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Teresa M. Chan
Authors: Mark Keuchel, D.O.,Al’ai Alvarez, M.D.,Curtis Knight, M.D.
Editor: Teresa Chan, MD, MHPE
A Case
The interns had an upcoming simulation module on placing central lines. A small group of them decided to show up early to play around with the equipment and see if they can practice on their own. Each of them had either seen one performed or got to place one during medical school. Everyone had an idea of what the correct steps were and each one felt comfortable practicing without the assistance of an instructor giving them direct feedback.
John, one of the interns, grabbed the syringe and attempted to cannulate the internal jugular in the mannequin. He kept poking the neck and was getting frustrated. Jill, recalling some steps from when she did placed a line, took over. She started telling John her version of how it should be done. Jim read out loud the steps emailed for their asynchronous learning as Jill continued to attempt with the cannulation. Everyone was feeling frustrated without the teacher.
Overview
Dr. Laura Joplin’s theory suggests that all learning is experiential. According to Joplin’s theory, a person learns from “experiencing” and interacting with the subject. Dr. Joplin felt that experiential learning programs had two main responsibilities to the learner:
- Provide an experience
- Provide a reflection period on that experience.
These two phases of learning are joined in the “action-reflection” cycle. According to Joplin, the simple provision of an experience by itself is not sufficient for learning; a learner’s reflection on the action is of critical importance.
The five-stage model describes an experiential learning strategy that combines the following stages: 1) Focus; 2) Action; 3) Support; 4) Feedback; 5) Debrief.
Feedback and support are critical throughout the process from the moment of initial action through the conclusion of the learning experience. This framework gives educators a model to deliberately strengthen the experiential nature of their course design, highlighting that it is the educator’s responsibility to provide a learner-centered education.
Main Originators of the Theory
Laura Joplin
Background
Joplin’s five-stage model was created to be intentionally simple and define the act of learning, but is not a learning theory itself. The model is organized around a ‘hurricane-like cycle’ in which a challenging action occurs between the initial focus stage and the final debriefing. These ‘action-reflection’ cycles are differentiated from experience alone by incorporating a reflection process. The application of the cycles can be in either a ‘maxi’ or ‘mini’ scope, depending on the intent of the project; the cycle can focus on large-scale course design or a brief teaching moment or insight.
The first aspect of the model is the focus stage. It is here that the educator identifies the task and the attention of the learner becomes engaged. The educator is tasked to shine light on a specific topic to help orient the learner. The education must also be cautious not to be too specific, as this cause learners to have tunnel-vision. The focus stage is necessary to align the learner’s attention with the educator’s goals. Actions in the focus stage depend on the type of activity to be performed. A focus stage may be as simple as verbally discussing the goals or it may be more complex, such as reviewing an article before an action.
The second part of the model is the action stage. This stage of the model surrounds the learner in direct confrontation with an often-unfamiliar situation requiring the learner to engage in problem solving. The inherent stress of the situation gives the learner an “experiential” learning. Active learning is facilitated by participation rather than passively reading or watching a video. The learner must be given “responsibility” in the learning process, a component that is absent in textbooks where the author decides the sources. The education is responsible for ensuring the learning difficulty is appropriate for the learner. By actively engaging the learner, the brain is considered “on” and the new information can be processed and retained.
