Critically discuss the influences which could impact on you as an education leader in planning education programmes.

Critically discuss the influences which could impact on you as an education leader in planning education programmes.

 

Medicine and Nursing Basic Education – the Statutory Framework in the Republic of Ireland.

In any education programme, the learning outcome must be the primary target. For professional courses, the regulatory bodies have been awarded statutory responsibility for setting both standards and content of medical education and professional behaviour.  In the Republic of Ireland, under Section 88 of the Medical Practitioners Act 2007, the Medical Council is mandated to inspect a school that is approved by the Council in a five yearly cycle during which any significant change to the content of the programme must be referred to the Council for approval. The programme must comply with Article 24 of EU Directive 25/36/EC for programmes of basic medical education. A requirement is the provision of suitable clinical experience in hospitals and other training sites under appropriate supervision. It must also comply with the basic requirements of the World Federation for Medical Education Global Standards for Quality Improvement in Medical Education: European Specifications 2007 adopted in September 2009.

In 2005 in Geneva/Copenhagen, the World Health Organisation and the World Federation for Medical Education set out common guidelines for basic medical education1. These are non-binding guidelines and intend to set out best practices in medical education and to encourage co-operation in the implementation and running of accreditation systems including the exchange of experts and mutual recognition of accreditation systems with national agencies being willing to submit themselves to international review.  The accreditation system must be transparently trustworthy. This must be based on academic competence efficiency and fairness.

The results of medical school inspections published on the website of the Medical Council indicate that these are not cursory events.

The Nurses and Midwives Act 2011 replaced the Nurses Act 1985 as the legislation under which nursing is regulated in the Irish Republic. Training institutions are approved by The Nursing and Midwifery Board Bord under section 34 and must be reviewed at least every five years. Training must comply with any EU Directive 2005/36/EC on nursing. The Board must recognise the qualifications of nurses from other EU states and must enter agreements with third countries with regard to recognition of degrees and diplomas.

The above would be major drivers of the direction of education programmes in this area.

Learning Outcomes

Teaching is an attempt to enable to use aural, visual and practical instruction to enable the student to understand and be familiar with the subject matter to allow the student to arrive at the desired outcome terminus. The curriculum is shaped to attain that specific end and this is referred to as curriculum mapping.

Educational Psychology

Bloom’s taxonomy was created by an educational psychologist Dr Benjamin Bloom in 1956 to encourage an escape from rote learning. Cognitive, affective and psychomotor were the three domains. The goals of each learning episode should result in the acquisition of new skills, knowledge and/or attitudes2.

 

Bloom’s taxonomy is still the most widely used in educational and training. There are alternatives such as the Structure of Observed Learning Outcome (SOLO) Taxonomy.  It describes the levels of understanding of increasing levels of complexity3.

SOLO Taxonomy

The developments of five levels in the order of understanding go from left to right below. In the pre-structural area, the learner does not understand and misses the point of the lesson. In the uni-structural area, the learner focuses on only one relevant area and has a basic concept of the subject. In the multi-structural domain, the learner has several disconnected ideas about the subject but these are disconnected. Assessment at this level is primarily quantitative. At the relational level, there is integration of the different aspects into a totality of understanding of the subject. For the extended abstract, the learner conceptualises the subject at a higher level of abstraction and may create new ideas based on the totality of knowledge acquired.

In 2000, Anderson and others4 revisited Bloom and adjusted the six levels to

  1. to remember, 2. to understand, 3. to apply, 4, to analyse, 5. to evaluate, 6 to create.

These academics are essentially repeating the Bloom mantra. But these structures are useful in planning an education programme to ensure that there is a coherent means to progress to the objective of the syllabus.

Recognition of Learning Outcomes

Bologna Process which was agreed in 1999 is necessary to facilitate the recognition of degree programmes across the EU member states5. It is impossible to ignore the ramifications of this agreement on policy in which 46 countries now participate.  It now should feature as an indispensible component of any third level education programme which is being developed.

