What happens to competency over time?

At one point during the first day of the stakeholders meeting for our Botswana preservice education project, Peter Johnson (the Director of Global Learning @ Jhpiego & my boss) drew a graph on a flip chart that represented various trajectories for clinical competency over time. Taking what he drew, I expanded & embellished a bit and sketched the graph below.


So what's going on here?

On the y axis is competency level and on the x axis, time. As education proceeds, competency level increases (I've drawn the progression as linear but it most likely proceeds in fits & starts). The most important point in time is graduation, after which a number of trajectories could be followed. For purposes of simplification I've only drawn three:

1. With no opportunity to practice & put to use the knowledge, skills & attitudes developed in school, competency quickly drops.
2. With a low level of or irregular exposure to opportunities, competency stays flat.
3. With continued opportunities to practice, competency increases until the individual becomes proficient.

Obviously option 3, represented as the line that continues to climb, is the most desirable. Unfortunately, what we often find is that, after deployment, newly prepared healthcare providers are not exposed to the number of opportunities required to drive them toward proficiency and they struggle to maintain or eventually even lose their newly acquired competencies.

So what do we do then?

Well, the potential answers are worthy of an entirely different post, but a few quick thoughts:

• There may be ways to use technology, e.g. clinical simulations, to increase exposure & at least maintain competency levels.
• The reason exposure is limited may be due to the fact that their education is not really preparing providers for the reality of their profession; that what they're learning isn't what they'll be doing upon graduation. A task analysis and changes to curricula may be in order.
  
• Policies may not be in place that allow healthcare workers to fulfill the role for which they've been prepared. For example, nurses may be educated to initiate and manage ART but national policy may only allow doctors to do so.

As per usual, I'm not saying anything new. I just felt compelled to share the graph. And maybe it has inspired you to stop & think for a minute. Are you maintaining competency?

Trip Report 2.0 - Jun 24 2009 (Challenges)

On the 24th & 25th of June I co-facilitated a meeting/workshop of stakeholders in our preservice education program in Botswana. Members included representatives from the Ministry of Health; the Nursing and Midwifery Council; principals, deputy principals and heads-of-department from all 8 Health Training Institutes; and service providers from the Francistown hospital. The session I led was aimed at eliciting challenges from the participants and relating them to some of the findings and recommendations from the learning technology readiness assessment we conducted in February (See Assessing Learning Technology Readiness: A Pre-Service Case Study from Botswana for details and tools).

So, what are some of the challenges?

• Too much to do - But not enough time & resources. Pretty self-explanatory.
• Additions to the curriculum - Without removing anything. Bloated curricula.
  
• "Forced" programs (e.g. IMCI) - No input from local folks. Hence, no buy-in. And resistance.
  
• Large number of students - Higher enrollments without consequent increase in faculty/staff.
  
• Lack of human resources - See "Too much to do" above. Again, pretty self-explanatory.
  
• Little support for program implementation - Lots of great ideas but not a lot of help to realize them.
  
• Student attitudes - Kids are enrolling to get jobs, not because they want to be healthcare professionals. Doesn't make for the best learning environment.
  
• Meeting student learning needs - Everyone learns differently. And the kids are tied to their mobile phones & all over Facebook :P
  
• Not enough (time for) clinical exposure for faculty - How do you teach something you can't even do yourself?
  
• Curriculum conflicts - How are you sure that what you're teaching is aligned with all elements across the curriculum?
  
• Not enough simulation - Students don't have enough time to practice before they're required to see & treat live patients.
  
• Effective teaching and assessment skills - Just because you're a teacher doesn't mean you really know how to teach. Same goes for assessment. Doing isn't always doing well.
  
• Faculty attrition - The good ones get promoted.

That is a pretty significant list. But it's pretty consistent with what we see in many other countries. And that's a good thing. Because we have some proven ways to address these sorts of challenges -- using traditional methods as well as technology-supported approaches. Again, see Assessing Learning Technology Readiness: A Pre-Service Case Study from Botswana if you're curious to learn about some of the specific ways in which we plan to apply various learning technologies.

I'm excited to see where this all goes...

Does form really follow function?

After reading Henry Petroski's article in today's New York Times Magazine, "Bridging the Gap," I found myself getting caught up in one of my favorite lines of thought: the relationship between form and function. One familiar relational construct is "form follows function." And it's a popular one -- a Google search for the phrase "form follows function" retrieves almost one quarter of a million results. But can the converse also be true? Is it possible that function can also follow form?

If you were to ask David Nye, I think his answer would be an emphatic "Yes!" I'm currently reading his "Technology Matters: Questions to Live With", and am reminded about the discussion of Thomas Edison and the phonograph in the chapter, "Is Technology Predictable?" Apparently, Edison and his colleagues came up with the following illustrative potential commercial uses for their new invention: speaking doll & other toys, speaking clock, advertisements, calling out directions, delivering lectures. At the end of a long list, and seemingly almost an afterthought, "a musical instrument." The point? Sometimes it's the last application of a technology you think of, or one you didn't even imagine, that catches on and organically becomes the most successful. And I realize now that I have a decent, very low-tech example of this "function follows form" dynamic.

My wife is growing tomatoes in a pot on our back deck. The plant seems to be growing quite well: it's rather tall and we're already seeing a number of tomatoes. The challenge? How do we stabilize the plant under the weight of its fruit? The solution? A wooden dowel, anchored in the soil, placed along the edge of the pot to bypass roots and get support, and positioned deliberately so as to provide support to the plant without requiring it to be tied down. The plant, pot and dowel are all forms with specific pre-existing functions: to reproduce; to hold soil and grow plants; and (commonly) to be cut into small pins that reinforce joints and support shelves. But given their current forms, the functions became: to grow branches at specific points and angles; to anchor a wooden dowel; and to support a rapidly growing tomato plant. Here's what it looks like...



And now, if I think back to my Introduction to Biology course in my Freshman year at Villanova University 18 years ago, this question of the relationship between form and function was raised in the very first few weeks. I have always remembered it this way: in biology, form follows function. Luckily for me, I still have the textbook, Neil Campbell's Biology (2nd Edition). What is actually written? In "The Correlation of Structure and Function" section of the first chapter: "Form fits function." I'd like to think that Campbell, in using the term "fits" rather than "follows," was implying that the relationship was not necessarily unidirectional; that, like pieces of a puzzle, both are required to complete the picture and neither can really be elevated to the point that one is dependent upon the other.