Online Approaches to Reflective Learning

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					Online Approaches to Reflective
    Learning – initial studies

  Isobel Braidman, Maria Regan, Simon
     Wallis, Caroline Boggis and Tim

    University of Manchester Medical
   Manchester Medical School
    Teaching and Learning

• PBL driven from years 1 - 5
• Emphasises participant – led learning
• Introduced contact with patients at both
  community and hospital level, clinical and
  communication skills to years 1 and 2
  (Phase 1)
• Issues of professional identity and
  development raised earlier
Phase 1 Personal and Professional
     Development Portfolios

Years 1 and 2           discussions

                           Supported by
           GMC’s Good      tutor facilitator
Students are familiar with…..

• Group facilitation techniques
• Face to face discussion of professional
• Framework of reflective learning for
  personal and professional development
Challenges to portfolios in
       Years 3 - 5
            >450 students per year

            Located in hospital sites spread
            over North West England

            Each has its own specific

             But a common University of
             Manchester portfolio had to
             be delivered
Overview of portfolio in years 3 - 5

   PHASE 1
                              GMC’s Good
                              Medical Practice
 Work place
               Phase 1 + Extra sections
                (research, governance)

    Medlea Portfolio                             On line
               Support: Students, Student        WebCT
               Facilitators, Clinical Mentors,
               Hospital Deans/Portfolio Leads
Phase 2 Personal and Professional
     Development Portfolio

           GMC’s Good
           Medical Practice

    + Extra sections
(research, governance)
  appropriate for work
                         +                        Supported
     place learning
                                                  by peer
                              On line discussions facilitators
                              through WebCT       from same
                                                  year as
             Online reflective learning
• Text based discussion encourages more
• Interchanges are asynchronous - allows time to
  assimilate arguments of others and relate them
  to learner‟s own experiences
• Important in the context of work place clinical
• Contrast with face to face which promotes more
  “new ideas”/thought showering
Newman et al (1997). Journal of the American Society for Information Science 48:484 -
   496. Garrison (1997). Open Learning 12:3 - 11.
     Online reflective learning
• How to turn groups of individuals
  exchanging information into communities
  of reflective learners?
• Require framework for the group‟s
  activities, so that the group can focus their
• Necessitates understanding how such
  groups develop
• Community of Enquiry Model
Community of Enquiry Model

                        Supports discourse
Cognitive presence                            Social presence
                        LEARNING                 Defines milieu of
Defines                 EXPERIENCE               discourse

                     Tutor presence

                      Establishes structure
                      and process
Importance of student facilitators

 • Volunteering to take responsibility for the
   learning of their peers
 • Taking responsibility is important marker
   for professional development
 • Important group to follow as a cohort
On line reflective discussions
  Advertised for         >60 responded
student facilitators   received training in
     in Year 3             facilitation

                       Year 3 divided into
  Web CT page             63 groups of 8
  established          students, each with
Web Page
         Prompts and Links

•   Should there be a common health professional code? (Nursing
    and Midwifery Code of Conduct and Ethics http://www.nmc- )
•   Should medical students make a declaration or take an oath?
•   When do you think medical students should adopt a professional
•   Should this apply in your private life?
•   How will you protect yourself and your colleagues from the
    “hidden curriculum”?
•   How do doctors maintain professional behaviours when society is
              What happened?
     First reflective exercise: What is
appropriate professional behaviour for Year
             3 medical students
          Prompts for discussion, web links and resources to
             stimulate thinking accessed through Web page

                 Facilitator calls first face to face meeting of
                group, to decide balance of on line and face to
                    face meetings and other ground rules

                      End point of exercise – each group reaches
                     consensus over code of conduct and these are
                           pooled; students show evidence of
                       participation by downloading contributions
      Research Questions

• What was the extent of Web page usage?
• How did group members interact online
  with each other and with student
• Did these discussion exhibit critical
• What was the content of the interactions?
• Did the student facilitators fulfil their role?

• Mixed Method approach used
• Web postings for quality of interactions
  analysed by Community of Enquiry Model
  (Garrison et al) for cognitive, social and tutor
• 5 groups randomly sampled from each
  hospital sector (n=20)
• Focus groups both students and facilitators
• Individual semi-structured interviews
• Completion of questionnaire
Community of Enquiry Template 1
              „You have to gain the patients trust. …you
                                can do this are by acting professionally and
                                being polite and considerate…., gaining their
                                trust and then maintaining …the trust initially
                                   „Another example
                                and not abuse it‟. [of relations with
                                   patients] that I encounter during my
               Resolution          attachment…… is when a dietician of a
                                   diabetic clinic is trying to advise patients
                                   to loose some weight …...‟
                                            „Who is responsible for formal
                                            training….? For example are
                                            nurses learning to use equipment
                                            trained by other staff

Cognitive presence                               „To start off the discussion
                                                 I thought I would pick a
                                                 couple of questions on our
               No of triggers                    discussion list‟
Community of Enquiry Template 2
                     „I don‟t think it is possible to regulate
                     the relationships between doctors and
                     their ex-patients, but if anyone else
              Group  agrees or disagrees, let me know‟.
                           „I agree with what X and X said
                           about being sensitive and
                           empathising with patients‟.

