Chapter 41 Peer coaching to generate clinical reasoning skills
Novice health professionals who lack clinical experience are challenged to a greater degree than experienced clinicians when faced with the task of clinical reasoning. These novices commonly have a reduced ability to judge the relevance and importance of clinical tasks, especially when contrasted to expert performance (Edwards et al 2004, Jensen et al 2000, Oldmeadow 1996). Novices also tend to make errors in the process of reasoning when attempting to make clinical decisions because of their reliance on hypothetico-deductive reasoning processes (Edwards et al 2004, Jensen et al 2000). This stems from a knowledge base that is being restructured, moving from a predominance of biomedical knowledge to more clinically meaningful patterns (Boshuizen & Schmidt 1995, Carnevali 1995). Boshuizen & Schmidt termed this tendency to make frequent errors an intermediate effect.
The education of novices needs to address the development of their clinical reasoning abilities, including consideration of multiple determinants of health (Jones et al 2000, WHO 2001). They need to value diverse sources of information from the available research evidence as well as the patient’s knowledge and views on health and illness. This information is used to develop their professional craft knowledge and skills such as manual handling and communication to facilitate diagnosis and treatment. For continued growth as health professionals they need to value and develop capability in critical reflection (Jensen et al 2000, Schön 1991). In this chapter we discuss the use of peer-centred learning as a method to facilitate the development of clinical reasoning in novice practitioners.
Learning from peers is sometimes referred to as cooperative learning. Cooperative learning, however, is a broad educational strategy that encapsulates many forms of peer-centred learning. For example, Johnson & Johnson (1978, 1987) and Johnson et al (1981) used the term ‘cooperative learning’ to describe principles of group learning; that is, learning that is enhanced by group interdependence and individual accountability.
The literature on peer learning and the definitions that emanate from this work are abundant. Gerace & Sibilano (1984), for example, defined peer teaching as collaboration between two people of equal rank working together to solve a problem. Lincoln & McAllister (1993) examined the concept of peer learning in detail and raised an important differentiation between process and procedure. Peer learning is the process, and is related to the outcomes of the collaborative learning experience. In contrast, peer tutoring, peer teaching, peer review and peer evaluation are specific procedures that allow peer learning to occur. The procedure discussed in this chapter to describe the peer learning experience is peer coaching (Ladyshewsky 2000). It is an educational procedure in which peers coach one another through clinical experiences using demonstration, observation, collaborative practice, feedback/discussion and problem solving.
Clinical experience is a significant part of novice practitioners’ learning. Clinical experiences are used to restructure biomedical knowledge into more meaningful clinical patterns, which ultimately guide practice (Boshuizen & Schmidt 1995, Carnevali 1995). For example, clinical patterns attended to by physiotherapists comprise more than biomedical diagnostic information. Therapists, as a result of their clinical experience, also develop and revise clinical patterns relating to physical, environmental and biopsychosocial factors. These factors all contribute to the development and understanding of patients’ problems, and thus are integrated into clinical patterns of management strategies, clinical patterns for recognizing safety precautions and contraindications, and clinical patterns related to judging prognoses.
The importance of experiential learning for the cognitive structures of learners has been described by numerous authors (e.g. Barker-Schwartz 1991, Boud 1988, Brown et al 1989, Graham 1996, Higgs 2004, Kolb 1984). Boud (1993) argued that learners construct newer forms of knowledge and understanding using their previous experiences as a template. These experiences are influenced not only by the novice practitioner’s underlying knowledge base, but also by the social and cultural context of the learning situation. Brown et al (1989) described learning that encompasses both physical and social contexts as ‘situated’ learning. Learning in these real-life situations allows concepts to evolve because the situation, and the negotiations and discussions that occur with others, recast the information into a more densely textured form (Graham 1996). That is, knowledge acquired in the context for which it will be used (i.e. clinical practice) is made more meaningful and accessible (Rumelhart & Ortony 1977, Schön 1987, Shepard & Jensen 1990).
Boud (1988, 1993) challenged educators to put more emphasis on how students learn from complex experiences. On the basis of constructivist learning theory, which states that learners construct their own unique forms of knowledge, it can be argued that more attention needs to be paid to learning from experience (Boud 1993, Brown et al 1989, Mezirow 2000). Strategically engaging the learner in the actual learning experience, therefore, is one method of enhancing learning.
Quite often during the course of a clinical education experience a novice practitioner is exposed to a wide variety of patients and problems. Hopefully, some of this experience is translated into learning and the novice practitioner’s competence is improved. More often than not, however, novice practitioners do not gain as much as they could from the patient management experience, particularly if they have poor self-evaluation skills. Boud (1988) described a strategic approach to learning from experience as a series of three stages, generalizable to any learning experience. The first stage involves returning to the experience so that the learner can recapture as many parts of it as possible. The second stage involves attending to conceptions about performance, and reflecting on the conceptions that arose during the experience. Recognizing these conceptions helps learners to understand how they influence their specific interpretations and general understanding. The third stage involves re-evaluating the experience, where the new experience is related to prior experiences and new knowledge is reorganized using a variety of cognitive and metacognitive strategies such as association, integration, validation and appropriation (Boud 1988). Association involves connecting ideas and feelings which are part of the original experience to existing knowledge. Integration involves processing these associations to see if there are patterns or linkages to other ideas. Validation involves testing the internal consistency of these emerging concepts in relation to existing beliefs and knowledge. And appropriation involves making this new knowledge an integral part of how one acts or feels.
