Hiorns and Ryan, 2006). These clinicians require ... (Newman, 2000; Arvedson, 2008). Sound clinical ... (O'Donoghue and Dean-Claytor, 2008). Healthcare.
Research and Learning Methodologies
Developing clinician expertise in paediatric dysphagia: what is an effective learning model? Janice Duivestein, Alison Gerlach Background: Developing and maintaining clinician expertise in specialized rehabilitation practice areas can be challenging, and requires effective education and learning strategies. To widen the scope of this series, this article looks at education and learning models, how to develop and assess them, and their value in practice. This article provides an example relevant to any specialized learning. Content: The authors use the example of paediatric feeding and swallowing difficulties (dysphagia) to describe the evaluation and exploration of the education and learning models at two paediatric agencies in British Columbia, Canada. These models are designed to support occupational therapists and speech language pathologists in developing expertise for performing videofluoroscopic swallow studies (VFSS), a component of a comprehensive paediatric dysphagia evaluation. Clinicians involved in providing specialized paediatric dysphagia services, including VFSS, were engaged in this study through a participatory action research approach. Data on current education and learning models and clinicians’ experiences were collected through questionnaires and a focus group. Results identified three interconnected themes: ‘dynamic and interactive learning is necessary to reflect the complex and changing practice environment’; ‘supports and resources provide infrastructure to enhance learning’; and ‘personal characteristics influence learning.’ Conclusions: Findings from this preliminary participatory action research study suggest that education and learning models to facilitate the development of clinician expertise in paediatric VFSS should consider employing a multi-faceted approach in which the necessary supports, resources and interactive learning environments are available for both new and experienced clinicians. Key words: n clinical reasoning n dysphagia n education n paediatric n participatory action research n videofluoroscopy Submitted 5 May, sent back for revisions 14 June; accepted for publication following double-blind peer review 27 October 2010
Janice Duivestein is Clinical Assistant Professor, Department of Occupational Science and Occupational Therapy, University of British Columbia, and Neuromotor Program Manager, Sunny Hill Health Centre for Children; and Alison Gerlach is Clinical Instructor, Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, British Columbia, Canada Correspondence to: J Duivestein Email: jduivestein@ cw.bc.ca 130
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hildren with developmental disabilities or those with complex health issues often experience feeding and swallowing difficulties (dysphagia) which can result in additional health and nutritional risks (Burklow et al,1998; Sullivan et al, 2000; Fung et al, 2002; Field et al, 2003). Children with paediatric dysphagia are best managed by an interdisciplinary healthcare team (Lefton-Greif and Arvedson, 1997; Geggie et al, 1999; Williams et al, 2006). Such teams provide comprehensive evaluations of swallowing disorders, often including an instrumental evaluation referred to as a videofluoroscopic swallow study (VFSS) (Arvedson, 2008). VFSS (see Figure 1) enables identification of airway risk for aspiration, determination of possible causes of the swallowing disorder and opportunities to evaluate remedial strategies (Logemann, 1998). Occupational therapists (OTs) and/or speech language pathologists (SLPs), working in conjunction with radiologists, are typi-
cally the clinicians who assume primary responsibility for performing VFSS (Zerelli et al, 1990; Hiorns and Ryan, 2006). These clinicians require specialized knowledge, skills and expertise to assess and analyze the swallowing disorder, consider contextual factors and determine appropriate solutions (Newman, 2000; Arvedson, 2008). Sound clinical reasoning and decision-making are critical in this process as the outcome of an evaluation can affect a child’s health, safety and quality of life (Arvedson and Lefton-Greif, 2007). Developing and maintaining clinical expertise in specialized rehabilitation practice areas, such as paediatric dysphagia, can be challenging and requires effective education and learning strategies (O’Donoghue and Dean-Claytor, 2008). Healthcare agencies providing paediatric dysphagia services are often responsible for the education and training of clinicians, as the required combination of knowledge, skill and experience is typically not available
