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Radiography 17 (2011) 28e32

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Radiography

journal homepage: www.elsevier .com/locate/radi

The development of an innovative approach to postgraduate ultrasoundeducation: An evolving process

Vivien Gibbs*

Faculty of Health & Life Sciences, University of the West of England, Glenside Campus, Stapleton, Bristol BS16 1DD, United Kingdom

a r t i c l e i n f o

Article history:Received 22 March 2010Received in revised form1 June 2010Accepted 5 June 2010Available online 13 July 2010

Keywords:Postgraduate educationUltrasound educationAction based learningEnquiry based learningLife long learning

* Tel.: þ44 117 328 8412; fax: þ44 117 328 8437.E-mail address: vivien.gibbs@uwe.ac.uk

1078-8174/$ e see front matter � 2010 The College odoi:10.1016/j.radi.2010.06.002

a b s t r a c t

Increasing economic pressures on higher education institutions to limit the number of modules offered,together with the conflicting pressure from hospital departments requiring an increasingly skilled andflexible workforce, have resulted in the requirement for a more creative approach to delivery ofuniversity postgraduate programmes. One approach implemented at the University of the West ofEngland, Bristol was to extend the role of an Action Based Learning (ABL) module within the MedicalUltrasound programme.

Following completion of the first year of this newly accredited module, the experiences of studentsand staff were evaluated. Results of the evaluation and feedback demonstrated both positive andnegative features of this style of learning, and the programme team decided to use this feedback toenhance the student experience for future cohorts undertaking the module.

The second delivery of this module is now complete, and the module has again been evaluated. Thefollowing article discusses the evolutionary process involved in developing this module, and reviews theenhancements introduced over a two-year period.

� 2010 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

1. Introduction

The University of the West of England (UWE) has been deliv-ering postgraduate healthcare programmes since the transition ofhealthcare education from the hospital environment to the highereducation sector in the early 1990s. In 2000 a Medical Ultrasoundprogramme was introduced. Numbers were initially small but theUniversity subsidised the course from undergraduate funds.

When the programme was due for revalidation and reac-creditation in 2007, the economic climate was changing and thecourse team was aware of the requirement from the University toonly run modules which were economically viable i.e. witha minimum of twenty students registered. In order to remaincompetitive with other Ultrasound training providers, it was notpossible to increase fees for the modules to reflect the smallnumbers accessing these modules. This however, conflicted withthe growing demands from clinical ultrasound departments to sendstudents for training in a wide variety of subjects. The rapiddiversification of Diagnostic Ultrasound scanning into an everincreasing number of sub-specialty areas, was leading to requestsfrom departments wishing to train staff in an increasing number of

f Radiographers. Published by Else

specialty areas such as breast, paediatric, and musculoskeletalscanning, which would have resulted in a number of new moduleshaving to be created, each of which would probably have less thanfour students enrolled. In addition, the accrediting body, theConsortium for the Accreditation of Sonographic Education (CASE)requires students to experience interaction with a variety ofstudents, in order to benefit from a rich learning experience.

The revalidation of the programme provided an opportunity toconsult with clinical leads and specialists in order to re-think thestrategy for ultrasound training, and it became apparent that onesolution to this problemwas to utilise a generic ultrasound practicemodule where students studying different specialty areas would beregistered on the same module.1 In order for this to worksuccessfully, students would be required to negotiate and takecontrol of their own learning process. The module was entitled‘Negotiated Specialist Practice in Ultrasound’ (NSPUS) module. Aswell as ensuring a larger cohort of students on the module, thissolution would have the additional benefit of requiring students totake control of their own learning process rather than beinga passive recipient of knowledge delivered by others.2 This isgenerally considered a more effective method of learning, partic-ularly at postgraduate level.3

The Negotiated Specialist Practice module is delivered using anAction Based Learning (ABL) format where students are facilitatedby an experienced ABL practitioner. ABL was originally described by

vier Ltd. All rights reserved.

