임상술기 연습에 관한 자기조절 프로세스 평가: 파일럿 연구(Med Teach, 2011)

Assessing self-regulatory processes during clinical skill performance: A pilot study

 

TIMOTHY J. CLEARY1 & JOHN SANDARS2

1University of Wisconsin-Milwaukee, USA, 2The University of Leeds, UK





 


Introduction


SRL은 '개개인이 스스로의 목표에 대한 전략적 추구를 최적화하기 위하여 학습에 대해서 주도적으로proactively 피드백을 생성하고 활용하는 순환적 프로세스'이다. 비록 이론적인 모델은 다양하지만 사회-인지 연구자들은 자기조절은 세 가지 순차적 phase로 구성된 순환적 고리로 발생한다고 주장한다.

Self-regulated learning (SRL) has been described as a cyclical process whereby individuals proactively generate and use feedback about their learning to optimise their strategic pursuit of personal goals (Schunk 2001). Although theoretical models vary, social-cognitive researchers argue that self-regulation occurs in a cyclical loop characterised by three sequential phases:

  • forethought, (processes preceding action),

  • perfor- mance (processes during action) and

  • self-reflection (processes following action) (Zimmerman 2000).

 

 

  • 사전숙고 단계는 목표 설정이나 전략 기획 등으로서 한 개인이 학습 또는 과제수행을 어떻게 하게될지에 영향을 준다.
    From this perspective, forethought processes, such as goal-setting and strategic planning, impact how an individual engages in learning or performing a task.

  • 수행 과정에서 고도로 자기조절적인 개인들은 자기통제 전략 목록을 가지고 (attention-focusing, self-instruction, self- monitoring) 얼마나 자신이 학습 또는 수행을 잘 하고 있는지 측정한다.
    It is during the performance phase, when highly re
    gulated individuals enlist the use of self-control tactics, such as attention-focusing or self-instruction and self- monitoring behaviours to gauge how well they are learning or performing.

  • 이 단계에서 수집된 정보는 (학생 스스로든 외부에 의해서든) 목표 달성, 수행 결과의 원인, 최적화를 위해서 필요한 전략 수정 등과 관련하여 수행에 대한 자기-성찰에 활용된다.
    The information that is generated during perfor- mance, either by the student or from external sources, is used by a learner to self-reflect on his or her performance relative to goal attainment, perceived causes of his or her performance outcomes and the strategies that one needs to modify or sustain to optimise performance.



세련된 자기조절학습자의 가장 큰 특징은 각각의 순환 루프의 phase에서 학습 및 수행 프로세스에 전략적으로 몰두engage한다는 것이다. 따라서 이 사람들은 과제 준비와 목표 설정의 과정에서 전략적 차원으로 사고한다.

A hallmark feature of sophisticated self-regulated learners is that they are strategically engaged in the process of learning or performing a task during each phase of the cyclical loop (Cleary 2011). Thus, these individuals think in terms of strategies during task preparation or goal-setting,


고도로 자기조절적인 사람들은 전략을 매우 정교하게 다듬으며, 그 전략을 활용하여 과제를 수행하는 과정에서 자기-모니터를 빈번하게 한다. 마지막으로 이러한 학생들은 학습전략의 효과적인 활용의 측면에서 스스로의 수행을 평가하고, 전략을 더 능숙하게 활용하기 위해서 지속적으로 성찰한다.

Highly regulated individuals will also use highly refined tactics to perform a task and will frequently self-monitor their use of strategies during task performance. Finally, these types of students evaluate their performance relative to their effective use of learning strategies and continuously reflect on ways to enhance the proficiency of these tactics. 


운동선후에 관한 연구에서 일관되게 나타난 연구결과는, 전문가 혹은 고성과자는 전략적 자기-조절적 사고에 몰두한다는 점이다. Zimmerman and Kitsantas 는 학생의 자기조절적 사고와 프로세스를 학습/수행 활동의 전/중/후반으로 나누어서 기록해보았으며, 사회인지 연구자들은 이러한 평가방법론을 SRL microanalysis라고 명명하였다.

Research in the athletic domain has consistently shown that experts or high performers will engage in strategic self-regulatory thinking and processes more frequently than low performers Zimmerman (Cleary 2002). & To Zimmerman 2001; Kitsantas &comprehensively capture students’self-regulatory thoughts and processes before, during and aftera learning or performance activity, social-cognitive researchers developed an assessment methodology, called SRL microanal-ysis (Bandura et al. 1982; Cleary & Zimmerman 2001; Cleary2011).