The European Credit Transfer System (ECTS) has been adopted. A Bachelor degree requires 180-240 ECTS credits and a Master degree requires 90 to 120 ECTS with a minimum of 60 ECTS at the Master level. This allows flexibility in setting the length of both degree programmes. More than 50% of European universities have reviewed their degree curricula to reflect the Bologna reforms and have set new quality procedures. (See below)

Qualification frameworks are dependent on specified learning outcomes which constitute the basic foundations of the Bologna agreement on education reforms for the European Higher Education Area (EHEA). The idea is to set a framework around the expected learning outcomes in terms of what the student knows, understands and is able to do, for a given qualification. There has been a shift from teacher to student-centred learning. This process is clearly necessary to introduce accreditation systems and quality assurance in higher education especially in a polyglot multi-lingual union such as the EU.

Through EU ministerial meetings in Berlin in 2003, Bergin in 2005 and London in 2007, EU states committed themselves to the development of National Qualification Frameworks (NQF) for their higher education systems by 2010. At Bergin, there was agreement on an overarching framework for qualification over three cycles including the possibility of intermediate qualifications in some countries. In London, further impetus was applied to the NQF by engaging the Council of Europe to facilitate the task. The frameworks were to be designed to encourage greater mobility of students and teachers and to improve employability. A website has been developed by the Council of Europe with information regarding qualification frameworks within the European Higher Education Area (EUA)6.

The qualifications framework also shows how a learner can move between qualifications. The focus is on outcomes and because of that, several paths may lead to a given qualification. The framework sets a template for the development of new degrees and the co-ordination and contextualisation of existing degree courses.

National Qualifications Framework (NQF).

There are 10 essential steps to develop the framework. The Departments of Education in each state are responsible and in the Republic of Ireland, the Higher Education Authority is the relevant devolved agency. Engagement with the third level colleges, staff, students and employers are necessary to complete the framework.

Each country should self-certify the NQF when developed. The standard should be compared with and be compatible with the overall EHEA framework. The system must include input from external non-national experts – in essence external examiners. Self certification reports are submitted to the Bologna Secretariat and/or the Council of Europe.

In November and December 2006, the Irish and Scottish self-certification reports were published and the report for England, Wales and Northern Ireland was published in February 2009.

The NQF provides a pathway to relate national frameworks to each other. This facilitates international transparency which facilitates international recognition of qualifications and consequent easier mobility of students and graduates across borders.

From an Irish centric viewpoint, it will allow Irish students to qualify in other European states and have the qualification recognised in Ireland. There are downsides in Medicine where some senior medical personnel claim that the clinical performance of students from continental Europe is inferior to Irish training in the clinical arena. Irish medical schools already have joint schools with non-EU countries where clinical training is carried out in home countries but the pre-clinical years are taught in Ireland. Education accreditation is through the Irish Medical Council. These are in Kuala Lumpur, Malaysia, with Perdana University and RCSI; Penang Medical College and RCSI –(fully accredited by the Irish Medical Council for 5 years);Allianz University Medical College in Kedah with University College Cork and Galway – re-inspection in 2013; International Medical University at Gombak with National University of Ireland, Galway – fully accredited by the Medical Council until 2017. This shows the importance of international accreditation in education. Therefore educators will be heavily influenced by international comparator rules and accreditation regulations.

The Irish submission to the Bologna Secretariat concluded that:-

 

• The Irish Higher Certificate is an intermediate qualification within the Bologna first cycle.

• The Irish Ordinary Bachelor Degree is compatible with the Bologna first cycle descriptor. However, holders of Irish Ordinary Bachelor Degrees and their equivalent former awards do not generally immediately access programmes leading to second cycle awards.

• The Irish Honours Bachelor Degree is compatible with completion of the Bologna first cycle.

• The Irish Higher Diploma is a qualification at the same level as completion of the first cycle, and is a qualification typically attained in a different field of learning than an initial first cycle award.

• The Irish Masters Degree is compatible with completion of the Bologna second cycle.

