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Embedding a patchwork text model to facilitate meaningful reflection within a medical leadership curriculum

Charlotte moen, patricia prescott.

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Correspondence: Charlotte Moen, Post Graduate Professional Education, Faculty of Health & Social Care, Edge Hill University, UK. Email: [email protected]

Corresponding author.

Accepted 2016 Oct 22; Received 2016 May 3; Collection date 2016.

Keywords: Patchwork Text Model, meaningful reflection, medical leadership, curriculum

This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use of work provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0/

Introduction

In the UK following the Francis report there has been a focus on clinical leadership and medical engagement as it is recognised this is essential to improving patient care, safety, organisational performance and innovation. 1 This has resulted in the development of competency frameworks, the inclusion of clinical leadership within medical education and leadership and management standards for all doctors. 2 - 4

Reflection is key to good medical practice. 2 - 6 A reflective outlook raises consciousness, prompts movement from the routine of practice to its critical appraisal and drives change.  It is central to appraisal and medical revalidation. 5 , 6 , 8 Revalidation is the process by which all UK doctors demonstrate to the General Medical Council, though annual appraisals, they are up-to-date and fit to practise. 8 In order to provide this evidence, UK doctors complete a National Health Service reflective portfolio. The reflections are structured using the headings: Description, Feelings, Evaluation, Analysis, Conclusion and Action Plan.  For example the catalyst for reflection for an anaesthetic trainee may be performing an epidural, whilst observed by the consultant, who then ‘signs off’ for that procedure.  However the current process has been perceived as a ‘tick box’ exercise. 5 - 7 In order for reflection to become meaningful it is critical, to develop a curriculum where reflection is meaningful, authentic and tailored to the individual. 

Meaningful reflection within a medical context

Meaningful reflection occurs where reflection transcends the level of the action, to the deep exploration of underlying beliefs, attitudes and behaviours, 5 , 6 in other words the scrutiny of personal paradigms. The key to learning from significant experiences is  the movement from the narrative, surface approach to the deeper interrogation of learning, as well as developing self-awareness in order to identify development needs. 6 Additionally, appreciating differing opinions, for example those of peers, patients and supervisors encourages the development of new insight and the transformation of perspective. 

There are multiple perceived barriers to written reflection. Medical practitioners may not value written reflection, if it is a requirement. 5 - 7 There is a perception of the time consuming nature of reflection, the reluctance to question one’s own practice and uncertainty of expectations. 6 , 7 All of which might lead to a default, shallow engagement with reflection meeting threshold requirements, without commitment to the process.

It is apparent reflection is essential to a doctor’s personal development as well as to enhancing patient care. However it is clear there are some complex issues; whilst verbal reflection is acknowledged to be natural, written reflection, in an academic context at master’s level can be a significant challenge.

A patchwork text approach

A Patchwork Text approach (PWT) 9 is defined as:

 “... a variety of small sections, each of which is complete in itself, and that the overall unity of these component sections, although planned in advance, is finalised retrospectively, when they are ‘stitched together’. Thus a ‘patchwork text’ assignment ... is gradually assembled ... and consists of a sequence of fairly short pieces of writing”. 10

The PWT approach promotes critical understanding particularly where insights into personal paradigms are a significant aspect of the learning process. There are several different designs however within each approach there are common elements that adhere to fundamental objectives: (a) continuous learning, (b) deep learning, (c) integrated understanding of a topic and (d) meta-cognitive self-reflection on the learning journey. 9 Based on these objectives, a core set of elements (multiple assessment tasks; pacing of tasks and the integration of work into a comprehensive whole) together with a range of optional elements are identified.

