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Monthly Archives: January 2013

Why clinical learning is a lot like Drivers’ Ed

January 31, 2013
Clinical Education
2 Comments

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Complex skills are best learned in authentic environments

Buying a new car has meant finding a good home for my beloved 95 Chevy. A colleague is now the proud owner, only there is one small but crucial detail…he has never learned how to drive a car with manual transmission (stick shift). Thus, last Sunday afternoon his friend was the one who drove off into the sunset after we did the deal, but that’s no long-term solution. Oh Chevy, I see grinding gears and burning clutch in your future!

Driving a stick shift isn’t easy. In fact, in the beginning it feels pretty complicated and there’s not always much room for error. I’ve been thinking about some of the ways that learning to drive shares common ground with learning the complex skills of clinical practice.

1. The stakes are high: If you don’t master key practical skills, your own and others’ safety are at risk. Have you ever stalled out on a steep grade with other cars right behind? Not a good situation in which to freeze up or panic!

2. It can be a challenge to practice new skills in an environment that feels safe yet also authentic: See Point 1 – you need the experience of stalling the car on a steep hill to learn how to get going again, but you don’t want the reality of rolling backwards into the guy behind. My drivers’ ed training car had a clutch and brake for both me and the instructor/passenger, so I knew that a mistake wouldn’t be catastrophic. Simulation in healthcare education accomplishes the same objectives of safety + authenticity.

3. An experienced mentor can make all the difference: My driving instructor was about 70 years young and had over 40 years experience in teaching new drivers. Everything that a student could possibly do or say he had seen or heard, and literally nothing rattled him. He had this very calm and patient demeanor, which I guess is how he survived that long teaching people like me how to drive. Just knowing that any mistakes I made were par for the course and all part of the learning process freed me up to get into the zone of deep learning.

4. Corrective feedback in the moment shapes behaviour: Direct observation and feedback about the skills I was practicing effectively and where I needed more work helped me learn faster and better. Abstract instructions and memorization aren’t nearly as effective for integrating and mastering practical application of complex skills.

Perhaps a couple of “continuing education” sessions on how to drive a stick shift would not go amiss for Chevy’s new owner. Who knows, might save the cost of a replacement clutch and maybe more. SWP, are you listening?

Reflective Listening: The most powerful tool in the tool-box?

January 25, 2013
Clinical Education, Motivational Interviewing
9 Comments

 TO LISTEN

Ears + Eyes + Undivided Attention + Heart

Zen rocks lake

Group facilitation is more about listening than speaking

Facilitating groups is a delicate art: groups progress through certain well-defined stages of development, and our style as facilitators needs to be pitched to where the group is at. Furthermore, facilitators need to respond to the “two clients” – the individual, and the group – and attend to both content and process. This multilayered complexity, whether in education or clinical contexts, is a big part of what makes groups so energizing and exciting.

What is reflective listening?

In its simplest form, it’s a response that paraphrases or mirrors the spoken content of a person’s statement. Reflective listening is a way to check back and make sure that we’ve understood what someone else tells us. This type of response is also a good alternative to the “Righting Reflex”!

Done artfully, the skill of reflective listening looks easy but is far from it (at least in my own experience). Really impactful reflective listening goes further than paraphrasing, and mirrors back the implied meaning beneath a person’s words; exploring the emotions, assumptions, ideas, hopes, concerns or wishes. These types of complex reflections demand our full listening attention and focus on the other. We all want to feel understood, and reflective listening helps bridge the communication gap in a respectful and validating way.

Here’s an analogy: simple reflections are like the tip of an iceberg – the content “above the waterline” – while complex reflections go deeper.

This video example of an angry client demonstrates how the practitioner uses lots of reflective listening to establish understanding and build rapport.

Reflective Listening in Groups

Reflective listening in groups ups the ante because of their interpersonal complexity. But, looked at another way, groups give us even more options and opportunities to use this important skill. I’ve come up with three general categories for practicing reflective listening in groups (and I’m sure that there are more):

1. Simple versus complex reflections

2. Reflecting an individual’s comments versus content taken from the group’s overall contributions

3. Reflecting group content versus group process.

Note that a facilitator might decide to use any one of these approaches (and within each category are a myriad of alternate ways of responding)…that’s the artful strategy part!

Here’s an illustrative example of a hypothetical client who is coming to the first session of a support group for people living with heart disease. The facilitator has asked group members to share their goals for attending, and the last client to speak says:

“I’m only coming to group today because my doctor and my wife are both pressuring me.”

