Creating space

30 pages of high quality, concise and clear information about community placements

Introduction

Experiential learning has been conceptualised as a continuous adaptive and transformative process arising from interior dialogue characterized by the working through of tension produced by the interaction of material experience and abstract ideas and prior and new knowledge (Kolb, 1984).

Critics of experiential learning have both questioned the ontological and epistemological assumptions underpinning this view and also argued that there is no robust evidence that practice that takes its lead from experiential learning theory has any added value in terms of educational outcomes when compared to other approaches (Kirschner et al., 2006).

In light of this critique what are we to make of the accounts from students and from organizations that provide them with community placement opportunity reported elsewhere in this blog which seem to demonstrate that learning is happening, that it is different in character and valency to that occurring elsewhere in medical education and a complement and addition to it?

A closer reading of the critiques of experiential learning may provide one route to a plausible explanation. These suggest that a lack of structure and context may in important ways limit the capacity of experiential learning to achieve transformative outcomes; that learners cannot easily escape the bounds of their lived experience without the provision of support and guidance from others as a kind of toolkit to doing so.

CBP programmes have plenty of structure and context and perhaps it is this that creates potential for experiential learning of value to take place.

Both context and structure have a number of dimensions.

I tend to think of context as the wider, more abstract space around and within which CBP takes place. I would include as context ways that CBP takes place in a different space and setting to other aspects of the programme (specifically, not a university or medical environment) and often involves different kinds of resources and materials. I also think that the approach to learning and vision of knowledge and understanding is rather different to much of medical education. I would also want to situate the value attached to CBP and the weighting that carries in assessment as part of the context. If one conceptualizes context as a field of similarities and differences between CBP and a wider programme of medical education it is possible to understand it, as I think students do, as both complement and critique of medicine and medical education.

I think of structure as being about the organizational dimensions of CBP – the what, when, where and how of its operation. I think what structure does is create a narrative trajectory into which placement experience as can be inserted as learning.

It is important that structure preserves enough scope and offers sufficient freedom to the student that they can have an immersive experience and yet gives shape and provides what we might think of narrative impetus and coherence to the experience.

The balancing act between this ‘framing and freeing’ can be considered in all sorts of ways in CBP. For example, how does one use assessment to move things on, prompt the adaptive and process aspects of learning without creating an imposition that distracts students and demands the concretising of thinking which may be inimical to learning? How does on supervise and orient students’ action in ways that maximize breadth of exposure to a setting without rushing them through and past complex experience? How long should they be in the field? In what ways should time in the field be made explicitly to talk to other learning contexts or bracketed off?

Reflecting particularly on observations and encounters at Monash here’s my sense of important elements and considerations with regard to structuring the CBP experience.

Timing and timescales

When should community-based experiential learning take place?

At Monash the CBP programme sits in second year. The Durham community placement straddles Year 1 and 2. The common-sense assumption is that because curricula in medical education are spiral (reiterative and accretive) early intervention provides the basis for later learning. In the case of CBP, the proposition is that by coming early in a UG programme it underpins and orients students’ thinking and attitudes towards not just their future academic learning but also their approach to future clinical practice.

How long should a programme of CBP be and with what frequency should students be in the community?

At Monash CBP lasts 14 weeks spread across two semesters that are separated by a break of around 7 weeks.  At Durham students spend 20 weeks on placements in two blocks of 10 weeks separated by a period of 4 months made up of exams and a long vacation. The Monash students spend one day a week (Tuesday) during CBP with their provider organization. That yields a total of 84 hours of planned engagement in the programme. At Durham the placement experience also takes place once a week (Thursday afternoon) and yields a total 60 hours of planned engagement.

The benefits of chunking CBP into day long blocks are considerable. Indeed, Monash moved to this structure from half days about 8 years ago. This was because students recognized that practical demands, such as travelling between campus and community, were minimized by this arrangement. They also liked the freedom to focus on CBP for the day without the distraction of incorporating other studies. For providers the extended availability of students was an asset. Planning activities was easier and also their integration to the daily pattern of work.