                                        „….all the extra things linked
                                        with competitiveness like
Social Presence                         trying to look good in front of
                                        consultants, which I know I
           Emotional                    do, I‟m only human!‟
Community of Enquiry Template 3
                             I would agree with everyone that when defining
                             an ex patient you should consider what he/she
                             was treated for……Would a sensible suggestion
                             be if you meet someone and recognise
             Discourse, consensus, you should give serious thought to any
                    sharing  relationships?
                                      „Under „Mystudies‟ you can click
                                      straight onto WebCT or you can also
                                      click onto Year 3 portfolio, this takes
                 Clarification        you to the WebCT home page‟.

                                              „We also need to include
                                              evidence in our portfolio of our
Tutor presence
                                              participation i.e. print off parts of
                                              our internet discussions so
               (management)                   everyone needs to get involved.‟
      Results – Use of web page

                                            Hourly Usage of WebCT during March 2007
• Online discussions                90
  used vigorously                   80
  from November –                   70

  June                 No of Hits   60

• All 63 groups have                40
  participated                      30

• >3,300 messages                   20

  posted                            0
                                         1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Analysis of message interactions

Cognitive Presence in Messages

                  3%          CTE (No of triggers)
                              CE (Exploration)
                        37%   CI (Integration)

            51%               CR (Resolution)
Analysis of message interactions
Social Presence in Messages

                     26%      (Emotional)

                              SOC (Open)

                              SGC (Group
               39%            cohesiveness)
 Analysis of message interactions

Tutor Presence in messages

      18%                    Organisational
                48%          (Management)


Example of facilitator interaction with group - 1

Message no. 1737[Branch from no. 1660]
Posted by (MMMP3EJS) on Thursday, March 1, 2007 5:56pm
Subject: Re: Relationships with patients
Hi everyone!
I think the points you have been discussing are all very true and very important to
remember each time we speak with a patient. I too have noticed how patients will speak
openly and in long detail about their illnesses and current problems with us as medical
students and then as you mentioned, decide not to tell the Dr in order not to "waste their
time" or bother them too much. A good point was made when X mentioned the
importance of our role in passing this information on to the Dr in charge of the
patient's care. I once spoke to a patient at my GP practice ready to present her history to
the Dr, she gave her consent to speak with me and went on to explain that her husband
was seriously ill and had been transferred to a hospital in another part of the country. I
explained that I would be able to go in to the consultation with her and help to explain her
situation if she liked. I think the fact that I could transfer this information to the GP and
accompany her was a comfort. It is also interesting that X mentioned the importance of
avoiding giving false reassurance to patients. Sometimes, if not careful, this could be an
easy way out of a difficult conversation. How has everyone else dealt with some of the
situations come across when patients are looking for reassurance in your answers?
           Reflective Content
• „Has anyone ever considered just how much of a
  difference we can make to a patient just by sitting and
  talking to them? I can appreciate that the doctors and
  nurses are generally too busy to have time just to sit and
  chat with patients, so I think that since we have this
  opportunity as medical students then we should make
  the most of it.‟

•    „This incident touched me quite a lot personally,
    because I'd just had first hand experience in my personal
    life with people suffering from HIV/AIDS.‟
         Student Reaction

From preliminary analysis of structured interviews

 ‘I think is good and anything that encourages
 people to write more I think is good, and I think
 that you can use it anytime, anywhere is
 definitely a benefit, and especially if you’ve got a
 busy timetable, it’s much easier to fit in fifteen
 minutes of an evening to write a reply to
 someone than it is to try and meet up with
 someone and so, yeah, I think it should continue’.
 Summary and Conclusions

• Initial observations indicate that the online
  discussion facility used by almost all Year 3
  students, despite being widely dispersed
• It is possible to support this with student
  facilitators, drawn from the same year.
• We also provided reflective learning by this
• Community of Enquiry Analysis showed
  interactions in some groups became more
  sophisticated over time
• Role of student facilitator requires clarification for the
• Does downloading evidence of participation in online
  discussions for the purposes of portfolio
  review/appraisal, influence the nature of these
• Student Facilitators felt that discussions required a focus
  and requested further exercises
• Further activity provided “How to become a safe
• On line reflective discussions facilitated by students is
  now being rolled out to Year 4

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