CHAPTER 6: Introduction to teaching methods

Part 1 dealt with what your students should learn. This part goes on to explain how you can teach them. The two parts should be read and used together, because students will only be well trained if the teacher uses good methods and teaches the right skills.

Part 1 pointed out the importance of training students how to do a job rather than just know about it. Again in this part the main emphasis will be on students "learning by doing" rather than simply listening. This principle could be summed up by the old Chinese proverb:

"hear and forget... see and remember... do and understand".

The aim of this part therefore is to help you to choose the best teaching method for each part of the course and to give some advice on using each method effectively.

The part is arranged as follows. Chapter 6 gives general guidance about problems such as motivating students and making subjects meaningful to them. The three remaining chapters describe particular methods that can be used in teaching attitudes (Chapter 7), skills (Chapter 8) and knowledge (Chapter 9). Chapter 10 brings all the ideas together in a description of how to plan a lesson.

6.1 The role of the teacher

How can the teacher help students to learn? It used to be thought that teachers needed to tell students as much as possible, passing on their knowledge. Now teachers arrange for students to gain experience by working in health centres. They may also advise students to read a few pages from a manual and set questions for students to discuss in groups. In all these ways the teacher is helping students to learn.

Some teachers feel that they must do all the talking themselves. They feel that they are not really teaching unless they are telling the students some new information. But this is quite wrong.

If a teacher gives a lecture and the students do not learn, then the teacher is talking - not teaching.

The following chapters explain different ways in which you can help students to learn. You may already use some of these methods. You may feel that some of the methods will not work for your students. However, all the methods described have been used by teachers. Even if you cannot use a method as described here, you will probably be able to adapt it so that you can use it.

Remember that change is always difficult. It is easier for teachers to carry on using the same teaching methods. When you have prepared a course of lectures, it takes only a little effort to keep on giving the same lectures year after year. If you want to try new ideas you need to work to make those ideas succeed. Some students will find it difficult to use some of the more active forms of learning. You must explain to your students what you are trying to do and make them interested in the new teaching methods. If students have been used to sitting in classes just listening to the teacher it will be uncomfortable for them to learn for themselves. You need to understand this feeling and reassure the students that they can learn from their own experience - with a little guidance from you.

6.2 How well do you teach?

Below there are a list of questions for you to answer about your own teaching. If you can answer "yes" to most of the questions, then you are probably teaching well. If you answer "no" or are not quite sure what the question means, look at the corresponding section. For example, the first three questions are concerned with "clarity", which is discussed in Section 6.3.

Clarity (Section, 6 3)

Can the students hear what you say and read what you write? Do you use simple language? Do you use visual aids? Do you summarize the main points?

Making your teaching meaningful to students (Section 6.4)

Do you relate what you are talking about to the students' lives? Do you give a lot of examples? Do you relate what you are talking about to the work the students will be doing?

Active learning (Section 6.5)

Do you ask students to answer questions? Do you ask students to apply information in solving problems? Do you arrange for students to practice thinking and practical skills?

Giving feedback (Section 6.6)

Do you tell students how well they are doing? Do you point out any errors or faults? Do you explain how students could do better work?

Ensuring mastery (Section 6.7)

Do you check that all your students understand each point? Do you frequently check whether every student has learned the necessary skills and knowledge?

Individualize (Section 6.8)

Do you allow students to work at different speeds? Do you encourage students to learn in their own way? Do you use several teaching methods?

Caring (Section 6.9)

Do you show the students that you care whether they do well? Do you prepare thoroughly for teaching sessions? Do you listen to students' comments about your teaching?

6.3 Clarity

Obviously your teaching must be clear. The students must be able to hear what you say and read what you write. All teachers believe that what they say and write is clear - but are they right? Can your students read what you write? Ask another teacher to sit at the back of your class and tell you whether he or she can see and hear clearly. Look at your board at the end of a lesson and see whether it is set out clearly. Can you read your own writing? If you cannot, the students definitely will not be able to.

The students may be able to hear the words you say but not understand them. If you use words that are unfamiliar to students or speak a different form of the language, it will be difficult for them to learn. Make sure that you talk in a way that the students can understand.

The students may be able to hear the words you say, but they may not really understand them.

To help you make writing or diagrams clearer you may be able to use visual aids such as charts, posters, flannelboards and possibly slide-projectors or overhead projectors. These will all help to improve clarity. Some useful tips are given in Section 9.7.

Most teachers use a blackboard or chalkboard of some kind. Sometimes the board will look a mess at the end of a lesson, with no pattern to the words and untidy diagrams. Decide before the start of the lesson what you are going to show on the board. Then during the lesson, write the key words or phrases in order so that they show the structure of the lesson. Remember that students tend to copy the words and the layout the teacher writes on the board. Make sure that what you write would look good in the students' notes.

At the end of the lesson, summarize the main points - as this book does.

Summary

Make sure that your students can hear what you say and read what you write. Also check that your students understand the words you use.

At the end of the lesson summarize the main points.

6.4 Making your teaching meaningful

Exercise

Look for about 2 or 3 seconds at the two diagrams below.

Figure

Now turn over the book and try to draw the two diagrams. Then read on.

Comments

You could probably draw diagram B. It has a pattern to it that makes sense - three squares joined together. Diagram A was probably much more difficult to remember. There was no shape or meaning to it. But in each case the number of lines was exactly the same.

What does this have to do with teaching? The diagram that was easier to remember has "meaning". It is similar to patterns you have seen before. If you can make your teaching have meaning then your students will learn more easily.

How can you achieve this in practice? Here are some suggestions.

(a) Explain in advance what you are going to say. This can be done by telling your students what the objectives are for a part of the course. In this way the students will know what they need to learn and so they can make more sense of the teaching.

(b) Try to relate what you teach to students' lives. Your students will have a lot of experience which is useful and important. For example, when you are talking about sanitation, find out what your students know about the subject. You can then use their knowledge as a basis for teaching. Do not assume that students know nothing about the subject you are teaching. If you are talking about diseases such as schistosomiasis, find out whether the students know people suffering from the disease. If you do this, the teaching will have meaning for the students.

This book tries to make the ideas meaningful to you by explaining them as problems that you may face in your teaching.

(c) Explain new words. When you are giving information to students, you will have to use and explain new words and concepts. Some teachers like to use long and complicated words just to show how clever they are. This must obviously be avoided, but you will need to use some new words. When you do, you should define them carefully. You should also use a lot of examples to explain their meaning and, if possible, arrange for the students to practice using the words. This may be in discussion or in writing. In this way the students will begin to get a fuller understanding of the meaning of the words or concepts you use.

Examples of explaining a new idea

For example, you may want to explain the concept of circulation of the blood to students. This will involve the use of a possibly unfamiliar word "circulation." It will also introduce the idea of blood travelling round the body, which may also be unfamiliar. To teach this idea you might define the word circulation and then ask students to think of other things which circulate, such as money or traffic.

Then encourage the students to use the concept. For example, ask them to tell you what are the effects of the blood circulation. They might say that it allows certain substances to be carried from one part of the body to another. They might describe what would happen if the body was badly cut. In this way your students will quickly gain an understanding of the concept involved.

(d) Use examples. When you are describing a new idea or a method of treatment, give examples. You might talk about an experience that you have had recently. Even better you might talk about a patient that the students have just seen, or the water supply for a village that they know.

Note that this book uses a lot of examples to explain the ideas.

