopy skills to speech and language therapists Robinson and Dennick
and Vygotsky [11] stressed the importance of the social context of cognitive development. The didactic sessions had a maximum of eight students, with the practical skills teaching in pairs, taught by three expert SLT endoscopists and one ENT surgeon. Volunteers were used as simulated patients to maximize and standardize the experiences for students. In addition, the students themselves carried out their practical skills training sessions using each other and volunteered as patients in a simulated situation. Gibbs Reflective Cycle [12] enabled the students to embed reflection into the course and hence to develop their professional ‘reflective practice’, as ¨ n [13]. described by Scho Miller [14] described the development of clinical skills, competence and performance for clinical assessment in a pyramidal framework, subsequently known as Miller’s Triangle. Using this model, the expectation was that by the end of the 6 months course, students would build up their knowledge and skill, from knowing about EEL and its applications, through acquiring and retaining motor skills (being able to perform EEL), and finally becoming competent and independent endoscopists. These models of learning theory underpin practical skills teaching in medicine. We followed the Royal College of Surgeons practical skill teaching protocol which is both didactic and experiential, combining motor and deep learning with activities from behaviourist theories – such as repetition and practice, feedback, role modelling and instructional sequences and reward [15]. It comprises six elements as follows: (1) Conceptualization – To put the practical training into cognitive context, the students discussed the rationale for EEL in SLT practice as a method for contributing to differential diagnosis, rehabilitation and the improvement of quality outcomes. Professional and health and safety protocols were presented. Students discussed ethical issues such as consent, the use of topical anaesthesia and how to manage unexpected findings, for example previously undiagnosed carcinoma of the larynx. (2) Visualization – A short video of the procedure was viewed and left for reference in the tutorial room. In pairs – novice endoscopist SLT with a novice assisting SLT – the students observed the expert SLTs demonstrating the procedure in real time using a volunteer as a patient. (3) Verbalization – The expert SLT repeated the examination, breaking the skill down into its components and talking it through. The
students followed a procedural template to track the activity and for use later in their own practice and were encouraged to ask questions for clarification. (4) Practice phase – This was a crucial phase and could be repeated as often as required. Dewey [16] stressed the importance of the learner’s active involvement in the learning process and Kolb [9] referred to this as ‘concrete experience’ in his experiential learning cycle. Each student handled the flexible laryngoscopes to become familiar with technical elements, such as lens focus, light balance and control of the tip of the endoscope, in preparation for passing the scope transnasally. The novice endoscopist then passed the flexible scope via the nares and manoeuvred the tip into position above the larynx of the volunteer, the novice assisting SLT taking notes and observing the comfort of the volunteer. During this phase, the expert SLT provided constructive feedback, initially as comments or supportive redirection, for example demonstrating how to manoeuvre the endoscope to provide a panoramic sweep of the laryngeal and pharyngeal structures. Building from this, the novice endoscopist was then directed to look at finer levels of detail, such as achieving a view of the laryngeal anterior commissure and asking the volunteer to carry out a series of diagnostic probe activities to assess vocal cord function. The novice assisting SLT completed the procedure feedback template to share with the novice endoscopist, supporting self-reflection and discussion, and contribute to their portfolio. Each pair of students changed roles and during the whole course they also had the opportunity to work with different partners and supervisors, enriching their experience and promoting deep learning, and accommodate individual learning and teaching styles. (5) Skill mastery – Each student had the opportunity to carry out the EEL on 10 occasions during the first 2 days of the course. Crucially, when students returned to their own clinical environments in between the teaching sessions, they were required to allocate time to consolidate and build their skills. Evidence of this activity away from the course was provided in the form of logs and portfolio documentation. (6) Skill autonomy – Deliberate practice with repetitions is necessary to become an expert [17]. Indeed, the RCSLT competency framework [8] requires that the SLT endoscopist carries out 35 successful endoscopy procedures before autonomous independent practice can commence. This takes the form of five procedures
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as assistant endoscopist, 10 procedures as the endoscopist under supervision with assistance and 20 procedures autonomously under supervision. The total number of procedures undertaken on the course and in between was very relevant to the participants in their transition to autonomous endoscopist.