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through professional academic programmes or in general healthcare settings (Kurjan, 2000; Bailey et al, 2008). In the province of British Columbia (BC), Canada, paediatric VFSS is performed by OTs and SLPs at only five healthcare agencies. Consequently, only a limited number of clinicians have acquired and maintained the expertise needed to perform paediatric VFSS. Healthcare agencies are accountable for maintaining effective, quality services and ensuring that education and training programmes are effective in meeting clinicians’ learning needs. Participatory action research (PAR) is a systematic approach of inquiry that can be employed to address a practice issue by engaging the individuals most involved and impacted by the issue and examining the issue from their perspectives and experience (Cockburn and Trenthan, 2002; Stringer and Genat, 2004). Through this engagement, results and potential solutions can be generated that are both meaningful and useful to the participants (Meyer, 2000; Spalding, 2009). PAR was therefore chosen as a viable approach to use to explore clinician perspectives of the effectiveness of the educational and learning models at two healthcare agencies in BC, for developing expertise in performing paediatric VFSS. PAR is cyclic in nature, involving design and planning of the research, collection of data, analysis of data, implementation of identified outcomes and evaluation of those outcomes. (Meyer, 2000; Stringer and Genat, 2004). A variety of qualitative research methods such as interviews, focus groups and field notes are commonly used to gather data (Meyer, 2000). PAR is desirable to use when addressing complex clinical issues as the focus is on identifying potential solutions to ultimately improve clinical practice (Meyer, 2000; Carpenter and Suto, 2008).
DEVELOPING DYSPHAGIA EXPERTISE The initial literature search elicited primarily quantitative studies focused on measuring whether clinician knowledge of anatomy, physiology and skill in VFSS interpretation could be improved using specific training and tools (Logemann et al, 2000; Wooi et al, 2001; Hind et al, 2009). The search was then expanded to encompass educational approaches for increasing general dysphagia knowledge and skill. Reported approaches included conferences and workshops, learner-centred strategies, technologyaided strategies and mentoring (Modi and Ross, 2000; Scholten and Russell, 2000; Steele et al, 2007; Nightingale and Mackay 2009). Limited literature was found outlining the development of clinical reasoning abilities specific to dysphagia evaluation. Goldberg et al (2006) described positive learning outcomes from an experiential
Figure 1. Videofluoroscopic swallow study of disordered swallowing with aspirated material in the airway.
learning experience involving student SLPs working with experienced clinicians providing communitybased dysphagia services. General rehabilitation literature identified experiential learning, problembased learning, reflective practices, mentoring and discussions with colleagues as effective methods for facilitating development of clinical reasoning (Titchen and Higgs, 2000; Ciaravino, 2006; Velde et al, 2006; Ajjawi and Higgs, 2008). In line with a PAR approach, further review of the literature was undertaken as the initial findings suggested that personal and environmental factors, such as self-motivation, type of work experience and access to colleague support, play important roles in successful learning and development of clinician expertise. In their theoretical model of expert practice in physical therapy, Jensen et al (2000) identified personal characteristics and traits in addition to dynamic, multidimensional knowledge, movement assessment and clinical reasoning as ‘dimensions’. King and colleagues (2008) reported that motivation and complexity of work experiences were factors determining how quickly paediatric rehabilitation therapists attained expertise, whereas Subramaniam (2003) examined knowledge use among OTs performing infant feeding assessments, and suggested that collaboration with colleagues and hands-on practice with support and feedback are necessary to help develop practice expertise.
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Research and Learning Methodologies Aims and research questions Because of the significant health risks for children with dysphagia, developing and sustaining clinician expertise to provide quality paediatric dysphagia services is essential. Two BC children’s health agencies that provide paediatric dysphagia services were interested in formally evaluating their existing education and training models for VFSS practice. Both agencies agreed to participate in this research project to explore clinicians’ perspectives on the existing education and learning models. The specific research questions were: n Were learning needs of clinicians being met to ensure acquisition of the necessary knowledge, skills and clinical reasoning and decision-making abilities to perform paediatric VFSS? n What education and learning model was perceived by clinicians to be most effective in meeting their learning needs?
