The development of an innovative approach to postgraduate ultrasound education: An evolving process

Article Outline

• Abstract
• 1. Introduction
• 2. The Negotiated Specialist Practice Ultrasound (NSPUS) module
  • 2.1. First year of module delivery
  • 2.2. Second year of module delivery
• 3. Methodology
• 4. Results
• 5. Discussion
• 6. Conclusion
• References
• Copyright

Abstract 

Increasing economic pressures on higher education institutions to limit the number of modules offered, together with the conflicting pressure from hospital departments requiring an increasingly skilled and flexible workforce, have resulted in the requirement for a more creative approach to delivery of university postgraduate programmes. One approach implemented at the University of the West of England, Bristol was to extend the role of an Action Based Learning (ABL) module within the Medical Ultrasound programme.

Following completion of the first year of this newly accredited module, the experiences of students and staff were evaluated. Results of the evaluation and feedback demonstrated both positive and negative features of this style of learning, and the programme team decided to use this feedback to enhance the student experience for future cohorts undertaking the module.

The second delivery of this module is now complete, and the module has again been evaluated. The following article discusses the evolutionary process involved in developing this module, and reviews the enhancements introduced over a two-year period.

Keywords: Postgraduate education, Ultrasound education, Action based learning, Enquiry based learning, Life long learning

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1. Introduction 

The University of the West of England (UWE) has been delivering postgraduate healthcare programmes since the transition of healthcare education from the hospital environment to the higher education sector in the early 1990s. In 2000 a Medical Ultrasound programme was introduced. Numbers were initially small but the University subsidised the course from undergraduate funds.

When the programme was due for revalidation and reaccreditation in 2007, the economic climate was changing and the course team was aware of the requirement from the University to only run modules which were economically viable i.e. with a minimum of twenty students registered. In order to remain competitive with other Ultrasound training providers, it was not possible to increase fees for the modules to reflect the small numbers accessing these modules. This however, conflicted with the growing demands from clinical ultrasound departments to send students for training in a wide variety of subjects. The rapid diversification of Diagnostic Ultrasound scanning into an ever increasing number of sub-specialty areas, was leading to requests from departments wishing to train staff in an increasing number of specialty areas such as breast, paediatric, and musculoskeletal scanning, which would have resulted in a number of new modules having to be created, each of which would probably have less than four students enrolled. In addition, the accrediting body, the Consortium for the Accreditation of Sonographic Education (CASE) requires students to experience interaction with a variety of students, in order to benefit from a rich learning experience.

The revalidation of the programme provided an opportunity to consult with clinical leads and specialists in order to re-think the strategy for ultrasound training, and it became apparent that one solution to this problem was to utilise a generic ultrasound practice module where students studying different specialty areas would be registered on the same module.¹ In order for this to work successfully, students would be required to negotiate and take control of their own learning process. The module was entitled ‘Negotiated Specialist Practice in Ultrasound’ (NSPUS) module. As well as ensuring a larger cohort of students on the module, this solution would have the additional benefit of requiring students to take control of their own learning process rather than being a passive recipient of knowledge delivered by others.² This is generally considered a more effective method of learning, particularly at postgraduate level.³

The Negotiated Specialist Practice module is delivered using an Action Based Learning (ABL) format where students are facilitated by an experienced ABL practitioner. ABL was originally described by Revans⁴ as a process used in industry to help managers to improve their performance. The process has subsequently been adapted for use in education to promote independent learning, by encouraging students to develop knowledge and abilities specific to individual student needs.⁵ The NSPUS module typically consists of a number of students who meet together regularly to present problems to their peers in order to find ways to overcome them. The role of the other members at this point is to listen and support the student in moving forward with the problem or issue. An experienced facilitator is initially required until the students feel confident to run the process themselves.¹

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2. The Negotiated Specialist Practice Ultrasound (NSPUS) module 

2.1. First year of module delivery 

Students enrolled on the NSPUS module are initially required to meet with the module leader and the clinical supervisor to negotiate and define exactly what the area of study will encompass. They then need to write their own strategy for learning at the start of the course, and identify (in negotiation with the module leader) what activities will be undertaken to achieve the module learning outcomes, and exactly how each of these will be assessed within the framework of the module. Attendance at the University is required for approximately one day every three weeks, and students spend the first 2 h of the day working in their small learning ‘sets’⁴ or groups, identifying problems encountered with their learning process, either theoretical or practical. For the first year of delivery of the module at UWE, students in each group were all studying different specialty areas of ultrasound, but feedback from participants indicated that it would be more advantageous if students were put into groups with others studying a similar subject area. It was originally assumed that diversity of experience within a group would result in valuable discussions and viewpoints on how each student could best tackle their particular problem. In many cases this did happen, and beneficial interactions were observed. However, because of the feedback received from participants, for the second delivery of the programme this strategy was reconsidered, and students are now divided into groups studying common subject areas where possible.