 

일반적으로, 이 고도로 구조화된 평가 접근법은 개개인이 잘 정의된 활동을 하는 동안 순환적 피드백 고리의 각각의 세 단계에 들어가 있는 다양한 조절 구인들을 대상으로 하여 맥락-특이적 질문을 던진다(목표 설정, 자기 모니터, 전략 활용, 인과관계에 대한 귀인). 이러한 접근법의 핵심 목표는 개개인의 준비도 혹은 학습에 대한 접근법, 활동 중에 일어나는 사고와 신념, 성찰에 대한 전략적 마음챙김mindful으로서 활동 후의 성찰과 수행결과에 대한 반응 등을 밝히는 것이다. 즉, 가장 효율적으로 학습하고 수행하기 위해서 필요한 전략을 얼마나 개개인이 인식하고 있는지, 이들 전략의 정확성accuracy는 얼마나 되는지, 목표 달성에 효과성은 얼마나 되는지 등에 대한 것이 포함된다.

In general, this highly structured assessment approach involves administering context-specific questions targeting the various regulatory constructs embedded within each the three phases of the cyclical feedback loop (e.g. goal-setting, self-monitoring, strategy use, causal attributions) as an individual engages in a well-defined activity (Cleary 2011). The key objective in this approach is to identify whether individuals’preparation or approach to learning or performance (fore-thought), thoughts and beliefs during the activity (perfor-mance control) and reflective thoughts and reactions following performance reflect strategic mindfulness. That is, to what extent are individuals mindful and aware of the strategies that they need to learn or perform most effectively, the accuracy with which one uses these strategies and the overall effectiveness of these tactics for reaching their goals.

 

SRL microanalysis 의 핵심은 세 단계 조절 프로세스 내에서 구체적 loop에 대한 개별화된 평가 프로토콜을 활용하고, 개방형과 폐쇄형 질문을 모두 활용하는 것이다. 더 나아가서 SRL microanalysis에서 연구자들은 microanalytic 질문을 특정 맥락이나 수행에 맞추어 바꿀 수 있다. 즉, 비록 모든 질문에 있어서 일반적인 질문의 표현은 특정 구인의 개념적 정의와 사전 연구결과를 따르게 되나, 관심의 대상이 되는 특정 수행에 맞춰서 질문을 변화시킬 수 있다.

The core features of SRL microanalysis include the use of individualised assessment protocols and the use of open-ended and close-ended questions targeting the specific loop.processes within the three-phase regulatory. Furthermore, SRL microanalytic methodology allows research-ers and practitioners to customise the microanalytic questions to match the particular contexts and/or performance situations of interest. That is, although the general phrasing of all questions are generated from conceptual definitions of the particular constructs (e.g. goal-setting, causal attributions) and prior research, questions are modified to reflect the particular performance events of interest. 


방법

Method


표본

Sample


재료와 절차

Materials and procedures


모든 SRL microanalytic 평가 프로토콜은 가이드라인에 따라 개발

An SRL microanalytic assessment protocol was developed based on guidelines used in other contexts (Cleary 2011).


측정

Measures


자기효능감

Self-efficacy. 


Bandura의 가이드라인에 따라서 다음과 같이 질문 구성. pre-task와 post-task에 측정.

Based on Bandura’s (2006) guidelines for self- developing self-efficacy scales, a 2-item measure of efficacy was used to assess students’ confidence in successfully drawing blood. All items began with the phrase,

 

‘‘On a scale from 0 to 100, with 10 being not sure, 40 being somewhat sure, 70 being pretty sure, and 100 being very sure, how sure are you that you can obtain an acceptable blood sample from this arm...’’.

 

This stem was followed by (a) on your first attempt, (b) on your second attempt. This 2-item measure was administered pre-task and post-task. The average coefficient alpha across pre-task and post-task was 0.81.


전략기획

Strategic planning


여기서 활용한 one-item microanalytic 척도는 마네킹에서 채혈을 시도한 직후에 학생의 생각을 조사하기 위하여 설계되었다.

"여기서 채혈을 하려고 준비할 때 무슨 생각을 했나요?".

여섯가지 카테고리로 구분.

This one-item microanalytic measure was designed to examine student cognition immediately preceding their attempt at taking blood from the mannequin. Participants were asked, ‘‘What are you thinking about as you prepare to draw blood from this arm?’’ Participant responses were coded indepen- dently by the two authors into one of six categories:

      • 프로세스/기술 process/ technique,

      • 성과 outcome,

      • 환자 상호작용 patient interaction/care,

      • 자신감 confidence,

      • 모르겠다 do not know and

      • 기타 other.