• The Irish Post-Graduate Diploma is an intermediate qualification within the Bologna second cycle.

• The Irish Doctoral Degree is compatible with completion of the Bologna third cycle.

 

The Irish education progression pattern was also defined in that report and the level of awards is appended at each stage7.  Each of the 10 levels in the framework is quality assured against the framework standards established against objective standards of knowledge skill and competence originally set by the National Qualifications Authority.

 

The National Framework of Qualifications is defined as “The single, nationally and internationally accepted entity, through which all learning achievements may be measured and related to each other in a coherent way and which defines the relationship between all education and training awards.”

 

A summary of the typical arrangements for educational progression are as follows:

 

• Entry to a programme leading to a Higher Certificate is generally for school leavers and holders of equivalent qualifications. Level 6

 

• Entry to a programme leading to an ‘ab initio’ Ordinary Bachelor Degree is typically for school leavers and those with equivalent qualifications. In addition, there are 1-year add-ons to Ordinary Bachelor Degree programmes for holders of the Higher Certificate. Level 7.

 

• Entry to a programme leading to an Honours Bachelor degree is typically for high-achieving school leavers or holders of equivalent qualifications. In addition, there are typically programmes of 1 year duration leading to Honours Bachelor Degrees for holders of Ordinary Bachelor Degrees. Level 8.

 

• Entry to a programme leading to a Higher Diploma is typically for holders of Honours Bachelor Degrees but can also be for holders of Ordinary Bachelor Degrees. It is of note that the Higher Diploma is typically in a different field of learning than the initial award. Level 8.

 

• Entry to a programme leading to a taught Masters degree is typically for holders of Honours Bachelor Degrees. Also in some cases, entry to such programmes can be permitted for those with Ordinary Bachelor Degrees or equivalent who have some relevant work experience. Furthermore, in some cases, entry to such programmes is permitted for people with extensive experience. Level 9.

 

• Entry to a programme leading to a research Masters Degree is typically for holders of Honours Bachelor Degrees, typically with a high classification attained – first or second class honours. Level 9.

 

• Entry to a programme leading to a Post-Graduate Diploma is typically for holders of Honours Bachelors Degrees but can also be for holders of Ordinary Bachelor Degrees.

Level 9.

 

• Entry to a programme leading to a Doctoral Degree is typically for holders of

Honours Bachelor Degrees. The general model is that a holder of an Honours Bachelor Degree with a high classification enters initially onto a Masters research programme, and transfers on to a Doctoral programme after one year on the Masters research programme. In total, the number of years in the programme would generally be at least 3 years. There is also access to research Doctoral Degrees for holders of Masters Degrees whether taught Masters or researchMasters. Level 10.

 

 

Third Level Education Quality Assurance

The Irish Universities Quality Board was subsumed into Quality and Qualifications Ireland under the new Qualifications and Quality Assurance (Education and Training) Act 2012 which was commenced in November 2012. Further Education and Training Awards Council (FETAC), Higher Education and Training Awards Council (HETAC) and National Qualifications Authority of Ireland (NQAI) were legally dissolved at that time.

Formal quality indices and procedures to satisfy the quality assurance standards of the new national authority would be foremost in my mind when the course is being designed. There has to be a clear link between the qualifications in the Irish national framework and the cycle qualification descriptors in the European Framework. Otherwise the project of mutuality would fail.

In setting out any new course, these requirements must be placed at the core of the enterprise. The Irish Framework is statutorily required to be based on learning outcomes and the qualifications are linked to  ECTS or ECTS compatible credits.

ECTS

The ECTS is based on the principle that 60 credits measure the workload of a full-time student during one academic year and can only be obtained by completion of the work required and the appropriate assessment of the extent of the learning outcomes achieved. Credits are given for every component of the course and have to be carefully allocated and nuanced with the introduction of new innovative academic courses8. Learning outcomes identify the essential learning to be achieved to earn the award of credit. Usually student workloads range from 1,500 to 1,800 hours for a full academic year so one credit equates to 25 to 30 hours of work. Each component is weighted by the amount of effort that a student needs to achieve the learning outcomes of that particular component of the course. Non-formal credits can be awarded when there is successful validation and assessment of the educational activity. This can include work placement.

