Teaching Metacognitive Skills: Instructional design, video production & pedagogy Flinders University Adelaide, Australia Kim Devery - Project Lead Flinders University Adelaide, Australia The second presentation on behalf of Kim Devery is Teaching Metacognitive Skills: Instructional design, video production & pedagogy

Kim Devery & Jennifer Tieman End-of-Life Essentials Lead Palliative & Supportive Services School of Health Sciences Flinders University This follows on from the previous presentation which provided a background to the End-of Life Essentials eLearning and the framework behind our education.

End-of-Life Essentials eLearning Modules & quality resources on end-of-life care for doctors, nurses and allied health professionals who work in acute hospitals Developed from Australian Commission on Safety and Quality in Health Care - National Consensus Statement: Essential elements for safe and high-quality end-of-life care Just to summarise on the previous session, our team developed free evidence-based, peer-reviewed modules and practice change resources for doctors, nurses and allied health professionals who work in acute hospitals. This was developed from the essential elements for safe and high-quality end-of-life care identified in the 2015 National Consensus Statement produced by the The Commission

These are the learning areas of our education Communication Recognising dying Negotiating goals of care How to act when things go wrong And effective teamwork

Outline of presentation Background to the pedagogy Underlying assumptions to learning Cognitive task analysis methods Metacognitive skills Instructional design – critical self-reflection, knowledge translation & collection of impressions for growth and learning Making thinking skills explicit – eLearning, scriptwriting and video production For this talk I will discuss the background to the pedagogy I will talk about the underlying assumptions to learning, including Cognitive task analysis methods; and Metacognitive skills Instructional design – critical self-reflection, knowledge translation and collection of impressions for growth and learning One of the key aspects of teaching metacognition is to make thinking skills explicit – I’ll play some of our film and then discuss scriptwriting and video production I should say here that the work of Clark and Mayer in their work e-Learning and the Science of Instruction assisted greatly in the theoretical approach to this work

Background to pedagogy Underlying assumption Our targeted learners were already integrating end-of-life care into practice Build on knowledge End-of-life care / communication at the end of life is complex, difficult to practice, and often emotionally taxing for health care teams. Before we began we needed to understand our learners, and from the work of the Commission and the literature, we knew that our targeted learners were already integrating into practice some type of end-of-life care, and this education needed to build on their knowledge. We also knew that end-of-life care and communication at the end of life is complex, difficult to practice, and often emotionally taxing for health care teams.

Background to pedagogy Key to learning - giving patients agency Limits of project – scope, pitch Importance of language – palliative care, end-of-life care, dying – keep to the terminology of the Commission Dying in acute settings Hours, days, or weeks 12 months We also knew a major key to learning was to give patients agency and a stake in patient-centred care – that is, their own care. Of course we knew there were limits to what we could achieve in terms of specialisation or scope – so we needed to keep the education as generic as possible, without becoming bland. I’ll talk about pitch shortly. There is a lack of clarity and agreement about the meaning of many terms that are commonly used in relation to end-of-life care and strangely ‘dying’ is not an easy thing to define– End-of-life is the period when a patient is living with, and impaired by a fatal condition, even if the trajectory is uncertain or unknown it can be hours, days, or weeks or even up to 12 months We happily adopted the terminology from the Commission’s glossary that had been agreed upon by their consensus process.

People are defined as ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) Waiting until the very last days, or even hours of life, to identify dying does not allow enough time to provide the best care. Best care may include meaningful conversations and symptom control.  4. General Medical Council. Treatment and care towards the end of life: good practice in decision making.

Background to the pedagogy Knowing the range of various learners and abilities in health professional learners Advocates Specialists and interventionalists Powerless or institutionalised Isolated and overwhelmed Disengaged and disenfranchised Rogues Doctors, nurses and allied health professionals come at end-of-life care from various perspectives – we brainstormed the following stereotypes that helped us see who our target learners could be.