METHODS
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significant gaps, and that the proposed questions would elicit data relevant to the research questions. Interviews were audio-taped with permission and transcribed by the lead researcher.
Participants Purposeful sampling was used to recruit clinicians as participants; inclusion criteria specified any OT or SLP at either agency currently performing paediatric VFSS. Clinicians from one agency provide services to children with complex health issues through acute inpatient and outpatient service models, and those from the other agency address the dysphagia needs of children with developmental disabilities, primarily through an outpatient service model. Study information and consent forms were distributed by a third party to the ten clinicians who met the inclusion criteria.
Data collection
In keeping with a PAR approach, those individuals most involved in the identified problem and with a stake in the outcome were engaged in the research process. Clinicians (OTs and SLPs) at each agency were considered primary stakeholders due to their direct involvement in paediatric dysphagia management and as individuals most influenced by education and learning activities in this practice area. Key informants were managers of the two therapy disciplines (OT and SLP) at both agencies, a head radiologist, and the programme manager of an external agency providing similar dysphagia services. The role of these key informants was to provide information and feedback to the researchers in order to inform both the structure and process of data collection methods for the clinician participants. Inherent in PAR is the role the researcher plays (Stringer and Genat, 2004). The primary researcher for this project (JD) is a clinician practicing in paediatric dysphagia who also holds a leadership role with responsibilities for ensuring sustainable, quality dysphagia services. Ethics approval was obtained from the University of BC Behavioral Research Ethics Board and the paediatric agencies’ research review committees.
An anonymous questionnaire was distributed by a third party to the seven clinicians who consented to participate in completing the questionnaire. Anonymity was important to encourage participants to respond openly to questions about the effectiveness of the education and learning model at their respective agency in meeting their learning needs. To enhance anonymity, the questionnaire included only minimal demographic information. Six clinicians, from the initial identified pool of ten clinicians, consented to participate in the focus group. Due to scheduling difficulties however, only five were eventually able to participate. The focus group provided an opportunity to further explore information gathered from the questionnaire to gain a deeper understanding of the elements of the learning process and the factors that influence the development of knowledge, skills and clinical reasoning abilities. The discussion was audio taped, transcribed by a third party and reviewed for accuracy. Throughout the focus group session, discussion points were summarized by the researcher and reflected back to the participants to facilitate further exploration of the topics. Published dysphagia competency documents were also distributed to stimulate discussion. A summary of the focus group data was provided to each participant, with an invitation to offer clarification and contribute further ideas.
Key informants
Data analysis
Semi-structured interviews with key informants focused on development and implementation of the education and learning models currently used at their agencies, and the perceived effectiveness of these models in supporting clinicians’ learning needs. Key informants also reviewed an initial draft of a clinician questionnaire to ensure there were no
Data from the demographic and closed questionnaire questions were analyzed and reported descriptively to clarify participant characteristics and frequency of use of various education and learning strategies. Open-ended questionnaire questions and focus group data were analyzed using an inductive, thematic analysis process (Braun and Clarke, 2006).
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Data were read, re-read, grouped, and coded by the primary researcher. Coded categories were reviewed and re-organized into potential themes and a thematic map was developed. Themes were reviewed repeatedly and refined until final themes were identified. Due to the primary researcher’s stake in the research process, it was necessary for her to engage in a reflective process using peer debriefing in order to examine her role, involvement and relationship to the participants. During data analysis, peer review was completed with a colleague familiar with qualitative research methods but not involved in the research. Final themes were also reviewed and compared to the literature by the primary researcher. Incorporation of peer debriefing, member checking, triangulation and peer review during data collection and analysis enhanced the rigor of the research. Figure 2 illustrates the phases of the research process.