 

The majority of this coding scheme was based on coding schemes used in prior research across different tasks (Cleary & Zimmerman 2001; Kitsantas & Zimmerman 2002).

      • 프로세스/기술 카테고리 The process or technique category involved responses pertaining the application or use of venipuncture steps (as defined by protocol that was for the initial training). An example of a response coded for this category included, ‘‘I need to focus on all of the steps ...to put gel on and to get the needle at the right angle’’.

      • 성과 An outcome response pertained to being able to draw blood, such as, ‘‘To get a bit of blood from the arm’’.

      • 환자 상호작용 The patient interaction category involved responses pertaining to verbally interacting with the patient or ensuring their comfort. An example of a patient interaction response was, ‘‘To first explain things to the patient and to make sure I don’t hurt them’’

      • 자신감 The confidence category involved responses pertaining to students’ confidence or perceived ability to draw blood or their capability. An example of this category was, ‘‘To try to stay confident during the activity’’.

      • 모르겠다. The do not know category involved participant responses explicitly indicating that they were not sure or were not aware of any thoughts.

      • 기타 Finally, the ‘‘other’’ response category included any response that did not fit into the above categories.

 

Student responses were coded independently by the two authors. A per cent agreement of 93% was reached, with disagreements being resolved with discussion.



목표설정

Goal-setting. 


이 척도에서는 마네킹에 채혈을 시도하기 전에 가진 목표를 평가하고자 했다.

"여기서 채혈하기 전에 목표를 가지고 있었나요?"

This one-item microanalytic measure was designed to assess participant goals prior to their attempt at taking blood from the mannequin. After the planning question, the participants were asked, ‘‘Do you have a goal in mind before drawing this blood sample?’’ Identical recording and coding procedures using the same framework as with the planning measure were adhered to with the goal-setting measure. A per cent agreement of 100% was reached by the two coders.


메타인지적 모니터링

Metacognitve monitoring. 


채혈 중간에 한 구체적 실수에 대한 생각을 물어보았다.

"실수 없이 잘 했나요 아니면 실수를 했나요? 조금 더 이야기해 주세요"

This measure targeted students’ beliefs about specific mistakes they made during the veni- puncture task. Immediately preceding the participant’s attempt to put the needle into a vein, the participants were asked, ‘‘Do you think you have performed a flawless process thus far or have you made any mistakes? Tell me about them’’.

 

세 가지 카테고리: 프로세스/기술, 비-프로셋/기술, 모르겠다. 프로세스와 비-프로세스의 이분법적 구분은 이전 연구에서 성공적으로 활용된 바 있음.

For this question, student responses were coded into one of three categories: process/technique, non-process/technique and do not know. The process category was similar to that used for the planning and goal-setting questions. However, the non- process category was a global category that included all responses other than those involving the venipuncture tech- nique or direct statements of ‘‘don’t know’’. The process/non- process dichotomy has been successfully used in prior research. A per cent agreement of 100% was reached by the two coders.



만족

Satisfaction


"현재 수행에 대해서 얼마나 만족하나요?". 100점 척도. 10점 단위. 이러한 척도는 이전 연구에서 널리 사용되어왔음.

After the venipuncture task was completed, the participants were asked, ‘‘How satisfied are you with your current performance?’’ This one item measure is based on a 100-point likert scale with 10 point increments. This scale has been used extensively in prior research and has been shown to differentiate ability groups and also to predict students’ self- efficacy and interest for a task (Zimmerman & Kitsantas 1997).


자기평가적 기준

Self-evaluative standards. 


만족도 질문에 이어서 자신이 만족도를 평가할 때 사용한 준거를 평가하게 하였다.

"만족도를 판단하기 위해서 어떤 기준을 활용하였나요?"

Following the satisfaction ques- tion, the participants were prompted to answer a question assessing the self-evaluative criteria that they used to judge their degree of satisfaction with their performance. The participants were asked, ‘‘What did you use to judge your degree of satisfaction?’’, and then were given a laminated card with the following response options:

      • (a) 다른 사람이 어떻게 했을까 how you think others might perform this task,

      • (b) 채혈을 하기 위해 몇 번이나 시도했나 the number of attempts to obtain the blood sample,

      • (c) 계획 또는 테크닉을 얼마나 정확하게 했나 how well you used the correct plan or technique,

      • (d) 다른 요인 other factors and

      • (e) 모름 do not know.

 

Participants were prompted to select only one response option.




Results


Qualitative case descriptions were used to analyse and report the self-regulatory processes and motivation beliefs of all seven participants (Table 2).