RESULTS The precourse questionnaire was repeated after the course and all students reported that they had made good improvements in their knowledge and understanding. Observations by the supervisors showed that each student had achieved the learning objectives of the course. They reported that the use of reflective logs and clinical diaries had promoted consolidation of theory and knowledge. Each student had begun to provide an EEL service within their own clinical setting with reported benefits in both patient management and multidisciplinary working.
DISCUSSION Students expressed that moving from theoretical frameworks into applying practical skills was the most stressful aspect. Cognitive dissonance may result in the student actively avoiding these situations [18] and the students acknowledged that this was a barrier to progression. However, on this course, the teaching team was vigilant for these elements and the dissonance in itself was a motivator. Dewey [19] wrote that the most powerful learning occurs when the student is dealing with uncertainty. Through receiving personalized tuition, one-to-one tutorials and supervision sessions, students worked towards consonance and reported this approach to be one of the most useful and powerful aspects of the teaching. Mezirow’s theory of transformative learning [20], describing the social process of constructing a new interpretation of one’s experience, underpinned the teaching, allowing students to critically reflect on their own and each other’s performance and emerging skills. The collaborative style was enhanced with the addition of external expert SLTs contributing to the final day of the teaching, which was interpretation of images and treatment planning. Maslow’s hierarchy of needs [7] importantly stated that in order for people to achieve their full potential, their basic needs must be fulfilled (physiological needs such as hunger, thirst and warmth, safety needs such as physical and psychological safety including shelter, and social or 200
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interpersonal needs such as belonging to a group). The course was taught in comfortable tutorial and clinical rooms with ample refreshments and breaks, providing effective teaching and learning conditions. The small group environment provided a common sense of purpose and direction with the students building trust and with flexibility to change the curriculum if required. Students were nervous of handling the scopes, particularly the very experienced therapists who described feeling vulnerable in exposing their lack of skill. Students were given constructive feedback to provide formative assessment [4 ]. Effective feedback offers insight into students’ actions and their consequences. Constructive feedback produces significantly better outcomes [21]. Two widely accepted models of feedback in clinical education, Pendleton’s rules and agenda-led outcomes based analysis are described in Chowdhury and Kalu [22] and we followed a structured and constructive approach in the course. Rogers [6] stressed the importance of the teacher–student relationship, with teachers being facilitators rather than didactic transmitters of information [3]. In addition, however, supervision from an expert SLT was integral to successful outcome of the training. Vygotsky [11] described the ‘zone of proximal development’, where the teacher acts as the scaffold to move the student from their existing level of skill to a higher level. Furthermore, to promote continued theoretical learning and mastery of the practical endoscopy skills in an experiential learning cycle, supervisors local to the students were sourced. Identification of the local multidisciplinary team and a local mentor was a prerequisite of acceptance on the course, and this supervision was vital during the course of the training and for ensuring continuing development of competence in practical and interpretation skills. The didactic and practical sessions were interactive which according to the principles of constructivism promotes deep learning. Marton and Saljo [23] explored how students approached learning and demonstrated their deep and surface learning styles. Entwistle [24] suggests that surface learning such as copying can be transformed by interactivity into deep learning, demonstrating understanding and finally transformation of skills and knowledge. Maslow [7] and Rogers [6] emphasized the theory of ‘self-actualization’: that people wish to become the best that they can be and to fulfil their potential and achieve independence. The course design allowed students to continue their practical and theoretical development as &
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Teaching laryngeal endoscopy skills to speech and language therapists Robinson and Dennick
self-directed learners and produce action plans for their future development. The time between the taught elements enabled contextualization and integration of the new skill into local clinical practice. Social constructivism describes communities of practice as valuable in supporting each learner’s engagement, and students were encouraged to join their local multiprofessional communities of practice, such as the RCSLT Special Interest Group in ENT and local and external multidisciplinary learning events, for example conferences and research groups. This would allow for mapping their experiences onto others experiences and to engage in action planning for further experiences, a crucial element of Experiential Learning Theory. A progression model to promote breadth, depth, utility and proficiency of clinical practice is an area of interest in planning the next EEL course [25], providing a framework for continuing professional development, with prospective application of educational theory promoting effective learning [2].