Getting started

Getting students attached to the ‘right’ placement is important. However, what constitutes the ‘right’ placement is neither a straightforward matter nor is the attachment achieved without some art and craft.

My sense is that while students may have preferences for placements in certain areas (both in terms of geography and topical focus) and be looking for opportunities to engage with certain groups (children and young people, elderly, and so on) learning does not necessarily succeed or fail on the basis of a student attending a placement which fulfils all the parameters that they might identify. Of course, it’s important that there is good a degree of fit between a student’s interest and aspiration, learning intent and ambition and opportunities on offer but, as I will describe elsewhere, most people who work with students in community-based organizations are creating the opportunity or experience with students and around them so placements are highly reflective of both expressed and emergent needs and interests.

 

So, who gets what placement and how?

There does need to be some process by which student views and provider-identified opportunities are brought into rapproachment and form the basis for attaching students to organizations.

This is about negotiating the fine lies between allocation and selection, preference and choice. At Monash, where staff are placing more than 300 students in the community each year and working with over 100 community-based organizations, and where the work is done by one academic and less than one administrator, this is a demanding process completed to an exacting timescale (but it shows it can be done and done in a city – pay attention big, metropolitan medical schools in the UK).

The logistics of matching students to placements and the limitations imposed by the capacity of placement providers mean that it is unrealistic to offer students the opportunity to choose which placement they attend. The art is to facilitate wise indications of preference from students and to elicit sufficient information to make choices about where to place them that align most closely with their interests.

 

Presentation of information

The key task is to get students informed about placements. At Monash this is done through a website which contains profiles for each of the organisations that offer to take students. Each profile outlines the service, proposed activities and tasks and any prerequisites for student knowledge or skills. Profiles also contain links to agency websites.

The importance of thinking about setting and learning aspirations and opportunities is emphasized above but not to the exclusion of noting the relevance of other considerations in indicating preference such as logistics.

A Monash student can peruse the database of placement opportunities by sector (schools; facilities for the elderly; community health; etc.) location, and consider the extent of client interaction of offer and so on.

A Monash this process of proposing preferences is supported by a series of lectures and tutorials in which the relation of the CBP to the wider programme is spelt out, the way that public, welfare and community level organizations relate to one another, the range placements on offer described and expectations around ethical, professional and legal practice and behaviour in the context of CBP. In recent years some field educators (representatives of agencies) have contributed to the provision of information at this early point in the process.

Selection/election/choice or allocation?

The only practical and workable approach is to offer students the chance to indicate preferences and then use these to inform allocations. At Monash a student is allowed up to 7 preferences giving plenty of scope for the formation of a good ‘match’ in allocation. Thereafter the allocation process is random.

Getting to know you, getting to know all about you

Having been allocated to a placement the students need to make contact and be assessed by the placement provider. I really like the way Monash handle this. They set up a series of expectations that students must fulfill (so-called ‘hurdle requirements) including:

  • Making contact with their placement provider by a specific date;
  • Attending an interview with the placement field educator (the person who will supervise and support the placement) on one of two dates (effectively one of the first two placement sessions);
  • Doing this alongside the other students (usually between 2 and 8 in total) who are attending the same placement;
  • And, submit an agreement arising from this meeting for consideration by their academic adviser.

What I like about this is as follows:

  • It gives the relationship between student and provider the right gravity and valency – it’s a volunteer role, it’s about service to the provider and also it values the students’ skills and contribution;
  • It puts group work front and centre in the placement learning experience. Students are a resource for each other in CBP and will have to work together as professionals. This helps to set that up;
  • It means every student and every provider has a structured opportunity to clarify expectations, begin to draft a learning agreement/plan of work and focus on what the student can do for the placement organization.

