“The International Day of the Midwife is an occasion for every midwife to think about the many others in the profession, to make new contacts within and outside midwifery, and to widen the knowledge of what midwives do for the world. In 2010 and in the years leading up to 2015, ICM will use the overarching theme The World Needs Midwives Now More Than Ever as part of an ongoing campaign to highlight the need for midwives. This reflects the WHO call for midwives and the need to accelerate progress towards the achievement of MDGs 4 & 5.”

How about participating in the Virtual International Day of the Midwife. This is a free conference for midwives. An opportunity to come together from the comfort of your own home or from your workplace. You can access all the sessions online through the links that you will see beside the sessions. Come and join us. You will have an opportunity to ask the presenters questions or to share your own thoughts.

The academic year finally ended yesterday for  first year students in our new undergraduate midwifery programme in the South Island of New Zealand. This is the first in a series of posts reflecting on the year. I wrote extensively in this blog about my development process for the first year practice skills course. It has been a very busy year one way and another, and I have been somewhat less diligent in blogging about progress during the actual first year of course delivery. Now that we have reached the end of first year it is timely to reflect on how the programme in general and the practice skills course in particular have gone.

We started the year a couple of weeks before other Polytechnic students began and have ended the year a couple of weeks later than other students. This is because we are now delivering the equivalent of a four year midwifery degree programme in three years (more about that later).  As a lecturer it has been challenging to be working with students from virtually the very start of the year right through until  my last day in Polytech. Anyone involved in undergraduate education will know that the start and end of the year are times of preparation and consolidation when a lot of administrative tasks are undertaken. Having to do these things while also continuing to be involved with preparation and assessment of students is a challenge. In this post I will overview the class “intensives” where the student all come together as a class at Otago Polytechnic in Dunedin. Our programme involves the students coming to Otago Polytechnic for classroom learning and assessment four times in the year. We call these blocks “Intensives”.

Intensive 1

Students arrived at the beginning of February. We all went off for a couple of days stay at Wairua Scout camp after a couple of days looking around campus and introduction to lecturers and courses . Staff from the sports school came along and ran some activities for us. We also did some work on communication as well as having fun and getting know each other. During the second week we started formal learning with face to face lectures and skills practice. In the practice skills course students learned about standard precautions and vital signs monitoring.

As the year progressed we have reflected on what we are doing. Everyone seemed to feel the camp was a good activity helping us all to get to know one another and particularly useful as we were then going to be working at a distance from each other. I felt there was a problem with the second week. Lectures are now all online as self learning packages and the idea is that students learn online first then come to class ready to focus on learning the practical skill. There was no time for this online learning to occur so we had to deliver some lectures around the topic before the students could start to practice the skills. This meant that there was not really enough time for the class to work together on the practice skills. As a result of this reflection in 2010 we will split the first two weeks of the course. Students next year will arrive for the first week of the intensive and will then have a couple of weeks to work with the online learning resources before completing the second week of face to face intensive course work.

Intensive 2

It was good for all to get together once again in intensive two. This was also a two week intensive and had been planned as we felt there would be things that required face to face  delivery to the whole class. While this is the case for some  courses items we discovered that there was less needing to be delivered face to face than we have previously thought would be necessary, as a result this intensive will be reduced  next year from two weeks to one week.

Intensive 3

As with intensive two there was actually less teaching that needed to be done in this intensive than we had thought would be required. Students began the course on Maori health during this intensive and students and staff spent a couple of days and one night on a local Marae learning about issues around health care and birth for Maori women and their families. Students commented on how relaxed this was and how good it was to have another activity where they had an opportunity to come together in this way, but this time knowing each other a little better. I have to admit that I was somewhat skeptical about these two overnight activities before we began the new programme but I do now admit that they are valuable additions to a distance based blended programme such as ours. I would recommend this to any other institutions considering adopting a similar approach to midwifery education.

Intensive 4

The first week of this intensive  is the time for assessment and of course nerves are high at this time. Our students had some traditional class exams to do. The first was a three hour bioscience examination. The next was an exam loosely based on an “OSCE” type practice skills exam. Here student are randomly allocated one of 5 scenarios that they are already aware of and have had the opportunity to practice. Within these scenarios are two practice skills that the students have learned during the year. Women from our local community role play for these scenarios and a lecturer marks the students practical skill ability while the women are able to comment on students communication skills. Finally the students sit a one hour mathematics examination on professional calculations including drug calculations and infusion rates. We had intended to bring all students to Dunedin for all of these examinations but, in response to students feedback, we arranged supervised examinations for Bioscience and Procal in the students own area, with their practice facilitator invigilating, and they were only required to travel to Dunedin for the OSCE.

