Ophthalmic & Physiological Optics ISSN 0275-5408
Case-based discussion supporting learning and practice in optometry Alison Bullock1, Emma Barnes1, Barbara Ryan2 and Nik Sheen2 1
Cardiff Unit for Research and Evaluation in Medical and Dental Education, School of Social Sciences, Cardiff University, Cardiff, UK, and 2Wales Optometry Postgraduate Education Centre, Cardiff University, Cardiff, UK
Citation information: Bullock A, Barnes E, Ryan B, Sheen N. Case-based discussion supporting learning and practice in optometry. Ophthalmic Physiol Opt 2014; 34: 614–621. doi: 10.1111/opo.12151
Keywords: continuing education, optometry, peer review, qualitative, questionnaires Correspondence: Nik Sheen E-mail address: [email protected] Received: 13 May 2014; Accepted: 28 July 2014
Abstract Purpose: To enhance continuing professional development and address the risk that professional isolation poses, the UK General Optical Council introduced a requirement for all optometrists to engage in at least one case-based discussion per 3 year cycle of continuing education. In this paper, we explore participants’ impression of the acceptability, effectiveness and long-term impact-on-practice of case-based discussion as a mode of continuing education. Methods: Case-based discussion participants attended an evening session comprising a lecture and a group discussion. They completed three questionnaires: prior to the session, immediately post-session and 3–4 months post-session. We coded the questionnaires to allow matching. Results: Seventy-five case-based discussion groups were held with 379 participants; 377 completed both pre- and post-questionnaires and 331 (88%) returned a follow-up questionnaire. Case-based discussions were an acceptable method of learning, with many preferring it to distance-learning. Prior to the event, women, employees and part-time workers were more likely to have concerns about participating. In terms of learning, gaps in knowledge were more likely to be revealed in those who work in isolation. The respondents highlighted social aspects, reassurance of practice as well as new learning. Participants significantly improved selfconfidence ratings in all key learning areas. At three months post-session, the majority (75%) self-reported that they had implemented their intended changes to practice. Conclusions: The evaluation showed that participants felt that case-based discussion developed their knowledge, notably for sole practitioners, and influenced later workplace practice. The peer interaction of this mode of continuing education can combat professional isolation.
Introduction As the regulatory body for the optical professions in the UK, the General Optical Council registers 13 764 optometrists.1 Following the White Paper Trust, Assurance and Safety,2 and in preparation for a future revalidation process,3 the General Optical Council modified the continuing education and training (CET) scheme. One significant change was the introduction of mandatory participation in case-based discussions with peers. This is in part a response to a review of competency risks in diagnosis and condition 614
management associated with General Optical Council registrants4 which found risks linked to professional isolation, exacerbated by the tendency for registrants to undertake CET by text-based distance learning, without interaction with peers. Professional isolation can affect sole practitioners, self-employed locums or those working in rural areas but can also arise when opportunities for discussion of professional skills are limited owing to workload. Limited opportunities for shared learning or review may adversely affect professional competency, allowing mistakes or weaknesses of practice potentially to go undetected. Examples of
© 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 614–621
A Bullock et al.
