Module 2: Learning Styles / Adult Learning Principles

Objectives

  • To understand adult learning principles
  • Knowledge of how to appropriately situate learning for the adult learner using the Critical Reasoning Cycle
  • Identify your own learning style and understand how this may influence comprehension
  • Understand emotional intelligence and how this impacts on interactions

The Adult Learner:

Adult learning theory is based on the understanding that adults are:

  • autonomous and self-directed;
  • have accumulated a foundation of life experiences and knowledge;
  • goal and relevancy-orientated;
  • practical;
  • need to be shown respect.

The experiential learning cycle helps inform this theory. An adult will have an experience; think about it; identify the learning needs for the future; plan what needs to be undertaken; and apply new learning in practice. Good feedback will help the learner to establish the links between these steps. As a clinical supervisor / preceptor, it will be helpful to understand how and why adults learn.

Think of how, what and why you learn.

Characteristics of Adult Learners

  • Adults are independent and able to self - direct their learning
  • Previous experience informs their decisions
  • Life experience provides a rich source of learning and experiences on which to draw
  • Readiness to learn
  • Adults base new learning on old frameworks
Implications for Preceptors / supervisors
  • Takes longer to change beliefs and values
  • Reluctant to change practices
  • Provide sharing of experiences
  • Teach through actual experiences
  • Keep expectations realistic
  • Are actively involved in learning
  • Avoid wasting their time
  • Ensure chances for success
  • Provide support and guidance
  • Give learner control over pace
  • Make learning useful to work
  • Relate as helpful colleague
  • Address perceived problems first
  • Must be applicable to practice

Adults want to learn what they can use today (Knowles 1980)

Characteristics of Adult Learners
  • Have established beliefs and values
  • Are less flexible in thinking
  • Have rich reservoir of experiences
  • Learn by own and others experience
  • Have mixed motives for learning
  • Are accustomed to responsibilities
  • Are busy with many obligations
  • Less secure in learning situations
  • Fear inadequacy and failure
  • May need more time to learn
  • Don’t see supervisor as all knowing
  • Are problem-centred learners
  • Are reality-centred learners

(Partners in Health, Preceptorship Package, 2005).

Clinical reasoning cycle

Clinical reasoning is a cognitive and metacognitive process that involves elements of critical thinking (thinking like a health professional). It is a cognitive process that manifests into an action. There are four categories of action: clinical skills, clinical knowledge, problem solving and reflection, (Jeffrey & Bourgeois, 2010).

Clinical reasoning is a way clinicians can think about the issues they encounter in clinical practice.

Clinical reasoning cycle

(Levett-Jones et al, 2009) Source

Clinical reasoning (CR) is based on what expert/experienced practitioners do automatically or instinctively (tacit knowledge). They engage in CR multiple times for each patient in their care. CR offers learners a model and explanation of what may seem tacit and implicit. Poor CR skills result in failure to collect cues and therefore failure to take action. CR is an educational model that has the potential to enhance your learner’s skills. It also provides a language that supervisors / preceptors can use to facilitate discussion and reflection on case based learning and simulation. It is a language to assist the novice to learn from experiences in practice.

The following chart outlines how CR may be used in the practice setting. It is extracted from the nursing context but the process is relevant to any discipline and setting.