FINDINGS Questionnaire: closed-end questions Demographic data from the seven completed questionnaires revealed that four clinicians had greater than 5 years of experience and the remaining three had 2–5 years’ experience in performing paediatric VFSS. Because the pool of participants was small, profession (OT or SLP) was not asked, in an attempt to preserve anonymity. Six participants indicated that the education and learning models at their agency had addressed their learning needs, with the seventh commenting that there was ‘room for improvement’. Six participants had mentored a newer clinician with their learning in this practice area. The frequency with which various educational strategies were used is detailed in Table 1.
Open-ended questionnaire questions and focus group Data from the open-ended questionnaire questions and focus group were reviewed and analyzed together, with the focus group data providing richer and deeper exploration of the recurring themes elicited from the questionnaire data. Three final major themes were identified describing factors influencing education and learning related to paediatric VFSS. n Dynamic and interactive learning is necessary to reflect the complex and changing practice environment n Supports and resources provide infrastructure to enhance learning n Personal characteristics influence learning.
Dynamic and interactive learning Dynamic and interactive learning, the first identified theme, is necessary to reflect the complex, dynamic
R E S E A R C H
Phase 1 Data Collection Interviews: Manager/service leaders Radiologists External Agencies Literature Review
Q U E S T I O N S
Phase 2 Data Collection Questionnaire: Clinician participants Focus Group: Clinician participants
Phase 3 Data Analysis and Trustworthiness Thematic Analysis Triangulation Member Checking Peer Review Debriefing
Outcome and Actions
Figure 2. Multi-phase research process.
and fast-moving practice environment in which VFSS is performed. Critical considerations are the child’s health and safety, the child’s feeding ability and tolerance of the VFSS procedure, the family’s emotional state and expectations, the radiology environment, expectations of the healthcare team, and minimizing radiation exposure. Decision making during a VFSS must be rapid in order to limit radiation exposure but still address the feeding questions. As one focus group participant noted: ‘It’s a very emotional and important study. Emotions are high; stress is high for the family and the children. You have to be able to manage and coax the family along, and watch the child while watching the screen, and thinking on your feet.’ Table 1. Questionnaire – frequency of use of educational strategies Learning strategy
Respondents’ utilization
percentage
Books, in-house video review, video review – post-study with radiologist, working with experienced clinician, case discussion with colleagues, mentoring
7/7
100%
Journals, facility- developed information (manuals, guidelines, protocols, etc)
6/7
85.7%
Formal courses or workshops, case study review
5/7
71.4%
Audio-visual learning (videos, DVDs, etc)
3/7
42.8%
Competency-based checklist with resources, online websites, other- graduated approach to learning
1/7
14.2%
Self-paced learning modules, online courses
0/7
0%
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Research and Learning Methodologies Given this complex practice environment, all seven questionnaire respondents and all five focus group participants placed a high value on working with another clinician, not only to support the child and family, but also to collaborate on decision making during the study. Often the second clinician was more experienced and fulfilled a mentoring role. The opportunity to work with experienced clinicians was described by all respondents and participants as a key component of their past learning experience, and a major component of current models at both agencies. Collaboration was highly valued by both newer clinicians and those with more experience, as the dialogue and reciprocal feedback provided valuable learning opportunities. In the words of another participant: ‘I would agree that experience is probably the primary thing, which is a tricky thing to incorporate into an education plan – it’s probably just spending {time} doing studies with people who knew what they were doing more than anything else that I learned from. Even now, being able to talk to people about it and then throw ideas out and have another set of eyes to confirm what you saw that makes it true – true enough.’
Dialogues with colleagues of the same or other disciplines (radiologists, other physicians) were described as invaluable learning opportunities. Participants indicated that VFSS review with radiologists, and then again with colleagues, required them to make their clinical reasoning and decisionmaking process more explicit and enabled problem solving around complex situations. This in turn, promoted reflection on the actions and decisions made during the swallowing study, and gave a chance to hear other perspectives. Consensus with other colleagues on the VFSS findings and recommendations was perceived as confirmation of the reasoning and decision making process. Even a lack of consensus was viewed as contributing to experience and learning: ‘Sometimes the learning happens when you’re not agreeing – the other person has to justify why do they think that they saw this or why do they think a recommendation should be this. It’s the disagreement that helps.’