(e) Relate the teaching to the work that the students will be doing. Information and skills will have much more meaning to students if they know how they will be using the information in their job. You might, for example, want your students to be able to use a microscope. Some students will be interested in microscopes. Others may not be so interested and so will not learn well. However, if you explain that the students will use a microscope in their job as a way of confirming diagnosis of common illnesses, then they are likely to be much more interested and to learn better. The learning will have more meaning for the students.

Summary

You can help your students to learn by making sure that what you teach has meaning for them.

- explain in advance what your students are expected to learn
- relate what you teach to the students' lives
- explain new words and ideas
- use many examples to explain what you mean
- relate the teaching to the work that the students will be doing.

6.5 Active learning

Many experiments have shown that students learn very little when they are listening to a teacher giving a lecture.

They learn a little more if the teacher writes on the board and uses diagrams and pictures. In this way the students can see what they have to learn as well as hear it. But still rather little is learned.

To help students to learn you should give them some exercises to do, such as answering questions, writing notes or explaining an idea (to a friend or to the whole class). The students will also need to practice any skills that you teach them. The importance of these exercises is highlighted in the Chinese proverb at the beginning of the chapter.

“hear and forget... see and remember... do and understand".

Of course some exercises will be more helpful than others. As a rule, the exercise should make the students use information rather than just repeat it. Active learning can also be used in books or handouts. To illustrate the method here is an exercise for you to do.

Exercise

Imagine you are teaching students how to take a patient's temperature. Which of the following activities would be most useful after you have explained how to do the task?

A. Read a section from a manual on taking temperatures.

B. Copy your notes from the board.

C. Make notes in their own words on how to take temperatures.

D. Write down the temperature reading shown in five drawings of a thermometer.

E. Use a thermometer to find out the temperature of another student.

F. Calculate the change in volume of 5 cm3 of mercury when its temperature changes from 10°C to 40°C.

Write down your answers and give reasons.

Comments

With the exception of F. all of the activities are better than no activities at all. E is probably most useful because the students will need to use all the information you have given. They will have to read the thermometer as well as use antiseptic techniques, shake the mercury down, place the thermometer correctly under the tongue, etc.

Activity D is also useful as some students may have difficulty reading off a scale. It would help the teacher to find out exactly which students needed more help.

Activity C is better than B because the students have to explain the task themselves instead of just copying the teacher's explanation.

Activity A might be worth doing so that any points in the manual which were difficult to understand could be explained.
Activity F is probably not worth while because the students will not have to do this kind of calculation in their job. It will waste time and may confuse the students.

You should not use all the activities. Some may not be possible - for example, do you have enough thermometers? Instead, you should choose one or a few of the activities that you feel would help the students to learn best.

There are many different kinds of activities which are useful for different kinds of objectives. For example, you might develop projects for the students to do in which they collect data about health needs. You might use role-playing exercises in which students act the parts of different people they are likely to meet in their work. You might ask groups of students how they would solve a health problem in their community. All these methods will give you more work to do, but they will also help the students to learn. These methods are explained in more detail in Chapters 8, 9 and 10.

This book gives you exercises to do while you are reading. In this way the book uses active learning methods. Do you find that the exercises help you to learn?

Summary

It is easier for teachers to keep talking during a lesson, but it does not help learning. Instead, teachers should think of activities that will force the students to use the information that they have been taught. Teachers should use as many activities as are realistic, and so help students to learn.

Do not just talk - make your students do the work.

6.6 Giving feedback

Feedback is one of the fashionable words in education at the moment. What does it mean? Simply that when the students have done a piece of work, the teacher should tell them whether they have done it well. The teacher should also point out any errors or faults and explain to the students how the work could have been done better. This process of telling students how well they are doing is called feedback.

Feedback can also come from written material. If you ask students a number of questions and then give them the answers on a sheet of paper, this is also feedback. If you give guidance to the students they can sometimes give feedback to each other (see self-assessment in Part 3).

Of course, many teachers have been doing this for a long time, so the idea of feedback is not at all new or different. What are the ways in which feedback can be given?

The first point is that if students only listen to a teacher talking, there is nothing to give feedback on. So feedback and activity go together. To give feedback, you must first arrange for the students to do things that can be assessed. This means that there should be frequent tests of the students' ability to do the practical tasks required, to remember the necessary facts, and to use those facts in solving problems or communicating.

These tests may be formal examinations. If these are held, the teachers will have to do a lot of extra work and the students may become interested only in passing examinations and forget the real reasons for their training. A better way is for the activities and feedback to become part of the normal pattern of teaching. The students will be able to assess their own performance or that of other students if they are given guidance by the teacher. The feedback should usually have three parts.

1. Feedback should give some encouragement and praise for what has been done well.

2. Feedback should give an indication of the overall standard of the work. For example, "8 out of 10" or "Pass".

3. Feedback should point out any errors or faults and show how the performance can be improved.

Example of giving feedback

You might watch a student practicing how to bandage a patient to provide support for an injured arm. When the student has finished, you might say " Well done. You have done quite a good job. The bandage is tied firmly so it should not come undone by itself. You have also used the right method of bandaging, so overall the standard is satisfactory But you should have made sure that the lower arm was held level You have made the bandage lift the patient's hand slightly higher than his elbow To do this better you should...

Note that this example shows the teacher giving some praise - "well done".

The teacher gives an indication of the standard of the work - "quite a good job" - "it will not come undone by itself" - "right method" etc.

The teacher also points out the faults and shows the student how to do the job better - "you should have made sure that the lower arm was held level".

Summary

Give as much information as possible to students about the standard of their work. Praise the good things, but also show how they can eliminate errors.

6.7 Ensuring mastery

The phrase "ensuring mastery" simply means that you make sure that all the students know the facts and skills that they need at each stage.

Ideally this is done at the beginning of each lesson.

When you are teaching some topics, the students may need to have understood ideas taught in an earlier lesson. For example, if you are discussing a growth chart for babies, the students will need to know what a graph is and how to record data on a graph. These ideas may have been taught some time ago, so the students may have forgotten or possibly never have understood. This means that they will not be able to understand the growth chart.

"... so the students may have forgotten or possibly never understood".

To overcome this difficulty you should check at the beginning of the lesson that all students know the necessary facts and skills. Do not ask "Does everybody know about graphs?" If you do, the students will probably say "yes", whether they understand or not. Nobody likes to admit that they do not know something. Instead you should give a very short test. For example, you could draw a graph on the board and ask the students to write down what a specific point on the graph means.

You should also find out how much your students know at the end of the lesson - or even at various stages during the lesson. Again, do not just ask "Do you understand?" Instead ask the students to use the skill or tell you the facts.

This technique may seem obvious. Most teachers think that they do "ensure mastery". In fact if you talk to students and find out exactly what they know, you may be surprised at how little they remember from previous lectures.

Summary

At the beginning of the lesson, check whether all your students know the facts and skills that they will need Then, at the end of the lesson, make sure that ail the students have learned these essential facts and skills

6.8 Individualize

Most teachers agree that different students learn in different ways. Some students are very intelligent, while others seem to be rather less clever. Some students may be very good at learning facts but rather poor at doing practical work. Others are the opposite. Some students can learn from books, while others prefer to listen to the teacher talking. Other students learn best by practical experience of doing the job.

However, schools often treat all students as if they were identical. All students go to the same teaching sessions. There they listen to the same lecture and then do the same practical work.