During the day of attendance at UWE, students have a certain number of subject specific lectures and workshops. A number of lecturers are involved with the module, acting as both facilitators for the learning sets, and as personal tutors. Each student has individual meetings with their tutor, but in addition they can contact their tutor at any time during the module via email or telephone. Module leaders post information on an electronic notice board which students can access off-site. Despite some structured theoretical sessions, the concern is often that students feel they are teaching themselves. However, this is not a weakness of the ABL process, but rather its strength as it promotes independent learning.⁶

For the first module delivery, students were given only minimal formal lectures, but rather were given a framework on which to base their study. This style of learning is a difficult concept for students beginning the module. Students often struggle to make sense of ABL initially,⁷ and clearly are often placed outside of their ‘comfort zones’. Requests were made by students at the beginning of the module for a more didactic style of learning, where they could sit in a classroom and be delivered knowledge in the form of a lecture, with slides and handouts. It was observed that as the module progressed, some students began to realise what was expected of them, and move away from the traditional expectations they originally began with. These proved to be the minority, however, as feedback at the end of the module revealed that the majority of students felt they would have benefited from a more structured approach.

Following the delivery of the first year of the modules to 34 students, the module leaders distributed a standard university evaluation form, plus an additional questionnaire designed to obtain details on the student experience of the ABL process. This questionnaire was posted to all students with a pre-paid return envelope, and results were collated. Questions on the form were a combination of closed and open-ended, in order to elicit focused and constructive feedback. The questionnaire was designed to be straightforward to complete, to encourage a good completion rate. Students were strongly encouraged to return forms in order to provide the course team with information to improve the module for future intakes.

Following the first module run, 26 forms were returned in total, giving a 76% response rate. Results from the first module run were analysed and published.¹ Student feedback revealed mixed attitudes to this style of learning. Useful information was achieved from this first module run evaluation however, and the module team took the opportunity to review this and implement appropriate modifications to the subsequent delivery.

2.2. Second year of module delivery 

Overcoming initial student resistance has been a feature of the module, and methods for countering this were put in place for the second intake. Following discussion, the module team decided to incorporate an additional element into the second module run in the form of Enquiry Based Learning (EBL). EBL is student-centred, highly interactive and uses triggers to provide a starting point for discussion and acquisition of knowledge.⁸ It involves working in small groups facilitated by a member of staff whose role is to support and interact with the group. The triggers generate discussion which leads to further exploration.⁹ Its introduction into the module took the form of students being given a trigger task related to their area of study, during their attendance at UWE. These triggers took the form of, for example, either specific questions or case study scenarios, and were designed to give a focal point for students to independently research.¹⁰ The actual method of enquiry was left up to the students to formulate within their groups, but the objective was to research the topic and bring back the knowledge obtained relating to the trigger question, and share it with the whole class.

An additional feature introduced into the module for the second delivery was to ensure students were initially given more guidance on the ABL process, and that they all did the required background reading around the subject. Despite being directed to do this on the first module run, it was apparent that most students had not undertaken the required research into the topic, and it was only when nearing the end of the module that they realised what the process involved. As a result, the second cohort of students was given the task of writing a 400-word referenced report on the processes of ABL and EBL, and to submit it to their tutor after the first week. This ensured the students did the required investigation into the topic, and ultimately led to fewer complaints about failing to see the relevance of the ABL process.

Group sizes were reduced from the previous ten students on the first module run, to no more than seven. This reduced the amount of time required for students to listen to each others problems and reduced the likelihood of students losing concentration during the process. The smaller group size however, resulted in more groups and a subsequent shortage of facilitators; the ideal of one facilitator per group was no longer possible. To overcome this, ‘floating’ facilitators had to be used to move between groups giving guidance where possible.

After the first module delivery, a minority of students admitted that their information technology (IT) skills were not adequate to enable them to fully engage with the blended learning aspects of the module. As this was a major component of the module, these students were inevitably disadvantaged whilst struggling to obtain the necessary skills. Although help is available for students, many were unaware before starting the programme that they needed to improve their IT skills. It was therefore made explicit to all students registering for the second run of the module that appropriate IT skills were needed before beginning their studies.

