교육스킬 교수개발: 집중 장기 모델(Acad Med, 2004)

교육스킬 교수개발: 집중 장기 모델(Acad Med, 2004)

Faculty Development in Teaching Skills: An Intensive Longitudinal Model

Karan A. Cole, ScD, L. Randol Barker, MD, ScM, Ken Kolodner, ScD, Penelope Williamson, ScD, Scott M. Wright, MD, and David E. Kern, MD, MPH

교육스킬(TS)을 가르치는 것은 임상가-교육자(clinician-educator)의 professional development에 중요한 단계이다. TS프로그램은 효과적인 것으로 보고되고 있으며, 지난 15년간 그 availability에 있어서 엄청난 발전을 이루어왔다. 그러나 최근의 국내 조사결과를 보면, 의대 교수들에 대한 TS에 관한 FD활동이 계속 진행중인 교육병원은 39%에 불과하며, 평균적으로 50% 이하의 교수만이 참여한다.

Training in teaching skills is a critical step in the professional development of clinician– educators. 1–5 Teaching skills programs have been shown to be effective,6–18 and considerable progress has been made in increasing their availability in the past 15 years. However, according to a recent national survey, only 39% of teaching hospitals have ongoing faculty development activities in teaching skills for their department of medicine faculty, and, on average, fewer than 50% of their faculty participate.19

TS프로그램에서 사용되는 교수법 중 흔한 것으로는 강의, 토론, 원격교육, 코칭, 스킬연습(실습)이 있으나 성찰을 사용한다고 보고한 결과는 적다.

Among teaching skills programs that include more common teaching approaches (lecture, discussion, distance learning, coaching, and skills practice),6–11,16,20 few report using reflection.6–8 

성찰이란 한 사람의 경험에 대해 생각/감정/신념/행동을 인식하고 의식적으로 해석을 위해 주의를 기울이는 것이다.

Reflection is defined as giving conscious attention to one’s interpretations of expe- rience through awareness of thoughts, feelings, beliefs, and behaviors.21

자신의 발전속도에 맞춰(자기주도학습) 스스로 니즈, 리소스, 성장, 발전을 깨달을 때, 그리고 다른 사람에게 지지(지원)를 받을 때 Experiential learning 혹은 Reflective learning에 더 참여할 가능성이 높다.

Individuals are more likely to engage in experiential or reflective learning if they identify their own needs, resources, and improvement, progress at their own pace (self-directed learning), and feel supported by others.24

도전의 기회를 주면서도 지지적인 학습환경이 변화의 가능성을 더 높이는데, 이는 새로운 기술을 연습하고, 스스로 평가하고 그 결과를 정직하게 밝히며, 다른 사람의 의견과 피드백을 구할 수 있게 도와주기 때문이다.

A learning environment that simultaneously provides opportunities for challenge and is supportive further enhances the potential for change because it helps individuals practice new skills, self-appraise and disclose honestly, and solicit others’ opin- ions and feedback.25

자아-발견과 학습의 위험을 감수할 정도의 신뢰관계를 형성하기 위해서는 시간이 필요하다. 그러나 대부분의 TS 프로그램은 짧은 워크숍 과정인 경우가 많고, 더 긴 프로그램의 경우에는 그 빈도나 길이가 다양하다(4주~2년)

Time is required to build the type of trusting relation- ships26 that support taking risks in self-discovery and learn- ing. However, most teaching skills programs are short work- shops or courses.19 Longer programs vary in frequency and duration (four weeks to two years).6–11,16,20

이 논문에서 우리는 성찰적 학습에 필수적인 프로세스(experi- ence, reflection, self-direction, learner-centeredness, and re- lationship development.)를 복합적으로 강조한 TS에 대한 집중(주당 3.5시간), 장기(9개월) FD프로그램을 다루고자 한다.

In this article, we describe an intensive (3.5 hours weekly), longitudinal (nine months) faculty development program in teaching skills that emphasizes a combination of processes that are essential for reflective learning, including: experi- ence, reflection, self-direction, learner-centeredness, and re- lationship development.

PROGRAM DESCRIPTION

임상가-교육자를 위한 존스홉킨스 FDP는 1987년 처음 만들어졌으며, 1997년 교육과정과 교육방법의 개선을 거쳐서 현재까지 지속되고 있다. TS와 교육과정개발(CD), 퍼실리테이터-훈련 프로그램, 의학교육 펠로우십, 상담 서비스 등을 운영한다.