The final week of the year for students is the second week of this intensive. It is taken up with Midwifery Integration. This is a short course which is completed in both first and second year of the midwifery programme. Students are given a scenario and are  randomly allocated to groups. They have to explore the scenario with consderation of all the different aspects they have been learning about, in all their courses, over the year. At the end of the week they give a presentation to the class and lecturers about their scenario. This is an opportunity for students to integrate learning and consider a practice scenario from a variety of professional perspectives. This is a course we have run over the past five or so years at Otago Polytechnic. We usually run it over two weeks, one in the middle of the year and the other towards the end of the year. This year we dropped the first week as it has always been a challenge to find things the students can explore at this early time. The work the students did in this final week was extremely good. The presentation were generally excellent and the scenarios were well explored. As a lecturer it was very satisfying to see how the students were able to work with these scenarios and suggested that our new programme is working well and students are learning. Some of the work was well in advance of what we would generally expect in first year.This was a good way to complete the year and a nice way to say goodbye to the students.

Final reflection on the intensives

The intensives will always be an important part of this blended programme of midwifery education. It is interesting however that we did not need as much time for these as we had thought we would. In part this is probably because of the weekly tutorial groups which students attend and support a great deal of their practical learning . In my next post I will reflect on these tutorial groups. Students are aware before they enrol that these intensives are a key part of the programme and that they will be required to travel to Dunedin for them. This did not stop some students from complaining about the cost of travelling to Dunedin, of course, understandably, money is always an issue for students. As a result we did do more in the local areas with students than we had thought we might. Student also made connections with Dunedin based students and all our distance students were able to find billets during their stay in Dunedin which would reduce the cost to them.

Nicol (2006) states that good formative feedback provides clear guidance to students about what constitutes good performance while helping students to develop self assessment and reflective practice skills. It involves dialogue between students and lecturers, motivates learning and promotes self-esteem.

While formative feedback is important to guide student learning summative assessment give student the key to what counts for the course (Boud, 2000). Summative assessment suggests that there is an end point in the learning process where the student will have met learning outcomes is then assessed and pronounced competent or otherwise. It does not consider the nature of learning as a life long process which students need to engage with. While summative feedback may suggest ways in which the student can improve performance there is little opportunity for the student to do this unless there is a resit or resubmission opportunity. In my experience these opportunities are usually only given to failing students. Summative feedback therefore may have little influence on continued learning.

Why is feedback important?

Feedback helps students to close the gap between their current and desired performance and provides lecturers with information which can help to structure ongoing teaching. Feedback is of particular importance in formative assessment where the goal is to support student learning by identifying knowledge gaps and creating learning opportunities to bridge those gaps. It is important the feedback is closely related to the learning outcomes for the course and matches those outcomes with the students’ current performance. It is also important that students have an opportunity to consider and reflect on feedback and strategise how to meet their own learning needs.

What are the challenges or issues with assessment feedback?

If the goal of formative feedback is to assist student learning and identify how any further learning needs can be met, how do we know that the feedback we are giving students is effective in this way? It may be relatively easy to respond to areas of weakness for a whole class but how do we do that on an individual level? Do some types of assessment support this type of feedback loop more than others? It is important that feedback is given in a timely fashion and this can be a challenge if there are large numbers of assessments to consider.

How do you balance how much feedback to give?

I find sometimes that I spend a great deal of time giving feedback to students which is probably never really considered in any depth, this may be because much of the feedback I am giving is on summative assessments. It would probably be better to develop the art of skilful inquiry, asking the students to identify themselves where there learning needs are and how they well they feel they have achieved the outcomes. Students then need to have an opportunity to prove that they have met their learning needs and identify further goals. This process is a process well suited to a learning contract process of assessment.