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3. Methodology 

Following the second delivery of the module, an evaluation questionnaire was distributed to all participants, but to ensure a higher completion rate, these were given to all students on the final day of attendance and students were required to hand them in anonymously before leaving. The questionnaire was based on the original questionnaire given to students after the first module delivery, but with the addition of two extra questions asking about the EBL process. It was designed to elicit qualitative constructive responses, and took the form of both closed and open-ended questions. Students were encouraged to give honest responses in order to guide the module team in future delivery of the module. In addition, the final session of the module encompassed a discussion forum with students and the module leader, where students were encouraged to give honest, constructive feedback on their experiences of the module.

The module team is composed of four lecturers, and this team met at the end of the delivery of the module to feedback and discuss their views on the strengths and weaknesses of the module. Student responses were also reviewed at this meeting. Staff comments were recorded, fed into the process and actioned accordingly.

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4. Results 

For the second module run, 36 students were given questionnaires; 32 were returned, giving a response rate of 89%.

Table 1 demonstrates responses to the questions following the second delivery.

Comments from students revealed more enthusiasm for the module than those received from the first cohort. There was still some ambivalence towards the ABL process, and requests for more subject specific lectures were again made. This was outweighed however by the positive reaction of students towards the EBL style of learning which had undoubtedly focused the students’ learning by requiring them to explore a topic with a particular question in mind. The students had all decided to work in their ABL groups for this learning process, dividing the topic into smaller areas for different individuals to explore. This had served not only to reduce the amount of work required by individuals, but also to bond the group members whilst working together. Comments were received stating that this process was more time-consuming than being delivered the information by a lecturer, but most of these statements were tempered by the realisation that their learning was actually deeper and longer-lasting because of the enquiry based approach.

Feedback from the EBL process was very favourable, and students found this tool to be particularly useful in both directing their learning and expanding their knowledge. Students suggested that because it was a particularly effective element of the module, that it could be used more extensively. The students also reported that because they had to explore a particular subject themselves, they not only developed a greater understanding of the topic, but also noted improved memory retention and recall. Furthermore, feedback from the clinical assessors following the students’ final clinical assessments, confirmed that the knowledge base demonstrated by the majority of students was high.

Six students thought that there should have been more subject specific theoretical content, and this reflected the views of those who would have preferred more theoretical lectures. This is linked to the previous comments relating to the time-consuming nature of the EBL and ABL processes, and the general feeling of students that sitting in a lecture is a less demanding process, albeit not as effective.

The previously expressed irritation with the ABL style of learning was not as apparent as on the previous module delivery, and the course team attributed this primarily to the research and writing up of the ABL process that all students were required to complete at the beginning of the module. At the time, this was not a popular process with the students, who would rather have been spending time researching their professional practice area. However, all students did undertake the activity, and demonstrated a greater understanding of the process at an earlier stage in the module.

The support received from fellow students was again noted in the comments as being a powerful learning tool. This was apparent in both the EBL and ABL processes. Individuals stated that they had received invaluable advice from others in the ABL learning groups, and one student admitted that they would probably have withdrawn from the programme if it had not been for the support they received from their fellow group members. Several students commented that it was reassuring during the discussions to discover that others in the group were suffering from similar problems and crises of confidence as they were encountering, and that the process of sharing these experiences was a supportive, strengthening process.

Students commented that the learning groups had worked well because of the common subject focus that was provided by putting students in groups with a similar focus. When specifically asked whether they would have preferred to be mixed with students studying other topic areas, there was strong feeling that this would not be appropriate. Students who were put in with students studying completely different areas (due to lack of numbers in that particular subject area) felt that they were slightly disadvantaged, but had managed to find some commonality of themes and sharing of experience.

Students did feel that the size of the groups with maximum of seven, was about right. It was thought that this enabled varied feedback from within the group, but avoided potentially long discussions which would have occurred with a larger group.

Several students commented that they felt disadvantaged by not having a facilitator with them during the whole of the learning set discussions, particularly in the early stages of their studies. They found that a facilitator provided more structure to the sessions and kept the discussions more focused. The course team realised that this was a potential weakness and will be endeavouring to ensure that more staff are available to participate as facilitators on future module runs. However, an alternative approach which will be tried is to ensure each group elects a leader to take on the role of keeping discussions focused and structured. A facilitator will need to be available in the early stages of group formation, but should be able to withdraw if the group has an effective leader.

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5. Discussion 

The diversification of healthcare education into numerous subject areas puts pressure on providers of postgraduate education to deliver programmes with an ever increasing number of subject specific modules. However, higher education institutions will not be able to sustain this expensive form of education in the current economic climate, and alternative approaches need to be found.