The Johns Hopkins Faculty Development Program for Cli- nician–Educators was established in 1987, underwent curric- ular and methodologic revisions in 1997, and continues to be implemented at present. It includes programs in teaching skills (TS) and curriculum development (CD), a facilitator- training program, a medical education fellowship, and a consultation service.

TS는 임상가-교육자의 학생/환자/동료에 대한 태도/신념/행동에 대한 변화를 향상시키고자 설계되었다. 프로그램의 목표는 다음과 같다.

The TS portion is designed to promote change in clini- cian-educator attitudes, beliefs, and behaviors towards learn- ers, patients, and colleagues. Program goals are to enhance participants’ 

• (1) teaching effectiveness, 
• (2) professional ef- fectiveness beyond teaching, 
• (3) teaching enjoyment, and 
• (4) learning effectiveness.

프로그램 설계

Program Design

프로그램 구조: 다음에 대한 지속적 기회의 제공

The program structure assists learning by providing ongoing opportunities for 

• (1) 관계 개발과 협력을 통한 참가자와 퍼실리테이터 간 신뢰 구축
  building trust among participants and facilitators through relationship development and collabora- tion, and for 
• (2) 관찰-실습-수업 내 TS적용-성찰 의 사이클
  cycles of observing, practicing, and applying teaching skills in the classroom and in work settings, and reflecting upon these experiences. 

The program runs from Sep- tember to June each year, for 3.5 hours weekly. Participants spend the majority of this time in stable working groups that include one or two facilitators and four to eight participants.

종합적 목표

The program’s overall learning goals are for participants to experience, value, and improve skills in 

• (1) 자기주도학습과 자아발견의 촉진
  facilitating self- directed learning and self-discovery, and 
• (2) 협력적, 지지적, 그러나 도전을 불러일으키는 학습환경 만들기
  creating a col- laborative, supportive, yet challenging learning environ- ment.

내용 영역

Seven content areas are addressed in individual sessions, or modules, which are five to seven weeks in duration. Each module builds upon and incorporates skills learned previ- ously. For each, specific learning objectives are provided, to- gether with targeted readings.

Content areas include: 

• 성인학습 개념 Adult learning concepts 
• 시간 관리 Time management 
• 피드백 제공과 피드백 끌어내기 Feedback provision and elicitation 
• 소그룹 리더십과 참여 Small-group leadership and participation 
• 환자-의사 소통 Physician–patient communication 
• 임상상황에서 가르치기(precept) Precepting in clinical settings 
• 강의 Lectures 
• 팀 내에서 리더십과 운영 Leadership and management of work teams

기본적 교육 전략: 다음의 병렬적 프로세스

A fundamental educational strategy for the program is the implementation of a parallel process whereby 

• 퍼실리테이터가 참가자들이 학습할 스킬을 정함(model)
  facilitators model the skills that are being learned by program partici- pants, 
• 참가자와 퍼실리테이터의 신뢰 구축
  develop trust among themselves, and 
• 스스로의 지식/태도/기술을 바탕으로, 경험, 자기평가, 피드백을 통한 협력적 작업
  use experience, self-appraisal, and feedback to work collaboratively on their own knowledge, attitudes, and skills.

교육 방법

Educational methods used across content areas include 

• 정보제공 in- formation provision (readings, demonstration, presenta- tions), 
• 성찰을 동반한 경험학습 experiential learning with reflection (role-play, sim- ulated learners, real-life applications, and videotaping, all of which are learner centered and self-directed, and involve self-appraisal, feedback, problem solving, and discussion), and 
• 자기-인식 시간 personal awareness sessions (sharing of meaningful ex- periences with emotional content).

단일 모듈에 관한 설명

Description of One Module (skip)

The feedback module illustrates how structural components, learning goals, parallel processes, and specific educational methods are applied to a content area to support learning (see Figure 1). 