References

Boud, D. (2000). Sustainable assessment: Rethinking assessment for the learning society. Studies in Continuing Education, 22, (2), 151-167

Nicol, D. J., McFarlane-Dick, D. (2006). Formative assessment and self-regulated learning: A model and seven principles of good feedback practice. Studies in higher education. 31, (2), 199-219. Retrieved from the World Wide Web on 15th September 2009 from http://www.reap.ac.uk/public/Papers/DN_SHE_Final.pdf

The learning contract, which is the focus of this post, is an assessment in the first year practice skills course in our undergraduate midwifery degree programme.  Although this three year degree has been running for around 16 years this is the first year on the new model of course delivery. I have described this course in detail in previous blog posts. The new undergraduate degree programme is very similar in content to the previous programme however the process of delivery has changed dramatically this year. In this post I discuss the learning contract and explain why we are using this as an assessment in this course I also explain how this assessment is presented to the students and how it is marked.

What assessment in being used in the practice skills course?

One of the main assessment tools that is being used in this course is  a learning contract. The students are required to identify a learning need around a midwifery practice skill. They have to identify the knowledge they already have about this and what it is that they need to learn. Students then explain how they will go about meeting these learning needs, what resources they will access and how they will improve their knowledge and/or experience with the skill. Students thenrecord what they have learned and what, if anything they still need to do to feel confident in their knowledge of the skill.  Finally the student prepares a reflective piece about their experience of undertaking this project. This assessment gives the student 50% of the  mark in the practice skills course.

Why is this assessment being used in this course?

This assessment forms part of the students Midwifery Practice Portfolio. The Portfolio is a structured document outlining all the practice experiences a student has during the three year degree programme. Students also reflect on their learning and experiences within the portfolio.  They maintain a record of the skills practiced and competence achieved with these skills.  The portfolio also provides a mechanism for reflection on midwifery practice and professional relationships with women and colleagues.  Portfolios have been identified as a useful tool to assess learning and competence amongst health professionals and are commonly used in nursing (Joyce, 2005; McMullan, Endacott et al, 2003; Scholes, Webb et al, 2004). The professional portfolio has been identified as a useful tool to develop critical thinking, promote adult learning and is geared to the individual needs of the learner (ibid). Portfolios are a required component of the recertification programme for midwives in New Zealand (http://www.midwiferycouncil.org.nz/main/Recertification/)

As a component of the portfolio, learning contracts also fit within the pedagogical framework of adult learning. Anderson and Boud (1996) suggest that learning contracts are useful assessment tools for flexible learning courses. Learning contracts support and encourage student autonomy and responsibility with regards to learning. Anderson and Boud recommend that  learning contracts should be used across the course and should not be a single isolated assessment tool within a course. Within the learning contract students  identify when, what, how and why they will learn a particular skill, they perform a self assessment of their own learning and provide evidence to corroborate this, they also identify their future learning goals.  This prepares the student well for the reality of midwifery practice where lifelong learning is essential (Boud, 2000). It will give the student a model to follow as they progress from undergraduate midwifery education to midwifery practice. It is an important aspect of practice, for students and midwives, to identify learning needs and how these learning needs can be met.

How this assessment is is being implemented

Students have been encouraged to use the learning contract process to identify their learning goals, learning activities and learning achievements within the portfolio and are being asked to identify one skill which they will submit for assessment and marking within the practice skills course. They have been given a table, within the portfolio, as a guide to help identify the process they need to follow to do this.  Students have been asked to keep their topic focused on the skills which they are learning  in the first year of the programme and will record their learning experience and reflections on this experience. The learning outcomes for the practice skills course are

1. demonstrate an ability to use communication skills to develop effective professional relationships with their peers and colleagues.
2. utilise an awareness of effective communication to enhance the quality of the childbearing experience for women and their families.
3. safely perform a range of selected practice skills and be able to outline their underlying theories and rationale.
4. accurately perform drug calculations and demonstrate skill of medication administration.

This assignment is designed to meet outcomes 1, 2, and 3.

In the course outline students have been asked to identify a situation in practice where a midwifery assessment has been carried out and write a reflective account of this experience. Students then develop a learning contract relating to this subject area. The student reviews her existing knowledge around the subject area and identifies her learning goals. She then reviews how these goals will be met and verify that they have achieved these goals. Students have also been given guidance within the portfolio to demonstrate how they can prepare and present this learning contract.

