altPhysio | Getting rid of modules

This is the third post in a series looking at the ideas and processes we take for granted in a mainstream physiotherapy curriculum. In the first post I looked at the background behind a decision to form a new kind of physiotherapy school, and then wrote a second post questioning the assumption that there is an inherent value in the things we ask students to do. In this post I wonder if modules are the best we can do when it comes to configuring the basic unit of a curriculum.

Q: You made a decision early on that there wouldn’t be any modules at altPhysio. Tell us a little more about the thinking behind that decision.

Modules exist in a curriculum so that we can divide complex ideas into something more manageable and because the curriculum needs discrete units around which learning activities can aggregate. For the most part, those units are the modules that we use to aggregate other things like lectures, textbooks, assignments and tests. We like to think that modules are neat collections of related concepts that are combined with each other, forming foundations upon which other modules can build. The reality is that modules are somewhat arbitrary divisions of complex concepts into increasingly smaller and simpler ideas.

Modules are the organising principle of a curriculum, used to link related concepts, around which teaching and learning activities are aggregated.

The problem with modules is that we spend 4 years teaching students which blocks the concepts fit into and assessing them within the constraints of those basic conceptual divisions. Tests and assignments are given within the context of a module and it’s actually quite difficult to give learning activities that cross modular boundaries. After students are comfortable with pigeon-holing ideas into neat boxes we ask them to integrate the concepts from different modules as part of clinical practice, another separate module. How does it make sense to break complex ideas into discrete units and then expect students to put it all back together again, often by themselves?

Q: OK, so no modules at altPhysio. What about a PBL approach?

In a PBL curriculum the clinical problem is the organising principle, rather than the module. The concern with the kinds of problems found in PBL curricula is that the problems are not complex enough to model real world clinical situations, and they don’t run over long enough periods for students to get sufficiently engaged. Another concern is that the problems are often decontextalised from the situations in which knowledge gained is to be applied.

We knew that knowledge must be constructed in the same contexts in which it is to be used, but our classroom activities were so contextually disconnected from how we expected students to practice that they were effectively useless. How often have you heard clinicians and teachers complain that students have trouble transferring knowledge learned in the classroom context to the clinical context?

If we want students to solve difficult problems in the real world, they must be trained by solving difficult problems in the real world. A module-based curriculum – and to a certain extent, a problem-based curriculum – doesn’t create enough space for sufficiently complex tasks to be designed.

Trying to design an authentic learning task that is sufficiently complex to model a real world phenomenon, within the constraints of a single module is difficult. It’s possible to do it within a PBL context but also unsatisfactory. We wanted to take a systems approach to designing the kinds of problems we wanted our students to solve, which we think more accurately describes real world clinical problems. When we started looking at relatively large-scale Projects as the organising principle in a curriculum, we found that it gave us the space we needed to build activities that would help students develop the characteristics we say are important.

Q: Tell us what a Project looks like. Where do they come from?

We work closely with clinicians from a variety of contexts who provide us with the basic framework for all of the Projects in our curriculum. They submit Contexts from their clinical experiences according to a framework that we provide for them. Any situations in their contexts that meet the boundary conditions that we set, can be included in the curriculum. A Project involves students working together in groups to achieve complex objectives, none of which are possible for students to complete on their own.

Our Projects usually run over 3-12 months and involve a variety of activities, which may include short lectures, research, practical sessions, field trips, virtual and augmented reality simulations, and interaction with qualified professionals in online and face-to-face environments.

Some Projects run over multiple year levels too, so students can begin a Project in their first year and only complete it in their second year. This is especially useful when Projects grow in complexity in real time – because the real world is dynamic – and are extended beyond their original lifespan.

Most of our Projects are also inter-disciplinary because any sufficiently complex real world problem cannot be addressed by any single discipline. We get special input from people in a variety of different domains, including engineers, artists, horticulturalists…you name it we get them to come and spend time with students on their Projects. We want our students working on real world problems from day one in the programme, with input from a diverse range of the kinds of people they’ll be expected to work with when they graduate.

Q: You mentioned the boundary conditions that Projects need to satisfy before you’ll take them on as part of the curriculum. What are those conditions?