• Prior to this module, participants have been introduced to the concepts of adult learning. 
• The first of the five sessions in this module begins with videotaping each participant while he or she is providing feedback to a standardized learner. 
• A demonstration follows, from which participants identify those behaviors that are more or less effective. 
• Discussion then bridges to a didactic summary of core concepts and skills that incorporate adult learning concepts. A syllabus names expected participant outcomes and contains selected readings, a detailed skills glossary, and scenarios for skills practice. 
• Participants then observe their videotapes, self-assess, get feedback from the facilitator and each other, and identify learning strengths, needs, and resources for improving their skills throughout the module.

The first hour of most subsequent small-group sessions is reserved for the participants to share meaningful aspects of their professional and personal lives. 

• These personal awareness sessions utilize a process described by Novack and colleagues.27 
• The emphasis of these unstructured sessions is to focus on feelings with the chance to observe and practice active listening and emotion-handling skills (not interrupting, validating and empathizing with feelings). 
• The reflection and self-disclosure that occur often help participants to recognize and address attitudes, beliefs, and feelings that influence their capacity to use new skills and concepts. 
• In addition, these sessions reduce the sense of isolation that so often accompanies the professional life of a clinician–educator.28

In the skills session that follows, participants describe recent or distant real-life experiences with feedback. 

• Group members help their fellow participants identify accomplishments, learning needs, and ways to address them. 
• Participants choose resources for their learning, such as discussion of readings, problem solving, solicitation of other members’ thinking and experience, skills practice (usually in role plays based upon self-selected situations), or observation of videotapes. 
• They also direct their learning by asking for specific feedback about their performance. 
• Personal reflection and learning may occur if they also explore related attitudes and feelings.

Participants identify their progress in providing effective feedback and new learning needs based upon their selfappraisal and others’ feedback. 

• There is time for two or three participants to go through this process in a single session. 
• Usually, more than one participant’s needs are met in learning activities that focus upon on the needs of one participant. 

A self-summary of significant learning completes each session and informs planning for the next week.

Among participants, providing “negative” feedback is universally identified as difficult. 

• In addition to practicing skills, individuals are helped to recognize and explore their thoughts and feelings about providing negative feedback and to hear others’ perspectives. 
• They also experience other members’ support and empathy. New insights and motivation for change occur.

Throughout the module, a parallel process is applied. 

• Facilitators use effective feedback skills and support learnercentered participant discovery and learning while they lead the experiential and reflective activities. They keep the group focused on each individual’s stated needs, and help individuals build relationships and learn from each other. 
• Participants observe these skills, and also have direct experience with the methods as learners. 
• Following each session, co-facilitators of each small group use reflective learning by meeting to talk about their co-facilitation, their beliefs and feelings related to challenges encountered, and alternative ways to respond. They also plan for the next session.

The final feedback session includes 

• videotaping each participant providing feedback to a standardized learner, 
• reviewing these videotapes (as in the first session), 
• summarizing participants’ learning, and 
• planning for future applications. 

Group members explore their shared experience and the relative helpfulness of the learning and facilitation methods, and complete an evaluation instrument. 

At the end of the module, all facilitators meet as a team, share new insights, and use the verbal and written input from the participants to plan for upcoming modules. A module on small-group leadership, participation, and process follows that offers opportunities for continued practice and application of feedback skills.

METHOD

Study Population

131명의 TS프로그램 참가자와 131명의 비-참가자

All 131 TS program participants and 131 program nonpar- ticipants between 1988 and 1996 were recruited for the present study.

Design and Methodology

사전-사후 연구 설계. 일부 post-only 연구설계

A pre–post study design with comparison group measured changes in participants’ and nonparticipants’ self-assessments of perceptions and skills, and a post-only study design with- out a comparison group measured the participants’ assess- ments of programmatic components.

Outcome Variables, Instruments, and Measures

개인 수준 성과변인

Individual outcome variables.

• 교육 효과성 Teaching effectiveness, measured as skill levels for deter- mining learner needs, actively involving learners, lectur- ing, small-group teaching, one-on-one teaching, teaching in the presence of the patient, giving feedback, evaluating learners, and global teaching 
• 전문직으로서의 효과성 Professional effectiveness other than teaching, measured as skill levels for working in groups, time management, and administration 
• 교육 즐김 Teaching enjoyment 
• 학습 효과성 Learning effectiveness, measured as self-directed learning competence, a mean score of nine items assessing individ-ual self-perceptions as a nondependent learner, the ability to relate collaboratively with peers and teachers as helpers, an understanding of the assumptions of self-directed learn- ing, and the ability to utilize the various stages of the self-directed learning process.

