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Educational Handbook for Health Personnel Sixth Edition J.-J. Guilbert o o -t- lffi; '$/orld Health Organization, Geneva l.987 W H O O f f s e t P u b l i c a t i o n N o . 3 5 R e p r i n t e d 1 9 8 9 W H O o f f s e t p u b l i c a t i o n s a r e i n t e n d e d t o m a k e g e n e r a l l y a v a i l a b l e m a t e r i a l t h a t f o r e c o n o m i c , t e c h n i c a l , o r o t h e r r e a s o n s c a n n o t b e i n c l u d e d i n W H O ' s r e g u l a r p u b l i c a t i o n s p r o g r a m m e a n d w o u l d o t h e r w i s e r e c e i v e o n l y l i m i t e d d i s t r i b u t i o n . T h e y a r e u s u a l l y r e p r o d u c e d b y p h o t o - o f f s e t f rom typescript, rather than by letterpress, and do not necessarily receive editorial revision. t Ce livre est publi6 en frangais par l'OMS sous le titre: Guide p6dagogique pour les personnels de sant6. I
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t Ce livre est publi6 en frangais par l'OMS sous le titre: Guide p6dagogique pour les personnels de sant6. I I n f o r m a t i o n c o n c e r n i n g A r a b i c , B u l g a r i a n . C z e c h , F a r s i , G e r m a n , H u n g a r i a n , l n d o n e s i a n , l t a l i a n , P o l i s h , Portuguese, Russian, Serbo-Croat, and Spanish editions is available from WHO, Geneva (attention EPM/HMD). r s B N 9 2 4 1 7 0 6 3 5 X rssN 0303-7878 @ World Health Organization 1 987 Reproduction and translation authorized, for nonprofit educational activities provided that WHO origin is mentioned and that copies containing reproduced material are sent to: Chief, Office of Publications, World Health Organization, 1 2 1 1 G e n e v a 2 7 . S w i t z e r l a n d .
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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The author alone is responsible for the views expressed in this publication. Typesetting and page layout by the Audio-Visual Unit, Dundee College of Technology, Dundee, Scotland Printed in Switzerland by lmprimeries Populaires, Geneva 8 7 / 7 1 3 6 - 4 O O O ( B ) P R I N T E D I N S W I T Z E R L A N D 84/ 6261 - Populaires - 25OO (R) 88/ 187 1 - Populaires - 3OOO (R) Educational Handbook for Health Personnel How to help educators to increase their skills so as to make learning easier for the students o o 1987 objectives of the handbook When you have studied this handbook you should be able to:
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How to help educators to increase their skills so as to make learning easier for the students o o 1987 objectives of the handbook When you have studied this handbook you should be able to: define the professional taslts which will provide ttre basis for determining educational objectives plan a curriculum construct tests and other measurement devices. These skills will be based upon a measurable gain of knowledge concerning: I I r . r relationship between profeNsional training programmes and subsequent practice; principles of learning and rble of the teacher; role of objectives in educational planning; principles and methods of curriculum planning; principles and practice of educational evaluation. you will also have strcngthened your desire to go on learning and acquiring skills in education and will hare mastered an effective way of setting about it. Contents Identification ofyour needs as an educator
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Identification ofyour needs as an educator o Objectives of the Handbook o For whom is this Educational Handbook intended? o How to use the Handbook o o Pre-test o List of educational objectives o Theoretical background that will help you reach the educational objectives o Table of exercises proposed in the Handbook Chapter 1 Chapter 2 Chapter 3 Chapter 4 Educational obiectives o The educational spiral o Importance of defining professional tasks a Selection of uaining goals a Example of services provided by rural health units o Types of educational objectives o General objectives: professional functions o o a r o Construction and critique ofspecific educational objectives Professional activities and intermediate objectives Built-in relevance approach to educational planning Professional tasks and specific educadonal objectives Identifying the components of a task Formative and cenifying evaluation
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Formative and cenifying evaluation Evaluation planning o What is evaluation? o o Aims of student evaluation o . o Qualities of a measuring instrument (validity, objectivity and practicabiliry) o How to organise an evaluation system Selection of an evaluation method Advantages and disadvantages of different types of test Programme construction o Distinctive attributes of education for the profesions o Curriculum planning principles a o o a o o o o The purpose of teaching is to facilitate learning Teaching: a complex but challenging task Teaching methods and educational media Self{earningpackages The concept of integrated teaching The concept of integrated learning Planning of programme reform The use of specification tables Test and measurement techniques . Why evaluate? o Guidelines for evaluating a training programme a o Guidelines for evaluating educational objectives a o
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Test and measurement techniques . Why evaluate? o Guidelines for evaluating a training programme a o Guidelines for evaluating educational objectives a o Programme evaluation by the students Evaluation of students' level of performance Poins to consider in evaluating programme changes Assessment of practical skills Assessing attitudes Written tests The programmed examination Stages of assessment Test construction specification table o o o Relative and absolute criteria tests o Item analysis Chapter 5 How to organise an educational workshop Chapter 6 Index and glossary Chapter 7 Bibliography page 2 6 7 8 9 l 2 t+ L 5 1.01 1.0 5 l.o7 1.09 t . t 2 r . r g 1 . 2 3 L - 2 9 L . 3 4 r . 3 5 1 . 3 5 r . 4 3 2.Ol z.tz 2.I5 2.L9 2.21 2.30 2.33 2.40 3 . 0 1 3 . 0 5 3 . r + 3 . 1 8 3 . 3 3 3 . 4 1 3.+8 3 . 5 9 3 . 6 r 3 . 6 6 3 . 7 3 4 . O l 4.O4 4.O5 +.o7 4 . t o 4 . 1 5 + . 2 L 4 . 2 2 4 . 2 3 4.28 4 . 4 t 4.49 4 . 5 4 +.6t 4 . 6 5 5 . 0 1 6.Ol
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4 . O l 4.O4 4.O5 +.o7 4 . t o 4 . 1 5 + . 2 L 4 . 2 2 4 . 2 3 4.28 4 . 4 t 4.49 4 . 5 4 +.6t 4 . 6 5 5 . 0 1 6.Ol 7 . O l preface to the sixth edition result of national initiatives. It too was used 'educational workshops", during at many which interesting and constructive criticism the same effect as the was expressed to comments received from the readers partici- included rnany pating in the survey, who experienced educators: need for greater clarity (less jargon), more concrete examples and more practical exercises. Another attempt has been made in this edition to take this advice into account. Like the previous ones, this new edition will be revised in its turn, in the light of the suggestions we hope to receive from users. To ordir copies please see the list of addresses at the back of the book. For editions in other if you s)ould languages, or farther informati.on or expknations, do not hesitate to write to:
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like Chief, Educational Planning, Methodology and Evaluation Division of Health Manpower Development \World Health Organization l2I1- Geneva 27 Switzerland Your suggestions will always be welcome. There is a special sheet you can use for them at the end of this handbook. I Dr. S. Abrahamson and Dr. H. Peterson (USC, Dept' Med. Educ., Los Angeles). This sixth edition (1987) brings up to date, and improves on, the previous edition. It is taking into account the a collective work suggestions of critical numerous users of the earlier editions and the results of a survey carried out among 2OO selected readers, whom we take this opportunity of thanking. comments and
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comments and The first edition was prepared on the basis of documents distributed during a workshop organized by the Regional Office for Africa, the Brazzaville, in medical assistance of education.l It has been widely used in the Region and served as a basic document for many educational planning workshops. in December 1969 with consultants
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in December 1969 with consultants It then became evident that it would be useful to give the reader better guidance during his progression through the whole educational planning cycle. Although this objective would most likely be achieved by a completely programmed presentation it seemed that the complexity of the problems involved was not great enough to justify a method which would be so intricate and long to Prepare. Only practice could say whether this was correct. In 7975 a fully revised text was field tested and led to the 1976 revision distributed in over 1O,OOO copies in four languages. The 1981 edition was translated into 14 languages as a 4 W O R L D H E A L T H O R G A N I Z A T I O N ORGANISATION MONDIALE DE LA SANTE o Dear Colleagues, In our common struggle to achieve the objective of "Health for all by the year 20OO", the place of basic training and continuous education of health personnel is a crucial one.
