The following are notes I took while reading Fraser, SW & Greenhalgh, T. (2001). Coping with complexity: educating for capability.
During the past 6 months or so I’ve found myself thinking more and more that the way we teach health professionals (at least, in my experience) has had too much of a focus on technical competence, a mix of pure technical skill applied in contexts defined by the students’ basic knowledge base. I’ve suggested in various presentations and conversations that students need far more than the ability “to do” and that we need to shift the emphasis of our training to develop the underlying practice knowledge that’s often hidden in a professional culture obscured from the student. In clinical situations that are often complex, dynamic and multi-faceted, I’ve seen many academically strong students fall apart as they struggle to adapt to the changing context of patient management.
Recently I came across complexity theory and how it’s use in education could help students move from simple competence (technical skill, knowledge and attitudes) to capability (ability to adapt to change, generate knowledge and continue to improve), and its really helped me in terms of structuring my thinking around the subject. The aspects of complexity theory that appeal to me are that:
- Systems are constantly changing
- Those changes are uncertain and paradoxical
- Individuals within the system are independent and creative
- Even if problems cannot be solved they can nonetheless be “moved forward”
- Solutions may only need minimal specification
- Small changes can have large effects
I’ve observed these principles in practice but now I have a framework and a language to help structure the observations. So, how can principles of complexity be applied in an educational context? Fraser and Greenhalgh discuss 4 areas that it could be useful, and I was surprised to discover that I’ve been doing some of this already. Below are examples of how I’ve been teaching during this year and how it relates to complex systems.
The first area is in developing capability through transformational learning. One of the biggest problems I’ve faced is in trying to figure out how to teach something that can’t really be taught e.g. changing students’ thinking patterns from “passive-receptive” to “active-interactive”. One of the options is to provide the student with unfamiliar problems or contexts in a meaningful way (this isn’t about throwing the student into the deep end without support). In the Movement Science module I taught earlier this year, I gave the students practical problems that they hadn’t seen before and then asked them to solve the problems using theory (knowledge) and practical techniques (competencies) that had recently been covered in class. There were many acceptable solutions to these problems and many students figured out different ways to get to “the answer”. I’d move between groups to give guidance and answer questions that arose (immediate, contextual feedback is an important component of transformational learning). At the end of the class I asked one group to demonstrate their solution and then showed them how I would’ve solved the problem. I wanted to show them that even though we both used different approaches, and that we applied our knowledge and understanding in different ways, we still managed to “solve” the problem. I haven’t measured the outcome but anecdotally the students seemed to leave with a good understanding of the difficulties involved in clinical problem-solving. I wanted them to see that there isn’t an “A+B=C” solution to managing movement dysfunction.
The second area in education that can be understood through the lens of complexity theory is in relational learning. In the past, expertise derived from “having knowledge”. In an ever-changing world in which you can’t know a fraction of what’s available, expertise has become more about accessing knowledge from different sources. In other worlds, expertise is about forming relationships between concepts from possibly different fields. The relationships between concepts are just as important as the concepts themselves. Again, I’ve used this principle earlier in the year when I gave a concept mapping assignment, also in the Movement Science module, in which students had to demonstrate an understanding of complex relationships between concepts in a clinical context. I realised that although students had a good grasp of the concepts in the module, they weren’t familiar with the relationships between them. Of even greater concern was that many of them were unable to apply their knowledge clinically, even though they had a good understanding of the theory. After the assignment was over, one student told me that this was the most challenging assignment she’d ever done, and then thanked me for it! I’ve read somewhere that students want to be challenged, it’s just that they’ve become used to a system in which being passive can be successful. Without meaningful challenges, passively consuming content is easier than actually trying to understand. I’m hoping that through providing learning activities that push students out of their comfort zones we can help to begin a cultural mindshift within our department.
Non-linear learning. Check lists and clinical guidelines undoubtedly have their place but the problem is that they can only be used after the problem has been identified. It sometimes takes creativity and deep understanding to get to the point where a guideline can be applied. Einstein may have been right when he said that “imagination is more important than knowledge“. The real world is complex and difficult to navigate even with the right competencies, and yet we often don’t equip students to deal with the real world. Often when we try, the simulated environments we use don’t (can’t) come close to what will be expected of them in the rapidly changing clinical environments they will encounter after graduating. Our assessments / practical scenarios are too controlled and standardised. In fact, it’s almost impossible in our curriculum to present the students with non-linear problems because the curriculum is linear. It’s designed as a series of “blocks” of facts that build on each other, which doesn’t take into account the fact that life (and healthcare) aren’t that simple. There might be some way to incorporate non-linear teaching practices through the use of stories and case-based learning. I’m excited about the latter, as we’re introducing some aspects of case-based learning and PBL into a few of our module streams next year.
Process techniques. Building capability can be aided with minimal structuring, which is especially important as we move from mass education to individualised learning spaces. There is a focus on the process of learning, with protected time for reflection (not often seen in healthcare curricula), identified personal needs expressed through a learning plan and some kind of record of progress e.g. a portfolio. In addition, there is evidence that the effects of small group learning can amplify the knowledge of individuals so that the learning experience is greater for the group when trying to solve complex problems. One of the points made by the authors is that emergent learning will not occur merely because the group is formed. I learned this a few years ago when I created a wiki-based assignment with the goal of collaborative learning. Students worked as individuals within the group, not paying attention to each other at all. In retrospect this is probably because I didn’t provide the structure to guide them through the process.
Ultimately, Fraser and Greenhalgh emphasise the importance of shifting healthcare education from competency-based to capability-based assessment. We need to change our assessment focus from knowledge and technical skill to rather measure students’ ability to adapt to changing, complex clinical environments. It’s not enough for students to know what to do and how, they need to know when to do it and why.