The changing role of the paramedic demands that they are able to process often complex information, in often unfamiliar circumstances, to formulate treatment plans in order to provide the best possible care for patients. The paramedic's job is carried out against a background of National Health Service (NHS) cuts and increasing pressure upon acute services. To make these decisions, and to ultimately provide the best possible care for patients, requires in-depth assessments, conclusive history-taking and the ability to make effective clinical decisions. Effective clinical decision-making requires the ability to analyse information to make complex and intricate decisions that are best for the patient (Aleem et al, 2008). Higher education is crucial for the profession and, by 2019, the College of Paramedics aspires to have all paramedics entering the register educated at BSc level (Lovegrove, 2013). The reason for this is the evolving need for paramedics to effectively treat and refer patients in the community, become more autonomous and work across professions and disciplines (Lovegrove, 2013). The modern paramedic needs to be a critical thinker and lifelong learner, knowing how to access high-quality resources and apply evidence into practice. These skills should be at the core of a BSc Paramedic Science curriculum.
Scholarship of teaching
Ramsden (2003) highlights that students will not automatically learn the skills required to critically analyse, to link ideas and to apply them to real-life situations. Education needs to be designed to enable the student to learn in such a manner that these skills become inherent. Trigwell et al (1999) suggest that the quality of teaching is inextricably linked to, and measured by, the quality of learning.
Boyer (1990) introduced the idea of scholarship of teaching. It is a focus upon the knowledge of evidence relating to pedagogy and the act of teaching, as well as reflective practice, that together result in engagement of the student (Boyer, 1990). It is proposed that by analysing and applying pedagogical evidence we can improve the quality of our teaching and the quality of student learning. Application of ideas, both in health care and in teaching, can be difficult, because both settings are dynamic environments where rigid ideas can be troublesome to apply. Similarly, the needs of paramedic students may be different to the needs of other students. Therefore, reflection on practice is important in order to move knowledge and application of scholarship forward.
Deep learning
Marton and Saljo (1976) first described the concepts of deep and surface learning as the two ways in which information is processed by students. Surface learning is when students learn to regurgitate information without any understanding of what it means. Information is not processed or analysed in any meaningful way. In addition, surface learners are unable to link concepts and previous learning to new learning (Ramsden, 2003). This type of learning can be effective in enabling students to pass exams or perform procedures such as an intramuscular injection. In contrast, deep learners look at the meaning behind information. They analyse what the information means, not taking things at face-value. As a result they are able to link new ideas to previously learned ideas. They are also able to link ideas to practice and put new ideas into a context they already understand (Ramsden, 2003).
So in order to be a critical thinker and to implement the level of analysis required to make good clinical decisions, based upon linking information received from the patient with previously learned information, the modern paramedic student needs to be a deep learner. McManus et al (1998) found that medical students performed better in both final examinations and in practice when the students used deep learning techniques. This study is slightly dated, and in addition they seem to emphasise that students are inherently deep or surface learners, which is not a viewpoint that all of evidence agrees with.
Beattie et al (1997) suggest that the approach to learning can be determined both by the students' personalities, motivations and preferred study methods as well as by teaching styles, learning tasks and assessment strategies as determined by the lecturer. It seems reasonable to consider that approaches to teaching provide the opportunity for either deep or surface learning, but that there are internal factors of the student that also affect it.
This article will primarily focus upon the planning and implementation of teaching paramedic students to encourage deep learning. It will analyse the components of teaching and learning that can be used to encourage deep learning and will reflect upon the implementation of scholarship evidence into the teaching process in order to improve the quality of teaching.
Case study
The case study focuses on a series of two lectures that were delivered to 28 second-year paramedic students on a Foundation Science Degree programme. Both lectures were on the subject of history taking. History taking is a process of asking the patient/relatives questions in order to find out the exact nature, and history, of the illness they are presenting with. Some sources state that history taking forms 80% of the diagnosis (Scott, 2014), so it may be said that it forms the most important part of a patient contact. History taking needs to be focused on the presenting problem, and dynamic in response to the answers received. If done badly then the patient's problem may seem confusing and thus a diagnosis may not be reached or be incorrect. To do well it requires the attributes of deep learning: analysis, knowledge and the ability to link old and new information to form a diagnosis. It is for these reasons that history-taking lectures were chosen for the case study.