The influence of experiential learning and the use of discussion to enhance cognitive processing are present in the theoretical perspectives of other educational theorists. Belenky and colleagues (1986) described two concepts: connected knowing and separate knowing. Although both forms of knowing are important, connected knowing is a preferred educational orientation because it includes the sharing of common experiences and discussion of the feelings that inform ideas. Separate knowing is an orientation to learning that is characterized by impersonal and objective reasoning, commonly referred to as critical thinking. Barker-Schwartz (1991) argued that learning activities involving discussion of experiences and illustration of theory in practice will promote connected knowing. This same notion is emphasized in the literature on transformative learning, where critical discourse is promoted as essential for testing the validity of one’s construction of meaning (Mezirow 2000). Peer coaching, which promotes observation of theory in practice, collaborative practice, feedback/discussion and problem solving, can be used to promote this connection.
The use of PC appears to provide a rich opportunity for novice practitioners to more actively engage themselves in the learning experience. This is consistent with current conceptions of the complexity of clinical reasoning, in particular, dialectical reasoning. In the dialectical model, clinical reasoning has been described as a process ‘that moves between those cognitive and decision-making processes required to optimally diagnose and manage patient presentations of physical disability and pain (hypothetico-deductive or instrumental reasoning and action) and those required to understand and engage with patients (narrative or communicative reasoning and action)’ (Edwards et al 2004, p. 328). The development of more robust clinical knowledge and reasoning frameworks becomes possible because of the opportunities to refine and restructure knowledge in consultation with others.
Bandura (1971, 1997) discussed perspectives on social learning theory, and described three kinds of reinforcement that influence learning outcomes. The first is direct external reinforcement. Under this form of reinforcement, people regulate their behaviour on the basis of the consequences they experience directly. The second is vicarious reinforcement, which occurs by observing the experiences of others and then modifying one’s own behaviour based upon the consequences just observed. Thirdly, self-administered reinforcement involves regulating one’s behaviour according to standards. The nature of PC provides rich opportunities for these three types of reinforcement to occur. For example, feedback from a peer may help novices to recognize certain consequences of their behaviour or their failure to recognize a standard of behaviour required.
In a review of adult learning theory, Mezirow (1981) discussed technical, practical and emancipatory knowledge, three forms of empirical knowledge identified by Habermas (1972). Mezirow described them as three approaches to learning, and discussed their influence on the generation of knowledge. He argued that most educational methods emphasize the first two perspectives, which focus on the provision and evaluation of knowledge and skills. Mezirow felt they ignored the emancipatory perspective. Emancipatory learning ‘involves an interest in self-knowledge, that is, the knowledge of self-reflection. … Insights gained through critical self-awareness are emancipatory in the sense that at least one can recognize the correct reasons for his or her problems’ (Mezirow 1981, p. 5). Mezirow argued that metacognition or personal awareness about knowledge enhances cognition.
Emancipatory learning can be promoted by encouraging discussion and dialogue with peers and by participating in and leading learning groups (Mezirow 1981). This helps learners to identify real problems involving power relationships, institutional ideologies that are embedded in myths and their own feelings, for example. Mezirow argued that by critiquing these psycho-cultural perspectives, alternative meaning perspectives can be created. This type of emancipatory learning is critical in clinical reasoning, particularly if one considers the importance of personal knowledge in pragmatic/ethical reasoning (Edwards et al 2005, Jones & Rivett 2004, Neistadt 1996, Schell & Cervero 1993). These forms of reasoning involve considering the moral, political and economic dilemmas in clinical practice.
The above discussion illustrates the importance of learning how to learn and the use of metacognition. Metacognitive skills are cognitive skills necessary for the management of knowledge and other cognitive skills (Biggs 1988). Metacognition involves being aware of one’s cognitive processes and controlling them (Higgs & Titchen 1995). Skills in metacognition have been shown to enhance problem-solving and learning (Biggs 1988). Thus, academic programmes designed to enhance students’ capacity to generate and acquire new knowledge and to enhance their clinical reasoning abilities need to develop students’ metacognitive skills (Higgs & Jones 2000, Jones et al 2000, Lincoln & McAllister 1993, Rivett & Jones 2004, Terry & Higgs 1993, Tichenor et al 1995).
Although independent metacognition and ‘reflection-in action’ (Schön 1991) can be used by an individual practitioner, peers can heighten the cognitive and metacognitive experience by consciously engaging in specific discussion at each stage of the experience (Higgs & Titchen 1995, Jones 1995). Peer coaching is a particularly useful method to facilitate metacognition because of the joint problem-solving activities that take place between peers (Terry & Higgs 1993). This metacognitive activity can lead to enhanced clinical reasoning skill and greater levels of competency (Higgs & Jones 2000).