Aims, assessments and assessing

The CBP programme Monash has some intended outcomes that relate to both students’ community practice and knowledge and understanding of health promotion. Intended outcomes associated with community practice include being able to describe the ways that CBOs and various professionals and others within them work and are funded and organised, their roles in community health, welfare and well-being and advocacy and a cluster around understanding diversity in the population, the impact of social and economic factors and context on health.

I am not too concerned here with the detail around outcomes associated with health promotion but want to note that these reflect the way that a health promotion task is tailored into CBP as a means of grounding students’ learning and also supporting organizational development. More on this in a moment.

It’s worth noting that the way that outcomes function in terms of processes, complexities and diversity of experiential learning warrants further consideration and it is an issue that I will try and return to at future date. For now, I just want to stake out some interest in the challenges that might arise from bringing together a potentially reductionist and holistic understanding of learning.

Assessment points and assessors

A striking feature of the Monash CBP programme is the diversity of assessments, assessment points and assessors involved. It’s also worth noting CBP is worth a lot; that is in the region of 20% of the total assessment during the year.

Here are some highlights:

The placement plan

This document frames the progress of the placement. It comprises agreements on support, briefing and debriefing arrangements between the field educator (placement provider) and student, a statement of personal learning objectives by each student AND three goals – one for the student (something personal that they want to develop in the form of knowledge or skills) – one for the field educator (what skills and knowledge do they want the student(s) to develop) – and one for the group of students (in what way will they contribute as a group to the organization?)

This plan is a hurdle requirement and is assessed by the academic adviser (tutor). It has to be completed and submitted within the first few days of the placement.

Health promotion hypothetical

At Monash students are expected to work together to do something concrete and productive for the placement provider. Ideally this is a task or activity that could not be performed without their input. The hypothetical is a way of structuring and grounding this.

It has two parts. First, the hypothetical proposalwhich is 750 words. It has to be submitted after 4 days on placement.

Students are expected to identify (with the provider) a topic for health promotion in the organization. It might be around exercise, diet, links between agencies, addressing a knowledge, skill or information need in the community or initiating or supporting a structural change. The hypothetical proposal involves proposing the activity and identifying and drawing on some supporting literature to propose it.

The hypothetical assignment is 3000 words. This has to be submitted at the end of the placement (in fact about a month after the end)

This is the full account of the proposal made above including assessments and evaluations of the feasibility of the proposed intervention, the resource and material requirements and an embedding of the activity in an evidence base (including identifying if it doesn’t exist!). The hypothetical is a group product and should ideally include descriptions of actions and activities associated with implementing the intervention on placement.

Reflective essay and journal

Each student also writes a 1250 reflective essay about the CBP experiences. At Monash a student is expected to incorporate reflections of multi- and/or inter- disciplinary working, working with the client group and team working (with other students).

Students are also expected to submit one entry into an online reflective journal after every CBP visit. The journal has to be complete at the end of the placement (final submission is about a month after)

PPD assessment

Students are also assessed on their professionalism and engagement with CBP and the health promotion activities and associated on-campus tutorials by Academic Advisers (tutors). This assessment takes place twice and uses a likert-type scale to rate each student on their contribution, response to advice and guidance attendance, punctuality and group work skills. PPD assessments take place after about 5 weeks and again at the end of the placement. At least one of the tutorials takes place at the placement setting and may involve both the field educator and academic adviser.

Field Educator assessment

The field educator also assesses student progress, engagement and learning from CBP via a pro forma. This assessment comes at the end of the placement. They also sign off on the students’ log of attendance.  Monash is very clear about this. Attendance is expected on a weekly basis unless absence is requested or notified for medical or other good reason. Days lost are to be made up and attendance is 9 – 5 unless the placement provider and student agree to other hours for reasons associated with placement activities.

Support and guidance

CBP is demanding. Students are expected to engage in ‘real’ productive activity, to work together and to write about this, reflect on it and link it to evidence and reading. They do need support.