Of course, it is much simpler and cheaper to treat all students in exactly the same way. It is also easier to keep control of their whereabouts because the timetable will say where every student should be at any given time. But is this the most effective way of learning? Does it prepare students to take more responsibility for their own learning? Remember that after they leave the training school they will usually need to work and learn on their own.

Schools often treat all students as if they were identical.

What can teachers do to help the individual students to learn? Here are a number of suggestions which would be realistic in many training schools.

(a) Make sure that there is enough time for students to learn on their own. To do this you may have to cut down the number of lectures. Some people suggest that there should be as much as 2 hours of time free for individual studying for every hour in a class. This would allow the students to learn at their own pace outside the lecture room.

(b) Use some different teaching methods. Some students learn better from books, while some learn better when topics are discussed in a group. Some students learn well from films or film-strips (if these are available).

It is not usually possible to give a choice of teaching methods. However, teachers can use a variety of methods and so meet the needs of a larger number of students.

(c) Make more use of project work. To do this you set students a large-scale task such as finding out what village people think are their major health problems. Project work allows a lot more scope for students to learn in their own way. It also gives a contrast to the lectures.

(d) Talk to students individually. If you talk to the students by themselves you will find that some students are confused by one idea while others find the idea quite easy to understand. You will then be able to explain the idea yourself, or tell the students where to find the relevant information.

(e) Use self-instruction methods. Where possible use tape-slide programmer or programmed texts. Where this is not possible because of lack of equipment or suitable programmer, you can help students by giving them written notes. These notes can guide the students in using manuals for health workers. Notes can also be used in practical work to remind students of the skills that they need to learn.

Summary

Remember that your students are individuals. They learn at different rates and in different ways. They have different interests, experiences and abilities Try to find out what each student is like. Then use this information to vary your teaching so that as far as possible each student can learn in his or her own way.

6.9 Caring

Students will often do things for one teacher that they will not do for another. How then can you use this to help your students learn?

One thing that encourages students to make more effort is the belief that the teacher cares about them. Note that it is not enough for the teacher to care. The students must know that the teacher cares.

This does not mean that you should give higher marks than other teachers or allow poor standards of work or behaviour. This gives the opposite impression. Nor should you be content to say "I care about...". Simply saying the words will not persuade many of your students for very long. Instead, the way that you as a teacher behave will show whether you care or not.
Exercise

Look at the list of statements about a teacher. Which statements would you like to be true of you?

A. She wears clean and tidy clothes.

B. He always arrives for teaching sessions on time.

C. She prepares thoroughly for teaching sessions.

D. He shows that he is very knowledgeable about the subject by using all the technical words.

E. She is a very important and very busy person. So she has to hurry away from teaching sessions to do other work.

F. He never smiles or jokes, because learning is a very serious business.

G. She always praises students' work, however bad it is.

H. He talks to students and finds out what their personal interests and ambitions are.

I. She asks students to comment on the teaching sessions so that the sessions can be improved.

J. He ignores the comments students make about the lessons.

K. She requires the students to do work of a high standard.

Comments

The "correct" answers are probably obvious. The only statements that need expanding are D, G and H.

Statement D reflects one of the worst things that some teachers do. Teachers should not use technical words just to show how clever they are. They should take pride in the way they make ideas easy to understand.

Statement G is typical of teachers who are trying to encourage their students. But leachers should not praise bad work. Your aim should be to praise whatever is worth praise, but point out the weak points and insist on a high standard.

Statement H may seem unrealistic. Teachers do not have time to talk to all their students for long periods of time. But you should try to talk and listen as much as possible. When you are talking, try to find some shared interest. For example, you may know someone from the students age. You may be interested in the same sport as the student. The important point is for you to show the students that you care.

Summary

If the students believe that the teacher cares about them, they will have an extra reason for learning.

6.10 Motivation

Some mention must also be made of motivation. It is often said that motivation is the key to successful teaching. All that a teacher needs to do is motivate students and they will learn.

How can teachers motivate students? The answer is simply to use the ideas described in Sections 6.2 to 6.9. Each of these ideas will help to make the courses more interesting, easier to learn or more relevant to the student's career. Above all they will help students realize that you care about their success. All these ideas will help to motivate students.

6.11 Conclusion

Some people argue about whether teaching is an art or a science. In other words, some people believe that the talent for teaching is a natural gift that good teachers are born with. Other people believe that teaching is a science which is controlled by rules.

This part of the book is designed to show you that there are some general rules for teaching. If you follow these, your teaching will improve. If you do the opposite to these rules, then your teaching will almost certainly be poor and the students will not learn.

In order to teach well, you will need to apply the rules for your students, your subject and your school or college. You still have to think of ways to make your teaching sessions have more meaning for your students. You have to be imaginative and think of activities which will be useful to your students. You have to take the trouble to give feedback to your students and to show that you care about their success.

Summary

1. Make the learning active - ask questions, set problems and organize projects.

2. Give feedback - explain how well each student is doing and how his or her work could be improved.

3. Make your teaching clear - check that the students can hear what you say and see what you write. Speak loudly, use simple language, write tidily, and use visual aids.

4. Make your teaching meaningful - explain how it will help students to do their job better.

5. Ensure mastery - check that all students know the necessary tasks and can perform the necessary skills before and after each session.

6. Allow for individual differences - let students learn at their own pace, leave enough free time for individual study and use a variety of teaching methods.

7. Show that you care whether students learn - set high standards and get to know each student.

CHAPTER 7: How to teach attitudes

What is an attitude? Think about health workers in rural centres. They may know all about aseptic methods and have the skill to follow them. But when they are working by themselves, they may be tempted to take short cuts and not be very thorough. The way they behave will depend on their attitudes. So an attitude is a tendency to behave in a certain way.

7.1 Are attitudes important?

It has often been said that the attitudes learned during training are the most important part of the training. At the same time other people say that attitudes cannot be taught. What is the truth?

Certainly attitudes are formed or changed during training. This is quite clear to anyone who has worked with students and watched them develop over a period of time. Compare the attitudes of students who have completed a long period of training with the attitudes of a group who are just starting. The differences will usually be obvious. But how has this change taken place? Has the change been caused by the course? Can teachers control changes in attitude?

One of the problems for teachers is that attitudes are not easy to measure. You can set out to teach students how to inject a patient and at the end of the teaching session you can easily find out whether they have learned the skill. On the other hand, you may try to change their attitudes to patients by explaining that they should respect the patients' opinions. But at the end of the explanation it is very difficult to find out whether the students' attitudes have changed.

Another problem is that attitudes are hard to define or explain. Because of this, very few teachers would be able to list all the attitudes that they would like their students to have. So it is not clear what the students need to learn.

Attitudes are very important, however, and teachers must try to make sure that the students learn the right attitudes.

Attitudes are rather vague things

This is especially important if the students will be working in remote villages or will not be closely supervised after training. In such situations, they may be tempted to take life easily and not work very hard. This would cause a fall in the overall standard of health of the community. This drop in standards can only be avoided if health workers have the right attitudes.

7.2 How to teach attitudes

There are no guaranteed methods of teaching attitudes. Teachers must be aware that all of the experiences that students have may change their attitudes. But no single experience can be certain of having a specific effect on all students.

There are five general methods which teachers can use. These are discussed in the following sections.