Application of a patchwork text approach to a medical curriculum

Doctors are required to develop their self-awareness, to understand the impact of self on others and to be critical in their thinking, in order to identify their personal strengths and development needs. 2 , 4 The two key challenges are to encourage meaningful as opposed to a tick box approach to reflection and the development of master’s level writing. We suggest the solution is a leadership self-awareness curriculum based on an adapted PWT approach.  Below we outline this approach, applied to a master's level medical leadership module undertaken by senior trainees, in which we have incorporated all of the core elements plus most of the optional elements of the PWT approach. 9

A Reflective Journal, with templates to be adapted or adopted, is provided to record meaningful reflections. This can include reflection on: self-awareness tool results (e.g., Emotional Intelligence; JTI Personality Type; Team Role; Resilience); benchmarking against medical standards; 2 , 4 significant events within own context of practice (e.g., critical incident, service re-design, new procedure); 360 feedback; clinical audit; feedback from supervisors and patients. The reflective patches gradually develop as new self-assessment tools are explored and learning emerges. Trainees are encouraged to share their reflective patches both in the classroom setting and with ‘critical friends’. Thus the Reflective Journal scaffolds the progression from descriptive reflection towards critical reflection.

A formative assessment is integrated into the module, based on one reflective patch of the trainee’s choice (e.g., a reflection on how their personality type impacts on colleagues or how their leadership style impacts on their team/culture). The aim is two-fold; firstly to provide feedback on their academic writing, to feed-forward to their summative assessment, and secondly to explain how this one patch can be grown into the final assessment. Trainees choose which patches they ‘stitch’ together into their summative assessment. This is note-worthy as it facilitates a personalised approach to assessment. Although the trainees are exposed to many self-awareness tools/vehicles for reflection, they are able to explore in-depth the patches/events significant to self. The summative assessment comprises a reflective integrated portfolio that incorporates: (a) personal learning in relation to their leadership strengths and challenges, (b) insight into their leadership paradigm by considering what has shaped and influenced their perception of leaders and leadership, (c) identification of own values/behaviours and consideration of their alignment with NHS values/standards 2 - 4 (d) integration of literature and key policies/drivers for change  (e) recognition of  personal leadership goals.

The process of the development of the raw reflective patches (the significant incident), through to the meaningful synthesis of learning and insight, which makes cogent connections between the past, present and future, is what makes this assessment strategy meaningful.  It prompts the interrogation of both thinking and feeling, exploring differing reflective perspectives, appreciating how it might feel to inhabit someone else’s shoes.

The assessment is built on student choice and as such is bespoke, tailored to individual needs. Flexibility is also a feature in relation to time-management; the ‘bite size’ approach encourages reflection over short time frames so the assignment can be written in stages and because the focus is self-development, the context is both personally meaningful and context specific.

It is anticipated the long term benefits for trainees will be, that they continue with this structured approach and their Reflective Journal will become a life-long tool. This strategy would prepare trainees for their annual appraisal and re-validation in relation to leadership and management competencies.

Conclusions

Patchwork Texts is an innovative approach that supports a constructively aligned curriculum. A personal Reflective Journal facilitates doctors to be honest, self-aware and authentic in their choice of significant reflective catalysts. We suggest PWT combines meaningful reflection in and on practice, significant event analysis, and assessment for and of learning. An integrated formative assessment serves to feed-forward to the summative work and supports the development of master’s level critical reflection.  This model appears to offer an approach fit for both purpose and practice.

Acknowledgements

We would like to thank Dr Margaret Bamforth former Associate Post Graduate Dean at Health Education England (North West) for her constructive comments on our paper. We would also like to thank Health Education England (North West) for their permission to publish this paper. Finally thanks to our colleagues at the Royal College of Physicians. The medical leadership module referred to within the article was commissioned by Health Education England (North West). 

Conflict of interest

The authors declare that they have no conflict of interest.

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Academic Development Centre

Patchwork assessment

Using patchwork assessment to measure learning

Introduction.

The metaphor of a patchwork refers to the idea that a variety of assessment pieces (patches), which individually are complete in themselves, are stitched together into something new (a patchwork). It is a type of portfolio assessment Link opens in a new window but is distinct because the patchwork as a whole, which includes a reflective, integrative, summative ‘stitching’ section, is more than the sum of the individual parts. Alternative names for this assessment approach include: on-going narrative, evidenced story or collage of incidents. This assessment approach can include formative and summative elements. It also enables pivotal / critical learning moments, either at the time or retrospectively, to be identified and consolidated.

