1. Marcia Ditmyer, PhD
Assistant Dean of Assessment and Instruction
UNLV, School of Dental Medicine
April 21, 2017
Effective Teaching and
Learning Strategies in a
Competency-based Clinical
Learning Environment
2. All speakers agree that neither they nor
members of their immediate family
have any financial relationships with
commercial entities that may be
relevant to this presentation.
3. Marcia Ditmyer, Ph.D., MS, MBA
• Assistant Dean for Assessment and Instruction
University of Nevada, Las Vegas
School of Dental Medicine
• AAL Senior Consultant
• Education:
• Ph.D. Public Health and Research/Measurement
• MBA and MS Health Education
• Experience:
• 20 years Business and 17 years Higher Education
• 31 of that in Healthcare Field
3
4. Learning Outcomes
• Explain how the changing landscape of competency-
based education has transformed instructional design and
course planning strategies in a clinical environment.
• Identify instructional techniques that are associated with
high quality clinical teaching.
• Examine practical applications for teaching and feedback
styles effective with adult learners.
4
5. Explain how the changing landscape
of competency-based education has
transformed instructional design and
course planning strategies.
5
6. A Brief History
6
Adopted by N. Chomsky in 1965,
“…fundamental difference between
the competence or knowledge of
language and its application or actual
use of language.”
7. Competency-based ≠ Outcomes-based
7
Competency-based education (CBE) is based on the
broader concept of Outcomes-based education (OBE).
1.Students advance upon demonstrated competence.
2.Competencies include explicit, measurable, transferable
learning outcomes that empower students.
3.Assessment is meaningful and a positive learning
experience for students.
4.Students receive rapid, differentiated support based on
their individual learning needs.
5.Learning outcomes emphasize competencies that include
application and creation of knowledge along with the
development of important skills and dispositions.
Basically, we know that a list of college credits and
grades on a transcript or even a diploma are poor
proxies of what a student can do.
Competencies, in contrast, offer a more
meaningful reflection of what a student both
knows and can do with that knowledge.
9. 1995 1998 2002 2004 2008
CBE Timeline in Dentistry
In 1995, Institute of Medicine
(IOM) published Dental
Education at the Crossroads:
Challenges and Change.
In 1998, the CODA adopted pre-
doctoral dental program
accreditation standards requiring
competency-based assessment.
In 2004, the ADEA introduced
competencies in a report,
“The Competencies for the
New Dentist.”
9
In 2002, IOM published the
Core Set of Competencies
for enhancing patient care
quality and safety.
In 2008, ADEA Competencies
for the New General Dentist
were approved by their House of
Delegates.
10. THREE BASIC ELEMENTS
1
Students receive
differential support to
match their individual
learning needs; their
knowledge and skills
are increasingly
challenged.
Students progress at
different rates in different
areas, rather than
teacher driven…it is
learner driven.
Students advance based
on demonstration of
skills and content
knowledge as outlined in
clear, measurable
learning outcomes.
Paradigm Shift to CBE
10
2
3
What does CBE
Curriculum look like?
12. Single Subject measure
TEXT
Passive Participants
Teaching by telling…
knowledge acquisition
Role of
Instructor
Role of
Student
Purpose
Assessment
Multiple performance-
based measures
It is now a journey from
novice to expert.
TEXT
Learning experiences where
students apply what they learn
What Does This Mean for Instruction
Cognitive Apprentices
Memorize facts and
formulas for future use
Instruction Paradigm
Direct-Instruction
Model
Learning Paradigm
Competency-based
Model
A standard is used for judging
competence that is not dependent upon
the performance of other learners.
12
13. Assessment Environments
Didactic
Environment
Basic Didactic
• Tests with binary
responses
Applied Didactic
• Consist of prompts
for short answer or
essay answers
• Writing
assignments,
essays, projects
Experiential
Environment
Quantitative Skills
Assessment
• Number of specific
experiences were
successfully
encountered
Qualitative Skills
Assessment
• Standard for
evaluating/ observing
“competence” for
specific skills.
Discussion
Environment
Case/Report
Assessment
•Problems or clinical
scenarios are presented
for student research
which require final
presentation or report.
Problem-based
Learning
•Open discussion
between student and
faculty to explore
various topics.
•The goal of PBL is not
prescriptive.
13
14. 14
• Consider your program. How would you describe
instructional design and course planning strategies?
• Are you innovative? What is the educational culture?
• What barriers and challenges are you currently
facing?
• What do you anticipate facing in the future?
