Beyond knowledge and skills: the use of a Delphi study to develop a technology-mediated teaching strategy

Effective clinical practice requires that health professionals work within the dynamic, non-linear and complex environments of healthcare systems, and to engage with ill-structured problems that have no clear solutions [1]. They need to “adapt to change, generate new knowledge, and continue to improve their performance” over time. These attributes (defined as capability) [2] require more from the practitioner than a mere set of knowledge and technical skills. In order to effectively operate within the complex environments of healthcare settings, practitioners need abilities that include, but go beyond the knowledge and basic technical skills (defined as competence) [2] that are emphasised in undergraduate training. This includes having positive attitudes towards continuing professional development, lifelong learning, evidence-based practice, information and knowledge management and interprofessional collaboration [2].

In addition to discipline-specific knowledge, technical skills and generic attributes, healthcare practitioners are also moral agents who make decisions about patients based on personal connections and relationships with them. Values, beliefs and emotional factors are embedded within the interactions between healthcare providers and patients, suggesting that these interactions are more than the exchange of information. This active engagement with, and acknowledgement of, the emotional response to patients’ stories can help to develop the moral agency that is a necessary part of ethical clinical practice [3].

However, developing these attributes and attitudes requires a cultural change in teaching practices that focus on the development of knowledge and skills. Many clinical educators still adhere to a lecture and transmission-based approach to teaching [4], which is problematic if capability is the goal because it cannot be passively assimilated, and requires significant changes in clinical education that move it from being product- to process-oriented [2]. Teachers who adopt a transmission-based approach to teaching encourage the rote learning of facts, and a resultant superficial understanding of the topic. In contrast, teaching approaches that focus on the process of conceptual change lead to deep learning [4], and include informal and unplanned, self-directed and non-linear learning experiences. Specific strategies include, among others, experiential learning, reflective exercises, feedback, peer-supported small groups, case-based and problem-based learning, and role play [5].

Some clinical educators are beginning to experiment with technology-mediated teaching and learning practices, which blends classroom-based, face-to-face learning experiences with online interaction. This approach creates alternative means of communication between teachers and students, as well as deeper and more meaningful engagement with media-rich content. But, blended learning goes beyond the addition of technological components and requires a “…rethinking and redesigning [of] the teaching and learning relationship” [6, 7]. If the integration of technology into the curriculum is to be effective, it must move beyond content transmission and aim to facilitate communication and reflection in teaching and learning practices that are interactive, flexible, collaborative and authentic [8].

There are limited studies on the development and implementation of blended learning strategies within clinical education [7], with some authors asserting that “…the current pedagogic evidence base about these tools in the context of medical/health education is seriously lacking” [9]. This presents a challenge. Technological components cannot simply be tacked on to traditional approaches without careful consideration [10] but clinicians are usually not course designers, and neither of them are necessarily educational technologists. The different stakeholders may therefore lack the diverse skills necessary to effectively integrate technology into a blended curriculum that aims to develop the attributes required for effective clinical practice. Without a sound evidence base to work from, technology-mediated instruction in clinical education may be implemented without the necessary preparation and design. In order to prepare healthcare students for the dynamic and complex clinical environment, how can we ensure that technology-mediated instruction facilitates the development of both competent and capable practitioners?

In order to address these challenges, this study used a modified Delphi approach to identify technology-mediated teaching strategies that aim to develop capability in undergraduate healthcare students. The study is significant in that it identifies attributes that go beyond knowledge and skills, as well as strategies that could be used to develop those attributes within a technology-mediated approach to teaching and learning.

The major findings of the study are presented as responses to the overarching question that informed the previous round. However, only summaries of the first two rounds are presented here, in order to contextualise the findings of the third round. Responses from the third round are presented here in aggregate, as a narrative of the themes that arose during the analysis, and supporting quotes are presented.

Panelists in the first round were asked to identify what they thought capable students should “be”, as opposed to what they were expected “to do”. They strongly emphasised a process of active engagement with people and concepts when it came to the characteristics of “being” a professional. They spoke of students needing to engage with and be willing to be part of a developmental process, in addition to “having” knowledge, skills, understanding and attitudes, which were seen as products or final outcomes of a competent student. They also emphasised the personal, affective components of students’ approaches to practice, taking into account the challenges that they often face, and giving voice to the complexity of the clinical context. Panelists identified the challenges of authentic engagement with ethical contexts in healthcare, again highlighting the complexity of the situations that students face and the emotional context in which healthcare is practised.

In the second round, clinical educators were asked how they would go about facilitating a developmental learning process rather than focusing on the products of learning. Many panelists reported combinations of teaching strategies instead of only one approach. Teachers should provide a safe space for students to explore the domain independently, rather than telling students what they need to know. For this, appropriate role modeling is important, in which teachers demonstrate to students not only what to do and to know, but how to be. Using paper patients in small group sessions with guided discussion was a common suggestion, especially around the development of clinical reasoning and critical thinking. Educators should encourage the sharing of personal values and experiences among students and clinicians, as well as the impact of those experiences on themselves. They should build reflective components into the curriculum, asking students how they deal with stress and emotion, and then how they feel about, and deal with, those responses. Students should be encouraged to provide evidence of engagement with their own emotional responses through reflective self-report, which should include a feedback component from peers and more experienced clinicians, who each provide alternative viewpoints. They should also be encouraged to develop agency and active engagement with each other, rather than being passive recipients of information.