· providing information (Section 7.3)
· providing examples or models (Section 7.4)
· providing experience (Section 7.6)
· providing discussion (Section 7.6)
· using role-playing exercises (Section 7.7)

Even if you use all these methods, you must be aware that students' attitudes may be shaped by events which you have no control over. For example, students will read books, talk to people outside the school, and spend time with their families. The students will also have formed many of their attitudes before they start their training.

It is important therefore that you try to influence their attitudes as much as possible and that you do so correctly.

7.3 Providing information to shape attitudes

Information is not always enough to change people's attitudes but it may help. For example, the relationship between smoking and the risks of cancer and heart disease is well known by many people. For some people this information has been enough to persuade them to change their attitude to smoking and to give up the habit. For many other people, the information has not been enough.

Teachers can present information about attitudes in many ways. Lectures are one obvious method. Films are often more effective because they can also be used to show examples of the correct attitudes (see Section 7.4).

The important point is to show how the facts are relevant to the attitude.

Exercise

List the information you would provide to students if you wanted to teach them about the importance of following aseptic techniques. How would you make these facts relevant to the attitude of thoroughness in cleaning hands and sterilizing equipment?

As another example, what facts would you provide if you wanted to persuade a mother to have a more positive attitude towards breast-feeding?

Comments

You might have made the following points:

· The dramatic fall in mortality rates when aseptic methods were introduced in hospitals.
· The need for health workers to set a good example to the community.
· The ways in which infections can be transmitted.

These facts all show why aseptic techniques are important. They appeal to the reason in students. Sometimes less logical and more emotional facts may be more effective. For example, you might tell the students about an experience that you have had which shows what happens when aseptic techniques are not followed. This single experience will not have much logical importance, but you can make the story so dramatic and vivid that it has more effect.

7.4 Providing examples or models to shape attitudes

Most advertising is designed to change attitudes. A common technique is to show an "ideal person" (who is usually young and goodlooking) using a certain product. The advertiser aims to provide a model or an example which will be followed by the reader. This technique is generally very effective.

What has this got to do with teaching? Well, for many students their teacher is a very powerful model. Students often copy the way their teacher behaves. If teachers are rude to patients or careless in handling equipment, then their students will tend to follow their example.

On the other hand, if teachers are considerate to the people they work with, then their students are likely to behave in a similar way. Therefore it is essential that you always set a good example for your students.

Other people will also influence the students' attitudes. Other health workers, nurses, and doctors all provide models for the students to copy. You should therefore make sure that, as far as possible, these staff also set a good example.

7.5 Providing experience to shape attitudes

Throughout the students' training they will have experiences which will shape their attitudes. They may see patients with sores that have not been treated and that have become septic and possibly disabling. This direct experience of seeing the patients' suffering will have far more impact on shaping students' attitudes than a whole bookful of facts about the need for early treatment of sores and superficial wounds.

The teacher should provide students with as much direct experience as possible. For example, many health workers are responsible for improving nutrition in a community. In some schools the students grow all the vegetables that they eat and look after animals themselves. This experience will help them to have more positive attitudes to doing the work themselves. In these schools teachers also join in with the digging and cultivation so that students learn that manual work is not undignified.

Other useful experiences can also be provided. For example, students should see the benefits of an uncontaminated water supply in a village. They should see how good nutrition can lead to a better life.

Do you think that students should have the experience of cooking their own food during the course - or should the food be prepared for them? What attitudes would you expect the students to have in these two situations?

Exercise

List 3 experiences which you think your students should have that would help them to form good attitudes to patients.

1.
2.
3.

Comments

You may have written down ideas such as:

· Working with an experienced health worker who has a caring attitude to patients.
· Talking to patients about their worries concerning health.
· Meeting people who suffer from some disabling but preventable disease.

Note: It is always a good idea to discuss these experiences with your students so that you can make clear the kinds of attitudes that you want them to learn.

7.6 Providing discussion to shape attitudes

Discussion in small groups is generally thought to be helpful in shaping students' attitudes. Discussion also helps to make the previous three methods more effective. For example, it is helpful for students to describe and discuss the experiences that they have had with patients. During the discussion they will share experiences, so that the experience that one student has had may influence all the other members of the group.

Providing discussion to shape attitudes.

Another important feature of the discussion is the way in which the students' attitudes change when they talk about their own opinions. The process of putting their ideas into words and seeing the reaction of the other students can be a powerful way of changing attitudes. For this to happen, the group size must be small enough to give every student a chance to talk. A group of 7 or 8 students is best and 15 the maximum number for this technique to be effective. Note that it is not what the teacher says that is important, but what each student says. Teachers should speak very little in these small-group sessions. They may encourage the quieter students to give their opinions and have to stop the talkative students from talking too much. But only in exceptional situations (for example, when the group runs out of ideas) should teachers give their own opinions or take an active part in the discussion.

When there are very large numbers of students, it may be impossible to have one teacher for every group of ten or so students. One solution is to let the students meet without a teacher. This is possible because the teacher's role is only to help the students to talk. You can help your students to talk by providing some written guidance for their discussion. For example, you might give them a list of questions to discuss in their groups. You could then ask one student from each group to describe to the other students in the class what happened during the discussion.

Examples of questions for a discussion

Imagine that each of you has been sent to a different village to persuade the local people to build a piped water supply.

1. How would you start to persuade the local people? Would you try to make a speech to a large meeting or would you talk to individuals? If you choose a large meeting, who would you want to attend the meeting and how would you persuade them to come?

2. What rumours and objections about piped water supplies might you hear?

3. How would you respond to these rumours and objections?

4. What advantages would be likely to persuade the people to build a piped water supply?

5. Why do you think some people might object to the idea of piped water?

6. Would you arrange for a piped water supply to be built against the wishes of the village people?

Note that these questions are specific enough to start the students talking and to provide some structure for the discussion. But they also allow students to express different opinions and begin to form or change their attitudes.

Exercise

Write down the questions you would give to a small-group discussion. The questions should help the group to think about parts of their job where attitudes are as important as knowledge or skills. The aim of the discussion should be to encourage the students to talk about your questions and so develop their attitudes. For example, write down some questions that would encourage students to be more careful in their use of medical equipment.

7.7 Role-playing exercises

Attitudes are very important in communications with people. If you respect people, you will listen to them and speak to them in a different way.

Attitudes to people will often be improved if you understand the other person's point of view. One way of teaching attitudes is to give the students some experience of what it is like to be a patient or a mother with a poorly nourished child, or a shopkeeper who thinks that the health inspector is unreasonable. This can be done by using a technique called role-playing.

Role-playing is an exercise in which the students act the parts of different people and so begin to experience some of the feelings of these people.

The technique is also very useful in teaching communication skills and is described in more detail in Chapter 8.

7.8 Conclusion

Attitudes are important although they are difficult to define, test or teach. The ideas given in this chapter are only suggestions, because there are no widely accepted methods of teaching attitudes. It is certain that what you do will change students' attitudes. It is less certain exactly what that change will be.

Summary

1. An attitude is a tendency to behave in a certain way. For example, a person who has an attitude of thoroughness will generally keep full and correct records of his or her work.

2. Attitudes like this are not developed easily. For example, the teacher must do more than say "You should be thorough in keeping records".

3. Attitudes can be shaped by:

- providing the relevant background Information
- providing models or examples
- providing experience
- encouraging discussion among students
- using role-playing exercises.

CHAPTER 8: How to teach skills

8.1 What is a skill?

People working in primary health care use many skills. They may use their hands skillfully when they apply a dressing, build a water supply or repair equipment. This kind of skill is often called a psychomotor skill.