16. Teaching in Clinical Settings
• Clinical learning can take place in almost all sites
where patients are exposed to dental care.
• Teaching in the clinical context can be unpredictable
and dependent on the availability of sufficient clinical
cases.
• The clinical teacher plays a significant role in creating
an environment that facilitates the learning of
students.
• The best way to achieve this is to create a positive
learning environment and actively involve students in
their learning.
16
17. Excellent Clinical Teachers:
• share a passion for teaching;
• are clear, organized, accessible, supportive and
compassionate;
• are able to establish rapport; provide direction and
feedback; exhibit integrity and respect for others;
• demonstrate clinical competence;
• possess a broad repertoire of teaching methods;
• engage in self-evaluation and reflection;
• draw upon multiple forms of knowledge, target their
teaching to the learners’ level of knowledge.
17
Ramani S, Leinsteramee S. AMEE Guide 34, Medical Teacher, 2008; 30: 347–364
20. Students Road to Discovery
• To ask questions is to be on the road to
discovery.
• There are two questions to ask yourself:
• 'Where am I going?'
• 'Who will go with me?’
• If you ever get these questions in the wrong
order, you are in trouble.
~ Sam Keen
20
21. 2
Stritter, Baker, & Shahady, 1986
NOVICE EXPERT
INDEPENDENT
DEPENDENT
Exposure
Knowledge
& Facts
Acquisition
Applies Skills,
Decision Making
& Reasoning
Integration
Knowledge & Skills
(Competence)
PROFESSIONAL DEVELOPMENT
PRACTICAL
INSTRUCTION
Road to Competence
COMPETENT STUDENTS
make independent
choices, can reason on
their own, able to apply
what they learn, and
form their professional
identity!
21
22. How Do We Move Students To Competence
Answer: Outcome-DirectedThinking!
Highly effective people invest little energy on their
existing problem situations, rather focus their attention
and energy on their desired outcome.
Fisher, 1981; Cashman, 1986; Bostrom, 1988
22
23. • Let’s do a short exercise…
• Think of a problem that you have at work or home. For
purposes of this exercise, make the problem one that has been
disconcerting, but not so overwhelming.
• On an emotional scale of 1-10, make the problem a 3-5.
• Using the problem you selected above, answer the two sets of
questions on the next slides either in your mind or on a sheet of
paper.
• Simply answer the questions and pay attention to how you feel
as you answer each question.
Outcome-Directed Thinking
DO YOU HAVE YOUR
PROBLEM?
23
24. Question Set 1
• Why do you have this problem?
• Who caused this problem?
• Who is to blame for this problem?
• What are the roadblocks or obstacles to solving this
problem?
• How hopeful are you that this problem will be solved?
• Now take a few seconds to remember what it felt like
answering these questions.
24
25. Question Set 2
• What do you want instead of this problem?
• What will you see, hear, and feel to know you have
achieved this outcome?
• Imagine it is sometime in the future and you have the
outcome you want. What have you gained by achieving
this outcome?
• What resources will you have to activate or acquire to
achieve this outcome? What are your first steps?
• Now take a few seconds to remember what it felt like
answering these questions.
25
26. Now that you had a moment to notice how you
were feeling and thinking when answering these
sets of questions.
Compare your thinking process and think about
how your feelings and behavior differed
between question set I and II?
Were you problem-directed or outcome-directed?
26
27. Outcome-
Directed
Thinking
Model
Clawson & Bostrom, 2003
Thinking Pattern #1: Flipping
Questions
The first thinking pattern is called
FLIPPING. Made up of questions
which move or “flip” a person
from focusing on the problem in
their brain to building an image of
a desired state or outcome. The
key Flipping question is "What do
you want instead (of this
problem)?" When we ask
ourselves this question, we
immediately have to stop thinking
about our problem and start
thinking about what we really
want instead of the "mess".
Thinking Pattern # 2: Where
To Tap The “Right ” Outcome
There is another set of
questions outcome-directed
thinkers ask themselves in
developing compelling and
useful outcomes. This
thinking pattern helps them
work on or “tap” the right
outcome. The “right”
outcome is the outcome that
will provide the most
movement or leverage for the
system (person, department,
team, etc.) to move toward
the desired state.
27
28. Shift from Pattern to Process of Thinking
How aware are you of
your process of
thinking?
The “content” of our thinking
is all the values, conclusions,
ideas, beliefs, and other
forms of “knowing” that you
hold dear.
28
Our curriculum and program
has the content…it is how we
want our students to process it
that is important. Requires
active learning.