failures as well as good practice may not be shared and achievements may go unrecognised.4–6 From consultation with patient, profession and other stakeholder representatives, discussion with peers was seen as central to maintaining good practice.4 The New Zealand-based optometrists that Jacobs and colleagues7 surveyed, identified learning through interaction with colleagues as their most effective continuing education. Kaufman and Mann8 identified several common themes across the literature regarding adult teaching and learning, all of which emphasise the active contribution of the learner. Lave and Wenger9 described how communities of practice can develop within professional groups that regularly interact. While sharing and discussion of practice with peers is an effective way for individuals to learn complex clinical skills and practical information,8 it also fosters an increased sense of community and shared professional identity. As part of a community of practice, ideas for improving practice can be exchanged.10 According to Sfard11 theories of learning typically follow one of two broad models; ‘acquisition’ and ‘participation’. The acquisition model addresses the individual attainment of knowledge whereas in the participation model, learning is context-based and viewed as an ongoing process of group belonging. As Bullock and de Jong state: ‘Learning is thus about the acquisition of knowledge and also a process of social participation’12 Sfard argues that these two aspects cannot be separated.11 The previous trend for distance learning in Optometry accounts for self-directed acquisition of knowledge but limits the opportunity for participatory, collaborative learning. Introduced in January 2013, the main change was a requirement to ‘participate in at least one formal CbD group per cycle’.13 Case-based discussions groups are made up of four to ten peers with a nominated facilitator who ensures that everyone in the group participates and helps link ‘learning from the discussion to their own practice’.13 As described, the case-based discussions sessions fulfil several of Davies et als14,15 criteria for best practice in CET: a needs assessment, a focused initiative, interactive instructional methods, multiple sessions, opportunity for practice and feedback, enabling social and organisational support, and reinforcement techniques. Our aim was to evaluate case-based discussions groups, exploring the self-reported effectiveness of case-based discussion as a mode of learning and its value as a means of enhancing practice and to determine if professional isolation and type of practice affects self-reported improvements in learning. Methods A case-based discussion approach was used in Wales as part of the normal 3 year re-accreditation training cycle for
Case-based discussion supporting optometry practice
Optometrists and Ophthalmic Medical Practitioners to be able to provide extended eye care services in the community via the Wales Eye Health Examination and Primary Eyecare Acute Referral Scheme. Further information on these services can be found in the paper by Sheen et al.16 It was recognised that peer review and case-based discussions would, in future, be part of the General Optical Council enhanced CET requirements and our aim was to trial this in Wales using prepared case records. From January 2012, Optometrists and Ophthalmic Medical Practitioners were required to attend three groups over an 18-month period which was within the normal Wales Eye Health Examination and Primary Eyecare Acute Referral Scheme 3 year re-accreditation cycle. In the study period, eleven events were held in eight locations across Wales. The purpose of the re-accreditation case-based discussion was to improve the optometric management of cases with an emphasis on reporting and referrals to primary care doctors and secondary eye care. Our evaluation centred on all participants in their first case-based discussion groups in the 2 month period January to February 2012, the self-reported knowledge they developed and how this was applied to their practice. This project was reviewed and approved by the Ethics Committee of the School of Postgraduate Medical and Dental Education, Cardiff University, UK. The groups consisted of five to eight practitioners and a facilitator. Group membership was expected to remain the same over time. Members were allocated randomly so that groups contained a mix of clinical practice and levels of experience. There were 11 trained facilitators, all practicing optometrists. Each participant attended one evening discussion session and a lecture. As this was the first introduction to case-based discussions, the organisers pre-prepared case records and referral letters which focused on iritis and corneal abrasions. The evaluation of case-based discussion effect on practice was shaped by the Kirkpatrick framework for programme evaluation17 that has been widely used in business and education.18 The original Kirkpatrick framework comprises four levels. Level 1 is concerned with assessing the participants’ reactions to the activity (including relevance to needs). Level 2 relates to learning gains (knowledge acquired by the practitioners). Level 3 focuses on behaviour change as a consequence of participation (application of knowledge to practice). Level 4 is about impact (what difference changed behaviour makes to healthcare outcomes) and is outside the scope of this evaluation. Three questionnaires were completed (these questionnaires are available as supplementary material online): 1. A pre-event questionnaire collected practitioner selfratings of confidence and knowledge. This also contained questions on: contextual factors relating to participants and practices (length of time in practice, geographical location, lone or multi-practices, broad
© 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 614–621
615
Case-based discussion supporting optometry practice
A Bullock et al.