Modern takes on this Theory
The intentional aspect of Joplin’s five-stage model of experiential learning requires time and work that may not always be feasible in the clinical setting. Moreover, there is a generational difference in perception of teaching and learning. Because Joplin’s model can be applied in a “maxi” and “mini” scope, it is easily translatable in a busy shift. Knowing the five stages is important, and deliberate signposting of these steps may help learners better appreciate the process. Here’s how:
- “Let’s focus your attention to the way you’re holding the syringe.” [focus]
- “I’m going to give you feedback on what I’m seeing you do and how it may affect the success of your venous cannulation.” [reflection: feedback]
- “I’m going to give you a more specific feedback. I’m noticing your angle is too steep. How can you optimize this to allow the wire to thread easily?” [specific feedback, challenging]
- “I like how you’re stabilizing your hand as you advance the guidewire through the needle. It helps prevent kinking of the wire.” [specific support]
- “That’s great. You’ve advanced the wire successfully, and I’m noticing that you’re holding the wire carefully so as not to lose it. How do you want to proceed?” [debrief]
In a “maxi” application of Joplin’s model, consider the process of training as a team for a SimWars competition. A group of residents are selected to represent the department. Each one has a specific skill set needed for success, yet team cohesion is a very important characteristic of a winning team. A deliberate focus on developing this sense of teaming is a must. As the team practices different approaches to crisis resource management, the team must reflect on the efficiency and effectiveness of their communication styles. This aspect of teaming must be intentionally and consistently supported. The feedback must also be specific regarding the delegation of roles, the use of closed-loop communication, and the appropriate tone and delivery of orders. For every iteration, each of these areas must be addressed for improvement, including highlighting successfully performed tasks. Ultimately, the five stages are repeated using multiple sources of feedback; support and challenging occur as the team advances. Once ready, the team will demonstrate a well-rehearsed, cohesive implementation of crisis management. A final debrief is critical in order to further emphasize areas for improvement and celebrate successes.
Other Examples of Where this Theory Might Apply
Another example for the use of Joplin’s five stages is the framework for a residents-as-teachers model. By clearly defining the steps in successful learner-centered teaching, a junior teacher (residents) are able to be deliberate in their approach to teaching. Not only will they gain experience in mastery of the topics they are teaching, they will also apply the metacognition of effective teaching styles.
Limitations of this Theory
Joplin’s five-stage model is clear, deliberate and learner-centered – but teacher intensive. The time requirement and effort required for preparing adequate experiences and creating the feedback and debriefing to match the initial experience is not to be taken lightly. In order to be effective, Joplin’s five-stage model requires time and intentionality. On shift teaching using Joplin’s model may not be feasible as we often cannot put a patient through several iterations of a procedure. From a learner’s perspective, learning in this model can be exhausting, thereby defeating the point of a learner-centered teaching. It is important to cultivate buy-in from the learner and acknowledge early on that rapid cycles of observation and feedback may lead to feedback fatigue. Frequent check-ins are important, and the teacher must create a supportive learning climate for the learner to work independently with fewer intrusions.
Returning to the case…
The group of interns realized that experience alone is not effective to learn how to place central venous catheters. They needed an instructor to tell them what they were doing right and what they were doing wrong. When the teacher arrived, she used Joplin’s five-stage model to provide a deliberate method for reflection at each step of the cycle. This encouraged them to develop mastery at each step of the process. The key is not to simply be lucky with cannulating the vein. An experienced teacher can help guide the process and solidify technical skills for each step. The teacher offered individualized support for each learner. She gave specific feedback in the moment along with appropriate corrective actions. The teacher provided support for successful completion of each task. At the end of the workshop, each of the learner felt confident about their skills and was able to demonstrate mastery of the procedure. A debriefing session followed to discuss scenarios and offer troubleshooting tips. Simulation workshops are a great way to teach procedural skills, especially using Joplin’s five-stage model of experiential learning.
References
- Andreasen RJ and Wu C. Study abroad program as an experiential, capstone course: A proposed model. Journal of International Agricultural and Extension Education. 1999;6(2): 69-78.
- Joplin L. On defining experiential education. Journal of Experiential Education. 1981;4(1):17-20.
- Kolb DA. Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall; 1984.
- Torock JL. Experiential learning and cooperative extension: Partners in non-formal education for a century and beyond. Journal of Extension [On-line]. 2009;47(6) Available at: https://archives.joe.org/joe/2009december/tt2.php
Annotated Bibliography
1. Joplin L. On Defining Experiential Education. Journal of Experiential Education. 1981;4(1):17-20.
This paper introduces the idea of the 5-stage model of experiential learning. Her model is organized around a “hurricane-like cycle” emphasizing a challenging action that occurs between an initial stage of focus and a final debriefing stage. Feedback and support are present throughout all stages.
2. Kolb DA. Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall; 1984.
This book by Kolb built upon earlier work and lead him to believe that knowledge acquisition was obtained through “transformation of experience.” His theory had 4 stages in a cyclical pattern: concrete experience, reflective observation, abstract conceptualization, and active experimentation. This is an interesting theory that overlaps and augments the work of Joplin and is worth comparing and contrasting.