At first this approach was limited to short periods of learning, across a module or series of sessions, whereas more recently the method has been used across a year and even a whole programme.

Important aspects of patchwork assessment:

• it is personalised; you may set the task but the learner reflects on what they have learned through the process in addition to completing the task
• this constitutes continuous assessment which means that the learner is constantly building on achievement and moving towards autonomous learning
• continuous feedback is essential and this can be from you and / or their fellow learners; peer engagement is a common aspect of this approach as wider dialogue and reflection enriches the learning
• the stitching together (patchwork) cements and enhances learning from the individual tasks (patches) as this deepens learning as reflection on tasks, process, achievement and feedback across time combine.

Winter (2003) reporting the outcome of the Patchwork Text project, provides a neat definition of the approach:

The essence of a patchwork is that it consists of a variety of small sections, each of which is complete in itself, and that the overall unity of these component sections, although planned in advance, is finalised retrospectively, when they are ‘stitched together’. Thus, a ‘patchwork text’ assignment is one that is gradually assembled during the course of a phase of teaching and consists of a sequence of fairly short pieces of writing, which are designed to be as varied as possible and to cover the educational objectives of the teaching....The sequence of tasks within a Patchwork Text… is intended to build into the assessment process a recognition of learning as a gradual 'coming to know'.

What can patchwork assessment assess?

While a diverse range of subjects might adopt patchwork assessments the importance of critical reflection, particularly in the final ‘stitching’ of the individual elements, means that subjects where students need to integrate their practice/experiences with theory might find patchwork assessment particularly useful (e.g. clinical placements, work-based learning, teacher training, etc.). Furthermore, the importance of pivotal learning moments in patchwork assessment means that it is a particularly useful way of capturing learning over time. It may not be appropriate for highly conceptual subjects unless there is a need to reflect on how conceptual learning is being used and applied.

A patchwork assessment is not random; the 'stitching’ together of the patches, and their links and relationships, is crucial and so the tasks/incidents need to be carefully selected and planned. Formative feedback as the patchwork is developed should enable learners to gain confidence in analysis and synthesis of their learning and so reflect on its significance to their knowledge, understanding and practice. Whilst the process might be teacher-led at the outset it should become less so as the learner becomes more self-reliant and able to direct their own development and select the pivotal learning moments.

It will be important to consider the number of assessment pieces that would form the patchwork and consideration of the balance between formative and summative assessment is necessary. One possible model is that each patch is assessed formatively by self and / or peers and is compulsory; the summative element would then be how the individual elements are ‘stitched’, possibly through a critical, reflective and consolidating piece of writing. A further consideration is how the individual elements are identified; one approach would be that students select these themselves from a wider pool of material. In this case the reasons for the selection of the patches might offer an insight into students’ thinking. The modality of the elements would also need to be considered: written, pictorial, video, audio, presentation are all possibilities. The extent to which students have choice about the modality will need to be decided during design, however, this does not need to be consistent across the whole patchwork - for example the students may have choice about the individual elements but are required to submit a written summative reflective text to consolidate the individual elements. The curation of the individual elements needs consideration and perhaps a technological solution such as Moodle or (link to) MyPortfolio would allow the small sections to be built up over time and be available for consideration by tutors or peers.

Can it be used for group assessment?

Individual patchworks might be developed for learning and assessment. However, it would also be possible for a group to work together, perhaps with each person from the group contributing a single patch and then each individual produces a unique and consolidating ‘stitching’ making use of the various group contributions.