ProcessDescriptionExample
Consider the patient situation Describe or list facts, context, objects or people. This 60 year old patient is in ICU because he had an abdominal aortic aneurysm (AAA) surgery yesterday
Collect cues/
information
Review current information (e.g. handover reports, patient history, patient charts, results of investigations and assessments previously undertaken) He has a history of hypertension and he takes beta blockers
His BP was 140/80 an hour ago
Gather new information (e.g. undertake patient assessment) I’ve checked his BP and it is now 110/60, Temp 384.
Epidural running @ 10ml/hr
Recall knowledge (e.g. physiology, pathophysiology, pharmacology, epidemiology, therapeutics, culture, context of care, ethics, law etc) BP is related to fluid status.
Epidurals can drop the BP because they cause vasodilation.
In ICU we have standing orders for epidural management.
Process information Interpret: analyse data to come to an understanding of signs or symptoms. Compare normal Vs abnormal. His BP is low, especially for a person who is normally hypertensive.
Discriminate: distinguish relevant from irrelevant information; recognise inconsistencies, narrow down the information to what is most important and recognise gaps in cues collected. His temp is up a bit but I’m not too worried about it – I’m more concerned about his BP and pulse.
I’d better check his urine output and his O2 sats.
Relate: discover new relationships or patterns; cluster cues together to identify relationships between them. His hypotension, tachycardia and oliguria could be signs of impending shock.
His BP went down after we increased the epidural.
Infer: make deductions or form opinions that follow logically by interpreting subjective and objective cues; consider alternatives and consequences. His BP could be low because of blood loss during surgery or because of the epidural
Match current situation to past situations or current patient to past patients (usually an expert thought process) Patients who have undergone an AAA repair often have hypotension post operatively
Predict an outcome (usually an expert thought process) If I don-t give him more fluids he could go into shock
Identify problem / issue Synthesise facts and inferences to make a definitive diagnosis of the patient’s problem. He is hypovolaemic and the epidural has worsened the BP by causing vasodilation.
Establish goals Describe what you want to happen, a desired outcome, a time frame. I want to improve his haemodynamic status – get his BP up and urine output back to normal over the next hour.
Take action Select a course of action between different alternatives available I will ring the doctor to get an order to increase his IV rate and to give aramine if needed.
Evaluate Evaluate the effectiveness of outcomes and actions. Ask: “has the situation improved now?” His BP is up for now but we will need to keep an eye on it as he may still need aramine a bit later. His urine output is averaging > 30mL/hr now.
Reflect on process
and new learning
Contemplate what you have learnt from this process and what you could have done differently. Next time I would …
I should have …
If I had …
I now understand …

Adapted from Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine. 78(8), 1-6.

It is important for clinical supervisors / preceptors to use language that leads the learner through the journey of exploration. Here are some examples that may act as cues when questioning learners.

Responses from supervisors / preceptors that can be used to encourage, facilitate and promote effective clinical reasoning
  • Let’s explore this.
  • Let’s think this through.
  • Now let’s consider all the possible options/solutions/outcomes.
  • Show me how you came to that decision
  • Walk me through your thinking about this.
  • That is one option; let’s explore some others.
  • What are some possible outcomes of this approach?
  • That is a good thought/answer/response/idea … let’s expand on it.
  • Let’s consider some alternatives
  • Let’s figure this out.
  • Tell me about what you’ve learnt so far.
  • Great question!
  • Where would we find the answer to that?
  • Let’s try that one again.
  • Why don’t you lead us through that process?
  • It’s not just about the right answer it’s about learning the process
  • Good try … have another go.
  • Now that you’ve worked that out let’s try ….
  • OK. You are on the right track. Let’s try something a little more challenging now.
  • Have you considered what could happen if …
  • That is correct in this situation and for this person but what if …
  • What do you think about ….
  • How do you know that to be true … on what do you base your answer?

With any new concept there are certain pitfalls that can occur. The following table outlines some of the more common Clinical Reasoning errors that may occur.

Clinical Reasoning Errors
ErrorDefinition
Anchoring The tendency to lock onto salient features in the patient’s presentation too early in the clinical reasoning process, and failing to adjust this initial impression in the light of later information. Compounded by confirmation bias.
Ascertainment bias When a practitioner’s thinking is shaped by prior assumptions and preconceptions, for example ageism, stigmatism and stereotyping
Confirmation bias The tendency to look for confirming evidence to support a clinical diagnosis rather than look for disconfirming evidence to refute it, despite the later often being more persuasive and definitive.
Diagnostic momentum Once labels are attached to patients they tend to become stickier and stickier. What started as a possibility gathers increasing momentum until it become definite and other possibilities are excluded.
Fundamental attribution error The tendency to be judgemental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that may have been responsible. Psychiatric patients, those from minority groups and other marginalised groups tend to be at risk of this error.
Overconfidence bias A tendency to believe we know more than we do. Overconfidence reflects a tendency to act on incomplete information, intuition or hunches. Too much faith is placed on opinion instead of carefully collected cues. This error may be augmented by anchoring
Premature closure The tendency to apply premature closure to the decision making process, accepting a diagnosis before it has been fully verified. This error accounts for a high proportion of missed diagnosis.
Psych-out error Psychiatric patients are particularly vulnerable to clinical reasoning errors, especially fundamental attribution errors. Co-morbid conditions may be overlooked or minimalised. A variant of this error occurs when medical conditions (such as hypoxia, delirium, electrolyte imbalance, head injuries etc.) as misdiagnosed as psychiatric conditions.
Unpacking principle Failure to collect all the relevant cues in establishing a differential diagnosis may result in significant possibilities being missed. The more specific a description of an illness that is received, the more likely the event is judged to exist. If an inadequate patient history is taken unspecified possibilities may be discounted.