 

 In 2004, the ECTS was re-defined to provide greater consistency in its application. It allows credit accumulation and transfers between institutions both within and between countries. It also caters for the award of joint degrees.  ECTS play an important role in the setting out an estimate of the work needed to achieve the academic objectives. This quantification of time course and content facilitates student movement and transferability. Credits can be accumulated to acquire a degree from degree awarding institution.

The Irish education system lists the following credit requirements

Level 6 Higher Certificate = 120 credits

Level 7 Ordinary Bachelor Degree = 180 credits

Level 8 Honours Bachelor Degree = 180-240 credits

Level 8 Higher Diploma = 60 credits

Level 9 Masters Degree (Taught) = 60-120 credits

Level 9 Postgraduate Diploma = 60 credits

But Masters degrees by research have a two year time slot usually but no formal credit listings. Doctorates have no specific ECTS but what I have seen of taught doctorates, this is an achievable objective. I am a little sceptical about some of these doctorates with regard to standard inflation but that is a personal anecdote at present.

Joint Degree

The other issue that I would like to address in planning an education programme is a joint degree. This is particularly salient in the Arts and culture and should be used to break down societal barriers in divided communities such as in Northern Ireland. This RCSI programme as provided me with the armamentarium to develop such a programme in the biological sciences. The area of forensic science, toxicology and legal medicine stick out from my perspective now. It may be possible to fashion a degree between University of Ulster and Athlone Institute of Technology and/or Trinity College Dublin and/or RCSI if the Department was in the Department of Medicine rather than Pathology. In June 2010 at Sevres, the revised procedures for the assessment and recognition of foreign qualifications were adopted by the Lisbon Recognition Convention Committee9.  This area is complex but should be used as an excuse or an impediment to the development of joint degrees as these could play a role in the development and solidity of Europe’s greatest peace process – The European Union. I am concerned about the detail in the 2010 Lisbon document because it indicates that the ECTS system has a way to go before it can be widely used to fashion joint degrees.

Selection of the design details of a course to comply with the mapping requirements of the NFQ.

It is best to start from the terminus especially for a new programme. The learning outcomes must be mapped to the appropriate award or degree as defined in law. The syllabus should be configured in such a manner that the totality of the module contents will deliver the entire programme. Credits will be apportioned to the modules within the range of values as determined by the degree awarded. The modules will be set to reflect and map the objectives of the course and must have clearly written learning outcomes. This will allow flexibility of content to match changes in requirements. The content of the modules will determine the appropriate teaching methodology.

A redesign of an existing programme make fashion a collection of course contents into modules which are brought together to form a programme. The learning outcomes are derived from the modules and are mapped to the appropriate NFQ level.

It is ideal to include the eight sub-strands of knowledge, skill and competence into new major award courses. These sub-strands are knowledge breath, knowledge kind, Know-how and skill range, know-how and skill selectivity, competence – context, competence – role, competence – learning, to learn and competence- insight and the weight in a given degree will depend on the learning objectives of the degree10.

Teachers are the human capital of education. I would be influenced in my choice of curriculum mapping by the availability of excellent teachers. Brilliant teachers and inspiring communicators are a very valuable asset and students should be exposed to them where possible. The reality of international university league tables, which include feed-back from students as a metric, makes the student – teacher/lecturer/tutor experience a central core to international institutional success. It is also likely to improve the grades attained by students overall.

Assessments – an examination paper will assess by taking a sample of the course and using that as a marker. Professional courses have been subjected to greater assessment changes with structured clinical and practical examinations to assess a wide range of learning outcomes including skills. Not every item of learning outcome on the syllabus will be assessed. The assessment criteria should encourage learning at an appropriate level and should state how the learning outcomes are to be demonstrated to earn the credits11.

