I delivered a teaching session to foundation doctors in training about safe and effective use of insulin in hospitalised patients. This was an interactive session for junior doctors in training. The aim of the session was to review the evidence of how and why insulin errors occur in hospital and to discuss strategies to ensure safe and effective insulin use in hospital. The session started with a real case of insulin error leading to a patient death. I then reviewed how and why insulin errors tend to occur in hospital, and the scale of the problem, by asking students to discuss these in small groups, and also to feedback on a real case study which involved a fatal insulin error. I then asked them to suggest ways of minimising risks when prescribing and administering insulin. The session involved a number of different teaching techniques and the students interacted enthusiastically in multiple small group tasks. I have used reflective learning using a real life case to make learning more meaningful to students and to activate their previous and existing knowledge and experience. This was followed by final quiz which involved asking the students to spot the errors in insulin prescription chart which in turn made the session real to students. The learning outcome of the session was to recognise how and why insulin errors occur in hospital, to list the common errors in insulin administration and prescribing and to give examples of principles to minimise the risks of insulin errors. The lesson plan is attached at the appendix for further details.
II. Identify and describe a learning theory which is applicable to the case:
The learning theory which is applicable to this case and will be discussed is the experiential learning cycle theory. In this teaching session the students had to reflect and review how bad practice of insulin prescription can lead to a fatal and hazardous outcome. It then proceeded to interpret why they thought insulin errors occur in hospital. The students were divided into small groups to plan and come up with ideas and practical applications to minimize these errors. Finally using their day to day practice of filling and completing a drug prescription chart they were asked to spot the errors in the bad examples written in the charts.
Piaget described the moving force for cognitive development in adult learning as learning from experience. He described learning as dialectical relationship between accommodation and assimilation. Forming new ideas and being able to accommodate and adapt internally to it is accommodation, while assimilating events and incorporating it into previous experiences is called assimilation. Both of these processes can be happening at the same time and form the basis of cognitive development initially described by Piaget and further adopted in Kolb's cycle of experiential learning (Piaget 1970).
Further to Lewin, Dewey and Piaget's work on the model of learning and cognitive development, Kolb described a model of experiential learning as a process which is continuously modified by the learner's experience rather than a fixed series of outcome, ideas and concepts (Tusting and Barton 2006). This has been represented with what is known as Kolb' cycle:
Kolb's theory consists of a 4 stage cycle and includes learning by direct practical experience which is called the concrete experience. It involves doing or having an experience. This is followed by the review and reflection on this new experience. This step involves critical reflection on the experience and what it actually means to the learner. This is then followed by abstract conceptualisation or the ability to interpret and find the theories to support and back up this new experience. Following on from the previous step of reflection on the experience the learner is then asked to theorise and interpret the literature. This allows the learner to come up with conclusions, by learning from the experience, of how to do things differently next time. Following on from the conclusions drawn from the abstract conceptualization stage the learner then plans changes and tries what he or she has learned from the experience. At this stage of the cycle the learner actively tests and practically applies in action the new experience and this is referred to as active experimentation (Kolb 1984). The learner can also construct ways to modify the new experience and the cycle can start again when these changes are implemented to create a new concrete experience. In summary the process starts with doing or having the concrete experience, followed by reflecting on the experience then concluding or learning from the experience and finally planning, testing and experimenting what was learned from the experience and hence generating another concrete experience.
More than one cycle with different amplitude can be happening at the same time or at different times. In general Kolb's learning theory is drawn from the 4 different learning styles described in the diagram above (Tusting and Barton 2006).
III. The strengths and weakness of the theory:
The strength of this theory is the ability to explain how you can turn experience into learning. This is mainly achieved through critical reflective learning which is considered to be an important stage in Kolb's cycle of real life problem solving (Boud 1985). It also fits in well with students' different learning styles and their ability to adapt and finding the right balance between the different stages of the cycle. (Tusting and Barton 2006).
One of the pitfalls of looking at different stages and descriptions of the experiential learning theory is the way this is presented which tends to be an over simplification of the theory. Miettinen compared Kolb's cycle to Dewey's model and criticized the simplified interpretation of the cycle and algorithmic approach of Kolb's Cycle. He pointed out that reflection can easily be lost and also planning and/or application are commonly given less time if we look at it as a simple circle. He also challenged the fact that we shouldn't concentrate on learning styles of the learners but rather concentrate on developing integrated learning styles (Miettinen 2000).