We use Authentic learning – based on Situated cognition – as a framework to determine the basic structure of a Project. The framework is a way of thinking about task design so as to increase the probability of developing within students the competencies we want. Authentic tasks should meet the following criteria:

  1. Real-world relevance: Activities match as nearly as possible the real-world tasks of professionals in practice rather than decontextualized or classroom-based tasks.
  2. Ill-defined: Activities require students to define the tasks and sub-tasks needed to complete the activity.
  3. Complex, sustained tasks: Activities are completed in days, weeks, and months rather than minutes or hours. They require significant investment of time and intellectual resources.
  4. Multiple perspectives: Provides the opportunity for students to examine the task from different perspectives using a variety of resources, and separate relevant from irrelevant information.
  5. Collaborative: Collaboration is integral and required for task completion.
  6. Value laden: Provide the opportunity to reflect and involve students’ beliefs and values.
  7. Interdisciplinary: Activities encourage interdisciplinary perspectives and enable learners to play diverse roles and build expertise that is applicable beyond a single well-defined field or domain.
  8. Authentically assessed: Assessment is seamlessly integrated with learning in a manner that reflects how quality is judged in the real world.
  9. Authentic products: Authentic activities create polished products valuable in their own right rather than as preparation for something else.
  10. Multiple possible outcomes: Activities allow a range and diversity of outcomes open to multiple solutions of an original nature, rather than a single correct response obtained by the application of predefined rules and procedures.

If the Context submitted by clinicians meet the majority of these criteria, or if we see the potential to modify the Context enough that we can create a Project, we accept it into our workflow. Then we work with a variety of colleagues from different professions to refine the Projects over the course of 6-12 months. During this period we design the Project so that we can use it to accurately describe the kinds of competencies that we expect students will be able to develop while working in the Project. After that we incorporate the Project into the curriculum where they become another unit that students can sign up for.

Q: What do you mean when you say that students can sign up for Projects?

We don’t tell students what Projects to complete and allow them to choose from the full range of Projects available in that year level. Students know that they have a set number of competencies that need to be acquired in order to progress in the programme, and they know which competencies are integrated into which Projects. They make choices about the Projects they want to work on, based on which competencies they know they need to develop, as well as other factors that go into their decision making.

For example, consider a student who is going through some personal struggles; maybe a situation where someone close to them is ill. For that period they may choose a relatively low level Project that has a short duration. They know that the competencies developed in the Project will be fewer and maybe at a lower level than for other Projects, but this is OK because it buys them time to spend with their sick relative. In addition, since we don’t really have a timetable at altPhysio, students are able to organise their days and weeks in ways that give them space to focus on their personal lives, while at the same time continuing to work through the curriculum, albeit in a much less pressured environment.

The way that we’ve conceived of Projects gives us a level of flexibility and pedagogical range that we found impossible to achieve with modules or PBL. It means that we can have students working on complex, real world problems from day one. It means that at no point in the programme do we have to ask them to integrate concepts contained separately in different modules. Completing a Project at altPhysio requires that students think and behave like the professionals we say we want to develop.

 

Stop complaining about the “knowledge-practice gap”

The “knowledge-practice gap” is a well known problem in health professions education and an enormous amount of time is spent complaining about how difficult it is to narrow the gap. The truth is, the knowledge-practice gap is a problem of our own making, and the name we’ve given this problem hints at the answer.

We’ve set it up so that there is a tension between what happens in the classroom (acquire knowledge) and what is supposed to happen in practice (use knowledge). Or, to be more specific, there is a tension between how students think and behave in the classroom and how we want them to think and behave in the clinical context. This is the “gap” that we’re always talking about bridging; the difference between the knowledge that students acquire in the classroom, and the practical application of that knowledge in clinical practice.

However, instead of treating the problem as something natural to be overcome (“this is just the way it is”), we can just accept that the reason the gap exists is simply because what most of what we expect students to do in the classroom is not a practice at all. We set up a situation where we create different contexts for knowledge acquired and knowledge applied and then complain when students struggle to move between the different contexts.

The truth is that we already have good evidence to suggest alternative ways of thinking about the “different contexts” problem, and we know what to do about it. Situated cognition is a learning theory that proposes that:

“…knowledge is situated, being in part a product of the activity, context, and culture in which it is developed and used.”

In other words, knowledge must be acquired in similar contexts to the ones in which it must be used. If you think about the classroom context, what ways of thinking and being are students required to practice? Are they required to practice at all? In order to satisfy most physiotherapy educators, our students simply need to show up, sit down and listen. Even if we assume that they are able to construct knowledge in some meaningful way from this traditional approach to learning (generally speaking, they are not), how does this practice enable them to apply what they learn in classroom to the clinical context? Simply put, it doesn’t. The reality is that the knowledge-practice gap exists because of the way we teach.

In order to address the problem of the knowledge-practice gap we need to accept that students’ ways of thinking and being in the classroom must be similar to the ways of thinking and being we expect in the clinical context. We must therefore give students learning tasks in the classroom that require them to think and behave in the same way as we expect them to think and behave while on clinical rotation. The classroom practice and the clinical practice must therefore be similar. Seen from this perspective, there would be no knowledge-practice gap because there would be no difference in the contexts in which knowledge is acquired and how it is used.