They may talk skillfully when they persuade people to attend a maternal and child health (MCH) clinic or encourage farmers to grow crops that will improve nutrition. These skills are called communication skills.
Then there are skills in making decisions. The most obvious example is when the health worker decides on a diagnosis or treatment. Other examples are keeping records, ordering supplies, and choosing the site for a well or latrines. These skills are called thinking skills or cognitive skills.

The names - cognitive, communication and psychomotor - are not very important but are given because you may have read or heard these words elsewhere.

Another way of answering the question "What is a skill?" is to go back to Part 1. Each of the tasks defined in situation analysis is a skill. When these tasks are broken down into sub-tasks in task analysis, again each of the sub-tasks is a skill.

In task analysis, the sub-tasks were categorized as "actions", "decisions", and "communications". These terms correspond exactly with the words used above.

"Action" is the same as "psychomotor".
"Decision-making" is the same as "cognitive".
"Communication" is used in both places.

8.2 Are skills important?

The obvious answer to the above question is yes. Very frequently supervisors, doctors and senior health workers complain that when students finish their training, they know a lot of facts but they cannot apply them. In other words, they have the knowledge but they do not have enough of the skills.

What is the remedy?

· First, teachers must accept that their job is to help students to learn the necessary skills.
· Then they must make sure that there is enough time to teach the skills.
· Finally they should use good teaching methods.

This chapter will explain some of the teaching methods that can be used.

8.3 Methods of teaching skills

Teachers often use the following pattern when they teach skills:

1. Describe the skill - explain what the skill is, why it is important, and when it should be used.
2. Demonstrate the skill - let the students see an expert (often the teacher) use the skill.
3. Arrange practice sessions.

This pattern is generally sensible, although the stages cannot be separated completely.

It may be more interesting for students if the teacher starts with a demonstration. Students may need to see the skill being used again after they have had some practice.

Often the skill is described in a lecture (theory), then some time later - possibly weeks later - the students do the practical (practice). This is not desirable although there may be administrative reasons for teaching the skill in this way.

Ideally, theory and practice should be taught together

8.4 Describing a skill

The first stage in teaching a skill is to describe the skill. The teacher must explain why the skill is important and why students must learn it. The teacher must also explain when students should use the skill and the stages that are involved in performing the skill.

For example, if you are teaching students how to give an injection, most of them are likely to know something about injections and why they are important. But if you are describing the skills involved in persuading mothers to bring their children to an immunization clinic, some students may not realize why this is important.

When you explain the stages in using a skill, a task analysis will be very helpful. This is because the task analysis describes exactly what is done and the order in which each stage is done. The task analysis helps you to be very clear in your own mind about the stages involved in the task. It can also be used directly by the students. If you use task analysis in this way, it should be rewritten as a list of instructions for the students. Look at the example below which is used for teaching hospital nurses. (Note that the words used are sometimes difficult for students - could you improve them? Note also that this is the way medicines are given in the hospital where the nurses are trained - it is not necessarily the way you would train nurses to do this particular job.)

An example of written instructions for students based on task analysis

Giving medicine by mouth

Equipment

Trolley containing:

- all medicines required
- graduated medicine glass
- teaspoons
- jug of cold water
- small tray or plate for carrying drug to bedside
- receiver for used spoons
- soapy water and clean water.

Giving the medicine

1. Check the patient's name.

2. Read the prescription carefully. Give medicine at the stated time, either before or after meals, as instructed. If before meals, give 20 minutes before. If after, give immediately after.

3. Select the medicine and check the label against the prescription.

4. Ensure that the label is kept clean (if liquid medicine) by holding the bottle with the label against the palm of the hand.

5. Shake the bottle.

6. Hold the medicine glass at eye level while pouring the prescribed volume of liquid medicine.

7. Shake the prescribed number of tablets or pills on to the lid of the container and from there, on to a spoon and then on to the back of the patient's tongue, or mix with water.

8. Place powders on a spoon and then on to the back of the patient's tongue, or mix with water.

9. Make unpleasant medicine as agreeable as possible by giving the patient a sweet or drink of fruit juice afterwards, if this is allowed.

10. Stay with the patient until he or she swallows the medicine. Do not leave it on the patient's locker.

11. Record administration on drug recording sheet.

· These instructions could be used as a handout when the teacher describes the skill.

· Students can keep these instructions and refer to them when practicing the skill - or put them into their own manual for reference after the end of the course.

· Written instructions make quite clear what standard of performance is expected. (All teachers and examiners will therefore follow the same standard.)

· Written instructions can be used by students to assess each other and so help their own learning.

These written instructions are sometimes called procedure cards or job-aid cards. Again the technical names are not important. What matters is that some teachers have found that written instructions are very useful.

8.5 Demonstrating a skill

When teachers have described a skill, they should then demonstrate it. Sometimes the demonstration is given at the same time as the description. When you give a demonstration, there are a number of points that you need to follow.

1. The demonstration must be correct. Obviously you must not demonstrate bad methods. Nor should you demonstrate methods that require too much time or too much skill. You must also make sure that any equipment that you use will be available to the students when they are working in the field. For example, if you are demonstrating how to prepare posters for a talk to mothers in a village, you should make sure that you use only the kind of paper, paint and pens that will be available to your students.

2. The demonstration must be visible. All the students must be able to see what you are doing. This seems obvious but often teachers make mistakes here. The problem is most serious when there are large numbers of students or when the skill you are demonstrating cannot be seen from far away.

If some students cannot see properly you will need to repeat the demonstration. Senior students or teaching assistants may help you here. You could even use a film or a television recording to demonstrate the skill. However, most teachers do not have the necessary equipment for this.

The demonstration must be visible.

3. Explain what you are doing. It is not enough to perform the skill correctly and visibly. You must explain what you are doing and emphasize the important points. A handout or written set of instructions will help you to make sure that the students learn the necessary points.

An example of using a handout to help explanation

Preparing for an intramuscular injection

1. Put the two parts of the syringe and the needle in a metal container (a metal pan or tin). Cover them with water and boil them for 20 minutes.

2. Wash your hands with clean water and soap. Rub your hands together in the soapy water until they are really clean. Then rinse them in clean water.

3. Using a swab wetted with a disinfectant such as surgical spirit or alcohol, clean the lid of the bottle containing the substance to be injected (rub hard two or three times).

4. Using a clean swab, rub (two or three times) the place where you are going to put the needle in the buttocks for the intramuscular injection. On the buttocks choose a place for the injection that is fairly high up and towards the side.

5. Put the two parts of the syringe together and fix the needle on firmly. Do not touch the sharp end of the needle.

You could use this kind of handout in the following way. You would explain why intramuscular injections are given. You would then give the handout to the students. Then you would demonstrate each stage in turn by showing the students exactly what has to be done. During the demonstration, you would keep on referring to the handout. For example, you might say

"Now we come to stage 2. You should wash your hands like this. Note that the water must be clean and that I have to use soap. It is not enough just to get the hands wet. You must rub your hands together hard to remove any dirt and germs..."

An advantage of using a written handout while you are demonstrating a skill is that the students will become familiar with the handout. They can then keep the handout to refer to later.

Another advantage is that you are giving the students a record of the stages involved in performing the skill, so they do not have to take notes. This means that they can concentrate on watching the demonstration, rather than trying to do two things at the same time.

