Effective Teaching and Learning for Eye Health Workers

Transcription

1 Effective Teaching and Learning for Eye Health Workers Adapted from a series in the Community Eye Health Journal Detlef Prozesky, Sue Stevens & John Hubley

2 Effective Teaching and Learning for Eye Health Workers Adapted from a series in the Community Eye Health Journal Detlef Prozesky, Sue Stevens & John Hubley

3 Effective Teaching and Learning for Eye Health Workers Detlef Prozesky BSc MBChB MCommH PhD Director, Centre for Health Science Education Faculty of Health Sciences University of the Witwatersrand 7 York Road Parktown Johannesburg, 2193 South Africa Health Education and Promotion Module Convenor, International Centre for Eye Health, London, International Centre for the Advancement of Rural Eye Care, India and Pakistan Institute of Community Ophthalmology Sue Stevens RGN RM OND FETC ENB 998 Ophthalmic Resource Coordinator and Nurse Advisor International Centre for Eye Health London School of Hygiene and Tropical Medicine Keppel Street London, WC1E 7HT United Kingdom John Hubley BSc PhD Principal Lecturer in Health Promotion School of Health and Community Care Leeds Metropolitan University Calverley Street Leeds, LS1 3HE United Kingdom Published by International Centre For Eye Health With the support of Christian Blind Mission International, Dark & Light Blind Care, Conrad N Hilton Foundation, Stanley Thomas Johnson Foundation, Sightsavers International, Tijssen Foundation, Orbis

4 Acknowledgements We have drawn heavily on the book Teaching Health Care Workers, authors Fred Abbatt and Rosemary McMahon. We gratefully acknowledge them as the source of an excellent overall system and many inspirational insights. Dr Daksha Patel, Courses Convenor, International Centre for Eye Health, kindly reviewed this booklet. Ann Naughton was responsible for much of the original coordination for this collection. ISBN: Copyright International Centre for Eye Health Content may be photocopied, reproduced or translated provided this is not used for commercial or personal profit. Acknowledgement should be made to the authors and ICEH. Published and distributed by International Centre for Eye Health London School of Hygiene and Tropical Medicine Keppel Street London WC1E 7HT, UK Tel Fax Web: (Community Eye Health Journal) Web: Front Cover Photograph - Sue Stevens Designed by Regent Typesetting, UK. Printed by The Heyford Press Ltd, UK.

5 Contents Introduction 7 Page Section 1. Teaching and Learning 9 Section 2. Communication 13 Section 3. Developing a Course Curriculum 21 Section 4. Methods of Teaching 27 Section 5. Methods of Assessment 33 Section 6. Teaching and Learning Resource Materials 39 Section 7. Evaluation of Training 47 Glossary 53 References 54

6 6 Effective Teaching and Learning for Eye Health Workers

7 Introduction Human resource development is one of the three pillars of VISION 2020 The Right to Sight. Many people involved in community eye health are also teachers and some have never had any training on how to teach effectively. For these reasons, the Community Eye Health Journal published a series of articles on teaching and learning. A number of readers have asked for additional copies of the articles and this booklet, providing updated and additional material, is the result. As was the case with the original series, it aims to stimulate readers to become more effective teachers. It touches on a number of important topics related to teaching and learning in (we hope) a systematic and practical way. However, this can only be a beginning as education is a very broad field and readers are referred to the material in the reference section for further information. Our understanding of what must be done to prevent blindness and promote eye health has advanced considerably in recent years. The challenge ahead is to introduce these methods to the field as quickly as possible. Training is an essential activity in the spread of new knowledge and skills to eye health workers. It can take place in a variety of ways, through initial training of field workers or as part of the continuing education of existing field staff. Training can also involve attendance at short sessions, longer training through intensive workshops, on-the-job supervised practice or distance learning through newsletters, manuals, recorded cassettes and websites. To provide an introduction to planning, developing and implementation of effective training, the diagram below provides a summarised approach. Define training needs Prepare job description with list of tasks Evaluate training All aspects Implement training Plan curriculum Task analysis Construct learning objectives Select methods of teaching and assessment Draw up timetable Organise logistics Select trainees and trainers Arranges times and venues Find and develop materials Introduction 7