프로그램 수준 성과변인

Program evaluation outcome variables.

• 전반적인 프로그램 질 Overall program quality 
• 교육법, 퍼실리테이션, 학습환경 Educational methods, facilitation, and learning environment 
• 참여의 교육적, 전문가적 능력에 대한 효과 Impact of participation on teaching and professional abilities.

Data Analysis

RESULTS

Response Rate

Baseline Sample Characteristics

Outcome Variables at Baseline

Pre- and Postprogram Comparisons

Program Evaluation

프로그램 효과의 눈에 띄는 결과는 참가자의 교육스킬과 전문직스킬(professional skill)이 비참가자의 베이스라인 이상으로 올라갔다는 것이다. 

A noteworthy measure of this program’s effectiveness is that it brought participants’ appraisals of their teaching and professional skills up to the baseline level of nonparticipants’ self-appraisals of their teaching and professional skills; more of the nonparticipants had reported prior training in teach- ing skills.

또 다른 눈에 띄는 결과는 교육-즐김(teaching enjoyment)가 참가자 그룹 내에서 유지된 반면, 대조군에서는 감소한 것이며, 이는 프로그램이 임상가-교육자가 직면하는 문제에 대해서 완충 효과가 있을 수 있다는 것을 시사한다. Gerrity 등은 20개의 임상가-교육자의 커리어 만족도에 대한 연구에서 교육에서 오는 만족도를 상쇄시키는 2 개의 공통적 요인을 발견했는데, 하나는 교육과 진료 사이의 긴장(tension)이었고, 다른 하나는 교육스킬에 대한 의구심이었다.

Also remarkable is the finding that teaching enjoyment was maintained in the participant group while it declined in the comparison group, suggesting that the program may buffer some of the challenges faced by clinician–educators. In Gerrity and colleagues,31 review of 20 studies on clini- cian–educator career satisfaction, two commonly expressed factors that counterbalance the satisfaction derived from teaching were found to be the tension between teaching and patient care, and doubts about teaching skill.

참가자들이 성찰을 동반한 경험적 학습법을 정보-제공 방식보다 더 선호한다는 것이 고무되었다.

We were encouraged that participants rated experiential learning methods with reflection significantly higher than they rated information provision.

자기인식(personal awareness) 세션이 정보-제공에 비해서 낮게 나온 결과는 7명의 '전혀 유용하지 않음' 응답 결과를 제외하면 통계적으로 차이가 없다.

The lower rating of personal awareness sessions compared with information provision was no longer significant once seven participants who rated personal awareness sessions as “not at all useful” to their teaching were omitted from the analysis.

비록 상대적으로 낮은 평가에도 불구하고 자기인식(personal awareness)세션은 평균적으로 참가자들의 학습에 중간 이상 정도로 유용하다는 평가를 받았다. 우리는 이 세션이 참가자간 합력적, 지지적 관계를 형성하고 위험을 감수하게끔 해주는 데 중요하다고 생각한다. 또한 자기인식을 촉진시켜서 교육효과성을 향상시킬 수도 있을 것이다.

Notwithstanding their relatively lower rating, personal awareness sessions were rated, on average, as more than moderately useful to participants’ learning. We believe that they were important for promoting the collaborative and supportive relationships among our participants, enabling them to take risks,25 and to promote their personal aware- ness, which can enhance their teaching effectiveness.23

이 프로그램을 다른 장기-프로그램과 구분짓는 요소는 구조(매주, 3.5시간, 9달, 그룹 안정성)와 관계-협력-학습자중심-경험-성찰을 결합적으로 강조하는 것에 있다. 비록 다른 프로그램들이 이 요소들의 일부를 가지고 있었지만, 모두를 가진 것은 없었으며, 교육/전문직/학습효과와 관련된 영역을 모두 다룬 것도 없었다.

Key aspects that distinguish this program from other lon-gitudinal ones6–8,16 are its structure (weekly, 3.5-hour ses-sions for nine months in stable groups), and the combinedemphasis on relationship, collaboration, learner self-direc-tion, experience, and reflection. Although each of the otherprograms has some of these elements, none has all, nor doesany cover the breadth of content area related to teaching,professional, and learning effectiveness.