29. 29
Active Learning
• Active learning is a student centered approach in which
the responsibility for learning is placed upon the student.
• Teachers are facilitators rather than one way providers of
information.
Simple
Tasks
Complex
Tasks
The Active Learning Continuum
30. 30
A.D.D.I.E. Active Learning Model
ANALYZE: Identify Performance Gaps and Needs
DESIGN: Define Performance Outcomes; Deliver/Evaluate
Strategies
DEVELOP: Develop Training Materials, Lesson Plans, and
Evaluation Methods
IMPLEMENT: Deliver and Check for Understanding
EVALUATE: Assess Effectiveness and Continuously
Improve
A
D
D
I
E
31. Example Strategies in Clinical Settings
One-Minute Microskills
1. Get a commitment
2. Probe for supporting evidence
3. Teach general rules
4. Reinforce what was done right
5. Correct mistakes
Learner-Led Education
1. Summarize relevant history and physical findings
2. Narrow the differential: Likely? Relevant?
3. Analyze the differential
4. Probe the instructor
5. Plan patient management
6. Select a case-related learning issue
31
32. 32
Dimension Low Risk Strategies High Risk Strategies
Class Time Required Relatively Short Relatively Long
Degree of Planning Carefully Planned Spontaneous
Degree of Structure More Structured Less Structured
Subject Matter Relatively Concrete Relatively Abstract
Potential for Controversy Less Controversial More Controversial
Student’s Prior Knowledge
of Knowledge
Better Informed Less Informed
Student’s Prior Knowledge
of Skill
Familiar Unfamiliar
Instructor’s Prior
Experience in Teaching
Technique
Considerable Limited
Patter of Interaction
Between Faculty &
Students
Among Students
Active Learning Strategies: Level of Risk
33. 33
• Review the list of active learning strategies
• Select a clinic (or didactic) course you teach (or
plan to teach)
• Consider which of these strategies would be useful
in that course. Discuss at your tables
35. 1 TAB ONE
Add your own text here YES…
It is more effective to
design curriculum and
clinical teaching to include
multiple modes, so that
there is a way for all
learners of every learning
style to engage with the
topic.
1
DO TEACHERS
TEACH THE
WAY THEY
WERE
TAUGHT?
35
Stitt-Gohdes 2001, p. 136; Miller 2001; Stitt-Gohdes 2003; Spoon and Shell
1998; Delahoussaye 2002; Kolb, 1984, 1998
36. 36
Learning Styles
Why are we talking about learning styles
in section on teaching and feedback? We
spoke of patterns and process, now we
need to talk about learning styles…
…focusing on one’s learning style can
sometimes harm learning rather than
help.
What is important is to focus on meta-
learning—being aware of and taking
control of one's learning.
Howard-Jones, P. A. (2014). Neuroscience and education: Myths and messages. Nature Reviews Neuroscience Nat Rev Neurosci,15(12), 817-
824; Pashler, H., Mcdaniel, M., Rohrer, D., & Bjork, R. (2008). Learning Styles: Concepts and Evidence. Psychological Science in the Public
Interest,9(3), 105-119.
37. 37
Meta-Learning
Meta learning is the process by which
learners become aware of and increasingly
in control of habits of perception, inquiry,
learning, and growth that they have
internalized.
Within this context, meta learning depends
on the learner’s conceptions of learning,
learning beliefs and processes, and
academic skills.
Donald B. Maudsley (1979)
38. 38
Meta-Learning
• A student with a high level of meta-
learning awareness is able to assess the
effectiveness of her/his learning
approach and regulate it based on the
demands of the learning task.
• A student with a low level of meta-
learning awareness will not be able to
reflect on her/his learning approach or
the nature of the learning task set.
38
Donald B. Maudsley (1979)
39. 39
Kolb’s Learning Styles
Kolb's model differs
from others
because it offers
both a way to
understand
individual learning
styles and an
explanation of a
cycle of experiential
learning that
applies to all
learners
Kolb D. (1984); Kolb D. (1999); Coffield, F., Moseley, D., Hall, E., & Ecclestone, K. (2004);
40. NEGATIVE
Student usually does
not have a good idea
of what they are not
doing well. This
student feels they are
doing much better
then they really are.
NEGATIVE
Student usually has
a good idea of what
they are not doing
well.
POSITIVE
Student usually does
not have a good idea
of what they are
doing well. This
student feels they
are not doing as well
as they really are.
POSITIVE
Student usually has
a good idea of what
they are doing well.