8 SECTION ONE Teaching and Learning

9 This section sets the scene by examining some important concepts related to teaching, learning and education. The words we use to talk about teaching and learning People use different words when talking about teaching and learning. Sometimes the same word will mean different things to different people, and sometimes different words will carry the same meaning. For example, Americans tend to use the word evaluate to describe testing students to see if they have learnt, while the British often use the word assess. Here are some other examples of words with related meanings: educator, teacher, trainer, tutor, lecturer, facilitator student, pupil, learner, scholar What do these words mean to you? There will never be full agreement about the real meaning of each of them. If people appear to misunderstand us, we have to explain what we intend them to mean. About learning All of us understand things in the light of our past experience. This is also true of learning we get our ideas of what learning means from what happened to us in the past. So, for example, we may think of learning as something which takes place in a school or college, in a classroom. We may think of it as a person sitting alone at night, trying to memorise a lot of facts so that s/he can pass an examination. However, a bit of reflection will show us that learning is much wider than that. After all, children learn a great deal before they even get to school they learn to speak, to walk. Educational psychologists tell us that any activity which leads to a change in our behaviour is learning (Stones, 1966, pp.50 51). Here are some more ideas about learning : Learning can be formal or informal. We learn informally from what we experience day by day things which happen to us make us change the way we think and act. We may not even be aware that we are learning, which may cause problems for example, health workers may learn bad attitudes from the example of others. Of course, learning may also be formal we attend a course which is planned in a structured way, in a school or college. We don t just learn knowledge and facts we also learn skills and attitudes. This is especially important for health workers, since it is in our practical work that we have an effect on the health of the people we serve. A skill that is often overlooked is the ability to make decisions well, and this has to be learnt systematically. Note that we learn knowledge, skills and attitudes in different ways for example, we may learn a new idea from a discussion, but we learn skills by practising them and getting feedback. People learn in different ways. Researchers have identified different learning styles (Harris and Bell, 1986, pp ). Some people are receivers they like to memorise what is given to them. This is a very common style. It is reinforced by teachers who expect students to memorise, and reward them for it. Other people are detectives, they like to investigate what they are learning themselves to get to understand it. Yet others are generators, they like to decide themselves what they want to learn, and then look for opportunities to learn those things. Learning can be superficial or deep (Pedler, 1974). If knowledge is only memorised (superficial learning) it is soon forgotten and may never affect the way that person does her/his work. If the learner is made to use the new knowledge actively, the learning becomes deep. The learner connects the new knowledge to the concepts that s/he already has and understands how it can be used practically. It is therefore much more likely to be remembered and used. Motivation is important for learning (Handy, 1976, pp.31 47). What is it that makes people want to learn? Some learn because they want to do a better job they get satisfaction from the feeling that they are competent. People are also very strongly motivated by the hope that they will be rewarded for instance, Teaching and Learning 11

10 by gaining a qualification, leading to a promotion and better pay. The need to pass exams is therefore a very strong motivator. Learning continues throughout a person s lifetime at least informally. We all know that health workers should continue to learn throughout their careers because new information about health is constantly becoming available. However, many workers do not have access to formal in-service training. This means they have to take personal responsibility for staying up-to-date and they have to become life-long learners. About teaching Our understanding of what teaching is, is based on our past experience. Our earliest experience was in school, where the teacher was also a master or mistress, standing in front of the class, telling us what to do and what to learn. Some of us experienced the same kind of teaching at college. Others may have experienced teaching where the teacher is more of an equal, who takes account of our experience and even learns from us. That is why Abbatt and McMahon (1993, pp.15 21) say: teaching is helping other people to learn. They go on to say that the job of teaching health care workers has four elements: The teacher has to decide what students should learn. The students and their potential employers may take part in this decision, but all are guided by the same principle: it is the job that people have to do, that determines what they should learn. They have to learn all the knowledge, skills and attitudes needed to perform a specific job. The teacher has to help the learners to learn. This does not mean that the teacher spoon feeds the students, as if they were babies. It does mean that the teacher s first concern should be that the students should learn as well as possible. Teaching sessions or classes have to be planned carefully, taking into account the learning styles, the language, the background of the students. In short, the teachers must be student centred, not teacher centred. Teachers are not dictators and students are not servants. The teacher has to make sure that the students have learnt he/she has to assess them. Assessment helps teachers and students to see how well the students are progressing, so that they can attend to any weaknesses. It sets a standard, so that society is given people who are competent to practice. We must plan assessment carefully so that it supports the learning we want to see we know that students learn what they believe they need to pass the exams, and leave out the rest. The teacher has to look after the welfare of her/his students. Students who are stressed and unhappy do not learn well. Good teachers try to ensure that the general living conditions of their students are adequate. They also provide opportunities for personal counselling for them. Teachers need to cultivate an open and trusting relationship with their students. About education We know that scientists are able to teach rats and even worms to perform certain actions, by rewarding them if they choose the right action and punishing them if they choose the wrong one! Is that what teaching is all about? We feel instinctively that teaching is much more than this. We would like our students to grow intellectually, to widen their horizons, to start reasoning independently. Many people like to use the word educate for this process. Here is what two very different people have said: The great Socrates said that a good teacher should be like a gadfly (or black fly, well known to eye care workers!) which is an irritating and disturbing insect. The teacher asks difficult and important questions, and expects students to work out the answers themselves. This takes place in the form of a dialogue (not a lecture). The 20 th century Brazilian educationalist Paulo Freire says the same thing in another way teachers can be bankers or problem posers. The bankers see their students as empty vessels, to be filled with the teacher s knowledge and ideas (as one puts money into a bank). The problem posers understand that their students already have knowledge and experience, and stimulate them to use those resources by giving them problems to solve. This is clearly very important for people planning and delivering eye care services. They have to learn knowledge and skills, true enough, but then they have to be able to apply them in a variety of different circumstances. They constantly have to solve problems, to make decisions and they have to learn to do this well. 12 Effective Teaching and Learning for Eye Health Workers