patient demographics) and potential barriers to participation (geographical availability, distance to travel to events, cost, and absence from practice). (Kirkpatrick Levels 1& 2) 2. The immediate post-event questionnaire included a repeat of the confidence ratings and additional questions on: views on the discussion (exploring any reluctant to discuss cases or share failure) and the learning environment; views on learning gains (with reference to learning outcomes) and comparisons with other modes of CET (e.g. distance learning). (Kirkpatrick Levels 1 & 2) 3. A paper-based questionnaire was completed 3–4 months after the case-based discussion event. Questions invited reflection on learning from the discussion and how it might have made a difference to practice. (Kirkpatrick Level 3) Pre and post-event questionnaires were included in the participant information pack and follow-up questionnaires were mailed with reminders sent to non-responders. All questionnaires were assigned an individual code number to allow participant matching. All data were analysed in SPSS v20 (www.ibm.com/software/analytics/spss) using Pearson chi-square test of significance to explore response pattern by demographic grouping and Wilcoxon Signed Ranks Test for change in responses pre and post event. The responses to questions on a five-point scale were combined into positive (strongly agree and agree), negative (strongly disagree and agree) and neither agree or disagree categories for analysis. A p-value of
Case-based discussion supporting learning and practice in optometry Alison Bullock1, Emma Barnes1, Barbara Ryan2 and Nik Sheen2 1
Cardiff Unit for Research and Evaluation in Medical and Dental Education, School of Social Sciences, Cardiff University, Cardiff, UK, and 2Wales Optometry Postgraduate Education Centre, Cardiff University, Cardiff, UK
Citation information: Bullock A, Barnes E, Ryan B, Sheen N. Case-based discussion supporting learning and practice in optometry. Ophthalmic Physiol Opt 2014; 34: 614–621. doi: 10.1111/opo.12151
Keywords: continuing education, optometry, peer review, qualitative, questionnaires Correspondence: Nik Sheen E-mail address: [email protected] Received: 13 May 2014; Accepted: 28 July 2014
Abstract Purpose: To enhance continuing professional development and address the risk that professional isolation poses, the UK General Optical Council introduced a requirement for all optometrists to engage in at least one case-based discussion per 3 year cycle of continuing education. In this paper, we explore participants’ impression of the acceptability, effectiveness and long-term impact-on-practice of case-based discussion as a mode of continuing education. Methods: Case-based discussion participants attended an evening session comprising a lecture and a group discussion. They completed three questionnaires: prior to the session, immediately post-session and 3–4 months post-session. We coded the questionnaires to allow matching. Results: Seventy-five case-based discussion groups were held with 379 participants; 377 completed both pre- and post-questionnaires and 331 (88%) returned a follow-up questionnaire. Case-based discussions were an acceptable method of learning, with many preferring it to distance-learning. Prior to the event, women, employees and part-time workers were more likely to have concerns about participating. In terms of learning, gaps in knowledge were more likely to be revealed in those who work in isolation. The respondents highlighted social aspects, reassurance of practice as well as new learning. Participants significantly improved selfconfidence ratings in all key learning areas. At three months post-session, the majority (75%) self-reported that they had implemented their intended changes to practice. Conclusions: The evaluation showed that participants felt that case-based discussion developed their knowledge, notably for sole practitioners, and influenced later workplace practice. The peer interaction of this mode of continuing education can combat professional isolation.
Introduction As the regulatory body for the optical professions in the UK, the General Optical Council registers 13 764 optometrists.1 Following the White Paper Trust, Assurance and Safety,2 and in preparation for a future revalidation process,3 the General Optical Council modified the continuing education and training (CET) scheme. One significant change was the introduction of mandatory participation in case-based discussions with peers. This is in part a response to a review of competency risks in diagnosis and condition 614
management associated with General Optical Council registrants4 which found risks linked to professional isolation, exacerbated by the tendency for registrants to undertake CET by text-based distance learning, without interaction with peers. Professional isolation can affect sole practitioners, self-employed locums or those working in rural areas but can also arise when opportunities for discussion of professional skills are limited owing to workload. Limited opportunities for shared learning or review may adversely affect professional competency, allowing mistakes or weaknesses of practice potentially to go undetected. Examples of
© 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 614–621
A Bullock et al.
failures as well as good practice may not be shared and achievements may go unrecognised.4–6 From consultation with patient, profession and other stakeholder representatives, discussion with peers was seen as central to maintaining good practice.4 The New Zealand-based optometrists that Jacobs and colleagues7 surveyed, identified learning through interaction with colleagues as their most effective continuing education. Kaufman and Mann8 identified several common themes across the literature regarding adult teaching and learning, all of which emphasise the active contribution of the learner. Lave and Wenger9 described how communities of practice can develop within professional groups that regularly interact. While sharing and discussion of practice with peers is an effective way for individuals to learn complex clinical skills and practical information,8 it also fosters an increased sense of community and shared professional identity. As part of a community of practice, ideas for improving practice can be exchanged.10 According to Sfard11 theories of learning typically