1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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?

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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.