8.6 Providing practice in using skills

The most important stage in teaching students how to use a skill is the practice. Unfortunately this is often the most difficult to organize and can take the most time. Despite these problems, teachers must make sure that students have plenty of opportunities for practice.

The main features of a good practical teaching session are:

· All students practice the skill.
· The students receive feedback about how well they are using the skill.

The remainder of this chapter describes some methods that the teacher can use. These are:

- role-playing	(Section 8.7)
- projects	(Section 8.8)
- simulators	(Section 8.9)
- case-studies	(Section 8.10)
- job experience	(Section 8.11)

This list is not intended to be complete, but to give teachers some ideas about some of the methods that are available. Teachers need to find a method that meets the specific needs of their students. They can do this by adapting some of these methods, finding out about other methods or developing new methods.

8.7 Using role-playing to teach skills

Many teachers find that communication skills are the most difficult group of skills to teach, because there are fewer definite rules to follow. For example, it is hard to decide exactly what makes an explanation clear or persuasive.

Because of this, students need to develop their own way of communicating and so, of course, they must have plenty of practice. This practice should be supervised by a teacher, a senior student or a teaching assistant whenever possible.

Role-playing is often used for practicing communication skills. In this method the students act different parts as if they were in a play. But instead of words and parts the students are given an outline of a situation, as shown in the example below.

Example

Ask student A to act the role of a health worker trying to persuade a mother to have her baby immunized against polio.

Ask student B to act the role of the mother. Explain that the mother is worried because her mother has told her that the immunization is both dangerous and unnecessary. However, she must be persuaded to have her baby immunized, even though she respects her mother's opinion.

Ask student C to act the role of the grandmother. The grandmother expects her opinion to be followed. None of her babies were immunized and all of them grew up to be both strong and healthy. She believes immunization is unnecessary and dangerous.

Now tell the students who are playing the different parts that the health worker is talking to the mother and grandmother in the health centre. Ask them to talk and react in the way they think that the mother, grandmother and health worker would behave.

Ask the other students in the group to watch and listen to what happens. They should note down things that the health worker does well and any mistakes he or she makes.

They should think how they would have talked or reacted in the same situation. What other information would they have used? Would their manner have been different?

Probably the role-playing will last for only a few minutes. Now comes the very important stage - the discussion.

Ask various students how they would have behaved and invite discussion from the group as a whole about the way the health worker behaved. Ask them also how the grandmother and mother were likely to have felt. Would the grandmother have felt offended? Would the mother have felt bullied? You should encourage the students to think about the emotions of the people in the role-playing exercise. The students should also be made aware that facts are not enough for good communication.

Other role-playing exercises could also be used to help students to understand the problems of communication. The exercise could be fairly simple like the example described above or it could be more complicated. For example, you might add extra information such as the news that a baby in a neighbouring village died soon after immunization against a different disease. Or the baby's father might come into the health centre during the discussion. He might have strong opinions about immunization - either for or against it.

Whatever situation you choose to use, the students will need some reassurance. Some may be very shy or afraid of making mistakes.

It is probably not a good idea to force any student to take on a role until they have seen other students acting. You should try to keep the mood fairly light-hearted - and make sure that the students know that this is purely a learning experience and not an assessment.

While this is a very useful technique in practicing skills and giving students insight into communication, there are some limitations. The main one is that this technique should not be used with groups of more than about 25 students. This is because all the students should take part in the discussion at the end. With large groups this is impossible.

A second limitation is that the students playing the parts of the mother or grandmother are only acting. Therefore, the students should also have experience of communicating with people in the community to find out about their opinions and personalities.

Although these limitations are important, role-playing is still a very useful method in helping with communication skills.

8.8 Projects

Projects are an important part of many long courses. In a project the teacher asks the student - or a group of three or four students - to attempt a specified task. For example, the teacher might ask students to find out about the health problems in a village - or what superstitions schoolchildren have about nutrition or hygiene.

When students do project work they find out facts. But they also increase their skills in talking to people and collecting and reporting information, as well as in other areas. The exact skills will depend on the project chosen.

While projects can be very valuable learning experiences, they can go badly wrong. Teachers must give help and encouragement - without doing all the work. At the end of the project the students should present the reports to the whole class so that every student can benefit from the experiences gained in all the projects - and this takes time.

Projects are useful, provided that the teacher is enthusiastic, gives enough help and there are not too many students. They are very difficult to organize when there are more than about 40 students in the class.

8.9 Simulators

Simulators are extremely difficult to define in any way that is both reasonably simple and complete. It is better to quote some examples. An orange can be used as a simulator for students to practice giving injections, because it simulates the skin and flesh of the patient. Simulators are also used to train pilots how to fly aircraft. These flight simulators are equipped with all the normal aircraft controls and instruments which are linked through a computer to reproduce the behaviour of the aircraft. Simulators can be extremely complicated and costly or very simple and cheap.

Some simulators can be bought. For example, a simulated patient made out of plastic can be used to practice insertion of an endotracheal tube. Other simulations are based on paper and pencil exercises. These may be case-studies (see Section 8.10) or patient management problems (see Section 12.5).

The main aim of simulators (whether they are simple or complicated) is to give the students some experience and practice in using skills before they work with patients or expensive equipment. They are not intended to complete the students' training.

However, simulators are often not available. Teachers need to use their imagination to think of models such as the orange that can be used to help the students to practice skills.

8.10 Case-studies

Case-studies are paper and pencil exercises which are very valuable in teaching decision-making skills.

The essential feature is that a situation is described in words (or possibly pictures). Then the students are asked what they would do. The situation may relate to the diagnosis or treatment of patients, or to any of a wide range of managerial or organizational problems.

Example - Growth monitoring

Each student is given a copy of five growth charts which have been filled in for different children. The students are then asked to write down the advice that they would give to the mother of each of the children.

Note that this example requires the students to practice the skills of reading points on a graph and of applying the rules for deciding whether children are at risk. The students will also practice the skill of deciding what information to tell mothers.

This example does not give any practice in communication skills.

Teachers could use this case-study after they have taught the relevant information. When the students have answered the questions, the teacher should discuss their answers and give them feedback.

Example - Supervision

A supervisor visited an MCH centre and noticed the following record for injectable contraceptives.

	New cases	Old cases
March	7	12
April	10	9
May	6	7
June	9	12
July	11	10

What should the supervisor say to the MCH nurse?

Note that this example gives practice in the decision-making skills relating to analysing records (a key skill in management and supervision). It does not allow the students to practice the skills of communicating the information in a supportive way.

In this example, the number of old cases should be increasing every month if all the new cases continue to use this form of contraception. These records show a very high level of "drop-out" among patients. This is obviously a highly unsatisfactory situation. The students should be expected to recognize this and to write down a number of points that they would then make to the MCH nurse about how the situation could be improved.

8.11 Job experience

Perhaps the most useful practice students can have is to do the job itself. This practice must, of course, be supervised.

One way is for students to join qualified health care staff for periods of attachment. Ideally one or two students should work with the senior health worker to see how the job is done. Gradually the senior health worker or supervisor will ask the students to do more and more of the work. All the time, the supervisor must make sure that the students are not making any serious mistakes and that they are frequently told what they are doing well, what they are doing badly and how they can improve their performance.

Job experience is widely used - for example, ward rounds and attachments to wards. In some schools for health workers the students spend the whole of the second year of a three-year curriculum in job experience.

