경험기반학습: 의과대학생의 근무지 학습의 과정과 성과를 연결하는 모델(Med Educ, 2007)

Experience-based learning: a model linking the processes and outcomes of medical students’ workplace learning

Tim Dornan,1 Henny Boshuizen,2 Nigel King3 & Albert Scherpbier4


 


도입 INTRODUCTION


방법 METHODS

맥락 Context

연구 설계 Study design

연구자의 역할 Roles of the researchers

분석 방법Analytical methods


결과 RESULTS



1 학습의 핵심조건으로서의 참여

1 Participation as the core condition for learning


2 참여의 성격

2 The nature of participation


2a 관찰하기

2a Observation as participation


2b 행동하기

2b  Acting as participation


3 참여에 영향을 미치는 요인

3 Factors affecting participation


3a 환자와의 상호작용

3a Interaction with patients


3b 의사와의 상호작용

3b Interaction with doctors


3b.1 학생에 대한 의사의 행동

3b.1 Doctors’ behaviour towards students


3b.2 의료진의 분위기

3b.2 The climate of the medical team


3b.3 커리큘럼에 대한 의사의 지식

3b.3 Doctors’ knowledge of the curriculum


3c 간호사와의 상호작용

3c Interaction with nurses


3d 동료와의 상호 작용

3d Interaction with peers


3e 조직적 요인

3e Organisational factors


4 학생의 심리 상태

4 Students’ states of mind


4a 정체성 구축

4a Building a sense of identity


4b 더 자신 있게 되기

4b Becoming more confident


4c 지속적 동기 부여

4c Sustaining motivation


4d 보람 있는 기분

4d Feeling rewarded


5 학생 역량

5 Students’ competences


5a 학습 기술

5a Study skills


5b 지식

5b Knowledge


5c 임상 기술

5c Clinical skills


고찰 DISCUSSION


주요 조사 결과

Principal findings


그림 1은 연구 결과를 경험 기반 학습 모델로 결합한다. 학생들은 의료행위의 지식과 기술 외에도 자신감과 직업적 정체성을 획득하고 동기부여를 지속할 필요가 있다. 이러한 다양한 학습 성과는 복잡한 아말감complex amalgam에서 함께 달성된다. 다양한 학습성과에 도달하는 것은 학습 프로세스가 강화되고, 반대로 습득하지 못하면 학습 프로세스가 약화된다. 개별 의사(간호사 및 간호사)의 교육 분위기와 행동은 학생들이 환자를 돕겠다는 궁극적인 목표에 가까워지게 하는 임상현장에서의 참여를 가능하게 하거나 비활성화할 수 있는 큰 힘을 가지고 있습니다. 이들이 교육과정을 통해 진행되면서 학생들이 성취하는 성과와 이를 통해 성취하는 활동이 실무자의 역할에 관여하는 사람들과 더 가까워졌다. 효과적인 workplace teacher는 학생들을 지원함과 동시에 실질적인 역량과 긍정적인 심리상태를 쌓는 방법으로 도전할 수 있는 사람이다.

Figure 1 assembles the findings into a model of  experience-based learning . In addition to the knowledge and skills of medical practice, students need to acquire confidence and a sense of professional identity and sustain their motivation. Those various learning outcomes are attained together in a complex amalgam. Attaining them reinforces the learning process, and failing to acquire themweakens it. The educational climate and behaviour of individual practitioners – nurses as well as doctors – has great power to enable or disable workplace participation that brings students closer to their ultimate goal of helping patients. As they progress through the curriculum, the outcomes students achieve and the activities through which they achieve them became closer to those involved in the role of a practitioner. An effective workplace teacher is someone who can simultaneously support students and challenge them in a way that builds practical competence and a positive state of mind.


연구의 강점과 약점 

Strengths and weaknesses of the study


우리의 합성은 새로운 것이지만, 임상 교육 및 학습에 대한 기존 연구와 일관되며, 이는 다른 곳에서 검토된 많은 출판물에 퍼져 있다. 학생들이 너무 오랫동안 수동적인 관찰자로 남아 있으면 금방 지루해진다는 것도 이미 설명된 바 있고, 학생들이 더 적극적으로 참여하고 더 가까이에서 환자를 돌볼수록 학생들은 그 활동을 더 가치있게 평가한다. 학생이 교사나 환자에게 피해harm를 줄 수도 있다고 느끼는 불편함은 [공감의 감정]과 [새로운 직업 정체성에 적응해야 하는 필요성] 사이에서 긴장감을 조성한다.

