What do teachers do? A framework for improving teaching in healthcare education

Much of sub-Saharan Africa needs increased healthcare capacity. South Sudan is no exception, and for some years the government has prioritised this as a policy goal. The challenges to the provision of healthcare in South Sudan have been noted previously.^[1] More than 80% of medical services are provided by international organisations.^[2] In the medium and long term, South Sudan needs to be able to produce and retain healthcare practitioners: doctors, nurses, midwives, and those associated practitioners whose skills are needed to increase the country’s capacity to deliver healthcare.

At the operational level, progress depends upon the further development of institutional resources, and organisational effectiveness. This requires international support, and the continuing efforts of institutions such as Juba University Medical School, the College of Physicians and Surgeons, and the College of Nursing and Midwifery. What can we do as individuals to support this goal? 

We can strive to improve our healthcare teaching. 

Healthcare needs safe, competent practitioners who learn through teaching, mentoring, and supervision. So, in classroom and clinic, the healthcare teacher plays a vital role in helping the next generation of clinical practitioners to develop their knowledge and skills. In this context, learning is a process of expanding ability across eight trajectories,^[3] during which it is important to practice, safely, in those areas of work where abilities are challenged.^[4] Figure 1 represents this diagrammatically. It is important that the teacher knows where the boundaries lie for each learner, and structures their work and supervision to enable both learning, and safe practice.

‘Healthcare practitioners’ include all the various healthcare roles that the people of South Sudan require. By ‘teacher’, I mean teachers in university and college settings, but also supervisors and colleagues in the workplace, for it is in the workplace that people learn their healthcare practice - from experience, and from each other. ‘Learners’, include students, doctors, dentists, nurses, midwives, and associated healthcare practitioners, in undergraduate and postgraduate settings, and throughout their working lives. 

Healthcare teachers often work in difficult circumstances. To be effective, they have to realise they are indeed teachers, as well as clinicians, and they have to commit themselves to the improvement of their teaching. This is perhaps more challenging in the workplace, than it is in the university or college. Given a sense of identity as a teacher, and motivation to improve, teachers can decide what to do by thinking about their own practice, seeking ideas for doing things differently, and by seeking a clear understanding of how people learn. 

To support this process, we intend to publish, over several issues of the South Sudan Medical Journal, a series of educational ‘How to…’ papers. These are offered as guides to self-directed improvement by healthcare teachers. They will include practical tips, and educational ideas. They will also address scholarship in healthcare education, by giving guidance on research methods and evaluation in education. 

The aim is to target the essentials for the practising healthcare teacher, and so we will focus on supporting the educational activities listed in Table 1. Not all healthcare teachers will do all of these, but most will do some of them. 

1.      Teach in a range of settings

1.1      Teach large groups.

1.2      Teach small groups.

1.3      Teach in a clinical setting.

1.4      Support in-service learning.

2.     Assess performance

2.1      Assess performance using formative methods.

2.2      Assess performance using summative methods.

3.     Support progress

3.1      Respond to concerns about performance.

3.2     Review learners’ progress against educational goals.

4.     Improve healthcare education

4.1      Evaluate and improve teaching practice.

4.2      Evaluate and improve a taught course.

4.3      Evaluate and improve the clinical workplace to support learning.

4.4      Carry out research in healthcare education.

5.     Develop programmes of healthcare education

5.1       Design a new course.

Teaching large and small groups, involves using a variety of interactive techniques, audio-visual aids and learning resources suitable to the lecture theatre, classroom, and the size of the group.  Teaching in a clinical setting has to fit into the demands of the healthcare service – the needs of both patients and learners have to be accommodated.  Knowing the learner’s needs, informing, demonstrating, questioning and providing feedback, are important. An associated responsibility is to support in-service learning.  Here, considering a junior colleague’s learning needs in the allocation, structuring and supervision of work are important, as is the provision of normative feedback, and having appropriate expectations of performance.^[5]

Assessment might be formative, directed towards helping the learner understand their progress, strengths and weaknesses, and what they can do to improve. This is part of everyday teaching, and is often provided through feedback and discussion. Summative assessment is used to confirm that a learner has achieved the required standard on completing a course or programme.

Teachers often have to respond to concerns about performance.  In the university setting this will usually focus on academic performance. In the workplace, difficulties might touch upon a range of issues (see figure 1). There may be a need to provide for patient safety, and for adequate supervision, coaching, or mentoring. Reviewing learners’ progress is an appraisal, designed to help learners take stock of, and manage, their overall progress against goals. If progress is not meeting requirements, then the teacher will need to know their options, and how to proceed in the best interest of the learner, and the healthcare profession.

Figure 1. The expansion of skills and knowledge of healthcare practitioners

The aim is to expand the size of the inner core, and reduce the size of the outer sphere. The role of the teacher involves locating the learner on this diagram, and providing appropriate help.

Finally, teachers have a responsibility for the design, evaluation, and improvement of educational practice. For some, this might involve carrying out research in education, to improve local practice and to contribute to scholarship. Others may be in a position to evaluate and improve their own teaching, a taught course, or a clinical workplace, to better support learning.

That, then, is the framework for improving teaching in healthcare education. We will publish practical guidance in support of these objectives, over the coming months. One way of using these articles will be to identify your own improvement priorities as a teacher, and to use the information in the articles to help develop your own learning plan. Meeting with colleagues, to form a learning group, would allow discussion of teaching experiences, educational ideas, and improvement opportunities. We hope that a wide range of teachers will find the articles useful in supporting their self-directed learning, in South Sudan, but also those in similar roles elsewhere. 

References

1. Bregazzi R. Developing Postgraduate Medical Education in South Sudan, South Sudan Medical Journal 2015;8(2):38-9.
2. Médecins Sans Frontières. South Sudan Crisis Update 2014 http://www.msf.org.uk/sites/uk/files/southsudan-crisisupdate-august_final.pdf
3. Eraut M. Theoretical and practical knowledge revisited. In: 12th Biennial Conference of the European Association for Research on Learning and Instruction, Budapest; 2007
4. Vygotsky L. Mind in Society, the development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978.
5. Eraut M. Learning from other people in the workplace. Oxford Review of Education, 2007;33(4):403-422.

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