11 SECTION TWO Communication

12 In this section, we take a short look at the important role of communication in teaching. It also offers some ideas about improving this communication, leading to better teaching practice. About communication What is communication? According to the Concise Oxford Dictionary the word means the act of imparting, especially news, or the science and practice of transmitting information. These definitions clearly show the link between teaching and communication : teachers are constantly imparting new knowledge, or transmitting information. Hubley (1993, pp.47 51) shows us that communication is a complex process: Sender/source thinks of message puts message into words expresses the words Message Verbal Non-verbal Channel Person-to-person Radio, TV Written media Receiver hears/sees gives attention understands message accepts message At any stage of this process things may go wrong, making the communication less effective. For instance, the sender may not express what he/she wants to say clearly, or the room may be noisy, or the receiver may not understand the words the sender is using. To be effective, teachers have to try to minimise these barriers to communication. We do this in a number of ways for example, by making sure that the room is quiet and well lit, by speaking slowly and clearly; by only using words which the students should be able to understand. However, the most important way to overcome the barriers is two-way communication. This means getting regular feedback from the receivers (the students in this case). Are they really understanding what we are trying to put across? Sender/ source Message Channel Receiver Feedback improves communication Communication does not only take place by means of words. Non-verbal communication (or body language) is equally important. We are all familiar with the different kinds of non-verbal communication: This kind of communication is usually subconscious we use it without thinking about it. This is why we say that it is difficult to lie in body language. If teachers really attend to the body language of their students they will know when they are bored or confused. From the body language of their teachers, students pick up whether the teachers are confident and enthusiastic and encouraging. Communication 15

13 sounds (e.g. laughing) ways of talking (e.g. pauses, stress on words) posture (e.g. slouching) closeness (e.g. invading someone s space ) body contact (e.g. shaking hands) non-verbal communication/ body language appearance (e.g. untidiness) head movements (e.g. nodding) facial expression (e.g. frown) eye movements (e.g. winking) hand movements (e.g. waving) Person-to-person communication: presentation skills In the previous section, we discussed different styles of teaching. Some teachers like to talk, and expect the students to write down what they say and to learn it (this style encourages superficial learning and rapid forgetting!) Other teachers see their role as one of helping the students to learn at a deeper level to understand new ideas and concepts so well that they can apply them in a work situation. Either way, these teachers will do a better job if they communicate well with their students. An important element of communication in teaching is the use of teaching aids. We have all heard the saying: What I hear, I forget; what I see, I remember; what I do, I know. Pictures, written posters and practical demonstrations improve communication and we should use them as much as possible. Most of us have access to paper, posters, a chalkboard, or an overhead projector (some also have access to data projectors). We can use these to prepare aids for our lessons: summaries of important facts, pictures and diagrams, even models. The overhead and data projectors are particularly useful, because they allow us to face our students while using them. How can I know whether I am communicating well as a teacher? Communication is a skill and we improve our skills by getting feedback on the way we perform them. We can get such feedback by asking an experienced colleague to sit in on our teaching and to give us feedback. We can also ask someone to record us on a videotape as we teach, which we then inspect critically afterwards. In either case, the feedback will be better if we use a checklist to judge our performance. Here is such a checklist: 16 Effective Teaching and Learning for Eye Health Workers