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Dear Colleagues, In our common struggle to achieve the objective of "Health for all by the year 20OO", the place of basic training and continuous education of health personnel is a crucial one. The Conference of Alma-Ata recommended, among other things, that governments "[define] the technical role, supportive skills, and attitudes required for every caregory of health worker according to the functions that need to be carried out to ensure effective primary health care...". It also recommended that "health workers, especially physicians and nurses, should be socially and technically trained and motivated to serve the community; that all training should include field activities", and that due attention should be paid to the preparation of teachers of health workers.
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All these reasons lead me to regard the publication of this revised edition of the Educational Handbook for Healtb Personnel as particularly useful, in that it will facilitate the application of those recommendations. It is also a practical example of the technical support that an international organization such as ours must offer to back up national efforts in favour of primary health care. Of course it is only one element among many; a small stone that helps pave the difficult way to health for all. I hope this Handbook will continue to meet with the succes it has enjoyed for over 15 years among its many users. /MDr. H. Mahler Director{eneral l2ll GENEVA2T-SWITZERLAND Telegr.: UNISANTE-GENEVA Telex: 2782lOMS l2llGENEVE2T-SUISSE Tdtdgt.: UNISANTE-GENEVE for whom is this educational handbook intended? t969,
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Director{eneral l2ll GENEVA2T-SWITZERLAND Telegr.: UNISANTE-GENEVA Telex: 2782lOMS l2llGENEVE2T-SUISSE Tdtdgt.: UNISANTE-GENEVE for whom is this educational handbook intended? t969, the first edition was in Originally, teachers of the health sciences. written for Subsequently, however, the Handbook was used above all by hundreds of participants in meetings organized by WHO or held withWHO assistance (educational planning workshops, teaching methodology seminars, etc.......). A survey of 2OO users carried out in 197 5 revealed the following opinions.
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A survey of 2OO users carried out in 197 5 revealed the following opinions. A very small minority (10%) felt that the Handbook should be supplied only to partici- in controlled educational activities pants (workshops, seminars, courses, etc.) or reserved for "teachers of teachers". Tbe maiority, bouteuer, felt that dissemination should be as uside as possible, and be directed to all teachers of health sciences at all levels, to health administrators with staff supervision responsibilities, and to students, so as to help them to draw maximum benefit from their learning activities and participate in their
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organization. The latest poll, conducted in 1978, produced very apposite comments from about 100 users in all parts of the world and the consensus is still in favour of the widest possible distribution. Many teachers of the various health professions (dentists, nurses, sanitary engineers, physicians, pharmacists, etc.) have stated that the Handbook answers their needs, but some think that the author's training as a physician has still too often biased the choice of examples. A further effort has been made with this 1981 edition to produce a text better suited to eagryone working in the health professions. lt is, how- ever, very difficult to strike a perfect balance, for many reasons. While it is still true that most of the examples relate to the medical and nursing professions, it is the author's hope that each user of the Handbook will make a personal effort at adaptatioz, replacing
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most of the examples relate to the medical and nursing professions, it is the author's hope that each user of the Handbook will make a personal effort at adaptatioz, replacing the examples given by other more suitable ones whenever necessary.
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jargon and meaning of words the previous editions have Many users of asked for special care to be taken to simplify the language used. We hope they will be satisfied. It has not, however, been possible to avoid using certain technical terms (for example, discrimination index). Neither has it been possible to avoid assigning precise and resfficted meanings to words which are often used interchangeably in everyday parlance (for example' task, activity and function). In all such cases the words are defined in the Glossary (p.6.01 et. seq.). It is very important that we should understand one another, and for that we must give identical meanings to the words we use. But it is just as important not to get bogged down in endless discussions. Your aim is not to draft definitions of words for a dictionary. please accept the definitions proposed in Handbook, at least while you are using
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please accept the definitions proposed in Handbook, at least while you are using So this i t . how to use the handbook The presentation and layout of this Handbook are unusual. It should be stressed at this point that the approaches suggested in this book are the result of a deliberate choice by the author and reflect his ideas in the field of education. Various theories sometimes regarded as con- tradictory are explained to the reader so as to give him food for reflection, rather than to subject him to any philosophical con- is for the reader to make his straint. It choice, to draw initial conclusions and, in particular, to seek solutions for his own teaching problems by taking what is worth theoretical using among approaches suggested. To reject them whole- sale would hardly be constructive; it would be preferable to propose better ones. various the
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various the For each chapter a list of objectives is included (yellow pages) to give you an idea of what you will get out of the chapter. theoretical input (white pages) is The presented in the form of original docu- ments or short quotations from texts listed in the bibliography. through the Handbook there are All exercises (blue pages) to help you to determine whether you have increased your skills (see check list, page 15). Certain documents are printed large type so that they can be easily made into transparencies for use with an overhead projector (see technique on page 3.45). in The page numbering is also unorthodox: every chapter begins with a number ending in 01 (for example page 3.01 is the first page of the third chapter), however many pages there may be in the previous chapter. This meakes it easier to find a specific passage in the Handbook.
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Rather than try to explain the whys and wherefores of this unusual lavout. which irritating and complicated at some find first, and others as intriguing as a detective story, it seems simpler to invite you to use this book just as it is. You will then draw your own conclusions as to the "reasons" for its layout. There must be some... even if the author is not aware of them all! In any case you are warned not to read this Handbook like a conventional book, starting with the first page and hoping to get to the last. It is meant to be used as determined by the questions you put to yourself, your needs, and the teaching problems that bother you - by your own objectives, in short, whether or not they are already articulated. This is why we are going to try and help you in this essential but unusual and therefore difficult undertaking.
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This is why we are going to try and help you in this essential but unusual and therefore difficult undertaking. First situation: you are alone (on a desert island) or else you are accustomed and prefer to work alone. You are going to need grit, perseverance and 35 to 50 hours of free time. Good Luck! Second situation: a colleague also has the Handbook and agrees to work with you. It will not be such an uphill task. If you can get together a small working group of five persons, still better. Third situation: you are taking part in an educational workshop. The working methods for such a meeting are described in this Handbook (pp. 5.10 - 5.L2) and group dynamics will do the rest. In any case, the first thing to do is to iden- tify yoar needs. You are invited to proceed in three stages. identification of your needs as an educator First Stage
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In any case, the first thing to do is to iden- tify yoar needs. You are invited to proceed in three stages. identification of your needs as an educator First Stage What are the educational "questions" that you would like to have answered? (For example: "what is an educational object- ive?", "what does the word 'validity'mean with reference to an examination?"). What are the educational "tasks" that you take on? (For example: would "organizing a nutrition course for student like to nurses" or "teaching how to interview a patient"). r What are the educational "problems" you would like to solve? (For example: "I am in charge of 600 students in different university years: how am I to organize field work in preventive medicine?" Now ............ Try to draw up a preliminary list of your "questions", "educational tasks" or "problems" for the coming 12-month period.