Although formal and planned opportunities for dialogue were available, impromptu consultations with colleagues and case review sessions were also seen as promoting learning together. ‘When I first started, being paired up with a colleague so there was two of us for each feeding study and the discussion that we had afterwards and the opportunity 134
to go through the video very slowly and talk about what we were seeing and, if questions do arise, being able to pull in someone else who has a lot of experience. That’s how I gained confidence in being able to read videos.’
Learning supports and resources In the second theme, supports and resources were identified as key components of the infrastructure necessary to enhance learning. Traditional formal learning methods, such as courses and workshops, were described as helpful supports to clinician learning, although two participants had not attended courses specific to this practice area. Barriers to attending courses and workshops included few available courses in this speciality area, and financial constraints. A common thread that emerged during focus group discussion was that attending a course or workshop after gaining clinical experience was often more meaningful and relevant than when participants first started working in this practice area. Participants did however feel that it was essential for clinicians to acquire a solid basic knowledge base related to paediatric dysphagia prior to clinical exposure. ‘[Courses can help] … to get some good basic information even though you can’t glean onto those golden nuggets of information, you at least get the basics then – delve into some experience, then do some reading and course work - it’s then that you gain more from and learn more from once you’ve actually gotten your feet wet and got some experience doing the feeding studies.’
A further common thread shared by all five focus group participants, and expressed by 5/7 questionnaire respondents, was that a graduated and supported learning approach was best in facilitating acquisition of knowledge and skills, and providing opportunities to build experience to be drawn from in future practice. This graduated approach involved opportunities for observation, then participating in the VFSS, then leading the VFSS with support, and finally, independently performing the VFSS. The time frame for this process was felt to vary, depending on factors such as a clinician’s previous experience, complexity of the caseload, and level of support from other colleagues. Immersing the new clinician by ensuring repeated opportunities to observe and participate in paediatric VFSS was felt to intensify learning and build experience more rapidly. The depth of knowledge, skill and experience required for proficient practice can be daunting to new learners. Formalizing and structuring the
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learning process helps clarify expectations, identifies available supports and resources, and guides new clinician in their learning. Agency-developed resources and published competency documents were deemed as useful tools for this process. The need for increased recognition of the challenges, risks and uniqueness of this practice area was evident from both questionnaire (3/7) respondents, and focus group participants (5/5). Increasing workloads and limited time were cited consistently as challenges and concerns. In order to sustain services, there was heavy reliance on the few experienced clinicians available to act as mentors, without recognition of a formal mentoring role or protected time. In essence, they felt there was a need to legitimize the education and learning process required to support newer clinicians in this complex practice environment. As one focus group participant stated: ‘Our methods right now, which are mostly mentorship and working with more experienced therapists, really hinge on those more experienced therapists and those mentors really being able to teach well, and having the patience and the mentoring skills and the time. And so if we ever lost that and didn’t have a structure in place underneath...’
And as a second participant commented: ‘But it’s a pretty tenuous structure – one person goes off to a different department and then one person goes off on mat(ernity) leave and then one person gets sick – it’s a nightmare.’
The five focus group participants offered further thoughts regarding supports and resources by expressing the need for their own continued learning, despite years of experience. The need for additional time, providing student supervision, personal motivation and the presence of a learning culture in the work environment were voiced as factors influencing the success of ongoing learning. Despite time challenges, caseload demands and expressions that their own learning was not moving forward as desired, participants went on to describe various formal and informal learning initiatives in which they were currently involved. They also suggested future learning opportunities that could be initiated, such as practice-related interest groups and cross-agency sharing of resources and experiences locally, provincially and nationally.