Interprofessionalism will impact on educators

The Bologna process led to modularisation, which opened up the opportunity for integrated and inter-professional education (IPE). The World Health Organisation advocated IPE to improve the facility with which different health personnel can work together to meet the health needs of the people. The world manpower shortage of 4.3 million doctors, midwives, nurses and support workers was highlighted in the World Health Report 200612.  Scaling up training is easiest done by incorporating elements of IPE13.

Inter-professionalism can reduce medical errors for a health benefit. Many US medical schools incorporate IPE into parts of the curriculum. It is easy to envisage many parts of biochemistry, physiology and pharmacology sharing the sciences with students of medicine, sciences and pharmacy.

Poor teamwork in health care can and will impact negatively on patient care and outcomes. There has been a push towards team-based care to improve outcomes14. The place of an education leader in planning a new programme in education is influenced by age and prior experience. Professional identity formation plays a key role in the likely outcomes and the ease of introduction of IPE. Students develop a range of attitudes and beliefs about the profession that they are training to be admitted to. Part of this involves group interactions in the workplace and these set comparisons and professional boundaries with other groups.

The finding that older students and those with previous experience in health care had a negative attitude to IPE is predictable15,16. The new paradigm is that healthcare teams are at the core of clinical education and patient care and that the socialization process of common education processes will mould the participants into teams. Power processes at work are recognised by Bleakley in 200417.

Kings College in London could be used as a prototype as it offers courses in Medicine, Nursing, Pharmacy, dietetics, dentistry, physiotherapy and promotes patient centred communication within a team approach. In final year of medicine, keeping patients safe from medication errors is taught together in a practical example of IPE.  Kings is a corporate member of the Centre for Advancement of Interprofessional Education (CAIPE)18.

Concerns which will limit the extent of IPE

There are recognisable barriers which I would have to consider regarding IPE. These include differences in history and culture; inter- and intra-professional rivalries; differences in professional language codes; differences in professional schedules and routines; varying qualifications and status; differences in profession requirements, regulations and norms; fears of diluted professional identity; differences in accountability, payment and rewards; and concerns regarding clinical responsibility19. Other impediments are different requirements from professional regulatory bodies, different lengths of courses and entry requirements.

These are surmountable as I suggested earlier and common CPD between doctors and pharmacists could prove beneficial to more rational prescribing and better usage of antibiotics. Currently nurses attend some of the multidisciplinary meetings in endocrinology to mutual benefit.

If the course being planned involves practical experiences in areas with nurse expertise, my policy would be to engage in IRE because it makes sense. Again this would have to be mapped towards the desired learning outcome to reach accreditation standards.

Patient Safety

The Madden Report in 2008 on patient safety and culture highlighted poor teamwork and lack of integration of health care providers as risks to safety. The Report is extensive, covering 228 pages, interesting and wide-ranging20. My experience is that the balance between no-one in charge (ie. a team) and a dictator in charge has swung too far to the former. There is a clear danger there where responsibility for the individual patient becomes submerged in the mist of multidisciplinary teams and clock-in doctors and nurses. Recently formal medical handovers have occurred in a systematic manner in Connolly and Beaumont hospitals. To achieve uniformity in this is an important role for medical leadership. Professionalism and respect for others forms a key component of medical education.  The fundamental purpose of a profession is to provide a service that transcends financial and other self-interest21. Commercialism really should have no place in medicine but unfortunately it does.

Part of a medical school module should include discussion and definition of the changing role of nurses and nurse practitioners as well as other professions allied to medicine such as physiotherapy. These factors of IRE and patient safety gains would influence me in the design of a syllabus where relevant.

Molecular Biology

This is a burgeoning area of biology which impacts virtually across the board in health sciences. Any biomedical science course should include the basics in this area to allow professionals maximise their educational and learning returns from mandatory post-graduate continuing professional development. Clearly the degree of complexity of formal teaching and practical classes should be tailored to the particular audience but there is undoubtedly a module which could be shared across nursing, medicine and biomedical sciences.