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Now ............ Try to draw up a preliminary list of your "questions", "educational tasks" or "problems" for the coming 12-month period. E X E R C I S E identification of your needs as an educator Second stage Would you like to find out how much you know before studying the rest of the Hand- book? One way of doing this is to try to answer the questions in ^ pre-test* . To do so, read straigbt away the questions on p a g e s 1 . 5 7 - 7 . 6 0 , 2 . 4 5 - 2 . 4 7 , 3 . 7 9 - 3 . 8 3 and 4.75 - 4.80 and enter your answers on the answer sheet, page 10. If your score is low in this pre-test, this should be a source of satisfaction, for it may show that you were right to start perusing this Hand- book and that it will be worth your while continuing so that you can improve your weak spots. The test will help you make a personal diag- nosis of the teaching areas you need to bring
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The test will help you make a personal diag- nosis of the teaching areas you need to bring up to date. Your aim in doing this test is not to find the right answer but simply to take note of tbe fact that you do not find it! You may also rest assured that your score in the post-tesr (page 5.34) will be another occa- sion for satisfaction for it will show an appre- ciable gain after you have used the Handbook. If your score in the pre-test is high, you should choose areas which are still "uncertain" (those for which you did not find the correcr answer) and go into the matter more thoroughly. *This pre+est deals only with theoretical knowledge relating to group 2, page 2. You will have an opportunity ofgauging how far you have achieved the group I objectives by doing other exercises which appear throughout the Handbook (blue pages). 9 answer sheet for pre-test * Chapter I
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rEEEtrtr z@tr88tr r@trtrtrtr +trtrEEE s@8tr8tr O@8trtrtr z@BEE a@trtr8 gEtrEE 10tr8trtrtr 11 8trtrtr 72trtrtrtr 13trtr8tr 14trtrtr8 lstrtrtr8 16trtr8tr 17trtrEEtr 18tr88trtr rstrEtrEtr zotrtrtrD To check your raw score compare your answers with those given on page 5.34. identification of your needs as an educator Third stage To use this Handbook effectivelyfor your own needs, it is proposed that yoz choose from among the following educational tasks or objectives (broken down into four main themes) the ones which interest you a;nd, n which you would like to achieve a degree of competence. The time required for personal work (study of the text, practical exercises) on some of these tasks will be more or less long. Some call for a few minutes' work, others several hours to allow for study of the documents suggested (p.14).
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To guide you in this first choice, do not forget to take into account the "questions and problems" you listed on p.8 and your weak and strong points (results of pre-test, p. s.3a). Limit this initial choice to about f0 tasks, circling the numbers of those that seem most important fo,r you on the list (numbered 1 - 40) appearing on pages 12 - L3. It is natural that you should have some diffi- culty in making your choice at this stage, for you are not yet familiar with "educators' jargon". Do nor forget the Glossary (pp.6.01 et seq.) Don't worry in any case there is no risk involved! Moreover, you can always adjust your choice as your work progresses. Once your initial choice has been made, turn to p. L4 and follow the instructions given there, study the suggested pages and do the corresponding exercises (blue pages.) 1 1 educational a obiectives t evaluation 6 planning Z
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1 1 educational a obiectives t evaluation 6 planning Z 1. Define the following terms: professional task, activities, functions, role, institut- objective; specific objective; ional domains of practical skills; communic- ation skills and intellectual skills. ,) 3 . +. 5 . 6 . 7. 8 . 9 . the qualities of an educational List objective aird the sources necessary to ensure lts relevance. Define the professional functions of a member of the health team whom your is responsible for teachins institution training (general educational objectives) so as t6 dial with the health problems of society.* Analyse a major professional function by defining the various intermediate com- ponents (activities) making it up.* Define a professional task and identify its components (domains of practical and skills. intellectual skills). communication skills 'be
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Define a professional task and identify its components (domains of practical and skills. intellectual skills). communication skills 'be Draw up a list of the specific educational objectives relating to a professional task, rtatitts explicidv' whaf you feel the able to "do" after a studeit shbuld instruction (that he given course of was not able to do previously) and corresponding to the communication skills or practical skills involved in this task.x the domains 'of ^domain Taking a specific objective in a non- (i... practical or intelleitual communication skills), define in the form of specific educational objectives feel theoretical knoailedge you what the student should possess if he is to attain that objective.'r'
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Make a critical analysis of specific educational obiectives (listed by a partiiular colleaque). whethtr they include- all the-requisite (act, content, condition, elements criteria). * indicatine in havTng Draw up a list of the possible reactions of colleigues in your ficulty to the idea educational of from professional objectives tasks and propose strategies for over- coming those reactions. * -derived define t6 ' I 2 10. Draw a diagram showing the .relation- the other ship betweei evaluation parts of the educational Process. -and 11. Define the principal role of evaluation, its purpose and its aims. 12. Describe the difference between forma' tive and certifying evaluation. 13. List the good and bad features of a test. 1 4 . Compare the. advantages and disadvan- tages ot tests m current use. 1 5 . following
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tive and certifying evaluation. 13. List the good and bad features of a test. 1 4 . Compare the. advantages and disadvan- tages ot tests m current use. 1 5 . following t€rlnS: validity, Define the reliabilitv. obiectivitv, and describe the relationship tliat exists between them. L 6 . Choose an apProPriate evaluation method (questionnaire, written examrn- ation, "objective". test (MCQ or short, open-answer question) or essay questron' oial examinalion, direct observation, etc.) for measuring the students' attain- ment of a specifictducational objecti-Ye' Compare the alternatives in a specific- ation table.* 17. Define (in the form of an otganizational diagram) the organization oT an evalu- atron svstem suiiable for your establish- ment, and list the stages involved. Indicate: (a) (b) (c) important educational
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Indicate: (a) (b) (c) important educational the most decisions You have to take; the data to be collected to provide a basis for those decisions; the aims of the lys.teln. and sub- systems in terms of decisions to be the object of each tiken and decision (teachers, students, Pro- grammes). * 18. ldentify obstacles to and strategies for improv-ement of a system of evaluating students, teachers and programmes' t S e e f o o t n o t e , p . 5 . 1 9 . programme o construction r) implementation of evaluatio n4 1 9 . the Explain differences between "education", "teaching" and "learning", and describe the new trends in the teaching/learning system and the various learnmg sltuatlons. 20. Define the concept of relevance of a programme. 2 t . ) ) List 10 conditions which facilitate learning on the basis of the list and evaluate a specific learning activity. Indicate the aims and general methods of teaching. 2 3 .
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2 t . ) ) List 10 conditions which facilitate learning on the basis of the list and evaluate a specific learning activity. Indicate the aims and general methods of teaching. 2 3 . Specify at least two advantages and two disadvintaees for each tecTrnique and medium uied in teaching. 30. 3 7 . 3 2 . 33. 3 4 . 24. Select a teaching method that will make an educational obiective easier to achieve. 3 5 . Compare the alternatives in a specific- ation table.* the different elements that Indicate should be considered in the evaluation of a teaching programme. the different elements that Indicate should be considered in the evaluation of the educational objectives of a teaching programme. Define the advantaqes and limitations of a system of .evaluition of teaching by the students. *
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Define the advantaqes and limitations of a system of .evaluition of teaching by the students. * Construct an observational rating scale and/or a practical test to evaluite the behaviour of a student in the domain of communication and/or practical skills.{- Propose a question for a written (open- book) examination of the "essay" type or a series of six short, open-answer questions and indicate the norms of objective ferformance marking (marking table). * permitting Draw up three multiple choice questions (MCO in the domain of int'ellectual skills - at least two of the objectives must measure an intellectual process superior to level 1 "simple recall"-(either leiel 2 "interpretation'of data" or level 3 "problem-solving").* 2 5 . Indicate structlng a programme. the steps involved in con- 2 6 . Construct a programme or decide whether a .programme or course needs revision, using a specification table. *
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2 5 . Indicate structlng a programme. the steps involved in con- 2 6 . Construct a programme or decide whether a .programme or course needs revision, using a specification table. * 27. Construct a selfJearning package.* 2 8 . Define the role which, as a teacher, you would like to assume in order to motivate and facilitate the learninq of students for whom you are responsible.* 2 9 . Identifv to be the obstacles liable encountered in setting up a competency based curriculum qeared to the health needs of the com-munity and describe strategies for overcoming them. " 3 6 . Indicate the advantages and limitations of a programmed exairination. * 3 7 . the following.terms:. prerequisite P.fl". level test, pre-test, lnterval test, com- prehensive pre-final; indicate their pur- pose and the stages at which they are set. 3 8 . Explain the difference between a rehthte and an absolute criteria test. 3 9 .