14 Checklist for communication during teaching About the style of presentation Does the teacher speak clearly? (loud enough; not too fast; faces the class; avoids mannerisms like um ) Is the teacher s non-verbal communication suitable? (appropriate gestures and expressions; moves around; eye contact with whole class) Does the teacher speak understandably? (uses words that the students should be able to understand) Is the speed of presentation right? (the students must be able to absorb the material that is presented) Is there two-way communication? (the teacher checks regularly if the students have understood) Does the teacher aim for deep learning? (the teacher gives the students problems to solve; they participate and discuss) Is there evidence of a good relationship between teacher and students? (teacher and students respect each other, listen to each other) About the content Does the teacher emphasise important knowledge? (the main messages are clear and emphasised; unnecessary detail is left out) Is information presented in a logical sequence? (bits of information follow logically on each other; easy to understand and to remember) About the place where the teaching is happening Is the place suitable for good communication? (enough light; no noise from outside) Are the students comfortable? (adequate seating; students can see the teacher; not too hot nor too cold) About the use of teaching aids Are the teaching aids relevant? (the aids only deal with the subject matter of the lesson, and clarify it) Are the teaching aids well prepared? (only contain highlights/main points; neat; different colours are used) Are the teaching aids easy to read and understand? (letters and pictures are large enough; not too much information on one aid) Are the teaching aids skilfully used? (the teacher handles them with confidence; uses a pointer; does not mix them up) Communication 17

15 Written communication: handouts Teachers communicate by speaking, but also by writing. Students do most of their learning from written material such as books and notes. In many of our countries, student eye health care workers have to learn from documents in a language (often English or French) which is not their first language. We now know from research that almost all such students have problems with reading these second languages : they read more slowly, and understand less, than students whose first language is English or French. This is purely a language issue, and has nothing to do with intelligence. This fact is very important for teachers to remember when they select or prepare written materials for their students. Photocopies of journal articles or pages out of a textbook are often complex and hard to read be careful of using them. This is one reason why many teachers prepare handouts for their students, which they write themselves. It may be a summary of important points to be learnt; or a guide to students on work they have to do, or references they have to look up. Teachers may use handouts for students to refer to during a lesson, and students will definitely use them in their self-study time. Handouts are an important way of communicating with students and they must communicate effectively. Here is a checklist which should help you to write better handouts: Checklist for writing good handouts About the content Does it emphasize important knowledge? (makes clear what is important the students won t know) Does it present information in a logical sequence? (information logically connected, so it is easy to understand and to learn) Is it scientifically accurate and up-to-date? (information is true, comprehensive, in line with current thinking) About the style of writing Are the sentences short? (not more than 20 words; one idea per sentence) Are active verbs used as much as possible? ** ( feed children regularly, not children should be regularly fed ) Are the readers likely to understand the words? (no jargon; using the simplest word that will say what you want to say) About the layout/ presentation Is it legible/easy to read? (handwriting neat; cyclostyled copies or photocopies clear and not blurred) Is it well spaced and not too full? (a page too full with print is discouraging, boring, difficult to read) Is it striking and interesting? (different letter sizes; bold font used for emphasis; pictures or diagrams included) ** this is true for English in other languages the passive voice may be clear/ acceptable 18 Effective Teaching and Learning for Eye Health Workers

16 These days many teaching institutions have websites where teachers put their handouts for the students to find. It doesn t matter whether the handout is on paper or on a website it still needs to be well written. For those who are interested, there are simple readability tests (such as the Cloze and Gobbledygook tests) that you can use to see if your material is written at the right level for your students. The Cloze readability test You take a sample of the material that you want to test usually half a page. You then remove every fifth word, leaving a blank space (you can do this with correction fluid on a paper copy or by substituting a gap for the word on an electronic copy). You then give the sample to a few persons from the target group (the group which is going to use the material). You ask them to try to fill in the gaps. When they have finished you work out what percentage of replacements is correct, in each case. Then you calculate the average percentage of correct replacements, of all who took the test. This is interpreted as follows: % of missing words correctly guessed: the material is suitable % correctly guessed: the material needs revision so that it is more understandable. 0 39% correctly guessed: the material is too complex and must be completely re-written. The good thing about the Cloze test is that the people who are going to use the material, test that material for you. Communication 19

17 SECTION THREE Developing a Course Curriculum

18 Questions facing a teacher of eye care workers are: What do I need to teach? How do I decide what the students need to learn? How do I decide what to include in a course, and what do I leave out? Fortunately, there is a clear path that we can follow (Abbatt and McMahon, 1993) which is shown below. Describe the job Make a list of the tasks which make up the job Analyse each task Find out what skills, knowledge and attitudes are needed to perform the tasks Write down these as 'learning objectives' Describing the job In health care, the reason for training is clear we expect those who are being trained to do their jobs well. This means two things. Firstly, we have to be quite clear about who is going to be trained to do the job we need, what class or rank of worker, from which area, with which background. Then we have to define exactly what the job is that we want the learners to perform. If we think carefully about it, we will see that a job is made up of tasks. We therefore have to start by listing the tasks that our health worker should be able to perform competently. How do we arrive at this list of tasks? Here are some ideas: We watch skilled health workers at work and write down what they do every day We ask the health workers themselves to tell us which tasks they perform in their daily work. We ask other health team members (e.g. managers) the same thing We consult official documents, such as job descriptions for that category of worker We look at available health statistics and, from that, we work out what the health worker should be able to do Some tasks on the list will be more important than others. This may be because they are done more frequently, or because there will be serious consequences if they are badly done. It is important to think widely at this stage. Some people think that the only task that health workers have is to treat sick people. However, they have many other important tasks as well. Here are some of them: Management tasks e.g. planning a community eye care programme, maintaining the drug supply, keeping financial records, managing time properly Tasks related to preventing disease and promoting health e.g. health education Tasks related to teamwork e.g. resolving conflicts Tasks related to communication e.g. writing a referral letter Such tasks must also be included in the task list. Make a course plan Arrange the learning objectives in a logical way Developing a Course Curriculum 23