follow one of two broad models; ‘acquisition’ and ‘participation’. The acquisition model addresses the individual attainment of knowledge whereas in the participation model, learning is context-based and viewed as an ongoing process of group belonging. As Bullock and de Jong state: ‘Learning is thus about the acquisition of knowledge and also a process of social participation’12 Sfard argues that these two aspects cannot be separated.11 The previous trend for distance learning in Optometry accounts for self-directed acquisition of knowledge but limits the opportunity for participatory, collaborative learning. Introduced in January 2013, the main change was a requirement to ‘participate in at least one formal CbD group per cycle’.13 Case-based discussions groups are made up of four to ten peers with a nominated facilitator who ensures that everyone in the group participates and helps link ‘learning from the discussion to their own practice’.13 As described, the case-based discussions sessions fulfil several of Davies et als14,15 criteria for best practice in CET: a needs assessment, a focused initiative, interactive instructional methods, multiple sessions, opportunity for practice and feedback, enabling social and organisational support, and reinforcement techniques. Our aim was to evaluate case-based discussions groups, exploring the self-reported effectiveness of case-based discussion as a mode of learning and its value as a means of enhancing practice and to determine if professional isolation and type of practice affects self-reported improvements in learning. Methods A case-based discussion approach was used in Wales as part of the normal 3 year re-accreditation training cycle for
Case-based discussion supporting optometry practice
Optometrists and Ophthalmic Medical Practitioners to be able to provide extended eye care services in the community via the Wales Eye Health Examination and Primary Eyecare Acute Referral Scheme. Further information on these services can be found in the paper by Sheen et al.16 It was recognised that peer review and case-based discussions would, in future, be part of the General Optical Council enhanced CET requirements and our aim was to trial this in Wales using prepared case records. From January 2012, Optometrists and Ophthalmic Medical Practitioners were required to attend three groups over an 18-month period which was within the normal Wales Eye Health Examination and Primary Eyecare Acute Referral Scheme 3 year re-accreditation cycle. In the study period, eleven events were held in eight locations across Wales. The purpose of the re-accreditation case-based discussion was to improve the optometric management of cases with an emphasis on reporting and referrals to primary care doctors and secondary eye care. Our evaluation centred on all participants in their first case-based discussion groups in the 2 month period January to February 2012, the self-reported knowledge they developed and how this was applied to their practice. This project was reviewed and approved by the Ethics Committee of the School of Postgraduate Medical and Dental Education, Cardiff University, UK. The groups consisted of five to eight practitioners and a facilitator. Group membership was expected to remain the same over time. Members were allocated randomly so that groups contained a mix of clinical practice and levels of experience. There were 11 trained facilitators, all practicing optometrists. Each participant attended one evening discussion session and a lecture. As this was the first introduction to case-based discussions, the organisers pre-prepared case records and referral letters which focused on iritis and corneal abrasions. The evaluation of case-based discussion effect on practice was shaped by the Kirkpatrick framework for programme evaluation17 that has been widely used in business and education.18 The original Kirkpatrick framework comprises four levels. Level 1 is concerned with assessing the participants’ reactions to the activity (including relevance to needs). Level 2 relates to learning gains (knowledge acquired by the practitioners). Level 3 focuses on behaviour change as a consequence of participation (application of knowledge to practice). Level 4 is about impact (what difference changed behaviour makes to healthcare outcomes) and is outside the scope of this evaluation. Three questionnaires were completed (these questionnaires are available as supplementary material online): 1. A pre-event questionnaire collected practitioner selfratings of confidence and knowledge. This also contained questions on: contextual factors relating to participants and practices (length of time in practice, geographical location, lone or multi-practices, broad
© 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 614–621
615
Case-based discussion supporting optometry practice
A Bullock et al.
patient demographics) and potential barriers to participation (geographical availability, distance to travel to events, cost, and absence from practice). (Kirkpatrick Levels 1& 2) 2. The immediate post-event questionnaire included a repeat of the confidence ratings and additional questions on: views on the discussion (exploring any reluctant to discuss cases or share failure) and the learning environment; views on learning gains (with reference to learning outcomes) and comparisons with other modes of CET (e.g. distance learning). (Kirkpatrick Levels 1 & 2) 3. A paper-based questionnaire was completed 3–4 months after the case-based discussion event. Questions invited reflection on learning from the discussion and how it might have made a difference to practice. (Kirkpatrick Level 3) Pre and post-event questionnaires were included in the participant information pack and follow-up questionnaires were mailed with reminders sent to non-responders. All questionnaires were assigned an individual code number to allow participant matching. All data were analysed in SPSS v20 (www.ibm.com/software/analytics/spss) using Pearson chi-square test of significance to explore response pattern by demographic grouping and Wilcoxon Signed Ranks Test for change in responses pre and post event. The responses to questions on a five-point scale were combined into positive (strongly agree and agree), negative (strongly disagree and agree) and neither agree or disagree categories for analysis. A p-value of