Self-regulatory profile of successful task performers


Self-regulatory profile of strugglers




고찰

Discussion


성공적으로 채혈을 한 학생은 전/중/후에 mindful하였고 능동적으로 사고하였다. 그러나 struggler는 주로 채혈의 성공outcome또는 환자의 통증을 방지하는 것에만 초점을 두었다. 흥미롭게도 이러한 결과는 고성과자 혹은 전문가가 더 구체적이고 전략적인 목표를 설정하며, 과제 중간에 자기모니터링에 더 몰두하며, 스스로의 수행에 대해서 더 전략적으로 성찰한다는 것과 일치한다.

students who were successful at the venipuncture task were mindful and actively thinking about the venipuncture technique prior to, during and following performance on this activity. However, strugglers appeared to focus primarily on outcomes of drawing blood or preventing pain in patients. Interestingly, these results are highly consistent with previous research showing that experts or high performers set more specific and strategic goals, engage in self-monitoring during a task, and reflect strategi- cally on their performances than low performers (Cleary & Zimmerman 2001; Kitsantas & Zimmerman 2002; Cleary et al. 2006).



또 다른 중요 결과는 struggler들이 채혈의 전략이나 테크닉에 초점을 두는 것을 무시할 뿐만 아니라, 모든 phase에서 '성과outcome'에만 초점을 둔다는 것이다. SRL의 이론적 관점에서 forethought는 수행 단계의 휴형과 퀄리티에 영향을 주며, 이는 다시 수행에 대한 성찰에 영향을 준다. 우리는 성공적으로 수행한 학생은 forethought (planning, goal-setting), performance (monitoring) and self-reflection processes (self-evaluation, satisfaction)에 걸친 사고를 하고 있음을 찾아내었다. 반대로 struggler는 비교적 일관되게 모든 세 단계에서 '성과-지향적 사고'를 보여주었다.

Another important finding in our study was that the strugglers not only neglected to focus on the venipuncture strategy or technique, but also placed primary importance and attention on outcomes during all cyclical phases, such as drawing blood. From a SRL theoretical perspective, the quality of one’s forethought will impact the types or quality of performance phase processes, which will in turn impact how individuals reflect on performance (Schunk 2001). We found that the successful performers on the venipuncture task strategic exhibited thinking across forethought (planning, goal-setting), performance (monitoring) and self-reflection processes (self-evaluation, satisfaction). In contrast, strugglers exhibited a relatively consistent profile of outcome-oriented thinking across all three phases.


Struggler가 성과 목표에만 초점을 둔다는 것이 이론적으로 중요한데, 왜냐하면 목표가 학생의 관심을 과제 수행 전략에 가까워지게 혹은 더 멀어지게 만들기 때문이다. 예를 들면 '절차 목표'를 세우는 사람이 스스로가 그 과제를 얼마나 잘 하고 있는가에 대해 더 모니터링을 할 가능성이 높으며, 학습 접근법도 더 전략적으로 조절한다. 더 나아가, 한 과제를 수행하는데 필요한 프로세스나 테크닉을 마스터하기 전부터 성과에 초점을 두는 사람들은 sub-optimal한 수행을 하는 경향이 있으며, 더 maladaptive한 자기성찰반응을 보인다.

The fact that the strugglers focused primarily on outcome goals is a theoretically important finding, because goals shift students’ attention either towards or away fromtask strategies. For example, previous research has shown that individuals who set process goals are more likely to monitor how well they perform on tasks and will make more strategic adjustments to their learning approaches than those who set outcome goals (Schunk & Swartz 1993). Furthermore, individ- uals who focus on outcomes before they have truly mastered the process or techniques required for a specific task, will tend to perform at a sub-optimal level and will exhibit more and maladaptive self-reflections reactions (Cleary & Zimmerman 2001; Cleary et al. 2006).


자기평가기준의 특성 역시 흥미롭다. struggler는 성과-기반 사고를 하였다. 성과-기반 기준을 활용하는 것은 저성취 혹은 위험학생군에게 있어서 특히 문제가 되는데, 왜냐하면 다양한 자기 불구화 반응 또는 부정적 효과(회피, 불안)를 내기 때문이다. 그러나 연구 결과를 보면 성과-기반 기준을 사용하는 것이 언제나 문제인 것은 아닌데, 특히 고성과자에 대해서는 문제가 되지 않는다. 즉, 학생들이 어떤 스킬을 능숙하게 할 수 있게 되었을 때, '절차 목표'에서 '성과 목표'로 옮겨갔을 경우 성취와 동기부여 정도가 더 높아지 수 있다.