V. Gibbs / Radiography 17 (2011) 28e32 29

Revans4 as a process used in industry to help managers to improvetheir performance. The process has subsequently been adapted foruse in education to promote independent learning, by encouragingstudents to develop knowledge and abilities specific to individualstudent needs.5 The NSPUS module typically consists of a numberof students who meet together regularly to present problems totheir peers in order to find ways to overcome them. The role of theother members at this point is to listen and support the student inmoving forward with the problem or issue. An experienced facili-tator is initially required until the students feel confident to run theprocess themselves.1

2. The Negotiated Specialist Practice Ultrasound (NSPUS)module

2.1. First year of module delivery

Students enrolled on the NSPUS module are initially required tomeet with the module leader and the clinical supervisor to nego-tiate and define exactly what the area of study will encompass.They then need to write their own strategy for learning at the startof the course, and identify (in negotiation with the module leader)what activities will be undertaken to achieve the module learningoutcomes, and exactly how each of these will be assessed withinthe framework of the module. Attendance at the University isrequired for approximately one day every three weeks, andstudents spend the first 2 h of the day working in their smalllearning ‘sets’4 or groups, identifying problems encountered withtheir learning process, either theoretical or practical. For the firstyear of delivery of the module at UWE, students in each group wereall studying different specialty areas of ultrasound, but feedbackfrom participants indicated that it would be more advantageous ifstudents were put into groups with others studying a similarsubject area. It was originally assumed that diversity of experiencewithin a group would result in valuable discussions and viewpointson how each student could best tackle their particular problem. Inmany cases this did happen, and beneficial interactions wereobserved. However, because of the feedback received from partic-ipants, for the second delivery of the programme this strategy wasreconsidered, and students are now divided into groups studyingcommon subject areas where possible.

During the day of attendance at UWE, students have a certainnumber of subject specific lectures and workshops. A number oflecturers are involvedwith themodule, acting as both facilitators forthe learning sets, and as personal tutors. Each student has individualmeetingswith their tutor, but in addition theycan contact their tutorat any time during the module via email or telephone. Moduleleaders post information on an electronic notice board whichstudents can access off-site. Despite some structured theoreticalsessions, the concern is often that students feel they are teachingthemselves. However, this is not a weakness of the ABL process, butrather its strength as it promotes independent learning.6

For the first module delivery, students were given only minimalformal lectures, but rather were given a framework on which tobase their study. This style of learning is a difficult concept forstudents beginning the module. Students often struggle to makesense of ABL initially,7 and clearly are often placed outside of their‘comfort zones’. Requests were made by students at the beginningof the module for a more didactic style of learning, where theycould sit in a classroom and be delivered knowledge in the form ofa lecture, with slides and handouts. It was observed that as themodule progressed, some students began to realise what wasexpected of them, andmove away from the traditional expectationsthey originally began with. These proved to be the minority,however, as feedback at the end of the module revealed that the

majority of students felt they would have benefited from a morestructured approach.

Following the delivery of the first year of the modules to 34students, the module leaders distributed a standard universityevaluation form, plus an additional questionnaire designed toobtain details on the student experience of the ABL process. Thisquestionnaire was posted to all students with a pre-paid returnenvelope, and results were collated. Questions on the form werea combination of closed and open-ended, in order to elicit focusedand constructive feedback. The questionnaire was designed to bestraightforward to complete, to encourage a good completion rate.Students were strongly encouraged to return forms in order toprovide the course team with information to improve the modulefor future intakes.

Following the first module run, 26 forms were returned in total,giving a 76% response rate. Results from the first module run wereanalysed and published.1 Student feedback revealed mixed atti-tudes to this style of learning. Useful information was achievedfrom this first module run evaluation however, and the moduleteam took the opportunity to review this and implement appro-priate modifications to the subsequent delivery.

2.2. Second year of module delivery

Overcoming initial student resistance has been a feature of themodule, and methods for countering this were put in place for thesecond intake. Following discussion, the module team decided toincorporate an additional element into the second module run inthe form of Enquiry Based Learning (EBL). EBL is student-centred,highly interactive and uses triggers to provide a starting point fordiscussion and acquisition of knowledge.8 It involves working insmall groups facilitated by a member of staff whose role is tosupport and interact with the group. The triggers generatediscussionwhich leads to further exploration.9 Its introduction intothe module took the form of students being given a trigger taskrelated to their area of study, during their attendance at UWE. Thesetriggers took the form of, for example, either specific questions orcase study scenarios, and were designed to give a focal point forstudents to independently research.10 The actual method of enquirywas left up to the students to formulate within their groups, but theobjective was to research the topic and bring back the knowledgeobtained relating to the trigger question, and share it with thewhole class.