Adapted from Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine. 78(8), 1-6.

Learning styles

Many people recognise that each person prefers different learning styles and techniques. Learning styles group common ways that people learn. Some people may find that they have a dominant style of learning, with far less use of the other styles. Others may find that they use different styles in different circumstances. There is no right mix. Nor are your styles fixed. You can develop ability in less dominant styles, as well as further develop styles that you already use well.

Using multiple learning styles and multiple intelligences for learning is a relatively new approach. This approach is one that educators have only recently started to recognise. Traditional schooling used mainly linguistic and logical teaching methods. It also used a limited range of learning and teaching techniques.

By recognising and understanding your own learning styles, you can use techniques better suited to you. This improves the speed and quality of your learning.

THE SEVEN LEARNING STYLES   (http://www.learning-styles-online.com/overview/)

  • Visual (spatial): You prefer using pictures, images, and spatial understanding.
  • Aural (auditory-musical): You prefer using sound and music.
  • Verbal (linguistic): You prefer using words, both in speech and writing.
  • Physical (kinesthetic): You prefer using your body, hands and sense of touch.
  • Logical (mathematical): You prefer using logic, reasoning and systems.
  • Social (interpersonal): You prefer to learn in groups or with other people.
  • Solitary (intrapersonal): You prefer to work alone and use self-study

Learning Styles Chart
Source

ACTIVITY: Go to the link below to identify your learning style.

Website: free on line learning style identification

Duration: 16 questions

A quick free on-line questionnaire that helps you to identify the way you learn the best.

http://www.vark-learn.com/english/page.asp?p=questionnaire (new window)

REFLECTIVE EXERCISE: What was identified as being your learning style preferences and how will this inform your practice as a preceptor into the future?

Learning Styles ChartTip: To consolidate learning, have a student present a patient case study to the unit or another staff member to help reinforce knowledge!

Common Problems in Student Learning Experiences

These are some of the more common problems that you may encounter as a clinical supervisor / preceptor:

  1. Lack of learner focus:         
    • The learner attempts to do too many things at one time - the result can be failure to make a useful amount of progress in any one area
    • Focus may be reduced by lack of logical progression and limited grouping of related activities
  2. Loss of learning opportunities:
    • Many opportunities may be difficult to use effectively
    • Sometimes productivity can conflict  with learning needs
    • Expectations may be unrealistic and sometimes do not reflect the amount of preparation, orientation and support provided
    • Some important events occur unexpectedly
  3. Mistakes:
    • Reflect on how you feel when you make mistakes
    • Mistakes can happen
    • The pressure not to make mistakes is immense
  4. Supervised practice:
    • Supervised practice can be an intimidating experience
    • Few of us are truly at ease when someone is looking over our shoulder
    • Find ways to help without interfering (unless the actions have the potential to cause harm)

Emotional intelligence

Salovey & Mayer (1990) define ‘Emotional Intelligence’ as "the subset of social intelligence that involves the ability to monitor one's own and others' feelings and emotions, to discriminate among them and to use this information to guide one's thinking and actions" (cited in Cherniss & Goleman 2001, ‘The emotionally intelligent workplace’).

Emotional Intelligence is the integration of thought and feeling; between cognition and emotion. Goleman discussed four domains: Self-awareness; self-management; social awareness; and relationship management (Goleman, 2001). Having a higher awareness of these principles assists people to be more effective in the work place. Cherniss and Goleman’s book ‘The Emotionally Intelligent Workplace’ (2001) is available as a free download at the following site:

http://downloadmore.in/ebooks/Management/[downloadmore.in]Management_Ebook_The%20Emotionally%20Intelligent%20Workplace.pdf

ACTIVITY: Go to the link below to discover your emotional intelligence rating!

website:   HAY GROUP - EMOTIONAL INTELLIGENCE QUIZ

Duration: 13 questions

A quick free on-line questionnaire that helps you to identify your emotional intelligence.

http://www.haygroup.com/leadershipandtalentondemand/Demos/EI_Quiz.aspx

REFLECTIVE EXERCISE:  Do these results surprise you? Reflect upon a past situation and describe how an increased emotional intelligence may have changed the outcome.