19 In an earlier section we spoke about educating students rather than just training them. If we want students to be able to solve problems by themselves, it should be listed as a task in the overall job. In this way we can make sure they learn to do so, by educating them. Analysing the tasks What do we need to teach a person, to perform a task competently? According to Abbatt and McMahon, people need to be taught both skills and enabling factors (i.e. factors which a person needs to perform the skill properly). Let s take the following as an example: Teaching eye care workers to manage trachoma Skills needed for the task Diagnosing a case of trachoma Applying eye ointment Performing tarsal rotation Educating people and communities to prevent trachoma Enabling factors Knowledge of symptoms, signs, stages Knowledge of the organism, stages, treatment Knowledge of the anatomy of the eyelid, surgical equipment/materials to use Knowledge of the spread of the disease and methods of preventing such spread An attitude of concern and caring We see here that there are three kinds of skill, and two kinds of enabling factor: Skills Enabling factors 1. Manual skills 2. Communication skills 3. Decision making skills Educationalists call these five categories the domains of learning. 4. Knowledge 5. Attitudes This means that we have to look at each task, and work out the knowledge, attitudes and skills that the worker needs to learn to perform that task properly. Here is an example, for an ophthalmic assistant: Task: Diagnosing and managing a patient with chronic open angle glaucoma (COAG) Manual skill Communication skill Decision making skill Knowledge Attitude Measuring intraocular pressure using a Schiötz tonometer Performing fundoscopy with an ophthalmoscope Measuring visual fields Explaining to a patient how to take treatment Explaining the need to continue with treatment Deciding when to treat Deciding how to treat Deciding when to refer Anatomy of the eye Physiology of the aqueous humour Pathophysiology/course of the disease (treated/untreated) Epidemiology of the disease Drugs used (mode of action, dosage, side-effects) Problems experienced with treatment Encouraging and supportive. 24 Effective Teaching and Learning for Eye Health Workers

20 After this analysis we know exactly what the students have to learn. In fact, the items in the right hand column become our learning objectives. We simply rewrite them as follows: At the end of the course the students should be able to: Measure intra-ocular pressure using a Schiötz tonometer Explain to a patient how to take treatment for COAG Decide when to treat a person with COAG Describe the anatomy of the eye Demonstrate an encouraging and supportive attitude towards patients with COAG. Note the following: Each learning objective starts with an action verb. For the skills and attitude objectives this is easy, but for the knowledge objectives we have to use words like describe, list and discuss When you have analysed a couple of tasks you will notice that some tasks share the same learning objectives. This is especially true for the communication skills and the attitudes, but also for basic subjects like anatomy and physiology Teachers tend to expect students to learn too much knowledge more than they need to do the job. It is useful to keep the target concept in mind: never teach or assess material that is just nice to know Must know Should know Nice to know Making a course plan When you have finished analysing all the tasks, you will have a large number of learning objectives. These now have to be fitted into a timetable. As you do this, you have to keep the following in mind: The material must be presented in a logical sequence. This means two things: Firstly, we need to group things together that belong together. For example, we group everything around trachoma together: the causative organism, epidemiology, prevention, treatment etc. Secondly, some things have to come before others. For example, students need to learn basic optics before they learn to do refraction. You have to accommodate the time available for the course. Somehow there is always too little time which means that you have to prioritise. Some learning objectives have to be left out, or made shorter. You also have to avoid unnecessary duplication and repetition. You have to consider the teaching methods you are going to use. For example, practical sessions take more time and need more teaching staff. You have to consider the facilities that are available for training. If your own institution cannot offer enough places for practical sessions, students may have to travel to other sites. Developing a Course Curriculum 25