Biggs and Tang (2011) highlight the importance of constructive alignment when planning teaching activities. The fundamental basis of constructive alignment is that both teaching and learning activities and assessment strategies are aligned with the learning outcomes. This is important to ensure that all the components of the design of teaching activities are focused upon the overall outcome for all students. The fact that the learning outcomes are so fundamental to the design of the teaching activity demands that they are discussed first of all.
Intended learning outcomes
Once the topic of the case study was known, the intended learning outcomes (ILOs) were the first aspects of the teaching plan to be considered. Biggs and Tang (2011) highlight that ILOs are activities that the student can perform that could not be performed previously. So it is important to consider what level the students are currently at and where we want them to be by the end of the lectures. The two ILOS are outlined in Box 1.
In this case study it is feasible that many students were already familiar, to a greater or lesser degree, with the process and structure of history taking.
What this case study was attempting to achieve was for the students to be able to analyse information received from that process in order to inform further questions, and subsequently provide a provisional diagnosis. Therefore, the ILOs needed to represent the fact that students need to be able to both follow the structure of history taking, which would be considered a more surface-approach activity, and be able to analyse findings and link it to previously learned knowledge—very much attributes associated with a graduate and deep learning. The latter is the activity that would largely be new to students. Biggs and Tang (2011) state that ILOs should be student-centred and from the students' perspective.
The choice of verbs is essential when designing ILOs because they let the teacher and student know the level at which the activity is expected to be performed (Ramsden, 2003). For example, are students expected to merely describe information, which may encourage students to merely regurgitate rather than understand information, or are they required to analyse information, which would require a deeper approach to the material? In answering these questions we must consider the academic level the students are at (Biggs and Tang, 2011). Bloom's Taxonomy was designed to provide a taxonomy of cognitive understanding, from knowledge at the bottom to evaluation as the highest form of cognitive understanding (Luebke and Lorié, 2013) (See Figure 1). At each cognitive level Bloom gave examples of verbs that can be used at each stage.
The verbs in ILO 1 ask students to outline and explain. These are lower-order intellectual verbs that ask the student to show knowledge and comprehension to go through the process of history taking. Luebke and Lorié (2013) highlight that in order to reach higher score domains of Bloom's Taxonomy students are required to have already achieved the cognitive domain(s) below. Therefore, ILO 1 sets the baseline for knowledge and understanding from which students can build to achieve a higher level of cognitive intellect around history taking.
ILO 2 uses the verb ‘evaluate’, which was used to highlight to students that a much higher level of cognition was needed to achieve this ILO. However, this verb is asking for students to be working at the evaluation level of Bloom's cognitive intellect, which is the highest level (University of North Carolina at Charlotte, 2015). Although possible, it is very difficult to miss out levels of intellect in the pyramid and this ILO, in hindsight, misses out the analysis and synthesis stage. Students who do achieve the evaluation level, by definition, will be have demonstrated all levels in Bloom's cognitive domain. However, the result is that the ILO is unachievable for many other students, which is a fundamental characteristic that an ILO requires (Biggs and Tang, 2011).
Biggs and Tang (2011) highlight that the verbs used in ILOs should be the minimum achievements that are required from students. In ILO 2 it seems that the verb may have been used as an aspirational verb, that is, looking at the best we hope the student to achieve rather than the minimum we expect. This could have potentially severe consequences upon engagement. A better verb to use would have been analyse, because this clearly demonstrates to students that they are required to achieve the analysis stage of Bloom's Taxonomy, which is the stage above application and a natural follow-on from the cognitive level of ILO 1.