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3 8 . Explain the difference between a rehthte and an absolute criteria test. 3 9 . Calculate the acceptable pass level for a MCQ examination and establish the scoring criteria and norms which permit determination of the passing grade of a mini-test (made up of the questions mentioned in objectives 34 and 35).* 40. Do an item analysis of a question (cal- culate the difficultv index'and the dis- crimination index) ind draw the relevant conclusions. L3 Theoretical background that will help you reach the educational objectives of the workshop For objective Study the following pages of the Educational Handbook For objective Study the following pages of the Educational Handbook 1 2 3 4 ) 6 .1 8 9 1 0 1 1 L 2 r 3 I+ 7 5 L 6 L 7 1 8 T 9 20 Glossary and pp. 1.05-1.07, L . \ 7 , L . 2 3 , r . 2 9 , 1 . 3 3 - r . 3 6 p p . 1 . 2 0 , 1 . 3 3 , 1 . 4 3 - I . 4 5 , 1 . 4 8 - 1 . 5 0 Obj. 1 and pp. 7.O9-1.27
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L 6 L 7 1 8 T 9 20 Glossary and pp. 1.05-1.07, L . \ 7 , L . 2 3 , r . 2 9 , 1 . 3 3 - r . 3 6 p p . 1 . 2 0 , 1 . 3 3 , 1 . 4 3 - I . 4 5 , 1 . 4 8 - 1 . 5 0 Obj. 1 and pp. 7.O9-1.27 O b j . 3 a n d p p . r . 2 9 - r . 3 2 p p . 1 . 1 7 - 1 . 7 9 , I . 3 3 - 7 . 4 1 Obj. 2, Obj . 5 and pp. 1 .4 3 - 1 . 5 3 , r . 5 6 o b j . 6 a n d p p . r . 5 4 - I . 5 6 Obj. 6 and pp. 1.56, +.104.1+ O b j . 1 a n d p p . L . 6 3 , 3 . 7 1 , 3 . 7 5 p p . 2 . o 3 - 2 . o 5 p p . 2 . O 2 - 2 . 1 4 , 2 . 1 9 p p . 2 . t 5 - 2 . 1 8 p p . 2 . 2 6 - 2 . 2 9 p p . 2 . 3 O a n d 2 . 3 1 p p . 2 . 3 3 - 2 . 3 7 O b j . 6 a n d p p . 2 . 2 I - 2 . 2 3 , 2 . 2 7 , 2 . 3 8 Obj. 11 and pp. 2.40-2.43 O b j . 1 7 a n d p p . 2 . + 4 , 3 . 7 I 3 . 7 5 p p . 1 . 0 4 , 3 . 1 8 - 3 . 2 9 p p . 1 . 3 3 , 3 . O + - 3 . 1 2 2 L 2 2 2 3 24 2 5 2 6 27 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5 3 6 3 7 3 8 3 9 40 p p . 3 . 2 8 , 3 . 2 9
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4 . 6 3 p p . 4 . 6 5 - 4 . 7 3 and do the corresponding exercises (blue pages): see list on next page. L 4 Recapitulative table of exercises proposed Ilandbook Objective 3 3 Exercise Identifying professional activities Defining the main functions of health personnel 20/26 Analysis of the relevance of a programme 5 6 8 8 6 7 8 Identifying components of a professional task Selecting active verbs relating to a task Identifying the elements of an educational objective Evaluating an educational objective Drawing up specific educational objectives Drawing up enabling educational objectives Critical analysis of an educational objective I / T 1 Evaluation of knowledge about educational objectives Page 1 . 1 5 l . 2 t / 1 . 2 2 r . 2 7 t . 4 7 r .47 T . 5 L r . 5 2 r . 5 + l . ) ) 1 . 5 6 1 . . 5 7 / r . 6 0 2 . 0 9 Statement of educational decisions L 7 L2 Distinguishing between formative evaluation and certifying evaluation
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T . 5 L r . 5 2 r . 5 + l . ) ) 1 . 5 6 1 . . 5 7 / r . 6 0 2 . 0 9 Statement of educational decisions L 7 L2 Distinguishing between formative evaluation and certifying evaluation 2 . 1 6 t 2 . t 9 13,r4,76Selecting a method of evaluation 1 5 , 7 6 Comparing several methods of evaluation T7 1 8 Graphic representation of an evaluation system Identifying obstacles to and strategies for applying an evaluation system 2 . 2 3 2 . 3 8 2.+3 2.4+ 1 0 / 1 8 Evaluation of knowledge about evaluation planning 2 . 4 5 t 2 . 4 7 t 9 2 8 2+ 24 2 9 2 9 Describing learning situations Describing the teacher's functions Selecting a teaching method Comparing several teaching methods Constructing an organizatronal chart for programme implementation Identifying obstacles to and strategies for introducing a new programme 1 9 / 2 9 Evaluation of knowledge about programme construction 3 2 33 3 3 3 4 3 4 3 5 3 6 36 3 9 40
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Identifying obstacles to and strategies for introducing a new programme 1 9 / 2 9 Evaluation of knowledge about programme construction 3 2 33 3 3 3 4 3 4 3 5 3 6 36 3 9 40 Listing advantages and limitations of evaluation by students Drawing up a practical test or project test Constructing an attitude table Preparing an essay question Preparing short open-answer questions Preparing multiple-choice questions (A,lCQ) Preparing a programmed test Completing a specification table for a test Calculating the acceptable pass level (APL) for an MCQ test Calculating the difficulty index and discrimination index for a questlon 3 . 2 9 3 . 3 9 3 . 5 7 3 . 5 8 3 . 7 7 3 . 7 8 3 . 7 9 / 3 . 8 3 + . 1 9 + .22 + . 2 5 + .29 4 . 3 0 +.39t+.+O +.48 + . 5 5 t + . 5 7 4 . 7 r + .7 5 30/40 Evaluation of knowledge about test and measurement techniques 4.7 5 t4.80 acknowledgments
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+ .29 4 . 3 0 +.39t+.+O +.48 + . 5 5 t + . 5 7 4 . 7 r + .7 5 30/40 Evaluation of knowledge about test and measurement techniques 4.7 5 t4.80 acknowledgments This revised edition of the Handbook has involved a lot of meticulous and time-con- suming work over the last three years. Many people have offered advice and help and have supplied documents used in the text. From the start, the encouragement, support, advice and patience of T. Fiiliip, Director of the Division of Health Manpower Develop- ment, have been invaluable. B. Pissaro (Paris) has followed our work with unfailing interest and has carefully read and re - read the intermediate drafts. We wish to express special thanks to: S. Abrahamson (Los Angeles), C. McGuire and G. E. Milter (Chicago) for their appreciative comments and even more for their useful and judicious advice. We should also like to thank all those who have sent us helpful comments and suggestions,
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We should also like to thank all those who have sent us helpful comments and suggestions, H. Jason (Miami),
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Z. S. Al-Alway (Dacca), P. Alexander (Minneapolis), L. Allal B. Adjou-Moumouni (tomi), (Geneva), J. L. Argellies (Tunis), W. Barton (Geneva), G. R. Beaton (Johannesburg), A. Benadouda (Algiers), D. Benbouzid, (Algiers), J. Beneke (Copenhagen), D. Benor (Beer Sheva), V. Bergk (Heidelberg), P.J.B\izard (New Delhi), C. Boelen (Tunis), J. Brines (Valencia), S. Bukkavesa (Bangkok)l L. Burke (Mogadiscio), F. Canonne (Paris), P. Carteret (Lome), P. Chaulet (Algiers), D. Clark (London), A. Coelho (Lisbon), A. L. Courtieu (Nantes), K. R- Cox (Sydney),T. O. Crisp (Dacca), L. Daufi (Barcelona), R. Debr6 (Paris), H. Dieuzdde (UNESCO), J. F. D'Ivernois (Paris), C. Di Pasquale (Dakar), S. R.Dodu (Accra), M. A. C. Dowling (Geneva), C. Engel (Newcastle), V. Ermakov (Moscow), W. Felton-Ross (Bloomfield), J. -J. Ferland (Quebec), D. Flahault (Geneva), H. H. Freihofer (Bern), A.T. Garcia (Aden), S. Goriup (Geneva), J. P. Grangaud
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V. G. MacDonald (Wellington), N. Mclntyre (London), J. M. Mclachlan (Kuwait), S. Maes (Antwerp), A. Maglacas (Geneva), M. Manciaux (Paris), W. F.Maramis (Surabaya), A' Mazer (Marseillis), D. Melliere (Paris), A. Mejia (Geneva), P. I. Mintchev (Sofia), S. Mokabel (Alexandria), R. Mol (Veldhoven), K. Mowla (Islamabad), E. Muret (Paris, M. Nichol (Katmandu), G. Nicolas (Nantes), C. Nihoul (Ghent), N. M. O'Brien (Amman), G. H. Pauli (Bern), M. Pechevis (Paris), P. Pine (Marseilles), S. L.Purwanto (Djakarta), C. A. Quenum (Jitra), A. Rodriguez-Torres (Valladotid), J. E. Rohde (New York), (Btazzaille), A.A.Rahman L. Roy (Geneva), A. M. Sadek (Alexandria), J. C. Salomon (Paris), G. Scharf (Woipy), C.Searle J. D. Shepperd (Bangkok), S. Slimane-Taleb (Algiers), A. Stewart (Dundee), (Pretoria), V. Subhadra (Calcuaaj, A. E. Suliman (Dacca), G. Szabo (Debrecen), A. Thein (Rangoon),
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I. M. Lovedee (Rangoon)' We trust that anyone who has been overlooked will forgive us. Indeed, among the 1250 collea- grr., *fro have taken part iriworkshops with h"rry whose questions ihe author, there "r. to and opinions have helped in our .ifort, ensurJthat the Handbook is tailored to meet the needs of its users. These contributors are too numerous to be mentioned by name. Finally, our thanks go to: P. Duchesne, P. Etienne,M. Magnin,E. Riccard, the M. Schaltegger and M. Wolff and to English editors R. Binz, K. Grinling and C. Stevenson without whose untiring work this document would never have been com- pleted. t 6 educational obiectives the concept of educational obiectives
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t 6 educational obiectives the concept of educational obiectives The aims of this first chapter are to show the advantages of defining educational objectives; to show that if precision and ctarity of educational objectives are important, relevance to health problems is even more so; and to show that an approach based on objectives will ensure that health personnel are better prepared to perform professional tasks corresponding to the health problems of society. Those interested in this approach should read the following works by R.F. Mager. r Freparing instnrctional objectives (1962). I Goal analysis (1972). r Measuring instructional intent (L973, (Chapter III, pages 15 to 46) Fearon Publishers, California, U.S.A. And the following publication by the World Heahh Organization. r Criteria for the evaluation of objectives in the education of health personnel, WHO, Technical Report Series, 1977, No. 608.