The nature of the self-evaluative standards used by successful performers and strugglers in our study was also of interest. Unfortunately, the strugglers concentrated on outcome-based thinking. The use of outcome-based standards to judge poor performance is problematic, particu- larly for low achieving or at-risk students, because it can often lead to a variety of self-handicapping reactions and negative effects, such as avoidance and anxiety (Zimmerman 2008). However, research has shown that the use of outcome-based standards is not always maladaptive, particu- larly with regard to high achievers. That is, when students have demonstrated proficiency in a skill, they show height- ened levels of achievement and motivation if they learn to shift from process goals to outcome goals (Zimmerman & Kitsantas 1997).



몇 가지 동기부여 신념에 관해 중요한 점. 첫째, 비록 두 그룹이 모두 사전에는 중등도의 자기효능감을 보였지만, struggler보다 사전- 사후- 변화에 있어서 20점 차이가 있었다. 성공 경험 이후에 자신의 능력에 대한 신념이 향상된다는 측면에서 이러한 결과는 합당하다. 그러나 두 명의 struggler를 비교해보면, 두 학생 모두 3번의 시도를 했지만, 한 학생은 30점이 높아졌고, 한 학생은 30점이 감소했다.

a couple of important points about these two motivation beliefs are warranted. First, although both groups displayed moderate levels of self-efficacy for performing this task, the strugglers exhibited numerically (7-point higher self-efficacy pretest difference) In terms of changes in self-efficacy from pre-test to post- test, there was an average 20-point increase in self-efficacy among successful task performers. These findings make sense as individuals’ beliefs about their personal capabilities should increase following demonstrated success or mastery experi- ences (Bandura 1997). However, analysis of the two strugglers in this study underscores the potential importance of assessing at-risk students’ beliefs or perceptions of ability along with the actual skill or ability on a clinical task. That is, although both students needed three attempts to perform the venipuncture task successfully, one student exhibited a 30-point increase in efficacy, whereas the other student exhibited a 30-point decrease in their self-perceptions.



SRL microanalysis를 활용하는 궁극적 목적은 맥락-특이적 정보를 얻는 것 뿐만 아니라, 이러한 정보를 훈련시에 어디에 더 노력을 쏟아야 하는지에 대한 정보를 준다. Brydges 등은 '절차 목표'에 대해서 훈련받은 self-guided group이 '성과 목표'를 설정한 대조군보다 skill retention이 더 높았음을 보여주었다.

The ultimate purpose in using SRL microanalysis in medical education is to allow educators not only to gather context- specific information about how an individual thinks, plans and reacts during authentic clinical activities, but also to use such information to guide training efforts. For example, Brydges et al. (2009) found that a self-guided group trained in process goals displayed greater skill retention than a comparable group who set outcome goals.



 



Sandars J, Cleary TJ. 2011. AMEE guide No:58 self-regulation theory: Applications to medical education. Dundee, UK: AMEE.


Cleary TJ. 2011. Shifting towards self-regulation microanalytic assessment: Historical overview, essential features, and implications for research and practice. In: Zimmerman BJ, Schunk DH, editors. Handbook of Self-Regulation of Learning and Performance. Abingdon, UK: Routledge. pp 329–345.




 2011;33(7):e368-74. doi: 10.3109/0142159X.2011.577464.

 

Assessing self-regulatory processes during clinical skill performance: a pilot study.

 

 

Author information

  • 1University of Wisconsin-Milwaukee, WI, USA.

Abstract

BACKGROUND:

Self-regulated learning (SRL) is a cyclical process involving the proactive use of strategies and feedback to optimise performance. Previous research has used SRL microanalysis to assess and inform the training of athletic skills but there has been no previous research in clinicalcontexts.

AIMS:

The aim of this pilot study was to evaluate the use SRL microanalysis to assess the regulatory profiles of students who were successful and unsuccessful in a venipuncture task.

METHOD:

A SRL microanalysis protocol was administered to seven 3rd-year undergraduate medical students whilst they performed a venipuncture on a simulation mannequin arm.

RESULTS:

The use of SRL microanalytic questions had good inter-rater reliability. Students who were successful in venipuncture had high levels of strategic thinking before, during and after the clinical task, whereas the students who struggled on this task tended to focus on outcomes.

CONCLUSIONS:

The results shown in this study mirror the findings from previous research using SRL microanalysis. SRL microanalysis has strong potential as a structured assessment technique targeting the self-regulatory processes underlying clinical skill performance. Further research is recommended, especially on how the assessment of self-regulatory skills can be used to guide training for struggling students.

PMID:
 
21696270
 
[PubMed - indexed for MEDLINE]


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