An additional feature introduced into the module for the seconddelivery was to ensure students were initially given more guidanceon the ABL process, and that they all did the required backgroundreading around the subject. Despite being directed to do this on thefirst module run, it was apparent that most students had notundertaken the required research into the topic, and it was onlywhen nearing the end of the module that they realised what theprocess involved. As a result, the second cohort of students wasgiven the task of writing a 400-word referenced report on theprocesses of ABL and EBL, and to submit it to their tutor after thefirst week. This ensured the students did the required investigationinto the topic, and ultimately led to fewer complaints about failingto see the relevance of the ABL process.

Group sizes were reduced from the previous ten students on thefirst module run, to no more than seven. This reduced the amountof time required for students to listen to each others problems andreduced the likelihood of students losing concentration during theprocess. The smaller group size however, resulted in more groupsand a subsequent shortage of facilitators; the ideal of one facilitatorper group was no longer possible. To overcome this, ‘floating’facilitators had to be used to move between groups giving guidancewhere possible.

V. Gibbs / Radiography 17 (2011) 28e3230

After the first module delivery, a minority of students admittedthat their information technology (IT) skills were not adequate toenable them to fully engage with the blended learning aspects ofthe module. As this was a major component of the module, thesestudents were inevitably disadvantaged whilst struggling to obtainthe necessary skills. Although help is available for students, manywere unaware before starting the programme that they needed toimprove their IT skills. It was therefore made explicit to all studentsregistering for the second run of the module that appropriate ITskills were needed before beginning their studies.

3. Methodology

Following the second delivery of the module, an evaluationquestionnaire was distributed to all participants, but to ensurea higher completion rate, these were given to all students on thefinal day of attendance and students were required to hand them inanonymously before leaving. The questionnaire was based on theoriginal questionnaire given to students after the first moduledelivery, but with the addition of two extra questions asking aboutthe EBL process. It was designed to elicit qualitative constructiveresponses, and took the form of both closed and open-endedquestions. Students were encouraged to give honest responses inorder to guide the module team in future delivery of the module. Inaddition, the final session of the module encompassed a discussionforum with students and the module leader, where students wereencouraged to give honest, constructive feedback on their experi-ences of the module.

The module team is composed of four lecturers, and this teammet at the end of the delivery of the module to feedback anddiscuss their views on the strengths andweaknesses of the module.Student responses were also reviewed at this meeting. Staffcomments were recorded, fed into the process and actionedaccordingly.

4. Results

For the second module run, 36 students were given question-naires; 32 were returned, giving a response rate of 89%.

Table 1 demonstrates responses to the questions following thesecond delivery.

Question Yes No

Having engaged with the ABL process, do you appreciate itsrelevance to this work based learning module?

30 2

Do you think that you have obtained a sound knowledgebase with regard to the ABL process?

27 5

Having engaged with the EBL process, do you appreciate itsrelevance to this work based learning module?

32 0

Do you think that you have obtained a sound knowledgebase with regard to the EBL process?

31 1

Did the module have enough subject specific theoretical content? 26 6Did you have problems engaging with the self-study aspects

of this module?5 27

Comments from students revealed more enthusiasm for themodule than those received from the first cohort. There was stillsome ambivalence towards the ABL process, and requests for moresubject specific lectures were again made. This was outweighedhowever by the positive reaction of students towards the EBL styleof learning which had undoubtedly focused the students’ learningby requiring them to explore a topic with a particular question inmind. The students had all decided to work in their ABL groups forthis learning process, dividing the topic into smaller areas fordifferent individuals to explore. This had served not only to reduce

the amount of work required by individuals, but also to bond thegroup members whilst working together. Comments were receivedstating that this process was more time-consuming than beingdelivered the information by a lecturer, but most of these state-ments were tempered by the realisation that their learning wasactually deeper and longer-lasting because of the enquiry basedapproach.

