Sarah Yardley

Kirkpatrick's levels and education evidence'

Medical Education 2012: 46: 97–106

Experiential learning: AMEE guide No. 63

This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is ‘situated’; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.

Experiential learning: Transforming theory into practice

Whilst much is debated about the importance of experiential learning in curriculum development, the concept only becomes effective if it is applied in an appropriate way. We believe that this effectiveness is directly related to a sound understanding of the theory, supporting the learning. The purpose of this article is to introduce readers to the theories underpinning experiential learning, which are then expanded further in an AMEE Guide, which considers the theoretical basis of experiential learning from a social learning, constructionist perspective and applies it to three stages of medical education: early workplace experience, clerkships and residency. This article argues for the importance and relevance of experiential learning and addresses questions that are commonly asked about it. First, we answer the questions ‘what is experiential learning?’ and ‘how does it relate to social learning theory?’ to orientate readers to the principles on which our arguments are based. Then, we consider why those ideas (theories) are relevant to educators – ranging from those with responsibilities for curriculum design to ‘hands-on’ teachers and workplace supervisors. The remainder of this article discusses how experiential learning theories and a socio-cultural perspective can be applied in practice. We hope that this will give readers a taste for our more detailed AMEE Guide and the further reading recommended at the end of it.

What has changed in the evidence for early experience? Update of a BEME systematic review

Background: We previously reviewed evidence published from 1992 to 2001 concerning early experience for healthcare undergraduates (Dornan T, Littlewood S, Margolis S, Scherpbier A, Spencer J, Ypinazar V. 2006. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Med Teach 28:3–18). This subsequent study reviews evidence published from 2002 to 2008. Aims: Identify changes in the evidence base; determine the value of re-reviewing; set a future research agenda. Methods: The same search strategy as in the original review was repeated. Newly identified publications were critically appraised against the same benchmarks of strength and educational importance. Results: Twenty-four new empirical studies of early authentic experience in education of health professionals met our inclusion criteria, yielding 96 outcomes. Sixty five outcomes (from 22 studies) were both educationally important and based on strong evidence. A new significant theme was found: the use of early experience to help students understand and align themselves with patient and community perspectives on illness and healthcare. More publications were now from outside Europe and North America. Conclusions: In addition to supporting the findings of our original review, this update shows an expansion in research sources, and a shift in research content focus. There are still questions, however, about how early authentic experience leads to particular learning outcomes and what will make it most educationally effective.

Improving training in spiritual care: a qualitative study exploring patient perceptions of professional educational requirements.

Healthcare professionals express difficulties in delivering spiritual care, despite it being a core component of palliative care national policies. The patient perspective on professional training to address difficulties has not previously been sought. The aim of this study is to describe patient suggestions for development of training to deliver spiritual care. Qualitative semi-structured in-depth ‘palliative patient’ interviews (n = 20) were analysed thematically. Training suggestions encompassed practical care delivery. Patients supported staff who introduced questions about spiritual needs, and they expected opportunities to engage in spiritual care discussions. The ‘right’ attitude for spiritual care delivery was defined as being non-judgemental, providing integrated care and showing interest in individuals. Training issues included patient perspectives of boundaries between personal and professional roles. This study provides ‘palliative patient’ perspectives to strengthen recommended models of spiritual care delivery. It shows that user opinions on training can be helpful not only in deciding objectives but also how to achieve them.

The consequences of authentic early experience for medical students: creation of mētis

Context  Authentic early experience (AEE) describes experiences provided to new medical students to undertake ‘human contact’ to enhance learning. Although the concept of AEE is not new, and was commonplace prior to the Flexner Report of 1910, little is known about how or why meaning and knowledge are constructed through early student placements in medical, social and voluntary workplaces. Variance among settings means AEE is a collection of non‐uniform, complex educational interventions which require students to make repeated transitions between different workplaces and their university institution. The purpose of this paper is to develop theory in this context.