Who are our target learners? Apologies for the font size of this slide. This elaborates on the various HCP we are targeting The Advocates or Enthusiasts who are actively engaged in EOL activities The Specialists and interventionalists – such as senior doctors who are experts at treating ill health but are not programmed to deal with dying The Powerless or institutionalised –advocate for patients & families but feel powerless to affect patient treatment challenged by system The Isolated and overwhelmed – who could be early career HCP, who are still learning, and have limited experience in EOLc The Disengaged and disenfranchised – who find it easier to continue treatment, attitude is to provide health care not EOLc, may feel reluctant to act due to past mistakes And there are rogues who have a ‘my way or no way’ attitude to treatment, focus is to fix ill health, and where failure is not an option

Cognitive task analysis methods1 - the pitch The concepts of ‘novice’ and ‘able’ (or expert) were used in various ways to promote learner reflection on their own thinking Concurrent reporting – reflections and answers Critical decision methods – experts identify a way in which they solve problems 1. Clark RC, Mayer RE. e-Learning and the Science of Instruction, Wiley, 2011. Considering the wide variety of abilities and mindsets of HCPs, we employed a conceptual model of ‘novice and able’ to both conceptualise skill sets and to allow learners to appreciate potential growth. Instructional design methods allowed learners to reflect on their current practice while also concurrently reporting on the areas that they could work on to improve. We also provided the resources and practical exercises to change their communication, or screening tools to be better able to identify a dying patient. In addition we provided video of experts identifying how they approach problems or clinical issues around end-of-life care.

One example of how we developed the concept of novice and able was through a quiz that prompted the learner to identify their own clinical practice capabilities and understand their own mindset around end-of-life care.

Stepwise approach to instruction Because of the varied baseline knowledge and skills of learners - what is not known Quizzes Self-reflective questions Targeted learning based on adult learning principles Because of the varied baseline knowledge and skills of learners, our aim was for learners to understand what is not known. And we did this through Quizzes - like the able/novice quiz Using self-reflective questions such as, Q: think about how you provided care to a patient at the end of life, Did you feel that you didn't know what to say to the patient or family member? Targeted learning based on adult learning principles – what do you want to extend and grow?

Metacognitive questions behind the design Learner to reflect on: Their current practice Is this getting them anywhere? Why that approach? What other approaches could be considered? Recognising when to use different approaches Clark and Mayer defined metacognition as thinking, planning, monitoring and revising. For the educator, online or face to face, metacognition requires us to prompt the learner to think about what they are doing In this education the metacognitive questions­ that molded the pedagogy to expand learner expertise and give patient agency involved asking learners to reflect on Their current practice To question if it is getting them anywhere? To think about Why that approach? To think about What other approaches could be considered? Recognising when to use different approaches

Teaching metacognition skills – making expert thinking explicit Understand what is not known Displayed expert thinking On screen through text Consideration of alternative responses Giving a rationale for responses Responses to avoid Another method of teaching metacognition skills is by making thinking skills explicit. For example, if we had to learn about communication skills at the end of life – an enormous task. But when you break down that task into manageable pieces and prompt the learner to understand what is not known (and we did this via various ways including podcasts, quizzes, questionnaires, critical self reflective questions) and then Displayed expert thinking: On screen through text Consideration of alternative responses Giving a rationale for responses Giving a rationale for responses to avoid On screen thought text

Teaching metacognition skills – making expert thinking explicit Evaluation of a professional task Concurrently or retrospectively asking learners to record their thoughts at the same time they are responding/solving a problem Structured expert interview Making the education as interactive as possible We also made expert thinking explicit in a number of other different ways, by the: Evaluation of a professional task Concurrently or retrospectively asking learners to record their thoughts at the same time they are responding/solving a problem Structured expert interview Making the education as interactive as possible

What will happen to me - Nurse Now let’s watch an example of our film where all this comes together.

Making expert thinking explicit Scriptwriting – incorporating novice and expert responses Actor (expert) speaking to the learner, making known their inner thoughts Rewind, reframe and consider how the the response could be improved What we saw then was scriptwriting – incorporating novice and expert responses Video techniques of the actor/expert speaking to the learner, making known their inner thoughts ‘Rewind’, reframe and consideration on how the response could be improved

Feedback from our learners “I feel since completing the eLearning I am more confident in approaching end of life subjects with patients and their families.” “The eLearning has given me some valuable tools that I will reflect on and utilise.” “The knowledge that I gained from doing the eLearning course for end of life will assist me when looking after patients at end of life.” “I already recognised those patients approaching end of life, for me communication strategies that the modules taught were more valuable.” “I am now more confident when researching information around end of life.” Just to finish off I thought I’d share with you some comments we’ve received from our learners. People have said they’ve: Increased in knowledge and confidence when approaching EOLc Many have found our tools and communication strategies valuable And many have increased confidence in finding information

End-of-Life Essentials would like to thank the many people who contribute their time and expertise to the project, including members of the National Advisory Group and the CareSearch Palliative Care Knowledge Network Group. www.caresearch.com.au/EndofLifeEssentials