21 Problem-based learning (PBL) In traditional training courses the teachers work out what the students need to learn, and systematically make sure that they learn it. PBL is different. As its name says, this method bases all learning on problems. There are no lectures, instead, the students are presented with a problem usually a clinical one. Working in small groups and under the guidance of a tutor, the students themselves work out what they need to know, and what skills they need, to manage this problem. They then go to the library, the wards and clinics, to learn the necessary knowledge and skills. For example, one problem may be that of a patient with entropion and corneal scarring. The students work out that they need to learn about the anatomy of the conjunctiva, cornea and eyelid, the clinical course of trachoma, the causative organism, its treatment (medical and surgical), its prevention (improved water supply and sanitation, community participation, etc., its epidemiology, other causes of corneal scarring, etc). This one problem therefore makes the students learn a large number of topics and skills. The teachers still have to work out the content of the curriculum. But by carefully selecting the right problems, and enough of them, they make sure that students will cover everything they need to learn. The difference is that the students themselves discover what they need to learn, rather than being given all the information by their teachers. PBL has several advantages above traditional courses: Learners learn how to solve a problem by themselves, in a systematic way. This means that they can do it again in future, when they are faced with a new problem The learners only learn what is needed to solve the problem. There is less danger of learning a lot of unnecessary information They learn the different disciplines in an integrated way this makes it easier to remember and to understand new information Learners learn deeply rather than superficially because they are actively involved and they can see the need for what they are learning Curriculum reform and the SPICES model Curricula are always changing, as teachers try to remain up-to-date and to eliminate problems in their teaching. Over the last 20 years there have been strong movements in many countries, to improve the quality of training of health workers. Harden et al. (1984) describe these changes as follows: Student centred The most important consideration is that students should learn excellently. Teacher convenience and status comes second Problem based Students learn to solve problems (clinical and management) rather than just memorising facts Integrated We try to teach many subjects together all those parts which deal with a specific problem. We try to move away form teaching separate subjects Community based Students learn new knowledge and skills in community settings not just in large hospitals as in the past Electives The curriculum is not completely fixed students get some opportunities to pursue their individual interests Systematic We make sure that students learn to manage all important problems by planning their learning carefully. We no longer just put them into the ward (or clinic) and hope for the best You will notice that the first letters of the six words spell SPICES. This is a helpful checklist to evaluate our present curricula and to see where we may have to change. 26 Effective Teaching and Learning for Eye Health Workers

22 SECTION FOUR Methods of Teaching

23 There are many different teaching methods used. Most teachers use a limited number of methods ones that they are used to and feel comfortable with. Unfortunately, these methods may not be the best that are available. This section aims to give some guidelines about the methods that teachers should use. Teaching the different skills and enabling factors Let s return to our earlier example. How would we normally teach the skills, knowledge and attitudes needed here? Teaching eye care workers to manage trachoma Skill/enabling factor to be learnt Diagnosing a case of trachoma Applying eye ointment Performing tarsal rotation Educating people and communities to prevent trachoma Knowledge of symptoms, signs, stages, the organism, medication, anatomy, spread, prevention, etc. An attitude of concern and caring Suitable teaching method Students see patients in an eye clinic, with an experienced clinician to check the diagnosis Demonstrate each skill, then let students perform it under supervision until they are competent Let students practice educating people; give them feedback about the way they do it Give a lecture covering these facts Refer students to pages in a textbook to study Point out examples of good and bad attitudes to the students and discuss these together From this example a basic rule becomes clear for each of the domains of learning, we have to use specific and different methods to teach the objectives in that domain. Sometimes teachers do not understand this. This leads to the following mistakes: Using the wrong method altogether. For example, instead of learning practically how to communicate, students are given a lecture about communication Using a correct method in an incorrect way. For example, only one or two students perform a skill under supervision, while the rest only watch A feast of methods The generations of teachers who have gone before us have developed a large number of methods. All of these methods are now available for us to use. Here are some of the most commonly used ones, in relation to the domains of learning: Methods of Teaching 29

24 Teaching manual skills There is really only one way to teach a manual skill, and that is to carefully demonstrate it first and then let each of the students perform the skill under supervision. Both teachers and learners can be guided by checklists. Students get feedback, which means that the teacher shows them where they have made mistakes. Sometimes students practise on a model first, before working with a real patient for example, they can inject an orange or they can practise examining each other. About checklists A checklist is a step-by-step, written description of a skill that is excellently performed. Here is an example, for the skill applying eye ointment : Competent Partly done Not done Greet the patient and explain what you are going to do. Position the patient comfortably (sitting or lying down) Check that the ointment and the prescription agree Wash your hands Open the tube of ointment and hold it in your dominant hand With the index finger of the other hand, gently pull down the lower eyelid of one eye, to expose the lower fornix With the nozzle directed toward the inner canthus, squeeze the tube slowly to allow about 1cm of ointment to emerge in a thin line inside the lower eyelid Checklists like this have several uses: Teachers use them when they demonstrate a skill, and to give feedback to students Students use them as a guide when they practise the skill Teachers use them to assess skills in an examination Teaching communication skills Communication skills can only be taught by making students practise them, after a demonstration, and giving feedback on their performance. We often use role plays to teach these skills for example, one student gives a health education talk, while the others pretend to be a group of villagers. After the role play the teacher and the villagers give feedback to the educator, again using a checklist of the skill. Teaching decision-making or problem-solving skills The most common decision that eye health care workers have to make is a diagnosis and what treatment should be given. We teach this as follows: We start by explaining to students how the problem-solving process works. There are two main methods that people use the inductive and the hypothetico-deductive methods. Students have to know both. 30 Effective Teaching and Learning for Eye Health Workers