Authentic early experience in Medical Education: a socio-cultural analysis identifying important variables in learning interactions within workplaces

This paper addresses the question ‘what are the variables influencing social interactions and learning during Authentic Early Experience (AEE)?’ AEE is a complex educational intervention for new medical students. Following critique of the existing literature, multiple qualitative methods were used to create a study framework conceptually orientated to a socio-cultural perspective. Study participants were recruited from three groups at one UK medical school: students, workplace supervisors, and medical school faculty. A series of intersecting spectra identified in the data describe dyadic variables that make explicit the parameters within which social interactions are conducted in this setting. Four of the spectra describe social processes related to being in workplaces and developing the ability to manage interactions during authentic early experiences. These are: (1) legitimacy expressed through invited participation or exclusion; (2) finding a role—a spectrum from student identity to doctor mindset; (3) personal perspectives and discomfort in transition from lay to medical; and, (4) taking responsibility for ‘risk’—moving from aversion to management through graded progression of responsibility. Four further spectra describe educational consequences of social interactions. These spectra identify how the reality of learning is shaped through social interactions and are (1) generic-specific objectives, (2) parallel-integrated-learning, (3) context specific-transferable learning and (4) performing or simulating-reality. Attention to these variables is important if educators are to maximise constructive learning from AEE. Application of each of the spectra could assist workplace supervisors to maximise the positive learning potential of specific workplaces.

Ethical Issues in the Reuse of Qualitative Data: Perspectives From Literature, Practice, and Participants

In this article, we explore ethical issues in qualitative secondary analysis through a comparison of the literature with practitioner and participant perspectives. To achieve this, we integrated critical narrative review findings with data from two discussion groups: qualitative researchers and research users/consumers. In the literature, we found that theoretical debate ran parallel to practical action rather than being integrated with it. We identified an important and novel theme of relationships that was emerging from the perspectives of researchers and users. Relationships were significant with respect to trust, sharing data, transparency and clarity, anonymity, permissions, and responsibility. We provide an example of practice development that we hope will prompt researchers to re-examine the issues in their own setting. Informing the research community of research practitioner and user perspectives on ethical issues in the reuse of qualitative data is the first step toward developing mechanisms to better integrate theoretical and empirical work.

Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery

BackgroundPeople are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked ‘what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?’MethodsThis realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.ResultsThe final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.ConclusionsThis study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.Trial registrationPROSPERO International prospective register of systematic reviews CRD42013003862

Symptom perceptions and help-seeking behaviour prior to lung and colorectal cancer diagnoses: a qualitative study

Background. Lung and colorectal cancer are common and have high UK mortality rates. Early diagnosis is important in reducing cancer mortality, but the literature on lung and colorectal cancers suggests many people wait for a considerable time before presenting symptoms. Objective. To gain in-depth understanding of patients’ interpretations of symptoms of lung and colorectal cancer prior to diagnosis, and to explore processes leading to help-seeking. Methods. Semi-structured interviews were conducted with patients diagnosed with lung (N = 9) or colorectal (N = 20) cancer within the previous 12 months. Patients were asked about symptoms experienced in the period preceding diagnosis, their interpretations of symptoms, and decision making for help-seeking. Thematic analysis was conducted and comparisons drawn within and across the patient groups. Results. Patients were proactive and rational in addressing symptoms; many developed alternative, non-cancer explanations based on their knowledge and experience. Discussions with important others frequently provided the impetus to consult, but paradoxically others often initially reinforced alternative explanations. Fear and denial did not emerge as barriers to help-seeking, but help-seeking was triggered when patients’ alternative explanations could no longer be maintained, for instance due to persistence or progression of symptoms. Conclusion. Patients’ reasoning, decision making and interpersonal interactions prior to diagnosis were complex. Prompting patients for additional detail on symptoms within consultations could elicit critical contextual information to aid referral decisions. Findings also have implications for the design of public health campaigns.