DID-ACT – Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators

Project Overview

Clinical reasoning is a complex set of abilities healthcare students have to learn during their studies and continue to further develop in the workplace. Clinical reasoning encompasses the application of knowledge to collect and integrate information from various sources to arrive at a diagnosis and management plan for patients in a shared decision-making process. Due to its multifactorial nature and unconscious components it is both, difficult to learn and teach. A lack of clinical reasoning abilities is a primary cause of cognitive errors in patient care and threats to patient safety including unnecessary pain, treatments, or procedures for patients and increasing the costs of healthcare. In the European Union the number of errors and adverse events in healthcare is estimated at 8-12% of hospitalizations (WHO). Despite the importance of clinical reasoning for the workplace of healthcare professionals and patient safety there is still a lack of structured and explicit teaching, learning, and assessment of clinical reasoning in healthcare education. Such a training can help to improve patient safety and reduce costs – two priorities of the EU Health policy.

Project Objectives

The aim of the DID-ACT project is to fill this gap and conceptualize, develop, evaluate, and disseminate a clinical reasoning curriculum in healthcare education for students and a train-the-trainer course for educators on how to teach clinical reasoning.
Both, the train-the-trainer course and the student curriculum will leverage best practices in instruction, assessment and clinical reasoning theory and combine online and face-to-face teaching components to achieve optimal learning effects. To facilitate dissemination, the curriculum will be adaptable to existing curricula, enabling curriculum managers and educators to adopt it in a step-wise approach and integrate it into existing courses. This process will be supported by publishing guidelines.

Target Groups

Our primary target groups are educators, healthcare professionals, students and faculty staff who can benefit from the clinical reasoning curriculum and the train-the-trainer course. For researchers the curriculum offers a great potential to address open research questions in clinical reasoning teaching.

The secondary target group includes patients and the public who can benefit from better educated students. Non-healthcare institutions can adopt parts of the curriculum relevant for their students.

Outline of the work

Needs analysis (WP1): We will initiate the project by reviewing and analyzing the literature, course concepts and frameworks to elaborate specific requirements for a clinical reasoning curriculum based on our general needs analysis implemented in 2018. Additionally, we will analyze potential barriers for teaching clinical reasoning and specific needs of our target groups.

Definition of goals and development of a framework (WP2): We will build upon the results achieved with the needs analysis, and develop a curricular framework with goals, learning objectives, and teaching & assessment methods for healthcare students of all levels and a train-the-trainer course. This framework will be the main basis for the following course and curriculum implementation.

Implementation of a train-the-trainer course (WP3): We will develop a course about teaching clinical reasoning for healthcare professionals and educators. The course will cover the concepts of clinical reasoning and how to teach it in an effective way applying modern teaching and assessment formats, such as virtual patients or the inverted classroom methods. It will also provide an introduction and discussion of the student curriculum. The course will follow a modular and adaptable design combining online and face-to-face elements.

Implementation of the student curriculum (WP4): We will devlop a longitudinal and adaptable blended-learning curriculum for undergraduate healthcare students on clinical reasoning. The course will be designed based on state-of-the-art didactical approaches including a variety of teaching and assessment methods grounded in the constructive alignment theory. A core component will be a pool of virtual patients, which provide a safe environment for learning from errors and deliberate practice.

Evaluation and Feedback (WP5): In this work package we will conceptualize and implement the evaluation of the train-the-trainer course and the student curriculum developed. The aim is to provide a set of evaluation tools that can be used for a variety of integration settings, including questionnaires for course participants and facilitators and tools to analyze learner activities in the online environment (learning analytics).

Quality management (WP6): This WP will determine how the quality of the project will be monitored. This concerns both, the quality of the deliverables and the quality of the working process. An agile project management approach provides an ideal environment to implement quality assurance from the beginning and throughout the project, since the agile approach focuses on customer satisfaction and the value of a product.

Dissemination and sustainability (WP7): Our aim is to sustain the outputs beyond the lifetime of this project and share the resources and results in the wider community, such as healthcare education networks, higher education institutions and organization. Our aim is a wide uptake of the train-the-trainer course and the student curriculum in non-partner institutions. To foster the dissemination of the project we implement several activities, such as this website or a publicly accessible learning management platform which will include all course material as open educational resources.

