Strategies to facilitate learning

Questioning to promote critical thinking

Socrates once said 'I cannot teach anybody anything, I can only make them think'. The use of questioning is central to stimulating critical thinking, facilitating experiential learning and reflection on practice. But, research indicates that many teachers focus more on lower order questions that focus on recall, rather than higher order questions that focus on critical thinking and clinical reasoning. The effectiveness of questioning as a strategy to facilitate learning can be improved through reflection on the following principles:

• Establish a supportive environment where it's safe to say 'I don't know'.
• Be aware that the type of question asked (open or closed) pitches it at certain levels.
• Use the hierarchy of knowledge to go beyond factual recall - help the student think not just regurgitate book knowledge. (see examples below)
• Allow 10-15 secs of wait-time before requesting a response.
• Listen actively to the response.
• Try 'what if...?' questions.
• Positively reinforce the effort taken to respond to a question.

Hierarchy of Knowledge		Example higher/lower order questions
High order thinking skills	Creating	On reflection, how might you do X differently in the future?
	Evaluating	On balance, what do you think is the most appropriate action in this situation, and why?
	Analysing	What are the key points/issues that need to be considered in this situation?
Low order thinking skills	Applying	How might you apply the principles of X in this (new / different) situation ...?
	Understanding	Why might X be occurring ...? What is your rationale for ...?
	Remembering	What is the definition of ...? What are the causes of ...?

Watch this video vignette to see how this supervisor uses questioning to prompt a student's critical thinking about her practice.

• How well do you think the supervisor's questioning strategy prompted critical thinking?
• What would you do differently, or the same, and why?
• How do you plan to use these ideas in your own supervision practice?

Purposeful observation

Observation is a commonly used approach to clinical teaching in the health care professions. At best it is an active, purposeful task that stimulates deep learning and the development of professional 'know-how'. At worst it is a passive process that can lead to increased anxiety or even total 'shut down' in the learner. By asking a student to 'just watch' assumptions are being about their ability to make sense of what they see. But students, on the whole, need help and guidance to reach that end point. Purposeful observation can be a powerful strategy for maximising what students can learn from observing an activity.

Clare Morris (2007) describes three key questions for improving the learning outcomes from an observation activity:

1. What exactly is the learner being asked to observe? Be specific about what you want the student/s to pay attention to.
2. What prior knowledge does the observation activity assume? Check this out with students prior to the activity.
3. What are the intended learning outcomes (ie. the purpose) of the observation activity? Again, be specific about how you want students to use the learning gained.

Thinking aloud

Providing an informal narrative whilst teaching a skill, or procedure, is not uncommon in clinical practice settings. However, 'Thinking Aloud' is a strategy that can be used purposefully to promote critical thinking and clinical reasoning, to assess student learning and/or provide modelling of expert decision making.

Here are some suggested triggers for thinking aloud with students:

• 'What I am taking into consideration here is ...'
• 'The main reasons I am doing it this way are ...'
• 'I am weighing up the options of X versus Y ...'
• 'I am surprised at finding X because ...'
• 'What I am finding difficult here is ...so ...'
• 'I have modified my original plan because ... and'

Coaching

Coaching can be described as a process of assisting people to achieve their goals and fulfil their potential. Just as coaches do, clinical supervisors have the opportunity to shape values, modify inappropriate attitudes, stretch skills and build on the strengths of students to assist their achievement of quality outcomes. The GROW model (Goal, Reality, Options, Way Forward), originally developed by Graham Alexander in 1984, is a widely used framework.

Goal	Together with the student, you discuss the behavior to be further improved, and structure this change as a goal that he/she wants to achieve.
Current Reality	Ask the student to describe his/her current reality, ie. their starting point. For example: what is happening now (what, who, when, and how often)? what is the effect or result of this?
Options (or obstacles)	Explore all possibilities for reaching the goal and decide on the best options - let the student do most of the talking.
Will (or way forward)	Get the student to commit to specific actions in order to move forward towards his/her goal. In doing this, you will help establish a person's will and boost motivation.

An adaptation of the GROW model is TGROW (Topic, Goal, Reality, Options, Way Forward) model described by Driscoll (2007).

Facilitating reflection on learning

Learning from experience is as much about our understanding of what has happened, as it is about our engagement in it. Thinking back on experiences, and carefully re-evaluating them, is an essential part of students' development as professionals in their disciplines. Importantly reflective practice is more than simply 'recounting the events of the day'. It involves the conscious examination of experience and requires a concerted attempt to 'make professional sense' of what has been learned and the application of this knowledge to practice. Consequently reflective thinking can be likened to a 'bridge' between theory and practice and a powerful means of using theory to inform practice.

Meaningful reflection is not an easy process and clinical supervisors can be of great assistance to students in helping them work through the process. A good way reflect meaningfully on practice is to use a framework that prompts deep and purposeful thinking about what happened. The 4Rs of Reflection - shown below - is one such framework (Ryan & Ryan, 2012). Here are some questions, based on the 4Rs, which can be used to help students reflect on their practice:

Level	Stage	Example questions to get students started
1	Reporting	Recounting an experience (eg. an event, incident, issue etc.): What happened? Who was involved? What is significant about what happened?
2	Relating	Making a connection with previous experiences, discipline knowledge etc.: Have I encountered this before? Were the conditions the same or different? What knowledge/skills are relevant, and why?
3	Reasoning	Explaining what happened: How do I explain what happened, and how do I justify my reasoning?
3	Reconstructing	Informing future practice and/or professional understanding: How would I deal with this next time? What might work and why? Are there different options? What has this taught me about my practice / about myself? How will I use this experience to further improve my practice in the future?

The following video vignette shows a clinical supervisor helping a student to reflect on her practice. While you watch the video, think about the following questions:

• How well do you think the supervisor facilitated the student to reflect on her practice?
• What particular strengths did you observe in the supervisor's approach?
• What do you think she should have done differently (and why)?
• As compared to what is shown in the video, how similar/different are the strategies that you use for helping students to reflect on practice?

Reference
Ryan, M. E. & Ryan, M. C. (2012). Theorising a Model for Teaching and Assessing Reflective Learning in Higher Education. Higher Education Research & Development, iFirst, 2012, 1-14.

Giving constructive feedback

We all need constructive feedback in order to improve. Therefore, it will be no surprise that giving and receiving feedback on performance is an essential part of learning in the clinical workplace. However, giving constructive feedback is surprisingly difficult to do well. There are several models and frameworks for giving feedback which aim to ensure that it is specific, fair and useful to the student. The BOOST model is briefly described below:

Balanced	Include both good and bad points.
Observed	Only give examples of what you have seen the learner see and do, don't bring in your preconceptions or previous experience.
Objective	Make sure your feedback is factual and based on actions, not any prior emotional response you may have to the person.
Specific	Always use specific examples to illustrate a comment. Exactly why or how was the action done well or badly? Avoid broad statements.
Timely	Feedback should be given as close to the event as possible to ensure accuracy and effectiveness.

Other things to consider are where and when you give feedback, and who else is present at the time. A further consideration is how much feedback to give in order to maximise learning, and not overload the learner.

The following video vignette shows a clinical supervisor giving feedback to a student. While you watch the video, think about the following questions:

• How well do you think the supervisor applied the BOOST principles?
• What particular strengths did you observe in the supervisor's approach?
• What do you think she should have done differently (and why)?
• How similar/different are the strategies that you use for providing feedback to students on their performance?

You can also view a description of the BOOST model as a video by clicking here.

From the University College of London Medical School https://www.ucl.ac.uk/medicalschool/teaching-portal/teaching-skills/teaching-resources/giving-feedback