The programme team at UWE realised that a new style of delivery was required in order to meet the new challenges. Investigations suggested that an ABL approach would be a potential solution to the problem. The introduction of any new features into a programme require evaluation to determine the effectiveness or otherwise of the changes. It was apparent that in order to achieve success with the introduction of this NSPUS module, it was important to monitor the progress of the students in at least the first two cohorts. To do this it was decided to obtain in-depth evaluation from both the staff and students of this radical new module, following completion of the first year of delivery. This feedback from students proved invaluable, and was used to enhance the following year’s module.

Modifications were made to the second delivery of the UWE module, incorporating the feedback from staff and students. Evaluation of the second delivery was more favourable than that obtained from the first year. The modifications and enhancements introduced were positively received by both students and staff. Those students who successfully completed the module have demonstrated that they clearly invested much time and energy in acquiring new skills and knowledge. In addition, student assessment results demonstrated that a high level of achievement had been attained by the majority of the students.

The addition of EBL into the second module proved to be a positive enhancement, providing a focus to direct students’ acquisition of knowledge. This method of learning uses a process of enquiry and investigation, but importantly the student needs to take ownership of their learning.⁹ Often a group setting is used, with each member of the group focusing on the same trigger and reporting back their findings to the group. This process is designed to stimulate personal motivation within the student to achieve learning objectives and goals.¹¹ The introduction of EBL served to complement the ABL process, by providing additional subject specific guidance, whilst still requiring students to acquire knowledge for themselves.

Overall this style of learning requires fewer staff–student contact hours, but enables a more focused and effective use of staff time. Although additional staff are required to act as facilitators for the learning sets, this is limited to a maximum of 2 h a day for each of the students’ attendance days. Staff are required to be available for advice and guidance for the students’ individual study, but this can often be achieved electronically, thereby enabling a more efficient use of staff time.

Students’ initial reactions to new styles of learning have demonstrated a degree of difficulty with the process. They exhibit signs of being unsure about what is expected of them, and often irritation at the realisation that they need to be far more proactive than in the more traditional lecture-based style of learning. However, lecture-room delivery of learning for small groups is expensive, and not sustainable in the current economic climate. The course team at UWE has demonstrated that by careful monitoring of the implementation process of changes to the programme delivery, modifications can be made until the module has evolved into an acceptable format for both students and staff.

Reductions in training budgets, conflict with the requirement for documented evidence of Continuing Professional Development (CPD) in order to retain professional registration, and this puts additional emphasis on the requirement for more creative methods of education delivery. The ability of professionals to be able to learn independently and move away from an expectation of classroom based learning throughout their careers, will feature more prominently in this requirement for fulfilling CPD obligations.¹² Hemmingham³ observes that learning is more effective when individuals take responsibility for their own learning. Rather than expecting to be handed information, a more effective method of acquiring new knowledge is for students to learn how to become independent life long learners. Any student embarking on a programme of study needs to remember that whatever is to be learned must be learned by the student, and that active participation has to take place in the learning rather than passive listening. Training programmes therefore need to engender a sense of ownership and responsibility within the student.

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6. Conclusion 

Most individuals consider the learning process to consist of sitting in a classroom trying to absorb information given to them by someone considered to be knowledgeable about the subject. In healthcare education over the past few years there has been a growing realisation that we need to move away from formal classroom learning towards a more clinically based style of learning. Much research has been undertaken around effective learning processes which demonstrate that significant learning only takes place when individuals accept responsibility for their own learning, and actively participate in the learning process. Programme leaders therefore need to ensure they facilitate opportunities for the learner to be proactive in the learning process.

In these financially straitened times that the public sector finds itself operating in, pressures will grow for more cost-effective ways of delivering effective healthcare training. The scenario whereby postgraduate students sit in a class of less than twenty individuals is too costly in terms of resources, and will need to be reviewed. The use of ABL and EBL within the curriculum is a potential solution, as it provides for a more effective use of academic staff, where tutors can provide focused support for individual students. If used appropriately, the integration of Action Based Learning and Enquiry Based Learning are useful tools to successfully deliver modules at postgraduate level. Resources can be more effectively utilised by replacing classroom based lectures with more appropriate learning mechanisms. These not only encourage students to support each other in their studies, but also rely on students taking responsibility for their own learning, to ensure the learning is deeper and more effective. Once students have grasped the concept of these new styles of learning, they will come to appreciate that these are powerful tools that can be used in many aspects of life to acquire new skills and knowledge.

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