Learning activities
Learning theories are concepts explaining the variety of ways that adults may learn (Brandon and All, 2010). Brandon and All (2010) highlight that not only should one consider how the student learns best, but also how they will be expected to use information once employed in the particular workplace. Constructivist learning is the main learning theory that was considered when designing these lectures. Constructivist learning is a process whereby the learner constructs their own knowledge rather than simply acquiring it from the lecturer (Brandon and All, 2010). It compels the learner to use old knowledge along with new knowledge to find answers to problems, to innovate or to reach conclusions. This approach has clear parallels to the core aspects of deep learning, and to the verbs such as ‘evaluate’ that are used in the ILOs that require the same thought processes.
The approach also draws parallels to Knowles' theory of andragogy which, although not heavily researched as a concept in practice, is becoming increasingly important in higher education. Andragogy is concerned with adult learning and the processes by which adults learn, as opposed to children. It is an approach to learning where the learner is central to the curricula and learning, the facilitator/lecturer and learner create knowledge together. Learners have control over how learning takes place (Knowles et al, 2011).
Both of these theories, if implemented correctly, help towards the goals of the ILOs in developing the students' ability to explain and evaluate the components of history taking. This was achieved by, in the first lecture, giving the students a presentation on the framework for taking a history and then asking them to split into pairs where they had to simulate taking a history from each other. To do this required them to use the framework they had learned but consider which questions were important to ask in a dynamic way, adjusting questions in response to previous answers.
The initial presentation helps students to scaffold information, that is they have a good basis on which to build their new information. Choe et al (2014) support the decision to design the lectures this way, finding that constructivist learning gave nursing students a much better ability to make the same decisions in practice.
In the second lecture, the learning activity required students to, one-by-one, contribute one question towards the history taking of a simulated patient. Therefore, as a class they had 30 questions. This required the students to consider the information that had been received in response to their classmates' questions and prioritise which question would be of most use to try to find a diagnosis. After every seven questions each student voted anonymously as to what they thought the most likely diagnosis was.
This activity required the students to build upon knowledge of signs and symptoms of specific diseases, prevalence of illnesses, and the framework for taking a history taking that had been learned previously. This drawing of previous information and considering it alongside new information demonstrated a constructivist approach to learning and encouraged the students to take a deep approach to learning, because they had to problem solve, analyse information and reach reasoned conclusions.
It should be mentioned at this stage that types of learning can occur concurrently. In this situation it could be hypothesised that social learning was taking place as well. Social learning is the theory that people learn from others by direct observation and imitation (Bandura, 1971). The students in this case may have learned from the way classmates phrased questions or the types of questions that they asked.
Lecture design
The delivery was to a class of 30 students. This would be considered a small group lecture (Ramsden, 2003) but is not small enough to be considered a seminar group (Becker and Denicolo, 2013). Small groups have the advantage of allowing spontaneity in relation to questions that arise from students (Ramsden, 2003), which allows for a mutual sharing and discovery of knowledge between students and lecturer—some of the principles needed for deep learning and constructivism. In addition, Springer et al (1999) found that small-group working was positively correlated with higher academic achievement across disciplines at university. Small-group learning can increase engagement by encouraging cooperative learning, which will increase student achievement (Gillies, 2006).
The type of teaching can have a large impact on engagement. Student engagement is a difficult concept to define and the complexity of its nature make student engagement a difficult, yet fundamental, aspect of education (Bryson, 2014). There appear to be intrinsic factors that affect engagement such as motivation, connection and a sense of belonging to learning communities (Salamonson et al, 2009). In addition, the learning environment and teaching approach can have a large impact on engagement, and all these factors need to be considered when designing teaching activities. Students were encouraged to take part in the lecture; they were regularly questioned; and, as mentioned above, as a result of their contribution they dictated the direction and content of the lecture to a certain degree. It also makes it easier to spot disengagement—for example if a student is texting, looking out of the window, talking with another student—and enables the lecturer to attempt to engage the student in the material.
Other techniques that were used, and considered effective to encourage engagement, were the use of appropriate humour throughout, sometimes overstating opinions in order to initiate passionate discussion, and the use of regular coffee breaks so that students do not drift off easily. However, there was a point during the first lecture where a number of students simultaneously expressed a wish to have a coffee break and in hindsight were becoming disengaged and distracted. At worst, this could have resulted in a number of students becoming disengaged, thus adversely affecting the students' learning.