Another shortfall of the experiential learning theory is the fact that it doesn't take into account the learner's development i.e. the context of who are the learners, are not mentioned. However, there is evidence that Kolb's cycle can be viewed as spiral rather than a true circle and by doing so the development of the new experience can be included (Kolb 1984).
IV. Why the theory fits into the case:
Having a real life experience and being able to reflect on that experience, whether that was a good or a bad experience, play a vital role in the process of adult learning. As each learner has a distinct pre-existing knowledge and experience, it is important to develop and construct on this. Dewey described reflective thinking as a real-world problem solving and in the case of this teaching experience, having a fatal insulin error case from real life which can happen to anyone involved in prescription and administration of insulin, if not equipped with the required competency and applying the correct safety measures, will lead to adverse outcome. The process of reflective thinking using such an example has a great impact on learning (Dewey 1933). Lewin also described the feedback process using a problem solving example to assess deviation from the desired outcome and then evaluating its consequences, this case can illustrate this theory very elegantly as learning is a process which is continuously modified by experience (Tusting and Barton 2006).
The concrete experience in this teaching session is the death of a patient who received the wrong dose of insulin. The students then review and reflect on the real fatal case of insulin error. This is done through reading the piece of paper provided to them detailing the case and the circumstances which lead to the tragic consequences (review and reflect). In this stage of the cycle the students analyse the events which lead to the fatality and also through discussion with peers they reflect on the experience and what it means for them at a personal level and if that was their patient or they were involved in that particular or similar incident in their day to day practice. After they had the chance to reflect on the case and working in their small groups they interpret the events which lead to the fatality and assimilate the abstract concepts, using the pen and white board to list from the case and their experience examples of common insulin errors (theorize and interpret). This allows them to come up with conclusions about current practices and ways to plan changes next time. Following on from the conclusions they formed in the previous stage they then have to come up with action plans in terms of principles they will actively apply and experiment in practice to reduce insulin errors (apply and plan). They finally have the new concrete experience which is practically spotting the errors in the prefilled insulin prescription charts (do and practice). This could be considered as a new concrete experience following on from trying out what they have learned from the initial experience (the fatal case). That is to say the cycle starts again following implementation of changes from the previous cycle.
The students go through the cycle many times as they have different tasks to review, interpret and apply principles. However some of these cycles are not complete and I am planning to address these in the future sessions. One of the missing stages of the cycle is the do part or the practice stage following on from setting up action plans as in this case they have the charts already filled in. In an attempt to ensure that the cycle will be completed and all stages followed, I am planning to include a task where students are required to fill the insulin charts themselves.
V. How the theory give insight into the case:
The students have to come up with suggestions of why insulin error occurs in practice and ways of overcoming bad practices. They also looked into the root of the problem leading to this including appropriate undergraduate training and also linking this to medical schools (back to basics) critiquing the curriculum and whether it should be competency based. They tried to come up with suggestions and ideas and collate facts to elaborate and find the rationale for the situation. They finally should have tested the hypothesis they presented and its effect on the action plans they came up with and whether it lead to final resolution of the problem or the situation. This can be clearly described in this case as developing the competency in safe and effective drug prescription which not only helps the doctor to perform necessary day to day on-the-job requirements but also have an impact on the safe and healthy society he or she belongs to and serves.
The new concrete experience (the quiz) in this case can be criticized, as the students don't actually fill in the prescription chart or physically perform the tasks but are spotting the errors of somebody else. Also the concrete experience should not be part of the assessment and the quiz in this case can arguably be considered as a form of informal assessment to check students' understanding of the session (Merriam and Caffarella 1998). However, when I originally planned my teaching session and set up the learning outcome of the session the purpose of the quiz was not placed as an assessment tool although it was at the end of the session. I believe it should be the new concrete experience in the experiential learning cycle as it is all about how learners do actually learn and if I go back to the learning outcomes of the session, it is about insulin prescription safety. They need to be learning safe prescription so the insulin chart quiz here forms a concrete experience. The fact that the learner must actively 'do' something and observation is not a concrete experience can be debated especially in the context of this case.
VI. Personal reflection on the case:
In summary learning in this case occurred in a context which is of relevance to the students and is very close to reality. Furthermore, the interactions of the critical reflection of a life and death situation, abstract conceptualisation and active experimentation made the application of the theory in this case very attractive. However it was challenging at times trying to link the 4 stage cycle to this case as there were too many cycles which stem in and out of the case.