As the assignment date approaches students have been asking questions about this assignment. While I believe this is a good assignment technique in this course I am not sure that we have clearly articulated how this relates to the learning outcomes. I think this assessment will develop, change and grow for subsequent years.  I am interested to see how the students work with this assignment.

Is this assessment appropriate?

As described above there is a rationale for this assessment. Student are only now engaging with the process for submission of their learning contract. This may be because I am only getting my head around it too at the moment. I welcome your thoughts on this. If you are an educator of undergraduate health students do you think this would be a good way for your students to learn or be assessed? Are their any suggestions you have where this process could be better? I welcome any feedback on this. Please leave your comments in the comments tab below this post. Many thanks for coming to my blog and reading this post.

Conclusion

This post has outlined the learning contract which the most significant piece of assessment in the practice skills course in the first year of the undergraduate midwifery programme at Otago Polytechnic. Learning contract has been identified as a useful assessment tool for flexible learning, supports adult learners and gives the student skills which support lifelong learning. This is further described within the learning outcomes of the course, information in the course outline and within the portfolio document.

References

Anderson, G. & Boud, D. (1996). Introducing learning contracts: a flexible way to learn. Innovations in Education and Training International, 33, (4). 221-227.

Boud, D. (2000). Sustainable assessment: rethinking assessment for the learning society. Studies in Continuing Education, 22, (2). 151-167.

Joyce, P. (2005). A framework for portfolio development in postgraduate nursing practice. Journal of clinical nursing. 14, (4). 456-463

McMullan, M.,  Endacott, R.,  Gray, M. A.,  Jasper, M.,  Miller, C.,  Scholes, J.,  Webb, C. (2003). Portfolios and assessment of competence: a review of the literature. Journal of Advanced Nursing. 41, (3). 283-294

Scholes, J.  Webb, C.  Gray, M.  Endacott, R.  Miller, C. Jasper, M. McMullan, M. (2004). Making portfolios work in practice. Journal of advanced Nursing. 46, (6). 595-603

Image:  X class examinations from Bindass Madhavi’s phtos n flickr.com

In midwifery it seems  to me that much of what students learn is assessment driven, this is common amongst health professional education (Wass, Vlueten, Shatzer & Jones, 2001). The reality of student learning is that students feel pressured from their workload and gear their learning to meet the criteria of course assessments. Wass et al, stress the importance of ensuring that assessment of students is aligned with the competencies expected of them in clinical practice. They suggest there is no one way to assess clinical competence for medical student, the assessment process will comprise a variety of assessment styles which provide the students with a variety of ways to demonstrate their understanding. Factual written tests can demonstrate what the student’s background knowledge, written tests with a clinical focus can demonstrate that the student knows how to approach clinical issues, OSCE (objective structured clinical examination) allows the student to show the skills that they have developed and performance assessment (through practice supervision, video of skills in clinical practice or reflective logs can demonstrate that the student can act appropriately in the practice setting.  Osce’s have been found to be a useful tool for supporting learning and identifying competence in the nursing professions (Mason,  Fletcher, McCormick, Perrin &Rigby, 2005; ) however, although they have been found to be beneficial they need to be part of a broad picture of assessment of students competence (Rushforth, 2007).

In the school of midwifery we are always trying to look critically at what we assess and how many assessments we require students to do. In the new curriculum much of the online material is accompanied by formative assessments, quizzes and such like, which are not marked but will guide the students through key points of the learning resources they are accessing. A few students complete these and value this process however the majority seem to ignore them and only concentrate on assessments that are marked or are at least looked at and acknowledged by the teaching staff. This suggests to me that we need to consider carefully what we assess, how we do it and how this will support students learning.

References

Mason, S.,  Fletcher, A., McCormick, S., Perrin J. &Rigby, A. (2005). Developing assessment of emergency nurse practitioner competence – a pilot study. Journal of advanced nursing. 50 (4), 425-432

Rushforth, H. E. (2007). Objective structured clinical examination (OSCE): Review of literature and implications for nursing education. Nurse Education Today. 27 (5), 481-490.

Wass, V. Van der Vlueten, C. Shatzer, J.  & Jones, R. (2001). Assessment of clinical competence. The Lancet, 357,  945-948

By the way we do not usually wear hats like that (just in case you thought otherwise). It was an afternoon tea party, at the Savoy in Dunedin,   where we had the opportunity to pick a hat out of a box. I loved them, mine looked just like something my Aunty Nettie would have worn when I was a wee girl.