Feedback from the EBL process was very favourable, andstudents found this tool to be particularly useful in both directingtheir learning and expanding their knowledge. Studentssuggested that because it was a particularly effective element of themodule, that it could be used more extensively. The students alsoreported that because they had to explore a particular subjectthemselves, they not only developed a greater understanding of thetopic, but also noted improved memory retention and recall.Furthermore, feedback from the clinical assessors following thestudents’ final clinical assessments, confirmed that the knowledgebase demonstrated by the majority of students was high.

Six students thought that there should have been more subjectspecific theoretical content, and this reflected the views of thosewho would have preferred more theoretical lectures. This is linkedto the previous comments relating to the time-consuming nature ofthe EBL and ABL processes, and the general feeling of students thatsitting in a lecture is a less demanding process, albeit not aseffective.

The previously expressed irritation with the ABL style oflearning was not as apparent as on the previous module delivery,and the course team attributed this primarily to the research andwriting up of the ABL process that all students were required tocomplete at the beginning of the module. At the time, this was nota popular process with the students, who would rather have beenspending time researching their professional practice area.However, all students did undertake the activity, and demonstrateda greater understanding of the process at an earlier stage in themodule.

The support received from fellow students was again noted inthe comments as being a powerful learning tool. This was apparentin both the EBL and ABL processes. Individuals stated that they hadreceived invaluable advice from others in the ABL learning groups,and one student admitted that they would probably have with-drawn from the programme if it had not been for the support theyreceived from their fellow group members. Several students com-mented that it was reassuring during the discussions to discoverthat others in the group were suffering from similar problems andcrises of confidence as they were encountering, and that theprocess of sharing these experiences was a supportive, strength-ening process.

Students commented that the learning groups had worked wellbecause of the common subject focus that was provided by puttingstudents in groups with a similar focus. When specifically askedwhether they would have preferred to be mixed with studentsstudying other topic areas, there was strong feeling that this wouldnot be appropriate. Students who were put in with studentsstudying completely different areas (due to lack of numbers in thatparticular subject area) felt that they were slightly disadvantaged,but had managed to find some commonality of themes and sharingof experience.

Students did feel that the size of the groups with maximum ofseven, was about right. It was thought that this enabled variedfeedback from within the group, but avoided potentially longdiscussions which would have occurred with a larger group.

Several students commented that they felt disadvantaged by nothaving a facilitator with them during the whole of the learning setdiscussions, particularly in the early stages of their studies. Theyfound that a facilitator provided more structure to the sessions and

V. Gibbs / Radiography 17 (2011) 28e32 31

kept the discussions more focused. The course team realised thatthis was a potential weakness and will be endeavouring to ensurethat more staff are available to participate as facilitators on futuremodule runs. However, an alternative approach which will be triedis to ensure each group elects a leader to take on the role of keepingdiscussions focused and structured. A facilitator will need to beavailable in the early stages of group formation, but should be ableto withdraw if the group has an effective leader.

5. Discussion

The diversification of healthcare education into numeroussubject areas puts pressure on providers of postgraduate educationto deliver programmes with an ever increasing number of subjectspecific modules. However, higher education institutions will notbe able to sustain this expensive form of education in the currenteconomic climate, and alternative approaches need to be found.

The programme team at UWE realised that a new style ofdelivery was required in order to meet the new challenges. Inves-tigations suggested that an ABL approach would be a potentialsolution to the problem. The introduction of any new features intoa programme require evaluation to determine the effectiveness orotherwise of the changes. It was apparent that in order to achievesuccess with the introduction of this NSPUS module, it wasimportant to monitor the progress of the students in at least thefirst two cohorts. To do this it was decided to obtain in-depthevaluation from both the staff and students of this radical newmodule, following completion of the first year of delivery. Thisfeedback from students proved invaluable, and was used toenhance the following year’s module.