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And the following publication by the World Heahh Organization. r Criteria for the evaluation of objectives in the education of health personnel, WHO, Technical Report Series, 1977, No. 608. After having studied this chapter and the reference documents mentioned you should be able to: 1. Define the following terms: professional task, activities, functions, role, institutional objectives; specific objective; domains of practical skills, communication skills and intellectual skills. should be able to "do" after a given course of instruction (that he was not able to do prwiously) and corresponding to the domains of the communication skills or practical skills involved in this activity. 2. List the qualities of an educational objective and the sources necessary to ensure its relevance.
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2. List the qualities of an educational objective and the sources necessary to ensure its relevance. 3. Define the professional functions of a member of the health team whom your teaching institution is responsible for training (generol educational objectives) so as to deal with the health problems of society. 4. Analyse a major professional function by defining the various intennediate components (activities) making it up. 5. Define a professional task and identify its components (domains of practical skills, communication skills and intellectual skills). 6. Draw up a list of the specific educational objectives relating to a professional task, stating explicitly what you feel the student
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6. Draw up a list of the specific educational objectives relating to a professional task, stating explicitly what you feel the student 7. Taking a specific objective in a non- (i.e., practical or cognitive domain communicative skills), define in terms of educational objectives what specific theoretical knowledge you feel the student should possess if he is to attain that objective. 8. Make a critical analysis of specific educational objectives (listed by a colleague), indicating in particular whether they include all the requisite elements (act, content, condition, criteria). 9. Draw up a list of the possible reactions of colleagues with whom you work in your the idea of having to define faculty to educational objectives derived from pro- fessional tasks and propose strategies for overcoming those reactions. t.o2 If you are not certain of where you are going you may verY well end up
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t.o2 If you are not certain of where you are going you may verY well end up somewhere else (and not even know it ) Mager o Every individual should have access to a type of education that permits maximum development of his potential and capabilities. Education is a process, the chief goal of which is to bring about change in human behaviour The result of education is an expected change in the behaviour of the student in the course of a given period. The Educational Spiral This "behaviour" will be defined explicitly in the form of educational obiectives derived from professional tasks. An evaluation system will be planned so that better educational decisions can be taken. A programme will be prepared and implemented to facilitate attainment of educational objectives by the students.
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A programme will be prepared and implemented to facilitate attainment of educational objectives by the students. The evaluation process will be used to measure the extent to which the objectives have been achieved . . . it will measure the student's final abilities . . . and the effectiveness of programme and teachers. t.o4 the educational spiral the strength of Programme reform has been a source of concern for many years to those training health personnel and the alarm has often been the sounded. However, traditions impeding necessary reforms has been such that it has not been possible to avoid serious disturbance in many universities the world, always caused by a throughout face of reaction the apparent diehard in conservatism of the system. It would, however, be negative and dangerous merely to accuse of incompetence those at present in positions of teaching responsibiliry. They should be offered help.
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It would, however, be negative and dangerous merely to accuse of incompetence those at present in positions of teaching responsibiliry. They should be offered help. Societies change and have always been changing, but until the present century their evolution was relatively slow and adaptation to change was possible without unduly violent disorders. The form of teaching has remained unchanged for centuries. The university has wrapped itself in its privileges and remained deaf to the cry from without. The needs of society, the practical side of the matter, have been left to chance, whereas specific features of the situation in each country are changingever more rapidly. Hitherto, unfortunately, little or no account has been taken ofthosefeatures and the training of health personnel has followed traditional systems. What is required now is to make sure that educational pro- grammes are relevant.
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There can be no question of continuing to copy the models of the past or, in the case of developing countries, foreign models. Tbe educotional system leadingto tbe deaelop- ment of health personnel, at all leaels, must be re-examined witbin tbe context of tbe needs of tbe coantrJl concerned.r No educational system can be effective unless its purposes are clearly defined. The members of the health teum rnust be tained specifically for tbe tasks tbey will baae to perform, taking into account the circumstances under which they will work. These tasks can only be defined in occordonce witb a plan in which the nature of the seryices to be provided is specified, priorities are the staff needed to provide these allotted, services determined, etc. . . . . Professional training programmes must then be tailored to meet these needs.
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Professional training programmes must then be tailored to meet these needs. There is room for some degree of optimism in this sphere, for no financial assistance is needed for a move in the right direction. that is needed is a resource distributed All more or less equally around the world: mental ability. The management of that resource is the art of organizing talent and of coping intelligently with change. the professional tosks of health Defining personnel to be trained, the very basis of the training centres, educational objectives of is of crucial importance. Thus an educational programma, instead of being the result of a non-selective accumul- ation of knowledge built up over the centuries, must be shaped selectively in terms of tbe goal to be acbieaed. If that goal is modified in the course of time, the programme must also be modified accordingly.