This photo graph and article appeared in the Otago Daily Times during our first intensive in January.

Our new programme has a longer academic year than our previous programme, beginning earlier in the  year and finishing later. Instead of being divided into two semesters our new programme is divided into three trimesters. Each trimester begins with the students coming together in class for two weeks of sharing, learning, doing class presentations (which are part of the assessment processs) and having some face to face lectures.  It is really good to see everyone back together. We all know each other quite a bit better and there is an air of cammeraderie and friendship.

How is it going?

We decided to get some feedback from the students about how the programme is going for them. What is working well and what they feel needs to change.

Yesterday the students got into groups and discussed this then fed back to the class. This is what I took out of this discussion.

It was overwhelmingly postive. The students said they are enjoying the course and the online learning. There were only one or two who said they felt they would prefer to be in class and have lectures, most are more than happy with being able to engage with the learning resources when they want to and in the way that suits them.

Online resources:

Feedback on the online learning resources was very positive. Most like this way of learnign and enjoy the quizzes and activities.  They have aparticular topic that they cover each week and are given a list of questions related to that topic to investigate and discuss in the Elluminate session later in the week. The students wanted the questions to be posted at the same time as the modules.

Online quizzes

The learning resources are interspersed with quizzes and case studies to make the students think and to improve the learning experience. Most of the students enjoy these althous some acknowledge that they feel now compulsion to do them and so do not bother.  They felt it might help if the Quiz had to be completed before progressing on with the module and this is something I am going to look into. They particularly liked doing the crosswords but some of the quizzes were less useful. In particular they mentioned a memory game that I had set up so I will not bother with that one again. I have had trouble getting crowwords to work for me so I will have to find out how I can do this from those that are managing to get crosswords up. I was told Hot potatoes was a good programme for this and I have tried but have not managed to master it yet. I have done some lovely crosswords in Eclipse but i cannot get them to load properly so that the students can use them. These activites are formative assessments which are recognised as an integral part of online learning and so it is important that we find ways to help the students engage with these to improve their learning and the retention of the material they are covering.

Elluminate,

We use Elluminate for weekly class tutorials which the whole class can attend online. Again most really appreciate this and find these tutorials useful the questions that have been put to them in the online learning for the week are discussed here. A couple of students said they would prefer video conference . There was also some discussion about the possibility of having a class session for those in Southland and Dunedin who can attend while doing the same think on Elluminate for those who cannot attend or prefer to be online. This would be very tricky I think as there is alot for the lecturer to consider in facilitating an Elluminate session, text chat, voice chat and running the material on the white board screen. I think trying to manage this online and face to face at the same time would be too difficult and we do not have the manpower to run session twice.

Some students are very willing to discuss issues in Elluminate, some prefer just to text. some said they would be happy to speak face to face but do not feel so confident online. They wanted to point out that if they do not speak it does not mean that they are not engaging or learning. Some just like to sit and listen and learn. This is very similar to the classroom situation and it seems to be the same people who are happy to talk in class that are the ones who are happy to speak online. The lack of body language cues was discussed as a disadvantage.

Practice skills

The students are really enjoying the midwifery practice experiences they are getting. They are aware that thsi is much more than the previous students had and they really appreciate this. I had hoped that some of the skills assessment would be able to be done in an actual clinical setting with the midwives in practice but this is proving very difficult to achieve. The midwives feel a bit threatened and overwhelmed by these skills assessment forms and this is not happening so we will have to go back to doing this in the class room setting.

Small group tutorials

The students really like the small group tutorials and most feel that these are working really well for them, helping with the course work and learning and providing an opportunity to debrief and learn together.

Reflection

Overall it seems that the programme is working well for the students. I would like to try to do something to help them engage more with the formative assessments we have in place and will look into the idea of making these compulsory to complete before moving on. At least for some of the quizzes. I think the change to doing some of the skills assessment in the weekly face to face session will be positive. I have been reluctant to do this previously as it would be outside the topics time tabled for the week and was worried that this may confuse the students but I think they can all see the rationale and I think this will work. It is very pleasing that this feedback was so postiive. We also gave the students a questionnaire to complete and that is being analysed. It will be interesting to see if these results are any different to this feedback.