Personal characteristics Personal characteristics, the third identified theme, can influence learning and the ability to work in this specialized practice environment. This theme primarily arose from data gathered from the five focus group participants although was also commented on
in 2/7 questionnaire responses. Feelings of anxiety and lack of confidence were challenges frequently voiced by the participants when describing their early experiences performing paediatric VFSS. The complexity, health risks and unpredictability of the study environment, along with the emotions and expectations surrounding the outcomes, contributed to these feelings. The pace and environment for conducting VFSS requires the ability to think and process information quickly in order to make sound decisions and manage risks. One participant described VFSS as being less ‘concrete’, and more of an ‘art and science’ than other practice areas. Personal factors requiring consideration went beyond medical and health issues to include social and cultural influences as well as family stress and expectations. Understanding all these factors and how they might influence and be influenced by the information from the VFSS was essential. Over time, and with experience, participants reflected that they found themselves feeling calmer and more able to address unexpected issues or conflicts that might arise. Given the challenges, participants acknowledged that some clinicians never become comfortable in this practice area, despite education and support, and subsequently choose other practice areas. As one participant summarized the situation: ‘There can be more stress to it because you have to deal with stuff immediately. You have to be able to think on your feet and be able to do it right then and there, and you either love it or hate it.’
Given the specialized nature of this practice area and the limited number of agencies providing paediatric VFSS in BC, participants acknowledged a considerable learning curve, as it is rare for new clinicians to have the necessary experience or expertise. Ensuring adequate opportunities for learning was identified as a joint responsibility of the agency leadership and the new clinician. New clinicians must be prepared to identify their learning style and needs and to take responsibility for ensuring those needs are met. Time for observation and building of knowledge and skills is necessary, particularly given the health and safety issues associated with VFSS. The deeper learning that occurs with ‘hands on’ experience is essential and new learners must take the initiative to seek out these opportunities. ‘There’s a fine line – there needs to be responsibility on both levels because, as a new staff member, you’re asked to go do this and you’re not feeling comfortable with it, you’re not feeling confident, but the expectation is there that you’re going to do it, which is like any area that’s new, so you gather the basic skills and then you jump in at some point’.
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Research and Learning Methodologies DISCUSSION Findings revealed that the majority (6/7) of the clinicians perceived that the education and learning support provided by their respective agencies had met their learning needs for developing the knowledge, skills and clinical reasoning ability necessary for performing paediatric VFSS. Review of the data did not reveal a specific or prescribed education and learning model, but rather, recurring themes, which in turn offered insight into key elements required in an education and learning model to successfully promote learning in this specialized practice area. The findings also offered insights into the relative value clinicians placed on the different learning elements and identified specific factors that influence learning. Not surprisingly, key educational elements included multiple and diverse learning strategies, i.e., traditional methods (such as courses, workshops and resources), as well as interactive and experiential learning opportunities. This finding is corroborated by literature that reports multi-faceted learning approaches as most effective in achieving practice change (Grimshaw et al, 2001), in acquiring knowledge and skills to support clinical reasoning and decision-making (Ajjawi and Higgs, 2008), and in developing expertise (King et al, 2008; King, 2009). Opportunities to access more traditional methods of education, such as courses and workshops, were viewed as helpful in knowledge acquisition, and are cited in the literature as being valued by clinicians working in dysphagia and other rehabilitation practice areas (Rappolt and Tassone, 2002; Steele et al, 2007), despite some evidence that these passive methods have not been found to be as effective for changing practice (Grimshaw et al, 2001). Attendance at a course or workshop after having gained clinical experience may explain why participants valued these types of educational activities. Participants were able to directly translate course information to their practical experiences, thereby increasing their meaning and relevancy. Professional practitioners tend to embrace and use knowledge that is relevant and applicable to their daily practice (Queeney, 2000). Materials and resources, such as competency documents, learning plans and manuals, were recommended as useful tools or ‘roadmaps’ to assist new clinicians to understand expectations and guide learning. Novice clinicians are reported to value structure and guidance as they develop their knowledge and skills, and gain experience (Hodgetts et al, 2007). Health researchers have looked extensively at strategies used to support the development of clinical reasoning and decision making in student learners and clinicians (Titchen and Higgs, 2000; 136