25 Inductive method You collect as much information as possible about the patient or problem, and then come up with a list of possible solutions (or differential diagnosis) You use the information you have collected to exclude some of the solutions until you end up with the most likely one This is very time consuming. In real life clinicians only use this method if they really have no idea what is going on! Hypothetico-deductive method You start coming up with possible solutions to the problem as soon as you have collected the most readily available information (e.g. what the patient tells you about their problem) You only collect further information which will help you to confirm or reject those solutions or diagnoses (i.e. directed information gathering). As soon as you have a solution which is certain enough, you stop In real life this is the method clinicians mostly use. To use it well you have to be aware of the kinds of mistake you can make with it We then give students problems to solve (e.g. a clinical case), after telling them which problem-solving method to use. For the hypothetico-deductive method, we have to observe them as they work and ask them to explain, step-by-step, how their mind is working, as they collect information and begin to think of possible answers. We comment and give feedback on each step of the process, showing them where their reasoning is going wrong and why. Note that this takes time to do properly Such problems can also be written ones, such as case studies or patient management problems. Here we give students the information they need and ask them to diagnose the case and solve the treatment problem. Again, they have to explain, step-by-step, how they arrive at the answer so that we can give them good feedback Teaching knowledge Lecturing is the most common form of teaching knowledge. There are many other methods, most of which are probably better than lectures. Teachers may discuss important topics with small groups of students in tutorials. A group of teachers may present a seminar where they discuss different aspects of the same topic. Teachers may discuss a topic with students, drawing on what they already know about it. Teachers may arrange educational visits where students learn from what they see and experience. Teachers may give students projects to do, for which the students find the information they need themselves. If you are using a method requiring group work, it is important to keep the group size small, no more than 8-12, so that all can participate. About lectures There is no doubt that lectures are very popular with teachers but are they the method of choice for teaching knowledge? Consider the following: Most students learn very little during lectures they absorb the knowledge afterwards, by self-study It is surely a terrible waste of time to dictate notes to a hundred students, each having to take down the dictation by hand Studies have shown, without doubt, that lecturing leads to less retention than any other way of teaching knowledge The average attention span of people who sit listening to someone talking is around 10 minutes. This is why students get bored and go to sleep during long lectures. What do you think? Perhaps it is better to teach routine knowledge by giving good handouts, or referring students to pages in textbooks, for directed private study. Teachers should, rather, use precious classroom time to explain difficult concepts or to solve problems together. In any case there should be interaction between teachers and learners during lectures the method should stimulate and involve learners, rather than boring them. Methods of Teaching 31

26 Teaching attitudes Attitudes are relatively difficult to teach. All teachers can really do is to help students develop suitable attitudes. A very powerful way is by example, since students imitate the attitudes of their teachers. Another way is to point out examples of good and bad attitudes, and to discuss these with the students why should a good eye care worker have this attitude, and not that one? You can also instruct students to reflect in writing about the attitudes that they see in other health workers and to make a commitment to themselves about what they would like their attitude to be. Teachers and supervisors observe students and can give them feedback on how their attitudes are developing. Another strategy is to let supervisors give students marks for the attitude they display in their work. For those readers who would like to know more about these teaching methods, we recommend the following books: Abbatt, F. and McMahon, R (1993), Teaching Health Care Workers, second edition, London: Macmillan. The ideas in this book are more formal, in the sense that it emphasises the discipline of using the right method for the right domain. Werner, D. and Bower, B. (1982), Helping Health Workers Learn, Palo Alto, California: Hesperian Foundation. This book is a real encyclopaedia of ideas for less formal, interactive teaching. 32 Effective Teaching and Learning for Eye Health Workers

