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eLearning Blog

Clinical Teaching Fig. 4

Social Learning in Clinical Settings: Adult Learning Theory Applied to #MedEd

Developmentally, both individually and as a culture, much of our learning has been social learning. Social learning theory is the concept of learning from other people through observation, questions, collaboration, and knowledge sharing.

This theory can be applied by teachers of resident physicians or medical school students in a clinical setting to maximize teaching opportunities from informal, unplanned, and opportunistic situations to formal and planned lessons.¹ Because there are patients, family members, other learners, teachers, and various medical professionals in the clinical setting, there are countless moments when the best plan is to “expect the unexpected.” While planned teachable moments are important, unplanned situations also allow the teachers to model behavior for the learners that simply cannot be taught in a book or a classroom.

Clinical Teaching Fig. 1

How can teachers prepare for social learning in a clinical setting? Being that the setting is somewhat static for you as the teacher, consider how you can affect the role modeling aspects of social learning. Cognitive processes, or how people take in and make sense of what they experience, are key to any type of learning. Albert Bandura, the psychologist behind social learning theory, gives a useful framework for the cognitive processes that enable learning via role modeling: attention, retention, reproduction, and motivation. Simply put, people need to see what they want to reflect; they need to mentally (and physically) rehearse what they see to be able to retain it; they need the opportunity to take what they see and rehearse to be able to reproduce it; and then they need to receive reinforcement as incentive or motivation to continue doing it.⁴

Attention

There are important foundations to build as a teacher in order for students to be able to pay attention at the start of the process. Before you speak to your learners, review what you need to know as the teacher. You need to be prepared for them to pay attention. You need to know your patients, your learners, and your own facts. Identify the key areas of focus for that session’s education. By walking into your own clinical teaching sessions with your preparation completed, you set a culture of high expectations with the teacher demonstrating high standards and expecting the same from the learners.⁵

Building a safe environment is necessary so learners can feel comfortable rehearsing and reproducing modeled behaviors without fear of undue criticism or condemnation. Group settings, like hospital rounds, can be difficult when learners are at different knowledge and ability levels, so be sure to foster an environment where the concepts are challenged, but the learning is not. Create an environment of curiosity and camaraderie where you teach professionalism, respect, and enthusiasm by example.

When learners are eager to apply what they learn in a clinical setting, they may want to reach conclusions before it is time to do so. Sometimes there is no answer, there are only questions. In situations like this, the learners are paying attention to how the teacher reacts rather than what the teacher concludes. As the role model, help the learners find comfort in not knowing. Learners must develop a level of comfort with not knowing something, and confidence that they have the resources to find the answer. The answer may be to run a test or wait for the results of a medication, and they need to know, through your modeling, that wait-and-see is a perfectly acceptable response that brings with it a definite measure of credibility.

Clinical Teaching Fig. 3

Retention

Modeling in social learning theory relies on retention. A person must remember and recall what they see to be able to reproduce it. Perhaps even more importantly, they need to do so with accuracy or the wrong method or material will be retained. To set up the learners for success in their retention, set some ground rules for the social learning interactions. First, be sure the learners are engaged and not paying attention to distractions such as devices or other people. To pay attention to and retain information, a person must be actively involved both physically and mentally. If the learners wander off in any way, be sure to reengage them in a way that teaches them how to pull others back into focus. Because, in health care, engagement and reengagement need to happen at all levels and between all participants.

Second, particularly for retention, if the learners wonder if some of the material is incorrect, make sure that they know they should call it out and ask questions. This level of critical thinking aids retention for those particular pieces of information. Be sure they know that asking others and looking up information are very acceptable methods of working with people in clinical settings. And, at times, they might even deduce through discussion or debate that some of the information is not relevant. The idea is not to retain and reproduce anything they see, but to help them determine what is important and what should become part of their professional repertoire.

Reproduction

Make space and opportunity for reproduction. Give learners a role in patient care wherever possible. Not only is responsibility a great motivator, but it also gives the students the platform to practice what they are learning through paying attention to and retaining what the teacher is doing. As the learners demonstrate greater knowledge and ability, as well as proceed through outside classroom work, increase their levels of autonomy while gradually decreasing the levels of support you provide. They can then assist with teaching newer learners, reproducing some of your teaching methods, while still learning more from the modeling they observe. This is where reproduction seamlessly moves into motivation as learners gain confidence and competence in their own demonstrated abilities.⁶

Motivation

Social learning, in itself, can be a strong motivator for learners. People want to learn in that style, and that style makes people want to learn. Millennials strongly prefer working in group settings as teams with frequent communication and feedback. According to “Innovations in Teaching and Learning in the Clinical Setting for Postgraduate Medical Education,” in the medical field, millennials have been seen to have “stronger team instincts, tighter peer bonds and a greater need to belong to social groups than their Generation X counterparts” while also expecting more “frequent, positive, and affirming communication with supervisors than previous generations of workers.”⁷

All age groups benefit from feedback. Not all feedback will be positive, but modeling how feedback is given is almost as important as the feedback itself. As the teacher, give positive feedback in a group setting, but negative feedback privately. This feedback directly affects the learners’ motivation both to learn the material and to model what they’re learning. If a learner is smacked by negative feedback that is delivered publicly, the motivation to continue learning and modeling in a social setting may be stunted. If negative feedback is given, “sandwiching” it between pieces of positive feedback may be helpful. You as the teacher would also be wise to model self-criticism by evaluating your own performance in the social learning setting. To show that a teacher can examine how and why you came to a decision and learned from the scenario is a lesson that can be seen, retained, replicated, and used by learners and peers alike.

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[1] Steinert Y, Basi M, Nugus, P. How physicians teach in the clinical setting: The embedded roles of teaching and clinical care. Medical Teacher. 2017; 12: 1238-1244

[2] [4] Horsburgh J, Ippolito K. A skill to be worked at: using social learning theory to explore the process of learning from role models in clinical settings. BMC Medical Education. 2018; 18:156

[3] [5] [6] Seabrook, M. How to Teach in Clinical Settings. 2014: 1-2

[7] Murnaghan ML, Forte M, Choy IC, Abner E. Innovations in Teaching and Learning in the Clinical Setting for Postgraduate Medical Education. Members of the FMEC PG consortium; 2011