So, how do we create a classroom context where students are expected to think and behave in ways that are similar to how we expect them to think and behave in the clinical context? I think that Authentic learning is a good place to start. It’s a teaching framework that operationalises situated cognition. In other words, it’s a way of thinking about learning task design that includes attributes that would cause students to think and behave in one context that would help develop those processes for other contexts. I’ve written some notes on Authentic learning before, so won’t go into detail here, other than to share the characteristics of authentic learning, which are that tasks:

  • Should have real-world relevance i.e. they match real-world tasks
  • Are ill-defined (students must define tasks and sub-tasks in order to complete the activity) i.e. there are multiple interpretations of both the problem and the solution
  • Are complex and must be explored over a sustained period of time i.e. days, weeks and months, rather than minutes or hours
  • Provide opportunities to examine the task from different perspectives, using a variety of resources i.e. there isn’t a single answer that is the “best” one. Multiple resources requires that students differentiate between relevant / irrelevant information
  • Provide opportunities to collaborate should be inherent i.e. are integral to the task
  • Provide opportunities to reflect i.e. students must be able to make choices and reflect on those choices
  • Must be integrated and applied across different subject areas and lead beyond domain-specific outcomes i.e. they encourage interdisciplinary perspectives and enable diverse roles and expertise
  • Seamlessly integrated with assessment i.e. the assessment tasks reflect real-world assessment, rather than separate assessment removed from the task
  • Result in a finished product, rather than as preparation for something else
  • Allow for competing solutions and diversity of outcome i.e. the outcomes can have multiple solutions that are original, rather than a single “correct” response

Looking at the above list it should be easy to see how tasks designed with these characteristics in mind would be similar to the ways we would think about successful clinical practice. In other words, you could see how students who could successfully solve problems designed with this framework might also be able to solve clinical problems. The tasks we give them in the classroom would require them to think and behave in ways that we expect them to think and behave in clinical practice. No more knowledge-practice gap?

References

Proposal abstract: Case-based learning in undergraduate physiotherapy education

Abstract for a project I submitted earlier this week for ethics clearance. During 2012 – 2014 we converted one of our modules that runs in the 2nd, 3rd and 4th year levels from a lecture-based format to a case-based learning format. We are now hoping to have a closer look at whether or not the CBL approach led to any changes in teaching and learning behaviours in staff and students.

Case-based learning (CBL) is a teaching method that makes use of clinical narratives to create an authentic learning activity in which students navigate their way through complex patient scenarios. The use of CBL in a health professions undergraduate curriculum attempts to convey a multidimensional representation of the context, participants and reality of a clinical situation, allowing students to explore these concepts in the classroom. While the implementation of CBL has a sound theoretical basis, as well as a strong evidence base for use in health professions education, there are challenges in its effective use that are not easily resolved. However, if it can be shown that the approach leads to changes in teaching and learning practice, which enhance student learning, providing additional resources to resolve the challenges can be more strongly justified. This project therefore aims to determine staff members’ and students’ perceptions of CBL as a teaching method, and to find out how it influenced their teaching and learning behaviours.

This study will make use of a mixed method research design in which the experiences and perceptions of student and staff members are used to determine whether or not there was a change in their teaching and learning practice. Qualitative and quantitative data will be gathered using a survey of all students in the population, focus group discussions of students and in-depth interviews of all staff in the department. The survey will determine if the design of the CBL approach led to a change in what the students did. The focus group discussions will gather data on the nature of the changes and the underlying rationale for those changes. The interviews with lecturers will be conducted in order to delve more deeply into whether or not lecturers’ teaching behaviours changed, and again, to explore the underlying rationale of those changes.

The survey will make use of a self-developed questionnaire that will gather quantitative data using Likert scales and other closed-ended questions. The survey will be sent to all 3rd and 4th year students in the 2015 academic year. The same students will be invited to participate in the focus groups, and the researchers will make use of purposive sampling to allocate volunteers into two focus groups in each year level. All lecturers in the department (n=10) will be invited to participate in the in-depth interviews, including those who were not directly involved in the implementation of CBL. In addition, we will also invite ex-staff members who were involved in the process, as well as postgraduate students who assisted with student facilitation.

Qualitative data will be gathered during the focus groups and interviews. This data will be interpreted via the theoretical frameworks used in the design of the CBL cases. The focus group discussions and interviews will be conducted in English and recorded using a digital audio recorder. The audio files will be sent for verbatim transcription and the anonymised, transcribed documents will then be sent to participants for verification. The transcripts will be analysed thematically, coding the data into categories of emerging themes. Trustworthiness of the analysis will be determined through member checking and peer debriefing and participants will be given the opportunity to comment on whether or not the data was interpreted according to what they meant. The transcribed verbatim draft will be given to colleagues who were not involved in the study for comment.