Ciaravino, 2006; Velde et al, 2006; Ajjawi and Higgs, 2008). Many such strategies were reflected in our data, particularly the use of dialogue with colleagues both during and after the VFSS. Dialogue occurring outside the VFSS suggests that participants sought opportunities for reflection and feedback whereby they could dissect and critically review their reasoning and decision-making processes, and use this to build their knowledge base and experience. This process of ‘reflection-onaction’ (Schön, 1983) is described by Higgs and Titchen (2001, p 528) as ‘… a cool reflective process whereby practitioners evaluate their practice and examine how they acquire, use and create knowledge…’ This contrasts with the rapid thinking processes required in the radiology environment during VFSS. These latter types of processes are frequently referred to as ‘reflection-in-action’ (Schön, 1983), described by Higgs and Titchen (2001, p 128) as ‘‘hot’ action requiring the rapid processing of complex information and knowledge, often under pressure’. Opportunities for clinicians to engage in reflective activities in a variety of supported learning environments facilitate development of clinical reasoning and expertise (Subramaniam, 2003; Ajjawi and Higgs, 2008; King et al, 2008). Interactive learning experiences in the practice environment were highly valued and deemed an essential, core element of current and future education and learning models. Working closely with other team members, particularly experienced clinicians or mentors provided a graduated learning experience in the radiology environment. This dualclinician model offered ongoing learning opportunities for less experienced clinicians but also helped ensure adequate attention and support to the child and family during the dynamic, often emotional study situation. Using experienced peers as educational resources to act as role models and provide support and feedback enhances the learning experience (Rappolt and Tassone, 2002; Subramaniam, 2003; Ajjawi and Higgs, 2008). Participants described personal characteristics that they felt influenced the success of the learning experience. Anxiety and lack of confidence were described as common feelings during early experiences performing VFSS, but ones that resolved with experience. Clinicians who did not develop the confidence and ability to make clinical decisions in this dynamic, complex, practice environment, tended to move to other practice areas. The learning curve is steep and requires the ability to think and respond effectively in a rapidly changing clinical environment. Motivation, a commitment to learn and develop skills, seeking out challenging experiential learning opportunities, and engaging in self-reflection have been identified as essential for
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successful learning and development of expertise (King et al, 2008; King, 2009). Clearly evident in the success of the learning process was the need for managers to recognize the importance of educating new clinicians in this specialized area of practice and to support more senior clinicians who provide education and mentoring. High workloads, lack of dedicated time, and limited financial resources were identified as barriers to achieving adequate support for the learning needs of newer clinicians, and for ongoing learning and development. King et al (2008) suggested that managers should consider the importance of motivating clinicians through supportive work environments that foster personal growth. In a later article, King (2009) proposed a framework of personal and environmental strategies to encourage learning and development of expertise; strategies include formal and informal discussions, tools and frameworks to guide thinking and decision-making, adapting work schedules and experiences to enhance learning, coaching and mentoring opportunities and creation of a learning work environment.
Limitations and future considerations This was a small study focusing on a specific practice issue at two paediatric agencies in BC. The findings, therefore, should be considered preliminary and may not have direct transferability to other clinicians and agencies. Nonetheless, the broader education and learning concepts may be relevant and of interest to other agencies providing paediatric dysphagia services, or indeed, any agency looking to develop effective learning model for specialities in therapy and rehabilitation. Participant numbers were limited by involvement of only two agencies and the specific inclusion criteria. All those responding to the questionnaire or participating in the focus group had at least 2 years’ experience performing paediatric VFSS, with no new learners in the sample. This reflected the current staffing situation at both agencies and was therefore unavoidable. Expanding the research to other agencies providing this service might ensure that participants included both new and more experienced clinicians, and may offer additional perspectives to those found in this research. Findings from this project reflected clinicians’ perceptions of their education and learning model, and did not directly incorporate input and perceptions of the managers and other discipline colleagues. Such data would have strengthened the findings, and should be considered in future research. PAR involves not only the inquiry process, but also acting on the information and evaluating the effects of those actions on the initial problem (Stringer and Genat, 2004). Next steps in this proc-
ess involve determining and implementing changes to current education and learning models at the two involved agencies and establishing a method for evaluating the impact and success of those changes.