Project Management (WP8): The management is designed to deliver the projects aims in a cost-effective and timely manner. It includes the organization of face-to-face and video meetings. This WP will also facilitate the decision making about the project tasks and the timeline.

How to teach synchronously in a virtual setting

  • You need a reliable camera, microphone, and virtual platform and be familiar with its features, such as whiteboard, chat, polling, breakout rooms, etc.
  • At the beginning establish communication rules, e.g. whether participants should raise their (virtual) hand, use the chat, and/or just speak. Also, we recommend asking participants to turn on their camera
  • For small group work break out rooms work very well, just be clear about the tasks the groups should work on prior to dividing them into the groups.
  • For collaboration the use of integrated virtual whiteboards or other platforms such as Padlet are very useful. Just make sure prior to the session that you have everything setup and the links at hand, e.g. to post them in the chat.
  • Allow a bit more time for starting the session and the group works as there might be participants who are not familiar with the platform or technical problems might occur.

How to motivate unprepared participants

  • Make clear that the asynchronous assignments are a core part of the course and that its content will not be repeated. Even if it is difficult, stick to that when starting the synchronous teaching session.
  • If you expect unprepared participants, you can start the session with a student-centered group exercise mixing prepared and unprepared students to increase peer-pressure and make them realize that being unprepared does not feel good.  
  • Use the introductory or closing quizzes / tests so that participants can self- assess whether they have the required knowledge and you as a facilitator can see the level of knowledge and preparation of your participants.

Further recommended reading:

How to involve participants with different levels of experience

  • To account for such different levels, we recommend making use of the asynchronous preparatory phases which also include introductory quizzes in which participants can self-assess their prior knowledge and you as a facilitator can assess the differences within your group. Participants with less prior experience can also be guided to additional preparatory resources.
  • Encourage participants to work in pairs or small groups when preparing so that they can help and learn from each other. You could even facilitate this by dividing them into groups with different levels of experience.
  • Similarly, during the synchronous phases, we recommend forming groups with participants different levels of experience and emphasize the peer support aspects of such group activities.
  • We also recommend starting with rather smaller groups and allow more time than stated in the course outlines, if you expect a heterogenous level of experience. This way you can better manage this challenge.
  • Encourage your participants to ask questions, emphasizing that nobody knows everything and that it is important for learning to ask questions.  
  • Especially in the train-the-trainer course you might have to deal with over-confident participants, who especially in an interprofessional setting can dominate the group. This is a complex cultural challenge, but you could try to establish (and follow) communication rules at the beginning of a session.  

How to address potential overlaps or redundancies

  • Identify what is already included and what is missing in your curriculum related to clinical reasoning outcomes and compare it to the DID-ACT blueprint. Prioritize learning outcomes that are not yet covered but regarded as important.
  • Identify activities, resources, or teaching sessions with similar learning outcomes that might be in need for change anyway because of low evaluation results, teachers or students struggle with it. These could be suitable for adding or replacing parts with DID-ACT activities.
  • Ask teachers and students about overlaps and gaps they see in their teaching / learning of clinical reasoning and where they struggle. This could also be done by a reflection round after related teaching activities in the curriculum
  • Although ideally a longitudinal integration is aimed at, we recommend to starting small with a pilot implementation to gain experience and develop a show case.

How to teach in an interprofessional setting

  • Allow for enough time prior to the teaching for the organization and motivation / encouragement of stakeholders and participants
  • Allow for enough time and guidance during the course so that the participants from the different professions can get to know each other and their professions and discuss their different perspectives. This might mean that you need to calculate some extra time in addition to the suggested duration of the learning unit.
  • There may be a different understanding of clinical reasoning in the different health professions, so we recommend making participants aware of this. You could for example use and adapt activities from the learning units on the health profession roles to facilitate this.
  • Courses in an interprofessional setting should not come too early in the curriculum (not before professions have formed their own professional identity - however, this also depends on the aim of the course). 
  • Make sure you have enough participants from different professions. If possible, the facilitator could divide the participants in smaller groups with an equal distribution of professions. 
  • Similarly, you need an equal distribution of facilitators / facilitators from different professions.
  • Develop customized learning materials considering the different professions. If needed you can adapt the material and activities provided in the DID-ACT curriculum.

Further recommended reading:

van Diggele, C., Roberts, C., Burgess, A. et al. Interprofessional education: tips for design and implementation. BMC Med Educ 20, 455 (2020). (Link)

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