우리는 잦은 빈도로, 지속적으로, 집중적으로, 같은 참가자들에게 미팅을 하고, 또한 관계의 중요성을 강조한 것이 학습그룹 내에서 신뢰를 형성하는데 중요했다고 생각한다. 또한 각 세션의 길이는 스킬을 연습하고 다양한 수준의 성찰을 하기에 충분했으며, 이것들 각각만으로 가능한 효과보다 더 큰 효과를 얻을 수 있었다고 생각한다. 이러한 구조가 Schon이 reflective practice라고 말한 action과 reflection-on-action의 지속적 사이클을 가능하게 했으며, 프로그램 참가자들이 이러한 프로세스를 지속적으로 사용할 수 있게끔 해주었다.

We believe that frequent, ongoing, intensive meetings among the same individuals, with an emphasis on relationships are important to achieving trust in learning groups. In addition, the length of each session allows for time to engage in both skills practice and multiple levels of reflection, which may have more impact than any of these alone. This structure also facilitates suc- cessive cycles of action and reflection-on-action described by Schon33 as reflective practice, and could promote ongoing use of this process by program participants.

우리는 성찰학습의 성과가 있었는지는 알 수 없다(insights and reassessment of assumptions that, according to Mezirow,34 result in a shift in perspective, or transforma- tional learning 등). 그러나 참가자들이 프로그램을 마치고 나갈 때 관계의 중요성과 태도/신념/감정에 대한 성찰의 중요성, 그리고 학습자와의 연결성이 높아질 가능성, 학습자의 자기주도성에 대한 지지, 학습자들이 비판적 성찰이 가능해게 도와주는 것 등을 알게 되었을 것이다. 이것은 관점의 변화를 가져오며, 궁극적으로 구체적 스킬의 향상보다 더 중요하다.

We also do not know whether reflective learning outcomes (insights and reassessment of assumptions that, according to Mezirow,34 result in a shift in perspective, or transforma- tional learning) occurred. However, we speculate that par- ticipants leave our program with 

• an increased valuing of relationships and of reflection on attitudes, beliefs, and feel- ings, and 
• an increased likelihood of connecting with learners, of supporting their self-directedness, and of helping them be critically reflective. 

These anticipated shifts in perspective may ultimately be more important than enhancement of specific skills.

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Acad Med. 2004 May;79(5):469-80.

Faculty development in teaching skills: an intensive longitudinal model.

Cole KA1, Barker LR, Kolodner K, Williamson P, Wright SM, Kern DE.

Author information

• 1Johns Hopkins Faculty Development Program in Teaching Skills, and Division of General Internal Medicine, Johns Hopkins University, School of Medicine, Bayview Medical Center, Baltimore, MD 21224, USA. kcole@jhmi.edu

Abstract

Although reflection contributes to the personal growth of clinician-educators and is important for effective teaching, few teaching skills programs report its use. The Johns Hopkins Faculty Development Program in Teaching Skills, first implemented in 1987 as a theoretically grounded,longitudinal model for faculty development of clinician-educators, comprises a set of conditions intended to promote reflective learning. This paper describes the program and reports evaluation results for 98 participants and a comparison group of 112 nonparticipants between 1988 and 1996. Participants met with facilitators weekly for nine months for 3.5 hours, in stable groups of four to six individuals. Educational methods used across seven content areas emphasized relationships and collaboration, and included information provision, experiential learning with reflection, and personal awareness sessions. A pre-post evaluation design with comparison group measured changes in self-assessed teaching and professionalskills, teaching enjoyment, and learning effectiveness. A post-only evaluation design appraised overall program quality, educational methods, facilitation, learning environment, and perceived impact of participation. Program participants had significantly greater pre-post-change scores than nonparticipants for all 14 outcomes (p <.05). Multiple regression modeling indicated that program participation was associated with pre-post improvement in all outcomes except administration skills, controlling for all participant and nonparticipant baseline characteristics (p <.05). All measured programmatic characteristics were highly rated by participants. Experiential methods with reflection were rated significantly higher than information-provision and personal awareness sessions (p <.001). Evaluation results demonstrate a positive impact of this alternative approach tofaculty development on clinician-educator perceptions of their attitudes and behaviors towards learners and colleagues.

PMID:

 

15107288

 

[PubMed - indexed for MEDLINE]