Conclusion: Matching the syllabus of courses to desired learning outcomes has become a reality. Formal accreditation and standard setting with fair objective assessments have turned third level education towards the needs of students rather than placing the staff first. Recognition of education standards across borders opens up the possibility of student mobility and joint degrees. Quality controlling degree allows employers to have confidence in the standard of output of students from third level colleges.

 

 References:

  1. WHO/WFME guidelines for accreditation of basic medical education. Geneva/Copenhagen; 2005.
  2.  Bloom’s taxonomy of learning domains. http://www.nwlink.com/~donclark/hrd/bloom.html (accessed 3rd November 2013)
  3. Biggs  JB, Collis K. Evaluating the quality of learning: the SOLO taxonomy. New York, Academic Press. 1982.
  4. Anderson L W, Krathwohl DR, Airasian PW, Cruikshank KA, Mayer R E, Pintrich P R, Raths J, Wittrock MC. (2000). A taxonomy of learning, teaching, and assessing: a revision of Bloom’s taxonomy of education objectives. New York: Pearson, Allyn & Bacon.2000.
  5. European University Association. Strong universities for Europe. Bologna- an overview of the main elements. http://www.eua.be/eua-work-and-policy-area/building-the-european-higher-education-area/bologna-basics/Bologna-an-overview-of-the-main-elements.aspx (accessed 4th November 2013)
  6. Qualification frameworks in the EHEA. http://www.ond.vlaanderen.be/hogeronderwijs/bologna/qf/qf.asp (accessed 4th November 2013)
  7. Verification of compatibility if Irish national framework of qualifications with the framework of qualifications of the European Higher Education Area Final Report – November 2006.
  8. ECTS users’ guide. Education and Culture DG. Brussels, February 2009.
  9. Directorate General IV: Education, Culture and Heritage, Youth and Sport. Council of Europe and United Nations Educational, Scientific and Cultural Organisation, Division of Higher Education. Strasbourg and Paris, June 2010. http://www.coe.int/T/DG4/HigherEducation/Recognition/Criteria%20and%20procedures_EN.asp#TopOfPage (accessed 5th November, 2013)
  10. Framework implementation network. The university sector. Part 1. Technical aspects of designing and redesigning programmes/awards for inclusion in the National Framework of Qualifications (NQF). 2013.
  11. Gosling D, Moon J. How to use learning outcomes and assessment criteria. London. SEEC office. 2001
  12. World Health Organisation. World Health Report 2006: Working together for health. Geneva:World Health Organisation;2006
  13. World Health Organisation. WHA59.23: Rapid scaling up of health Workforce production. Fifty-ninth World Health Assembly. A59/23, 37-38. Geneva:World Health Organisation 2006.
  14. Grumbach K, Boderheimer T. Can health care teams improve primary health care practice? JAMA 2004;291:1246-51.
  15. Tunstall-Pedoe S, Rink E, Hilton S. Student attitudes to undergraduate interprofessional education. J Interprofessional Care 2003;17:161-72.
  16. Pollard KC, Miers ME, Gilchrist M. Collaborative learninig for collaborative working? Initial findings from a longitudinal study of health and social care students. Health Soc Care Comm 2004;12:346-58.
  17. Bleakley A. You are who I say you are: the rhetorical construction of identity in the operating theatre.   J Workplace Learning. 2006;17:414-25.
  18. Kings College London. Interprofesional education. http://www.kcl.ac.uk/health/study/facilities/chantler/teaching/ipe.aspx (accessed 6th November 2013)
  19. Headrick  LA, Wilcock PM, Batalden PB. Interprofessional learning and medical education. Br Med J 1998;316:771-4.
  20. Building a culture of patient safety. Report of the Commission on Patient Safety and Quality Assurance. Department of Health and Children; Government of Ireland 2008.
  21. Barr DA. Medical education – professionalism. N Engl J Med 2007;356:369.