This study highlights several themes that are relevant for those interested in using blended learning as part of clinical education. These are summarised as follows: personal and professional development must go beyond “having” knowledge and skills, and should incorporate students’ emotional responses and personal values; clinical educators who aim to develop these attributes should consider teaching practices that are interactive, integrated, reflective and formative; technology-mediated teaching and learning can facilitate the development of attributes that have an impact on professional practice; and integrating technology into teaching practice goes beyond simply choosing what tools to add to the curriculum. This discussion will emphasise the findings of the third round of the study, which looked at technology-mediated instruction, although a brief summary of the first two rounds are presented to provide context.

The first round of the study identified the attributes of healthcare practitioners that went beyond simply having knowledge and technical skills. These attributes were described by participants in terms of a state of being. In a world where what you “know” is quickly outdated, a sense of self that enables students to adapt to dynamic conditions is essential. By cultivating a sense of being rather than knowing, the curriculum becomes “future-proof” [18]. This process-centred notion acknowledges that knowledge should not be perceived as a static, linear set of facts. Instead, by considering it as dynamic, non-linear and multidimensional, we can help students prepare for the complexity of clinical practice by making use of teaching practices that facilitate the development of capability [2].

In the second round of the study, clinical educators advocated a combination of different approaches that sought to develop more complex outcomes than merely the ability to perform a procedure, or know a fact. The developmental nature of the process was emphasised, highlighting the importance of feedback and formative assessment as part of the process, rather than a separate function. These integrated teaching and learning practices emphasised the connection and interaction between people in a process that “values human relationships” [19]. It seems that many of the teaching strategies suggested in this study are a response to “the urge to reach forward to newer, more interactive, authentic, integrative and transformative approaches to learning and teaching” [20]. There is evidence to suggest that the instructivist paradigm of “transmitting” knowledge from teacher to learner must give way to constructivist models that facilitate the social nature of teaching and learning [2].

Constructivist approaches to teaching and learning have been demonstrated to be enhanced through the use of technology-mediated instruction, particularly when thoughtfully implemented [6]. Participants in this study acknowledged the potential role of technology in the development of knowledge and skills, particularly if they had features that facilitated behaviour that was interactive, integrated, reflective and which allowed feedback. In addition, ICTs allow for the displacement of content away from the classroom, freeing up time for interactive engagement with other students and the teacher [6]. When combined with the possibility for enhancing content with rich media, ICTs were acknowledged to have a potentially powerful role to play in the development of attributes relevant for clinical practice. However, panelists also discouraged the use of ICTs for it’s own sake, suggesting that a sound pedagogical teaching strategy must drive and support the implementation of technology in teaching practice, echoing the suggestions of other studies in this domain [9]. In addition, technology in teaching needs to be easy to use, and must be perceived by students to have value, if they are to engage with it [10]. For technology-mediated teaching to be effective, it must facilitate communication and reflection in teaching and learning practices that are interactive, flexible and collaborative [8].

Technology can also be used in the creation of online, collaborative spaces that encourage sharing and discussion of clinical encounters and ethical dilemmas. In addition, blended learning approaches have been demonstrated to encourage “flexibility, reflection, interpersonal and teamwork skill development, motivation, and collaborative learning environments - resulting in deep and meaningful understandings” [6]. ICTs may also provide an alternative where face-to-face contact is not possible e.g. students working alone in remote areas. However, panelists also suggested that the use of ICTs in the sharing and discussion of ethical challenges may be best supported with face-to-face reflection and feedback immediately after the clinical encounter.

It is clear that there are changing conceptions of the knowledge, skills and attitudes required for professional practice, which shift the focus from the products of learning to the process of learning. As clinical educators, we must move beyond describing our students in terms of things they should know and be able to do, and should develop teaching strategies that facilitate a state of professional “being”. We should use teaching practices that integrate knowledge from different curricular domains, that are interactive rather than transmissive, and should accommodate guided, reflective activities that include feedback as part of the curriculum. Technology-mediated instruction does have the potential to change the teaching and learning practices that aim to develop healthcare students who are better equipped to deal with the complexity of clinical practice. However, if we choose to integrate technology into teaching practices that are guided by these principles, then our choices of technological tools should reflect considered outcomes that are framed in the context of what we want our students to be, rather than what we want them to know and to do. Finally, the specific technologies we choose to integrate are less important than the teaching and learning environments we create.

^a PPD – Personal and Professional Development.

^b In the “flipped classroom” students are expected to “consume content in their own time i.e. at home, while homework assignments are completed in class. This gives the teacher the opportunity to spend more time engaging with students, rather than covering content [21].

^c f2f: face-to-face.

MR is a PhD student and lecturer in the Department of Physiotherapy at the University of the Western Cape, and is currently involved in a process of curriculum development. The larger research project is looking at the use of technology-mediated teaching and learning practices in clinical education at an undergraduate level. VB and JF are the project supervisors.