Although this method is widely used, it is not always well used. Often ward rounds will have so many students working with one teacher that only one student out of ten or fifteen is actually practicing a skill, while the others are just watching. This can be very boring and even at its best is not very effective.

At other times the teacher may spend too much time talking and demonstrating. In such cases the ward round then becomes a theory lesson with the teacher simply giving an informal lecture. This again stops the students from getting the practice that they need.

Despite these drawbacks, job experience can be a very powerful method of helping students to learn skills. Teachers should make every effort to arrange for students to work with qualified staff. Teachers should also explain to the staff that the aim is to provide the students with the opportunity to practice the skills under supervision - not to teach them theory.

8.12 How much time is needed?

It is very difficult to specify how much time students need to learn skills. For most curricula, too much time is devoted to teaching theory and not enough time to learning skills and attitudes. For many tasks, students will often take 2-4 times as long to master the necessary skills and attitudes as they do to learn the essential facts. (There are, of course, exceptions to this general rule.) It is clear, however, that the students need to spend a great deal of time practicing the necessary skills.

8.1 3 Summary

How to teach skills

1. It is absolutely essential to teach students the relevant communication, cognitive and psychomotor skills.
2. Skills are taught by:

- describing the skill
- demonstrating the skill
- allowing every student to practice the skill.

3. Role-playing exercises, projects, case-studies, simulators and job experience are some of the ways in which students can practice skills.

4. At least two-thirds of the time in every course for health workers should be spent teaching and practicing skills.

CHAPTER 9: How to teach knowledge

9.1 How important is knowledge?

Obviously all health workers must have some knowledge in order to do their job. But it is also true that other knowledge is not necessary. For example, health educators must know which local foods contain protein, but they do not need to know the chemical structure of each protein. Nor do they need to know the biochemical processes involved in the digestion of protein.

So some facts are very important and some are not at all useful. This means that teachers must choose which facts to teach. They must not just cover everything in a textbook or manual. Nor must they be tempted to show how much they know by teaching students a lot of irrelevant information.

Teachers therefore need to decide which facts are important, useful, and relevant. Task analysis is very helpful here because it shows what information or knowledge is needed to do each task. (Look again at Part 1.)

In deciding which facts need to be taught, teachers should ask themselves:

" What would the students do poorly if I left out this detail?"

If the answer is "nothing", then the information should usually be left out.

9.2 Teaching different types of facts

So far this chapter has explained that some facts are important while others are not necessary. However, the important facts may be important in different ways - so they should also be taught in different ways.

Example

Take as an example the training of a group of health auxiliaries who will be responsible for running an immunization programme. The course may include the following information.

A. Whether the vaccine can be stored in sunlight or whether it must be kept in the dark.

B. How to explain to parents that their children should be immunized.

C. The date when the vaccine was discovered.

D. Safe storage times for the vaccine at different temperatures.

Comments

A. Obviously this is important. Teachers must emphasize this fact and make sure that all the students remember it. It should be included in an examination.

B. This is also important - but it is more important that students can do the explaining rather than write down how they would do it. This means that they need to learn the relevant skill as well as the facts. The skill should be tested in an examination but the facts alone need not be tested,

C. It is not necessary for students to know when the vaccine was discovered. However, background information such as the story of the discovery of the smallpox vaccine may well help to make the lesson more interesting. It could be included, provided that your students realize that it is only background information. It does not need to be remembered. Nor should it be part of any examination.

D. The storage times are important and so the students should be told them. For some vaccines the information may be fairly detailed and difficult to remember. In this case, the facts should be recorded in a manual for the students to keep. The teacher must check that the facts are recorded accurately and that the students can refer to them when necessary.

9.3 Where should students get the facts from?

The students can learn facts or information by listening to the teacher. In this case, the teacher is the source of information.

However, there are many other sources of information that can be used. Many manuals are available which contain relevant information for health workers. There are also textbooks, films, film-strips and posters which have been prepared specially for health workers.

Another source of information is the real world. You do not always need to tell students what happens when a sore is left untreated. Nor do you need to describe the food which mothers give to their children. The students will have seen these things for themselves. So they can learn from their own experience. In a similar way, you can send the students out into the villages to collect information. The information gained in these ways means more to the students and is learned better.

Information from the real world means more to students and Is learned better.

Models of the human body are another source of information. These used to be very expensive and easy to break. However, plastic models have now become more widely available. These are strong, usually accurate, and sometimes quite cheap. These models are very useful for explaining the structure of parts of the body. A few working models are also available, which allow the student to practice skills such as inserting an airway. These are useful, although they may be very expensive.

So do not think that you must tell the students everything. Encourage your students to learn from their own experience, from books, from models, and from each other.

9.4 Planning the topics of the lecture

When you have decided that some facts need to be taught, you must plan the teaching session in which to teach them.

A useful way of doing this is to start with the task. Then decide on the main items that must be covered. For example, the task might be to control the mosquito that transmits malaria. Some of the themes you will want to cover are:

- sites where the larvae can be found
- methods of eliminating those sites
- methods of preventing mosquitos using the sites.

When you have decided on these themes, they should be put into a sensible order. (For example, you cannot talk about preventing mosquitos getting to their breeding sites, until you know what the sites are.)

Then think through each theme to decide how much detail is needed:

- what facts need to be learned
- what facts will make the lecture more interesting
- what facts should be recorded for reference.

9 5 Giving the lecture

There are many ways of giving a lecture. The advice given below describes just one pattern. You will need to adapt this and develop your own methods. However, this does give a basic guide which you can follow and improve.

1. Get the students' attention. Explain why the lecture is important to the students or tell a story that shows why it is important. Ask the students what they already know about the topic or why they think it is important.

2. Give a summary. Explain what themes you are going to cover. This helps the students understand how each part of the lecture is related.

3. Test how much students already know. Make sure that all students know the facts that you are going to use. For example, if you think the students need to know some anatomy to understand a point, check that they do know it.

4. Present the facts and information. You can either tell the students the facts or

- use handouts
- ask students to read a part of a book
- ask one of the students to describe the facts
- use audiovisual aids
- show models or equipment
- ask students to examine patients.

5. Set an exercise for the students to do during the lesson. The exercise should make the students use the facts they have just learned. This is a very important part of teaching. For example, you could ask individual students or groups of students "What would you do if... ?" or "How would you... ?" Another kind of exercise would be to write notes on a topic or fill in the missing words on a handout.

6. Summarize the lecture. Repeat the main points that you want students to remember.

7. Test the students. Check whether they have learned the important points.

8. Set an exercise to do after the lecture. Ask students to prepare for the next session by reading, doing some specific work in a hospital ward or the community, or revising what they have already learned.

You may think that this is not the kind of lecture that you used to go to when you were a student. This does not matter. A lecture should involve the students in doing things. Just listening is a poor and slow way of learning.

9.6 How to speak in the lecture

You should not spend the whole time talking. However, when you are talking there are some points to remember.

1. Do you speak loud enough? Often teachers speak to the students at the front of the class. The students at the back are unable to hear the teacher and so cannot learn. If you are not sure whether you can be heard, ask a friend to sit at the back of the room and tell you.

2. Do you speak clearly? The volume may be loud enough, but you may speak unclearly. You should make sure that the words are clear and that you speak to the audience. Do not look down at notes or talk facing the board.

3. Do you use simple words? Make sure that the language you use is simple enough for all the students to understand. This is especially important when the students come from communities where different languages are spoken.