CONCLUSION Applying learning theory to optimize skills mastery has transformed the development and outcomes of one practical skills course for SLTs. Using our understanding of learning theory to other practical skills course design, for example endoscopic evaluation of swallowing and videofluoroscopic evaluation of swallowing, may provide the same benefits. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Slade S. A survey of endoscopy use by speech and language therapists. Proceedings of the British Academic Conference Otorhinolaryngology; 2009; Liverpool. 2. Sadideen H, Kneebone R. Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning? Am J Surg 2012; 204:396–401. 3. Dennick RG. Theories of learning – constructive experience. In: Mathieson D, editor. An introduction to the study of education, 3rd ed. London: Routledge; 2008. 4. Dennick RG. Twelve tips for incorporating educational theory into teaching & practices. Med Teach 2012; 34:618–624. This article describes a group of learning theories that are fundamentally related and which can provide guidance on a range of teaching and learning practices. Common educational theories can be combined to provide practical tips for teachers and facilitators. 5. Ausubel DP. Educational psychology: a cognitive view. New York: Holt, Reinhart and Winston; 1968. 6. Rogers C. Freedom to learn for the 80’s. Columbus, OH: Charles Merrill Publishing Company; 1983. 7. Maslow AH. Toward a psychology of being. New York: Van Nostrand Reinhold; 1968. 8. Carding PN, Jones S, Morton V, et al. Speech and language therapy endoscopy for voice disordered patients. Royal College of Speech and Language Therapists position paper; 2008. 9. Kolb DA. Experiential learning. Englewood Cliffs, NJ: Prentice Hall; 1984. 10. Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice Hall; 1977. 11. Wertsch JV. Vygotsky and the social formation of mind. Cambridge, MA: Harvard University Press; 1985. 12. Gibbs G. Learning by doing: a guide to teaching and learning methods. Oxford: Further Education Unit; 1988. 13. Scho¨n D. The reflective practitioner: how professionals think in practice. New York: Basic Books; 1983. 14. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (Suppl 9):S63–S67. 15. George JH, Doto FX. A simple five-step method for teaching clinical skills. Fam Med 2001; 33:577–578. 16. Dewey J. Logic: the theory of enquiry. New York: Holt; 1938. 17. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79 (Suppl):S70–S78. 18. Festinger L. A theory of cognitive dissonance. Stanford, CA: Stanford University Press; 1957. 19. Dewey J. Experience and education. New York: Collier Books; 1963: 69. 20. Mezirow J. Transformative dimensions of adult learning. Jossey-Bass: San Francisco, CA; 1991. 21. Black P, Williams PD. Assessment and classroom teaching. Assess Edu 1998; 5:7–73. 22. Chowdhury RR, Kalu G. Learning to give feedback in medical education. Obstet Gynaecol 2004; 6:243–247. 23. Marton F, Saljo R. Approaches to learning. In: Marton F, Hounsell D, Entwistle N, editors. The experience of learning: implications for teaching and studying in higher education, 3rd Internet ed. Edinburgh: University of Edinburgh Centre for Teaching, Learning and Assessment; 2005. pp. 39–58. 24. Entwistle N. Styles of learning and teaching. London: David Fulton; 1988. 25. Harden RM. Learning outcomes as a tool to assess progression. Med Teach 2007; 29:678–682.
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