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Definition of professional tasks must Proceed from a study of needs, take account of available resources and indicate clearly and precisely what various categories of personnel will be called upon to do during their pro- in a given type of health fessional sreers service. t The study of needs, organization of health services, and definition o{ tasks and functions are, however, not dealtwith in this Handbook. Consequently, specialized texts should be consulted concerning those aspects (see Bibliography, p. 7.O1). ft t ! tr ! u n t] ! ! ! ! t n ! ! ! ! n tL The obiect of education is not to shape citizens to the uses of societyr but to produce citizens able to shape a better society. f 1 ! t r ! ! ! D ! t r ! t L ! . n ! ! ! ! t n 1 . 0 5 the educational spiral Defining Tasks and Educational Objectives lmplementing Evaluation Planning an Evaluation System
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t r ! t L ! . n ! ! ! ! t n 1 . 0 5 the educational spiral Defining Tasks and Educational Objectives lmplementing Evaluation Planning an Evaluation System Preparing and lmplementing an Educational Programme importance of defining professional tasks of being confined limited personal experience they will accept the use of more formal educational research methods. to stimulus can be a powerful
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of being confined limited personal experience they will accept the use of more formal educational research methods. to stimulus can be a powerful for This institutional change, particularly when used by faculry members whose experience in the educational process has already alerted them to the ways in which educational innovation the greatest can be accomplished with possible enthusiasm and the least possible hostiliry on the part of their colleagues. Such innovation, based upon carefully gathered to information sound educational principles, could enable to some medical education explore, in particular, non-traditional means of preparing the members of the health team for the professional tasks they will have to undertake. Without the incrusted educational that long adherence to a single tradition system creates, the opportunity for innovative experimentation is far greater. and dweloped according
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and dweloped according institutions This is a very difficult task which may well have daunted the most conscientious. We teachers should be offered consider that assistance in this field. That is the main reason why this Handbook has been prepared and used during work- shops on educational planning. importance of the prior If we stress the definition of professional tasks, it is because this is a precondition for ensuring that training programmes are really designed to meet the population's health needs. Over the last 10 years or so teachers, under the cloak of an educational revival, have used the title of educational objectives to disguise what they had been in the habit of teaching in the past. Such educational objectives have favoured the creation or continuation of training pro- grammes which only too often seem hardly relevant to the needs of the population.
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Indeed, if educational objectives are based on faulty principles, then the "best" system of training may well give "bad" results. There is even a danger that a "bad" message will be "better" communicated, and this is certainly not the goal sought. We therefore propose to demonstrate that the professional tasks of a member of the health team and the educational objectiues providing a basis for construction of his training programme must be almost identical. the
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the Another important point to bear in mind is that it can be useless to try to change a pro- gramme or teaching methods without also changing the system of evaluation (parti- cularly examinations). Experience has shown that if, on the other hand, the evaluation system is modified, this has a much greater impact on the nature of learning than has modification programme of unaccompanied by any change in the evaluation system. Evaluation provides a sound basis for programme planning. There- fore, an evaluation mechanism should be set up before proceeding to any reform of the programme. This makes it possible to measure the level at the outset (prerequisite level) finish and thus to and the determine whether the change has been positive or not. This process can be represented by what is called the educational spiral. level at the
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level at the If the teaching staff are given an opportunity to gain the new knowledge they need and to acquire the appropriate modern teaching skills, they will feel more secure and instead t.o7 Organizational diagram showing the relationship between the subsystem "Education" (inside the dotted linel and the subsystem "Health Seryice". Community Health Needs and Resources of Country's Analysis of Professional Functions and Activities Characteristics of Student Population and Teachers Definition of Educational Objectives Planning of Evaluation System Programme Preparation, Choice of Teaching Media and Methods lmplementation of Educational Programme Formative and Certifying Evaluation I I I I I I I I I I I I I I I I I I I I I I I I I I I I J Evaluation of Prof essiona I Performance r I I I I I I I I I I I I I I I I a 1 I I I I L 1 . 0 8 selection of training goals'
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this selection has been made Traditionally, by relying on the judgment of experts to determine what a neophyte in the profession ought to know and ought to be able to do. In the past we have relied almost exclusively on this method. As a result curricula are crammed with an ever-burgeoning amount of new and highly specialized knowledge which the student perceives as irrelevant to his own goals and which, in fact, may be of little value to other than the super sub*pecialist. Certainly expert opinion is an important source of information about the knowledge and skills which trainees should be able to demonstrate, but it is also possible to make this decision on the basis of scientific evidence about what competent health personnel need to know and need to be able to do in order to fulfil their responsibilities. A number of procedures have now been developed for collecting such
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competent health personnel need to know and need to be able to do in order to fulfil their responsibilities. A number of procedures have now been developed for collecting such data which provide an empirical basis for working out a behavioural description of the essential components of professional com- petence. This is of great assistance to faculties in setting goals and designing curricula. Three of these procedures are of special interest: the critical incident technique, the method of task analysis and the method of analysis of epidemiological data.
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The critical incident technique II.
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II. This method consists in collecting data about specific types of behaviour that charactetize professional effectiveness and ineffectiveness and using these data to make an objective, the essential per- empirical assessment of the profession. formance requirements of This technique is an outgrowth of studies in aviation psychology made in the United that States during World War that in reporting programme it was found the reasons for eliminating a trainee, pilot frequently instructors and check pilots offered such cliches and stereotypes as "lack of inherent flying ability", "poor judgment" or "unsuitable temperament". In an effort to determine the specific characteristics of to success or personnel that contributed failure, combat veterans were asked to report that involved incidents observed by bebaoiour whicb was especially helpful or especially inadequate in accomplishing the them In
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them In assigned mission. This request concluded with the statement: "Describe the officer's action. What did he do?" The several thousand this incidents submitted inquiry were analysed and categorized to provide a relatively objective and concrete the "critical requirements" description of of combat leadership. response to in to this method several hundred
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the health To apply professions, several thousand incidents des- cribing observations of especially effective or ineffective colleague behaviour are collected health workers from representing various age groups, geographical areas, professional categories and specialty interests. For example, in a critical incident intern and resident performance study of (i.e. of the general practitioner) commissioned the U.S. National Board of Medical by Examiners, the American Institute of Research which conducted the study collected over 3000 incidents from physicians across the country. The incidents submitted involved all areas of behaviour: practical, communic- ation and intellectual skills. They identified, for example, such general requisites of com- in gathering clinical petence as "Skill i.e., in taking a competent information," in performing an adequate history and physical examination, or "Skill in relating to
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in gathering clinical petence as "Skill i.e., in taking a competent information," in performing an adequate history and physical examination, or "Skill in relating to the patient and in gaining his cooperation in a treatment plan". In a similar study con- ducted by the University of lllinois Center for the critical Educational Development of performance requirements in orthopaedic surgery, over 1700 incidents were collected from more than 1000 orthopaedic surgeons representing various practice settings and sub-specialty interests. An empirical classific- ation defining 94 critical performance require- ments, grouped into nine major categories of competence, was derived from the incidents. This operational and prospective definition of the essential components of competence could then be used to determine the goals of specialty training, the design of programmes their achievement and the criteria and for If
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of the essential components of competence could then be used to determine the goals of specialty training, the design of programmes their achievement and the criteria and for If their methodology
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evaluation. for I F.o- "An overview of applied research in medical education problems, principles and priorities". Christine H. McGuire, WHO Report on the Workshop on the Needs for Research in Medical Education, Alexandria, March 1974. 1 . 0 9 educational planning were regularly based on such operationally defined, empirically derived goals, educational programmes would look quite different.
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Task analysis A second method of determining the essential components of professional competence which should define educational objectives consists in detailed task analysis of what various categories of health personnel actually do, and in deriving from that list of tasks a the knowledge and skills statement of (what should be done, not merely what is done) which they must have to perform competently. Such a task analysis should be based on careful, systematic observations of the activities of a representative sample of various categories of staff or on the daily logs of a representative sample who report in minute detail the way in which they spend their working days over a specified period of time, or on some combination of these two approaches. in a limited pilot
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Wherever this method has been employed, the results have been most enlightening. For studY of example, paediatricians in a typical small U.S. city, researchers found that all the physicians had different but consistent patterns for taking a history and performing a physical examin- the 481 patient visits observed, ation. Of 222 were well childr€n; afl zverage of lO.2 minutes was spent with these children (range, 7.5 minutes to 13.6 minutes) in contrast with an average of 8.L minutes spent with ill children (range: 7.4 minutes to 10 minutes). Of the 259 rll children, 104 (i.e. 40%) were diagnosed as having an infection of the upper respiratory tract, 15 had chronic illnesses and five had potentially dangerous diseases. For the total group of 481, optic fundi were examined only nine times and rectals were performed in only six cases; two physicians did not percuss the lung fields for any patient.