Feedback Matrix
EXPECTED
FEEDBACK
NOT EXPECTED
FEEDBACK
40
The most common model used to describe the acquisition of skills is the conscious-
competence model. This model is widely used in management training but no-one is
entirely clear where it originated.
41. The Acquisition of Skills
41
• The subject is not aware of the skill in
question
Unconscious
Incompetence
• The subject is aware of the skill and
recognizes the need to acquire it
Conscious
Incompetence
• The subject has acquired the skill but needs
to focus their attention on its performance.
Conscious
Competence
• The subject has achieved mastery of the
skill and can perform it without conscious
thought, other tasks can be performed at
the same time
Unconscious
Competence
Ramani S, Leinsteramee S. AMEE Guide 34, Medical Teacher, 2008; 30: 347–364
42. In the clinical setting,
it is common to have
learners with
different experiences
and at different
learning levels.
Faculty must identify
and acknowledge these
differences to include
all learners in the
process.
Having different
educational and clinical
experiences/levels can
provide a rich forum for
discussion.
SO LET’S
BRAINSTORM
THINK…
About the BEST &
WORST teacher you
ever had
TRAITS
That made them the
BEST/WORST?
42
43. How to Provide Feedback
• Tangible/transparent
• Owned/timely/ongoing
• Balanced & specific
• Actionable
• Self-reflective
• Written/documented
• Verbal/non-verbal
• User-friendly
• Consistent
• Formal/informal
• Direct/indirect
• Multiple sources
What is important
about providing
feedback?
43
44. Challenges in Providing Feedback?
What students are thinking…
•Not descriptive = “good job today”
•Not often/consistent
•Not understood (vague)
•Comes with emotion
(disappointment/aggravation)
•No cues for how to improve
•Not conducive to the environment
•Not about the activity, but something else
44
45. Students need to know what good work
should look like, and have clear and specific
success criteria against which they can
assess their work.
The test of good criteria is whether students
can use them for effective self assessment.
If they can’t, they need to be reworked.
Clearly Established Criteria
45
46. 46
Essential Communication Skills
O.A.R.S. is a skills-based model of interactive
techniques adapted from a patient-centered
approach, using motivational interviewing principles.
These skill-based techniques include verbal and
non-verbal responses and behaviors.
Both verbal and non-verbal techniques need to be
adapted to be culturally sensitive and appropriate.
48. 48
Purpose of O.A.R.S
1. Provide us with a common language when teach
communication skills.
2. Provide us with a “checklist” of skills as we do our
on-going skills self-assessment.
3. Provide us with a format to help us be intentional
when working with our patients/clients. Using skills
intentionally helps us become more efficient and
more effective in the work that we do.
49. 49
Argumentative Students/Patients
• When sense signs of an argument are present,
stop the conversation and indicate that the intent
is not to take sides but hat you are seeking
understanding of his/her point of view.
• Remember…argument, confrontation, lectures,
and fear tactics lead to patient/student resistance.
• This can be perceived as judging and typically
breeds defensiveness.
50. 50
Reframing Argument
• When this happens, reframe the patient/student’s
statement and offer a positive perspective on what
they have already done.
• During Reflective listening, turn the question back
on the patient/student.
• Develop Discrepancy – Develop between the
patient/student’s behavior and broader goals and
values. Most people are motivated to change
when it comes from themselves rather than
someone else.
51. Group Practice
1.Patient/Student: Focus on
“something you feel two ways about”
2.Clinician: Focus on gaining a better
UNDERSTANDING of the patient
3.Observer: Keep track of OARS on
tracking sheet
LET’S PRACTICE
O.A.R.S
51
53. Practical strategies
Teaching objectives
• Do you establish teaching goals for different types of clinical
encounters?
• Did you communicate your teaching goals to the learners?
• Did you elicit goals of the learners?
Teaching methods
• What teaching methods did you use and were they successful
(demonstrating, observing, questioning, role-modelling)?
• Do you use the same teaching strategies for all learners or do
you change your methods for different learner levels and skills?
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Ramani S, Leinsteramee S. AMEE Guide 34, Medical Teacher, 2008; 30: 347–364
54. Practical strategies
Feedback
•Did you give feedback? Did you ask for learners’ feedback on
your teaching?
•Planning for the next encounter
•Have you used reflective critique of your teaching to change
your teaching methods?
Professional Development
•Have you attended courses, studied educational literature or
held discussions with other teachers to improve your teaching
skills?
•Are you planning to engage in the scholarship of teaching, study
the impact of your interventions
54
Ramani S, Leinsteramee S. AMEE Guide 34, Medical Teacher, 2008; 30: 347–364