Assessment
It is crucial that assessment is aligned with the ILOs as a measure of whether the lectures have met their aims. Assessment is the process of evaluation of both the students learning and the level to which the design of the course meets its aims (Jarvis, 2010). Jarvis (2010) highlights that assessment may not just be measuring facts that the student has learned, but measuring the process and levels of logic. The activities, one in the first and one in the second lecture, also act as feedback and assessment for the students. In the first activity peer assessment is used, where, in pairs, feedback is given on each others' performance. Nicol (2010) highlights that peer assessment and feedback encourages attributes that are principles of deep learning, such as critical thinking, self-motivation and awareness and evaluating knowledge.
Feedback and assessment in the second lecture is by peers and the lecturer seeing the types of diagnoses that the students consider. This is easily done because all the diagnoses appear, anonymously, on the computer software and are projected onto the screen. The assessment is much more about the cognitive process of reaching a conclusion rather than the actual diagnosis reached, which is supported by Jarvis (2010) as a legitimate assessment. This is because in practice good history taking is much more about good reasoning than about reaching, necessarily, a definite diagnosis. The feasibility of each diagnosis on the board was discussed in the group facilitated by the lecturer. All the suggested diagnoses were feasible, which is particularly pleasing because the lecturer designed the simulated patient to have vague and not characteristic symptoms of an illness. It is concluded that because of this all of the students were able to both analyse and evaluate the symptoms that they ascertained from history taking and formulate a reasonable diagnosis, as is required from ILO 2. It is likely that all students were indeed working at the highest cognitive level of Bloom's Taxonomy: evaluation.
‘Deep learning results in tangible improved outcomes for paramedic students and the evidence supports the use of teaching and learning methods that encourage it’
Inclusive learning
Hockings (2010) highlights the importance of inclusive learning, where teaching is designed to ensure that students' learning is meaningful, relevant and accessible to all. The biggest challenge when considering inclusive learning in the cohort of paramedic students in this case study is dyslexic students. The author knew the students well and was aware of the three dyslexic students in the cohort. The potential for disengaging dyslexic students and causing them to underachieve compared to their peers is significant. Many students feel that although institutional support may be good, individual lectures pose one of their biggest challenges to learning at university (Mortimore and Crozier, 2006). For this reason, the writing on the PowerPoint was kept to short bullet points, enriched by lecturer/student discussion and questions. In addition, many dyslexic students are strong verbally, so both activities that were largely verbal will not have put them at an educational disadvantage. The success of the design of the lecture with diverse learners in mind is supported by the fact that the ILOs were met by all learners.
Evaluation
Evaluation of the lectures was carried out in a number of ways. Firstly, self-evaluation is very important and this has largely been achieved formally through the construction of this article, and more informally with the mentor who observed the case study lessons. The mentor commented that students appeared engaged at all times and he felt that the more difficult task in the second lecture helped to engage the students further. This is an important point, that activities must be pitched at the right cognitive level for all students to avoid disengagement.
Some students, without being asked for feedback, commented in a very positive way about the activity in the second lecture. In particular, the use of the computer software to record diagnoses helped to engage them. They requested more activities that were like that. Ultimately, teaching is about providing the best learning experience possible and positive comments like that from the students is a very good endorsement for how well a learning activity has gone.
Conclusions
The design and implementation of the two lectures has good foundations in evidence. The ILOs seemed to align with the teaching methods, learning activities and assessments. The use of verbs in the ILOs, and the constructivist design of the teaching and activities added to the likelihood of students being given an opportunity to take a deep approach to learning. Student engagement was reflected upon and times when disengagement may have occurred were discussed. The strengths and weaknesses of diverse learners, particularly dyslexic students, were considered so that all students were engaged and achieved the ILOs. In the future, more care will be taken when designing the ILOs; the use of an inappropriate verb could have severe consequences upon the design of the lecture and student achievement.
Deep learning results in tangible improved outcomes for paramedic students and the evidence supports the use of teaching and learning methods that encourage it. The education of paramedics at higher education institutes is crucial if the profession is going to meet the needs of the modern NHS.