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For the total group of 481, optic fundi were examined only nine times and rectals were performed in only six cases; two physicians did not percuss the lung fields for any patient. The greatest amount of time was sPent in discussion of nutrition and child development. The single most frequent topic on which advice was rendered in well-child care con- cerned toilet training. The authors of this
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I B.rg-"n, A., Probstfield, J. and Wedgewood, R- Per- formance analysis in pediatric practice: preliminary report' J o urnal o f M e dic al E d u cation, Y ol. 42 t 262 (19 67 ). 1 . 1 0 study concluded, "Few aspects of anll'child cdre appedr to require tbe skill of a pbysician . . . the question is also raised ds to uhether current training programrnes are aggrauating the physician manpower shortage by oaer' to community beahb training needs."t relation in This is a question that could apply to all members of health teams in every country; only task analysis or comparable empirical studies will give us the answer' - the target population.
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Epidemiological studies One of the most interesting of the newer approaches to the use of such studies consists three arbitrarily weighted in combining factors - disease incidence, individual dis- to define ability and social disruption priorities in health care needs and, hence, in educational effort. As initially developed by Dr. John W. Williamson2 the three factors are computed as follows: disease incidence the consists of a simple tabulation of frequency of the disease (e.g. pneumonia) or other medical condition (e.g. pregnancy) Individual dis- in ability involves a determination of the extent of patient disability or risk associated with a given medical condition; an Individual Dis- ability Weight (IDW) is calculated for each condition from three elements: the average length of hospital stay, mortality rates and disruption complication the disruption represents an estimate of
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condition from three elements: the average length of hospital stay, mortality rates and disruption complication the disruption represents an estimate of that would be produced by a given disease or condition in the social grouP of which the patient is a member; it is based on such factors as cost of illness, age of. patient and dependents, socioeconomic number standing and the like. For each discharged patient a Total Priority Weight (TPW) is calculated combining these elements. This is then arbitrarily Total Priority Weight diagnoses. among patient apportioned Finally, a cumulative total for each diagnosis is calculated from the total patient sample' The resultant ranking represents a quantit- ative estimate of health care needs or priorities for the population at risk.
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rates. Social of 2 willi"-*tt,J. a t i o n . Y o l . 2 O l : 9 3 8 et al. Joumal of American Medical Associ' ( 1 9 6 7 ) a n d V o l . 2 O 4 : 3 0 3 ( 1 9 6 8 ) . It is clear that even with unlimited resources not all of these needs could be met in the present state of our knowledge. The next step therefore consists of determining what portion of total health care needs can be met, given our present understanding of disease and our present treatment possibilities. indicates the target arca for This portion application of professional skills and helps to define educational priorities. The goals of education for health service staff can there- fore be defined as encompassing those areas of health care needs which cause the greatest total preaentable disability - i.e. those which cause the greatest total disruption that could be reduced or minimized by early diagnosis and appropriate intervention.
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In his early studies u3;ing this method to review hospital practice in two large community hospitals in widely separated metropolitan areas in the United States, Dr. Williamson that pregnancy, including uncom- found plicated delivery, ranked first or second in in both hospitals, that cerebral priority vascular accidents ranked among the first five diagnostic categories in both hospitals and that fractures of the lower extremities ranked among the first five in one hospital. These particular conditions are mentioned because in certain educational institutions there is a general tendency to reduce the amount of clinical instruction for the general medical student in some of these areas. For example, instruction in orthopaedic surgery is often elective despite the fact that trauma in general accounts for a very significant proportion of total preventable disability.
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While the study reported above was limited to hospital practice, the same method could easily be applied to any level of health practice. Secondly, while the findings from such epidemiological studies and the particular weights to be assigned to such factors as individual disability and social disruption will, of course, vary markedly in different parts of the world, the approach is clearly applicable to any sociery for which health personnel are being trained. In all parts of the world, use of such data the goals and priorities of will modify institutions and the emphases educational in curricula by focusing far greater attention on ambulatory medicine and on the more common causes of disability.
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on ambulatory medicine and on the more common causes of disability. Implications of applied research on goals and priorities It can be seen from the above that the means are now at hand for supplementing expert judgment with data derived from empirical studies to assist us in defining the roles and, hence, the skills required of students on completion of programmes. If such studies were carried out as a matter of course and if the findings were used to develop explicit the health pro- educational objectives for fessions, we should see revolutionary changes in the kinds of health professionals produced and in their training programmes. Further- more, such changes would have a fat geatet impact on meeting health care needs than would simple expansion of educational facilities of the conventional type.
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Here we should mention some simpler but also more rapid and less costly techniques which can be used to complement or replace other methods. These methods are not mutually exclusive: - Interviews with members of the profession, who are asked to describe what, in the light of their experience, should be the functions the health and tasks of any member of team. - Questionnaires, made up of either open- answer questions (what are the functions of ... ?) or closed-answer questions (which of the tasks listed below . . . ?). - The simplest method consists of asking each of a group of colleagues to put himself in the shoes of a person needing care and to describe the functions and tasks that he would wish a given member of the health services to be able to perform. Comparison of the lists submitted will lead to rapid agree- ment on a common list of sufficiently high
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services to be able to perform. Comparison of the lists submitted will lead to rapid agree- ment on a common list of sufficiently high quality to provide a basis for a productive discussion on the relevance of the programme, for example.
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"Transformation of the present professionally oriented technologically dominated health system into a patient oriented system is the needed ingredient for any successful curriculum change. The patient should be the primary concern of both education and service". George A. Silver 1 . 1 1 example of services provided by rural health units* Each health unit is meant to serve a population of 5000 persons, normally in one village and maybe a few smaller settlements around it. The healtb team of each of these rural health units is made up basically of, One physician (in charge) One assistant midwife One assistant sanitarian, and One laboratory assistant. The rural health unit provides the basic health services for the population it serves, i.e.' r Maternal and Child Health work r Communicable Disease Control work r Vital and Health Statistics work I Environmental Sanitation work, and r Medical Care work.
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r Maternal and Child Health work r Communicable Disease Control work r Vital and Health Statistics work I Environmental Sanitation work, and r Medical Care work. I Adapted from "Three approaches to the analysis of health manpower functions". HMD/79.7,pp.69 This list was obtained using the questionnaire method and refers to a survey canied out in Egypt in 1969. - 72' Maternal and Child Health work (a) Prenatal Care actiaities: 1 Comprehensive examination of new patients. 2 Follow up examination of patients. 3 Urine analysis (sugar and albumin, microscopic examination). 4 Taking blood samples and determin- ation of haemoglobin percentage. 5 Weighing of pregnant women. 6 Measurement of blood pressure. 7 Prescription of treatment. 8 Referring patients to hospitals. 9 Giving hypodermic, intramuscular and intravenous injections. 10 Supervision of cleanlinessofpregnant women. Ll Carrying out activities.
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8 Referring patients to hospitals. 9 Giving hypodermic, intramuscular and intravenous injections. 10 Supervision of cleanlinessofpregnant women. Ll Carrying out activities. health education 15 Conducting abnormal labour, and transfer to hospital where necessary. L6 Giving hypodermic, intramuscular and intravenous inj ections. (c) Postnatal Care actioities : L7 Home visiting for puerperal cases. 18 Detection and treatment of fever cases. t9 Giving hypodermic, intramuscular and inuavenous injections. 20 Carrying out health education and f amily planning activities. (d) Cbild Care actiaities: 2I Weighing of children. 22 Supervision of child cleanliness. 23 Vaccination against poliomyelitis, diphtheria and tuberculosis. 24 Temperature taking. LZ Home visiting for non-attendants and 25 Carrying out medical examination. during the ninth month. (b) Natal Care actiaities: 13 Preparation of delivery bags.