At Monash this comes via lecture and tutorials (and as I’ve mentioned above at least one of the tutorial takes place at the placement), via the field educator, academic adviser all backed up by the CBP team and a variety of other resources.

The field educator

I will describe the field educator role in more detail elsewhere in this blog but essentially the role is to monitoring and support students whilst on placement. They sign off on hours attended, hold daily briefings and de-briefings, assess students’ progress and contribution and link to the university.

The Academic adviser

The Academic adviser is a representative of the University (some were sessional staff and others FT academics) who run tutorials associated the programme including at least one site visit and tutorial with students whilst they are on placement. An academic adviser conducts the assessment of student participation and contribution to tutorials and marks their assignments.

Student peers

CBP at Monash attaches a lot of importance to group work, support and learning among students. The rationale is simple – doctors have to be part of teams and learning to doctor should prepare them for this.

Students also share experiences across placements both via informal networks and feedback into tutorials (which are centred around placement activities and learning as the context for exploring health promotion theory and practice). Of course, group work is not without its challenges often times around students feeling that contributions to activities (especially assessed activities) are inequitable. As a consequence the course handbook includes advice on group dynamics and working

The course lead and administrator

The course lead and administrator provide support to students, field educators and academic advisers and represent the CBP programme within the wider programme. It’s a lot of work. In my time at Monash these staff tended to arrive at work between 8 and 8.15 left after 5 and nearly always took work home.

Something I really liked was that the CBP lead spent one day a week (placement day, Tuesday) on the road visiting organisations and students.

They also provided a rolling training programme to field educators and academic advisers alongside liaising with academic colleagues who led the input to health promotion course which run alongside and into CBP.

Handbooks and materials

The course handbook is important. The Monash version is integrated – it contains sections for students, academic advisers and field educators, paper copies of forms and other useful information. It runs out at 30 pages. There has been conscious effort to reduce it in size and to make it accessible. It is available online but also a good quality, ‘glossy’ paper resource.

But the main and most impressive means of support is the website. CBP at Monash has its own, externally accessible and interactive site which holds all the information listed above and act as the portal for submission of assignments, reflective logs and so on.

You can look at the Monash portal at  www.cbpp.med.monash.edu.au

 

Some reflections

  • Process, process, process. CBP learning is a process and so therefore should be assessment and monitoring. This requires robust supporting structures and practice – a good website/database, capacity for staff to have regular contact with organizations providing placements etc. – and the development of appropriate (hence diverse), ongoing assessment points.
  • Value, value, value. If you are committed to CBP then invest in it (see above) but also give it weight in your programme (a day a week) and weight in assessment. Make some assessment hurdles and make others important such that they reward the endeavour of the engaged student, reflect the investment of the placement providers, and might encourage the instrumental learner.
  • Start with CBP? Why not think about building a programme outwards from CBP? If medicine the social practice of science then why not place CBP at the centre and construct the rest of the programme around it?
  • Why not have CBP throughout a programme rather than confine it Phase 1? The value it can confer, opportunities for learning it can offer and engagement with communities do not cease at the end of Phase 1 why break those links then?
  • Put your tutors in the field – it gives them and students a better sense of the value of community and also allows them interact with the provider.
  • Include assessable group work in your CBP. If we really want doctors to work together then we have find ways reflecting and facilitating that in medical education.

References

Kirschner, P.A., Sweller, J. and Clark, R.E. (2006) Why Minimal Guidance During Instruction Does Not Work: An Analysis of the Failure of Constructivist, Discovery, Problem-Based, Experiential, and Inquiry-Based Teaching, Educational Psychologist, 41(2): 75-86

Kolb, D. (1984) Experiential learning: experience as thesource of learning and development.  Englewood Cliffs, NJ: Prentice Hall.

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About learningtodoctor

Simon is Senior Teaching Fellow at Durham University.
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