Reflect 1

Reflect 2

Reflect 3

Notice how each reflective strategy builds on the next – but they aren’t sequential (or prescriptive for that matter). Just some pretty powerful tools that are appropriate across a spectrum of clinical, educational, professional and other kinds of groups. Because in the end, the best facilitation is more about listening than talking.

Resist the Righting Reflex

January 18, 2013
Clinical Education, Motivational Interviewing, Post-secondary Education
12 Comments

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Unsolicited advice is the junk mail of life (Bern Williams, in Miller & Rollnick)

Compassionate listening – stepping back and allowing learners to individually explore their ambivalence, concerns and ideas about an issue or concept – is at the crux of individual discovery and adult learning.

Here’s the rub: as educators we want to support student success, so when we see someone heading in the wrong direction or struggling, we’re often galvanized into action with all good intentions! This “Righting Reflex” is essentially the imperative to do something…to “fix it”, and often kicks in without any conscious awareness (see Miller and Rollnick’s 2013 text on Motivational Interviewing).

To add clarity: A a quick illustration of the Righting Reflex from a conversation I had on my way in to work this morning (for real):

Me: “I’m thinking that I’d like to buy a Smart Car.” 

Significant other: “Well what about a Honda CR-V? I know someone who has one for sale.” 

Me:   ?   !   ?

O-kayyy…How useful was that unsolicited (albeit well-meaning) advice in helping me think things through? And, to be fair, my own Righting Reflex isn’t hard to activate in both personal and professional spheres. Learner autonomy as being at the heart of constructivist approaches is widely discussed and accepted, yet in practice it’s “simple but not easy”.

In an ideal world, educators validate, explore, question. They evoke and encourage students to critically examine different sides of an issue. This doesn’t negate our roles of teacher, guide or concerned other, but it does place the onus – quite rightly – on the learner’s capacity for decision-making and problem-solving.

A big part of education in health care (and other fields) is less about teaching the correct answer, than in facilitating the process of ethical and nuanced judgment and decision-making. If we can resist the Righting Reflex we’re creating a positive space in which to explore, experiment and make mistakes.

So…as for my own automotive decision-making process…a design endorsement by the MOMA may just tip the balance!

The Three Most Important Tips for Teaching Online

January 4, 2013
Clinical Education, Post-secondary Education
4 Comments

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The brave (not-so-)new world of online learning

I have an online graduate course starting next week – this is my 11th year teaching in the “virtual classroom”, and the new term has put me in mind of some of the most valuable learning I have gained through experience, course evaluations and student feedback. Here are my Top 3:

1. Put out the welcome mat

Universities and organizations generally have a standardized, branded Learning Management System (LMS). The LMS is the platform in which the online course is delivered, so your customization options tend to be fairly limited. In other words, it is your words – versus the overall site design – that are key to a positive first impression.

For example, is the first announcement or discussion posting focused on technical instructions and course requirements? Or on how you will support students’ success in the course, and how enjoyable and inspiring the collective learning journey will be? Time spent crafting a warm and positive welcome helps set the stage for group safety and engagement.

2. Generate controversy

If fostering meaningful critical discourse is challenging in traditional classrooms, it can be even more so online. Students often feel more inhibited when posting messages as opposed to speaking up in face-to-face groups. And online conversation can quickly take on the flavour of a series of rather stilted “mini-essays” unless you model and shape conversational threads.

One effective way I’ve found to stimulate authentic and lively conversation is to post about a controversial topic related to the course content – preferably something that links to a website, video or social media site, or all three. In my addictions course, this might be the way that addiction is portrayed in popular media, and how that connects to broader theories of addiction. Now the class is critiquing theory in a context that highlights real-life applications and relevance.

3. Over-communicate but under-state

Over-communicate because people don’t read. That is to say, they read, but tend to skim or miss points that are buried in the “fine print”. It’s better to make the same points in different ways across the learning platform or course tools in order to ensure that no one gets lost or left behind. This refers to issues that are process-related (like assignment deadlines, accessing technical support or how students will be graded), as well as content-specific (for example key definitions, essential points or important references). In my courses I try to reinforce communication using discussion forums, weekly overviews, course announcements and email to make sure that everyone is on board and on track.

Under-state because there is a phenomenon associated with text-based communication known as “emotional magnification”. Without visual cues, the same content delivered in person with no ill effects can be experienced with greater emotional intensity and negative valence when delivered online. We’ve all experienced this in email and other digital communication modes, and the consequences can adversely impact the positive learning community you’ve worked so hard to foster. Special care in providing corrective feedback is warranted, and this is especially critical in group discussion forums.

There is lots more to online teaching than captured here, but these are my “Top 3” and will be front of mind for me next week as the new term starts.