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24 Temperature taking. LZ Home visiting for non-attendants and 25 Carrying out medical examination. during the ninth month. (b) Natal Care actiaities: 13 Preparation of delivery bags. L4 Conducting normal deliveries at home. t . t 2 26 Prescribing treatment. 27 Referring patients to hospitals. 28 Isolation of communicable disease cases. 29 Giving hypodermic, intramuscular 54 Isolation of detected cases. and intravenous injections. 30 Taking blood samples. 3L Circumcision of male children. 32 Prescribing the diet. 33 Home visiting for non-attendants. (e) Miscellaneous technical actiaities: 34 Preparing the clinic. 35 Sterilization of instruments and supplies. 36 Training of midwives and assistant (d) Actiaities related to deatbs, 55 Receiving notifications of deaths and search for relations. 56 Examination of the dead and establishment of death certificates. 57 Recording in the appropriate
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55 Receiving notifications of deaths and search for relations. 56 Examination of the dead and establishment of death certificates. 57 Recording in the appropriate registers. 58 Issuing of burial permits. midwives. Vital and health statistics work: 37 Preparation of drugs for distribution. 59 Recording of births and deaths Communicable disease control work: (a) Actitsities related to cases: Isolation of cases. 38 39 Disinfection of cases (during and after treatment). 40 Dusting of cases (for disinfestation). 4l Giving instructions at home (education). +2 Supervision of domiciliary treatment of tuberculosis patients. 43 Recording in communicable disease register. 44 Search for the source of infection. in the appropriate registers. 60 Making weekly and monthly reports. 6l Calculation of death ratios, etc. 62 Making statistical studies and inter- pretations. Environmental sanitation work,
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60 Making weekly and monthly reports. 6l Calculation of death ratios, etc. 62 Making statistical studies and inter- pretations. Environmental sanitation work, 63 Numbering of houses and population census. 64 Mapping areas and facilities. 65 Ensuring cleanliness in and around dwellings. 66 Hygienic disposal of refuie. 67 Constructing latrines in village houses. (b) Actiaities related to contacts: 68 Control of bilharzial snails. 45 Surveillance of contacts 46 Immunization of contacts. 69 Identification of breeding places of mosquitos. 70 Mapping breeding places of (c) General preaentiae actiaities: mosquitos. 47 Vaccination against poliomyelitis, 7t Checking hygiene of public latrines. diphtheria and tuberculosis. 72 Carrying out measures ordered by 48 Noting names of non-attendants. doctor. 49 Preparation of list of families. 50 Carrying out periodic dusting. 5l Recording in disinfection and dusting
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48 Noting names of non-attendants. doctor. 49 Preparation of list of families. 50 Carrying out periodic dusting. 5l Recording in disinfection and dusting registers. 52 Controlling insects and rodents. 73 Supervision of sanitation activities. environmental 74 Examination of food in public places. 7 5 Taking samples from food. 76 Destroying spoiled food. 53 Carrying out epidemiologic surveys 77 Surveillance of market and street for case finding. vendors. r . L 3 78 Taking water samples from public 1 0 1 Catheterization. standpipes. 79 Enforcement of cemeteries. laws concerning 80 Examination and certification of food handlers. 81 Carrying activities. out health education Medical care work (a) Diagnosis actioities: 82 Preparing the patient. 83 Taking the history. 84 Recording clinical observations. 85 Weighing the patient. 86 Taking the temperature. 87 Counting the respiration.
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82 Preparing the patient. 83 Taking the history. 84 Recording clinical observations. 85 Weighing the patient. 86 Taking the temperature. 87 Counting the respiration. 88 Counting the pulse. 89 Measurement of blood pressure. 102 Application of hot and/or cold compresses. 1 0 3 Administration of enemas and use of stomach pump. IO4 1 0 5 106 t07 108 LO9 1 1 0 1 1 1 Suction of mucus. Making dressings. Eye painting and irrigation. Making surgical stitches and per- forming minor operations. Removal of surgical stitches. Carrying out health education and supervising patient's diet. Observing patient's condition. Application of external treatment (ointment). Llz Radiotherapy. 173 Physiotherapy. 90 Clinicalexamination. Administrative work: 9I Requesting laboratory tests. 92 Taking blood samples and administer- ing transfusions. 93 Microscopic examination of blood and blood grouping. 94 Urine examination
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9I Requesting laboratory tests. 92 Taking blood samples and administer- ing transfusions. 93 Microscopic examination of blood and blood grouping. 94 Urine examination for parasites, chemical analysis and microscopic examination of urine. 95 Requesting X-ray examination. 96 Examination of stools. ll4 Assignment of jobs and activities. 115 Checkingattendance. Ll6 Giving leave permits. I77 Conductinglegal investigations. 118 Management of equipment and supplies. Ll9 Management of financial matters. LzO Filling in forms. I2I Book-keeping. 122 Correspondence. (b) Tberapeutic actiaities: 123 Preparation of monthly and annual 97 Prescribing treatment and/or diet. reports. 98 Giving hypodermic, intramuscular and intravenous injections and drips. 124 Recording attendance in waiting- room. 99 Giving oral medication. 725 Supervising housekeeping of the unit. 100 Applying artificial respiration.
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124 Recording attendance in waiting- room. 99 Giving oral medication. 725 Supervising housekeeping of the unit. 100 Applying artificial respiration. 126 Supervisingtransportation. ! t r t r n ! n D ! ! t r ! ! ! r - l D l n t r ! ! ! n Please Note! You are reminded that this list, drawn up in 1969, describes the services as they were and not as they sbould baae been. It might seem that preventive activities deserved greater prominence. ! ! n t ] ! ! t r ! n l c t r t r ! t r u ! ! n t r l ! 7.1,+ 1 . 2. Take one category of health peroonnel (e.g. physician, or nurse, or midwife, or medical assistant, or sanitarian) and circle the items on the preceding list corresponding to the afivitieswhich that category of staff is supposed to @rry outin your country at prossnL
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Then think of lome mtivities whieh fiat same catqory doss not undrtake at pretent but which you feel, in the light of your pe$onal exporionce, it shwld urllds&*o to improw the level of hsalth of the population it sorvsd. Draw asgtram sround each of the mrr@onding items on the lisa 3. Describe belo1y any srttbtd mthitiec correryonding to the first two questions. 1 . 1 5 Pcnonal Nots educational objective (derived from professional tasks) What the students should be of a learning period that beforehand. able to do at the end they could not do o o Educational objectives are also called "learning objectives" as opposed to "teaching obiectives". They define what the student, not the teacher, should be able to do. The definition of the objective of a course is that of the result sought, not a description or summary of the programme. 7 . 7 7 relationship between professional acts in the health field and educational obiectives
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7 . 7 7 relationship between professional acts in the health field and educational obiectives Professional Functions or GeneralObjectives Professional Activities or "l ntermediate" Educational Objectives Tasks and Specific Educational Objectives Note: The size of the circles relates to the number of objectives: the more specific they are the more numerous they are. The triangle indicates that at the general level objectives are "Wide", brgad, Vagqe, and that SpeCifiC ObjectiVeS are "pUnCtual", nafrow, preCiSe. 1 . 1 8 types of educational obiectives I I General obiectives: Correspond to the functions of the type(s) of health personnel trained in an establishment. Example: Providing preventive and curative care to the individual and the community, in health and in sickness. "lntermediate" objectives: Arrived at by breaking down professional functions into components (activities) which together indicate the nature of those functions.
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"lntermediate" objectives: Arrived at by breaking down professional functions into components (activities) which together indicate the nature of those functions. Example: Planning and carrying out a blood sampling session for a group of adults in the community. Specific (or instructional) objectives: Corresponding to (or derived from) precise professional tasks whose results are observable and measurable against given criteria. Example: Using the syringe, to take a blood sample (5 ml.) from the cubital vein of an adult (criteria: absence of haematoma; amount of blood taken within lOVo of the amount required; not more than two attempts). To gain better understanding of these three levels of educational objectives and the relationship between them, study pp. 1.23 - 1.25 and 1.29 - 1.36. 1 . 1 9 data necessary for formulation of educational objectives Health needs, demands and resources of society. Services to the patient (list of tasks).
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1 . 1 9 data necessary for formulation of educational objectives Health needs, demands and resources of society. Services to the patient (list of tasks). Service to the community (list of tasks). The profession itself. The students. Progress in sciences. The scientitic method. e t c . . . . . . For more details refer to: Criteria for the evaluation of learning objectives in the education of health personnel. Report of a WHO Study Group. World Health Organization Technical Report Series,1977, No. 608. 47 pages* a n d p p . 4 . 1 0 - 4 . 1 3 o f t h i s H a n d b o o k . * An annex to the report clarifies what different authors mean by educational obiectives, examines the different levels and types of objectives, lists the potential benefits of taking the trouble to formulate obiectives and reviews the data considered necessary for this. There is also a short section on how to word objectives properly.
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