27 SECTION FIVE Methods of Assessment

28 This section looks at a critically important aspect of teaching and learning the assessment of students learning. Why is it so important? Assessment is the heart of learning Assessment drives learning. Students take great trouble to find out exactly what the examination will be like. Why is this? Because they want to pass the examination, of course! There is always too much to learn, so it makes sense to concentrate on what you need to know to pass the exam. We may want our students to be able to make diagnoses but if our tests only test facts, the students will quickly learn just to memorise facts. If, on the other hand, they know that the test consists of clinical problems to diagnose and manage, they will study each clinical problem in such a way that they understand it well enough to diagnose and manage it. If there is no practical in the exam the students will stay out of the wards and clinics to spend all their time with their books. But if they know there is going to be an OSPE, (see page 37), they will spend time with patients to make sure they have mastered all the skills. REMEMBER! ASSESSMENT DRIVES LEARNING What does this mean, practically? It means we have to plan our assessment very carefully in such a way, that our students will learn what we want them to learn. Teachers often spend more time on preparing lessons and teaching them, than they do on assessing the results. Any time you spend on improving your assessment will be richly repaid your students will be better learners as a result. Why do we assess students? The main reason is obvious we want to see if they have learnt what we have taught them. This kind of assessment, which is done at the end of a period of teaching, is called summative it is a summary of what the students have learnt. But there are also other reasons for assessment: Assessment is very important for our students because it shows them where they are falling short. This is why teachers should always discuss exams with students afterwards, to show them what the right answers were, and where they made mistakes. For the same reason students must be given their marks, and their exam scripts, as soon as possible. Assessment which is done in this way, while the students are still learning, is called formative we are forming or improving the students. Assessment also gives the teachers important information. If the students do well in the assessment it also means the teachers are doing their job well. If not, the situation must be investigated. Perhaps the students are being overloaded, or the assessment itself is too difficult or tricky, or the students studying and exam techniques are faulty. We are training health workers to do a job. To protect society, we should only send out students who are safe who know their work well enough not to harm anybody. One of the reasons for our final examination of students is to make sure that they are safe. Society expects us to do a good job! Assessment should be valid Good assessment is valid. This means that it tests what it is supposed to test. Perhaps you want to assess your students to see if they can measure intraocular pressure. You can ask them to write short notes on how to use a Schiötz tonometer but that will not tell you if they can really do the job. Your method of testing is not valid. A better way is to stand by and watch them while they perform it on a patient, then you will really know if they can do it properly. This second method of testing is valid. In an earlier section, we discussed the domains of learning. We saw that each domain is taught in a different Methods of Assessment 35

29 way. The same is true of assessment: we assess each domain in a different way. In the table below, you will find examples of how we should assess the learning of our students, for each domain. Skill/enabling factor to be examined Manual skill Performing a tarsal rotation Communication skill Educating a family on how to prevent trachoma Decision making skill Diagnosing and treating a case of trachoma Suitable assessment method The student has to perform the operation on a patient with entropion, while the teacher watches and marks her/his performance with a checklist The student has to educate a family on the prevention of trachoma, while the teacher watches and gives marks with a checklist The students are presented with a patient suffering with trachoma. They have to question and examine the patient and explain how they come to a diagnosis, while the teacher watches and questions The teacher can also give the students a written case study, which gives all the history and examination findings, and ask them how they would manage the patient Knowledge Knowledge of symptoms, signs, stages, the organism, medication, anatomy, spread, prevention, etc. Attitude An attitude of concern and caring Written examination with short answer questions, multiple choice questions (MCQs), essay questions Oral examination The teacher observes the student as s/he works in the clinic. After a week or so the teacher uses a checklist to make a final assessment of the student s attitude If you follow the guidelines in this table, your assessment is likely to be valid it will test what it is supposed to test. Some teachers like to ask trick questions to catch out their students. Others like to ask questions about very rare, very obscure diseases. Such assessment is not valid. Valid assessment should be straightforward, and should focus on the must knows and must be able to dos the things that are really necessary for day-to-day practice. Finally, in every assessment the examiner has to take a sample of all that the students had to learn because there is never enough time to examine everything. To be valid the sample has to cover the whole range of knowledge and skills that the students were supposed to master. Assessment should be reliable Good assessment is reliable. This means that if we repeat the assessment on the same student at another time, or using another examiner, the mark will be the same. Some forms of assessment are more reliable than others. An OSPE (see page 37) is more valid than old-fashioned practical sessions, which use different patients for different students. A written exam (where everyone gets the same questions) is generally more reliable than an oral one (where different candidates get asked different questions by different examiners). You can make any form of assessment more reliable by giving a little thought to the matter. Practical exams are more reliable if you use a checklist to mark the performance of the student. Written exams are more reliable if the markers are guided by a very clear document which shows how marks are allocated for each question. 36 Effective Teaching and Learning for Eye Health Workers