Although our synthesis is novel, it is consistent with previous research into clinical teaching and learning, which is spread across a large number of publications reviewed elsewhere.8 That students quickly become bored if they remain as passive observers for too long has been described,16,17 as has the fact that the more actively they are involved and the closer their involvement comes to caring for patients, the more highly they value it.18–21 Students’ discomfort at the harm they and their teachers can do to patients creates a tension between their feelings of empathy and the need to acculturate to their new professional identity.22,23 



학생들의 직장 경험에서 간호사의 지배적인 위치가 주목을 덜 받았음에도 불구하고, ['교수-학습 연합'에서 의사 및 임상팀과 대학 관계를 형성하는데서 오는 기쁨highs]과 [굴욕에 의해 가르침을 받는 것이 주는 힘듦lows]도 잘 나타난다. '관계형' 교육 모델에 따르면, 교사-학습자 관계는 의사와 환자 간의 관계와 동일한 방식으로 중요하며, 교사는 지지support와 도전challenge을 결합하여 좋은 효과를 위해 이를 사용할 수 있다.25 특히 이행transition의 시점에 임상 학습의 감정적emotionally charged 특성이 잘 보고된다. 긍정적인 감정의 건설적인 역할은 현재 특히 교육 풍토의 영향에 대한 연구에서 더 많은 관심을 받고 있다.

The highs of forming collegial relationships with practitioners and their clinical teams in a  teaching-learning alliance  and the lows of being taught by humiliation are well documented, although the dominant place of nurses in students’ workplace experiences has received less attention.19)21,24 According to a  relational  model of education, the teacher)learner relationship is important in just the same way as the doctor)patient relationship, and teachers can use it to good effect if they couple challenge with support.25 The emotionally charged nature of clinical learning is well reported, particularly in relation to stress at times of transition. The constructive place of positive emotions26 is now receiving more attention, particularly in research into the effect of educational climate.27–29


연구의 의미

Meaning of the study


우리의 발견은, 학습을 [단순히 교사로부터 학습자로 넘어가는 속성]이 아니라 [실천 공동체 내에 상주하는 역동적인 상품commodity]으로 보는 학습의 현대 사회 이론과 잘 들어맞는다. 이론에 따르면 학습은 그러한 공동체의 문화에 흡수되고 흡수되는 과정이다.30-33 전문적 정체성의 개발은 의사가 되는 과정에 매우 근본적인 것이어서, 의사들의 눈에 믿을 수 있어야만 하는 것은 어린 의대생들에게 질병과 죽음을 맞닥뜨리는 것보다 더 많은 스트레스를 유발한다.35 스트레스 수준은 학생들이 직장에서 처음 배우기 시작할 때 절정에 이른다. 왜냐하면 이 시기에 학생들은 그들이 본받으려고 노력하는 의사들의 곁에서 자신의 무능과 무쓸모함을 깨닫기 때문이다.36-39 

Our findings fit well with contemporary social theories of learning, according to which expertise is not simply a property that passes from teacher to learner, but a dynamic commodity that resides within communities of practice; learning, according to the theory, is a process of absorbing and being absorbed into the culture of such a community.30–33 Developing a professional identity is so fundamental to the process of becoming a doctor34 that having to be credible in the eyes of practitioners causes young medical students more stress than encountering illness and death.35 Stress levels peak when students first start learning in workplaces because they become acutely aware of their own incompetence and unimportance beside the practitioners they strive to emulate.36–39 


학생들은 어느 정도 잘 맞는 새로운 전문적 정체성을 입어보면서try on 불편함을 느낀다.36 그들의 개개인성은 롤모델이 되는 의사를 찾고, 그들과 관계를 발전시키고, 그들의 행위pratice에 참여할 권리를 협상함으로써 표현력을 찾게 된다.19,40 그러므로 지도의사와 학습자 사이의 관계는 학습을 촉진함과 동시에 상당한 감정을 유발할 수 있다. 사회적 문화화enculturation 과정으로서의 의학을 배우는 것은 (비록 우리보다 더 전통적인 교육 및 학습 시스템이지만) 싱클레어의 관찰자 연구(41)에서 매우 철저하게 탐구되었다.

They feel discomfort as they  'try on'  new professional identities that fit more or less well.36 Their individuality can find expression through seeking out practitioner role models, developing relationships with them, and negotiating the right to participate in their practice.19,40 Thus, relationships between practitioners and learners can both facilitate learning and generate high emotions. Learning medicine as a process of social enculturation has been very thoroughly explored in the important participant)observer research of Sinclair,41 albeit in a more traditional system of teaching and learning than ours.


Unanswered questions and future research








. 2007 Jan;41(1):84-91.
 doi: 10.1111/j.1365-2929.2006.02652.x.

Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning

Affiliations 

Affiliation

  • 1Hope Hospital, School of Medicine, University of Manchester, Manchester, UK. tim.dornan@manchester.ac.uk

Abstract

Objective: To develop a model linking the processes and outcomes of workplace learning.

Methods: We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students.

Results: To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning.

Conclusions: The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.


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