Modifications were made to the second delivery of the UWEmodule, incorporating the feedback from staff and students. Eval-uation of the second delivery was more favourable than thatobtained from the first year. The modifications and enhancementsintroduced were positively received by both students and staff.Those students who successfully completed the module havedemonstrated that they clearly invested much time and energy inacquiring new skills and knowledge. In addition, student assess-ment results demonstrated that a high level of achievement hadbeen attained by the majority of the students.

The addition of EBL into the second module proved to bea positive enhancement, providing a focus to direct students’acquisition of knowledge. This method of learning uses a process ofenquiry and investigation, but importantly the student needs totake ownership of their learning.9 Often a group setting is used,with each member of the group focusing on the same trigger andreporting back their findings to the group. This process is designedto stimulate personal motivation within the student to achievelearning objectives and goals.11 The introduction of EBL served tocomplement the ABL process, by providing additional subjectspecific guidance, whilst still requiring students to acquire knowl-edge for themselves.

Overall this style of learning requires fewer staffestudentcontact hours, but enables a more focused and effective use of stafftime. Although additional staff are required to act as facilitators forthe learning sets, this is limited to a maximum of 2 h a day for eachof the students’ attendance days. Staff are required to be availablefor advice and guidance for the students’ individual study, but thiscan often be achieved electronically, thereby enabling a more effi-cient use of staff time.

Students’ initial reactions to new styles of learning havedemonstrated a degree of difficulty with the process. They exhibitsigns of being unsure about what is expected of them, and oftenirritation at the realisation that they need to be far more proactivethan in the more traditional lecture-based style of learning.

However, lecture-room delivery of learning for small groups isexpensive, and not sustainable in the current economic climate. Thecourse team at UWE has demonstrated that by careful monitoringof the implementation process of changes to the programmedelivery, modifications can be made until the module has evolvedinto an acceptable format for both students and staff.

Reductions in training budgets, conflict with the requirementfor documented evidence of Continuing Professional Development(CPD) in order to retain professional registration, and this putsadditional emphasis on the requirement for more creative methodsof education delivery. The ability of professionals to be able to learnindependently and move away from an expectation of classroombased learning throughout their careers, will feature more promi-nently in this requirement for fulfilling CPD obligations.12 Hem-mingham3 observes that learning is more effective whenindividuals take responsibility for their own learning. Rather thanexpecting to be handed information, a more effective method ofacquiring new knowledge is for students to learn how to becomeindependent life long learners. Any student embarking on a pro-gramme of study needs to remember that whatever is to be learnedmust be learned by the student, and that active participation has totake place in the learning rather than passive listening. Trainingprogrammes therefore need to engender a sense of ownership andresponsibility within the student.

6. Conclusion

Most individuals consider the learning process to consist ofsitting in a classroom trying to absorb information given to themby someone considered to be knowledgeable about the subject. Inhealthcare education over the past few years there has beena growing realisation that we need to move away from formalclassroom learning towards a more clinically based style oflearning. Much research has been undertaken around effectivelearning processes which demonstrate that significant learningonly takes place when individuals accept responsibility for theirown learning, and actively participate in the learning process.Programme leaders therefore need to ensure they facilitateopportunities for the learner to be proactive in the learningprocess.

In these financially straitened times that the public sector findsitself operating in, pressures will grow for more cost-effective waysof delivering effective healthcare training. The scenario wherebypostgraduate students sit in a class of less than twenty individualsis too costly in terms of resources, andwill need to be reviewed. Theuse of ABL and EBL within the curriculum is a potential solution, asit provides for a more effective use of academic staff, where tutorscan provide focused support for individual students. If usedappropriately, the integration of Action Based Learning and EnquiryBased Learning are useful tools to successfully deliver modules atpostgraduate level. Resources can be more effectively utilised byreplacing classroom based lectures with more appropriate learningmechanisms. These not only encourage students to support eachother in their studies, but also rely on students taking responsibilityfor their own learning, to ensure the learning is deeper and moreeffective. Once students have grasped the concept of these newstyles of learning, they will come to appreciate that these arepowerful tools that can be used in many aspects of life to acquirenew skills and knowledge.

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