CONCLUSIONS This preliminary study used a PAR approach to explore and evaluate the effectiveness of education and learning models geared at developing clinician expertise in performing paediatric VFSS at two agencies in BC. Our findings suggest that education and learning models to support the development of expertise in this specialized area of practice should consider employing a multi-faceted approach that ensures availability of necessary structures, supports and resources for both new clinicians and those charged with mentoring junior colleagues. Responsibility for ensuring successful learning lies both with the agency and the new clinician, and requires consideration of personal and environmental factors. Supported, interactive learning within this complex and dynamic practice environment is desirable, to ensure safe and competent practice and foster the development of expertise. Service models, such as a dual-clinician model for VFSS, provide important opportunities for mentoring and interactive learning for newer clinicians, as well as increased support for the child and family. IJTR Conflict of interest: None Acknowledgements: The authors would like to acknowledge the contributions of the dedicated clinicians and managers at BC Children’s Hospital and Sunny Hill Health Centre for Children in Vancouver, BC; the Feeding Service coordinator of Queen Alexandra Centre for Health Centre in Victoria, BC; Susan Stewart, Linda Hopkins and Jen Gellis, Sunny Hill Health Centre, and Dr. Susan Harris, University of British Columbia. Ajjawi R, Higgs J (2008) Learning to reason: a journey of professional socialization. Adv Health Sci Educ 13(2): 133–50 Arvedson JC (2008) Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Dis Res Rev 14(2): 118–27 Arvedson JC, Lefton-Greif MA (2007) Ethical and legal challenges in feeding and swallowing intervention for infants and children. Semin Speech Lang 28(3): 232–8 Bailey R, Stoner J, Angell, M, Fetzer A (2008) School-based speech-language pathologists’ perspectives on dysphagia management in the schools. Lang Speech Hear Serv Sch 39(4): 441–50 Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3(2): 77–101 Burklow KA, Phelps AN, Schultz JR, McConnell K, Rudoph C (1998) Classifying complex pediatric feeding disorders. J Pediatr Gastroenterol Nutr 2(2): 143–7 Carpenter C, Suto M (2008) Using methodological theory in planning qualitative research. In: Carpenter C, Suto M eds. Qualitative Research for Occupational and Physical Therapists. A Practical Guide. 1st edn. Blackwell Publishing, Oxford: 60–76 Ciaravino EA (2006) Student reflections as evidence of interactive clinical reasoning skills. Occup Ther Health Care 20(2): 75–88 Cockburn L, Trentham B (2002) Participatory action research: Integrating community occupational therapy practice and research. Can J Occup Ther 69(1): 20–30 Field D, Garland M, Williams K (2003) Correlates of spe-
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Key points ■ Developing and maintaining clinician expertise in specialized practice areas, such as paediatric dysphagia, requires that healthcare agencies develop effective education and learning strategies. ■ A multi-faceted approach, tailored to individual practice contexts, should be considered when developing an education and learning model to support clinicians in acquiring the necessary knowledge, skills, clinical reasoning and decision-making abilities. ■ Dynamic, interactive learning opportunities reflective of the practice environment are desirable to enable clinicians to develop the required expertise to perform paediatric VFSS. ■ The use of a dual-clinician model when performing VFSS offers a means of supporting clinician learning, reinforcing decision-making, and enhancing the effectiveness of the evaluation. ■ To achieve successful education and learning experiences for new clinicians, managers should consider the personal characteristics and learning needs of the clinician, and ensure appropriate resources and supports are available to meet those needs. ■ Clinicians must take responsibility to identify their learning needs and be motivated to seek out learning opportunities that will foster expertise. ■ Sustaining quality and effective services in this specialized area also requires recognition and support for experienced clinicians charged with mentoring new clinicians.
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International Journal of Therapy and Rehabilitation, March 2011, Vol 18, No 3
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