Constructive alignment of the learning outcomes and the assessment through the patchwork approach is possible with careful design of the assignment brief. Consideration of how marks will be awarded across the whole patchwork is important at the design stage. Different models for assessing the patchwork against the intended learning outcomes could be adopted including:

• each small section being assessed formatively by self-assessment, peer assessment or tutor assessment with the final reflective analysis accounting for 100% of the summative assessment
• particular learning outcomes could be associated with individual patches, with the reflective analysis, or with the work as a whole
• each of the small patches could contribute to the overall assessment mark in one of the following ways: choosing the best patches (and so the best mark overall), averaging over the submitted patches or providing a mark holistically across the whole patchwork.

Your learning outcomes are likely to include higher order Bloom-type statements such as evaluate or critique. A challenge in designing patchwork assessment is to include tasks that ensure that learners demonstrate the required thinking and reasoning in line with the learning outcomes; it is too easy to be descriptive rather than analytical. In planning for the assessment careful thought will need to be given to how to help students demonstrate this higher order thinking.

Diversity & inclusion

The potential for diversity and inclusivity in the patchwork assessment depends largely on the component parts of the patchwork. Offering students choices about the modality of the individual components could potentially facilitate an approach to assessment that would meet the needs of all students.

Academic integrity

The focus on individual experiences of learning and individual choices means that it would be very difficult for different students to produce similar work. Even when used for group assessment the consolidating summary would be a unique interpretation of these materials by each individual. (Click here for further guidance on academic integrity .)

As patchwork assessment is often grounded in practice (work-based learning, practice-based learning) an entirely AI generated text is less likely (or likely to be less convincing 'out of the box') than other text-based forms of assessment. Integrating creative, or visual methods within the patches may further minimise this. That's not to say that AI can't mimic reflective work, but the synthesis and making sense of experience, and the evaluative choices of what to include and what to exclude privilege human minds. AI may have a valuable role as coach in this sort of learning, performing the role of critical friend (or participant researcher) to help students scaffold reflective thinking, and process their experience through a dialogic interview process.

Student and staff experience

It can be hard for students to see a programme or even a module as a whole entity. Their experience might be that the various parts feel separate and lack coherence. Patchwork assessment has the potential to provide an opportunity for student to reflect on the individual parts and consolidate their learning through the process of ‘stitching’ together the different elements. The patchwork approach might be combined with other methods which would allow learning over time to be observed, such as blogs or on line fora posts.

Student might become more creative in the presentation than the thinking. For example, it would be possible for students to spend a great deal of time on developing a creative and interesting video or pictorial patch which was mainly descriptive and fail to incorporate the all-important reflective and analytical component.

Staff will need to:

• explain the approach carefully and clarify which skills will be developed through the process
• emphasise both the reporting and analysis/reflective aspects of the patchwork
• preparatory workshops on reflective writing
• learning how to use and give peer feedback
• examples of ‘good’ and ‘bad’ patches - and why they are good/bad
• development and discussion of the criteria
• a collection of frequently-asked question and answers - perhaps online
• discussion of the time needed
• how to use the technology if an online tool is being used e.g. Mahara.

Patchwork assessment, for some departments, might be a significant departure from current practice. The advice would be to start small and then build on the approach. Providing formative feedback and engaging meaningfully with students about their 'patches' may increase workloads - AI may have a role to play in helping us provide individuated feedback, but substituting human encounters and relationships with AI may leave others feeling a little queasy.

Useful resources

HEA Patchwork Assessment Practice Guide, including some case studies

https://www.heacademy.ac.uk/knowledge-hub/patchwork-assessment-practice-guide

Silva-Fletcher, A., May, H., Magnier, K. and May, S. (2014). Teacher development: A patchwork text approach to enhancing critical reflection in veterinary and paraveterinary educators. Journal of Veterinary Medical Education 41 (2): 146-154.

A number of useful links and articles available at http://www.richardwinter.net/node/13

Annotated bibliography

Class participation

Concept maps

Essay variants: essays only with more focus

• briefing / policy papers
• research proposals
• articles and reviews
• essay plans

Film production

Laboratory notebooks and reports

Objective tests

• short-answer
• multiple choice questions

Oral presentations

Creative / artistic performance

• learning logs
• learning blogs

Simulations

Work-based assessment

Reference list