4. Do you sound as if you are interested? Some teachers speak in a flat, monotonous voice. They sound bored and their students soon become bored. Vary the tone of your voice and try to show that you are enthusiastic and interested.

9.7 Visual aids

Some of the ideas and facts in your lecture will be best explained if you show a diagram or picture. So you will need to use a visual aid, such as:

- a chalkboard
- charts (tables, graphs and diagrams)
- a flannelboard
- an overhead projector
- a slide or film-strip projector
- films (movie)
- photographs.

At least some of these aids are likely to be available. Sometimes the material will be prepared for you to use - for example, film-strips, films and photographs. These can be difficult to obtain, but one agency, Teaching Aids at Low Cost (TALC), specializes in making and selling these aids as cheaply as possible.

Their address is:

TALC
P.O. Box 49
St Albans
Hertfordshire AL1 4AX
England.

You can prepare other aids for yourself. When you do this you should:

1. Keep diagrams as simple as possible - unnecessary detail only confuses the students.

2. Make sure that all lettering can be read by all the audience. This point applies especially when you are writing on a chalkboard.

3. Talk about each diagram to make sure that the students understand all the symbols. This is especially important when you use graphs or cross-sectional diagrams.

Make sure that all lettering can be read by all the audience.

9.8 Using handouts in lectures

Handouts are one way of adding to lectures. They can be used in two main ways.

· As a guide to taking notes.
· As a permanent record of the facts.

A handout may of course be useful in both ways, but often there will be an emphasis in one area.

Look at the example of a handout below.

Example: A handout for students to take notes on

Malaria
Signs and symptoms:
Treatment of patients:
Nature of disease:
Who is at risk?
How is malaria transmitted?
Prevention of malaria:

The idea of this type of handout is that it provides a structure to the lecture and so helps the students to organize their notes. Students should write their own notes on the handout while they listen to the lecture. This very simple handout helps to make the lesson more active, and therefore helps learning.

Note that the handout also helps to remind the teacher of the main points. Using this framework you could begin the lecture by asking whether any of the students have had malaria. You could then ask them what it was like (the symptoms) and so on. As each stage was completed, the students would then fill in the main points on their handout.

This second example is quite different. It provides a record of information that the student may need to refer to later. It is unlikely that the student would be expected to know and remember these details.

The teacher could give this handout to the students during the class. This saves time spent in drawing the table on the board and waiting for students to copy it down. This time can then be better spent by asking students questions to test their understanding of the information. For example, "If you do not have a refrigerator, how would you organize BCG vaccinations in your village?"

9.9 Summary

1. Only teach those facts that the students need to know.

2. Plan exercises for the students to use the facts they have learned - do not just talk.

3. Encourage students to find out facts from their own experience, books, models, and each other.

4. Use visual aids and handouts.

CHAPTER 10: Planning a teaching session

This chapter helps the teacher to plan a teaching session. In doing this it brings together ideas from previous chapters and deals with some specific situations. These situations are: teaching people who cannot read (Section 10.7), teaching people who already have some experience (in-service training) (Section 10.8), and teaching small groups of students (Section 10.9).

10.1 Planning a teaching session - overview

The point of planning a teaching session is to ensure that you use the teaching techniques described in this book in the most effective way. You can make plans in many different ways. One method is suggested here, but you will probably need to adapt this method to meet the needs of your students.

The steps are:

1. Decide on the learning objectives (Section 10.2).
2. Decide how to attract the interest of the students (Section 10.3).
3. Decide on the key points of the session - and their order (Section 10.4).
4. Decide what activities will be done by the students (Section 10.5).
5. Decide how to judge whether students have learned enough (Section 10.6).

10.2 Learning objectives

In practice, teachers are usually given a theme or topic for a teaching session and allocated a certain amount of time. For example, you might be told, "Please teach the students about anaemia. There are three one-hour sessions available". Sometimes more detail is given. This would be helpful but this section assumes that only the minimum details are given.

The first thing you should do is to think about the topic in terms of task analysis.

"What tasks will the students need to do?"

"What resources or equipment are likely to be available?"

" What situations will the students be expected to cope with?"

" What knowledge will they need in order to do the various tasks?" "Are there any attitudes that are especially important?"

Using this method, you should be able to produce a list of learning objectives for the lesson. These may be split into performance objectives (the sub-tasks related to anaemia) and enabling objectives (the knowledge and attitudes necessary to enable the students to do the sub-tasks). Some examples are given below (this list is, of course, incomplete).

Performance objectives	Enabling objectives
Examine patients for clinical signs of anaemia	Know where to look for clinical signs
	Know how to recognize the clinical signs
Obtain a medical history from patients	Know which questions to ask
	Know which items in a history indicate anaemia

Not - how to take a blood sample or do a haemoglobin test (for this category of health worker)

You should continue this list until you have covered all aspects of the work related to anaemia. The complete list is the list of learning objectives. Note that it is unlikely that this type of health worker will need to know anything about the components of blood. At this stage, you may feel that there is too much or too little detail to be covered in three hours. If so, then you will need to adjust the course. In some cases, you will need to go back to the employers and ask them to reduce the number of tasks or responsibilities related to the job or increase the total time available for training.

10.3 Attracting the interest of students

Now you have to think how to make "anaemia" meaningful and interesting to students. In general, students will find a topic interesting if it is related to their own experience of life (not books or previous lessons) or to the work they expect to be doing.

Therefore a bad way for you to start the session would be:

"Last time we completed the teaching on tetanus. Today we will go on to a new topic, anaemia".

Slightly better, but not much, would be:

"Last time we finished one aspect of antenatal care - prevention of tetanus. Today we go on to another important part of antenatal care - caring for pregnant women who have anaemia".

Better again would be:

" We are now going on to another aspect of antenatal care - caring for women with anaemia. Many pregnant women have anaemia and it is one of the serious problems of pregnancy. You can do a lot to reduce this problem and these sessions will tell you how".

A better way would be to follow the previous example and then go on to questions such as:

"Have any of you ever had anaemia?"
"Have any of your family had anaemia during pregnancy?"
" What did it feel like when you had anaemia?"

Other topics will need other introductions, but in every session you must try to find the best way of making the subject seem interesting and important to the students.

10.4 Key points

Every session needs to be structured in terms of ideas and topics. One way of doing this is to think of the questions or problems that the session will answer or solve. These questions or problems will, of course, be related to the learning objectives. For a session on anaemia, the questions might be:

A. "How can you tell if a person has anaemia?"
B. "What advice should you give to pregnant women to prevent them becoming anaemic?"
C. "What is anaemia?"
D. "How can it he treated?"
E. "Why is anaemia important?"

When you have listed all the key points or questions, you should then try to put them into a sensible order.

Exercise

What order would you choose? For example, if you would teach point E first, put the letter E beside number 1, below.

1.
2.
3.
4.
5.

Comments

Probably you have put them in the order C, E, A, D, B. However, the various points could also be taught in a different order.

The overall pattern of the session is now established. There will be an introduction designed to gain the students' interest. This will be followed by the main part of the session dealing with the key points in order. Finally there will be a summary.

10.5 Activities

Often teachers think mainly about what they will do during a session. This is natural, but it is better for teachers to think about what the students will do. As discussed in Section 6.5, students learn very much faster when they are active.

How could "anaemia" be made active?

The starting point is to go back to the objectives. Certainly students will have to practice all of the performance objectives. In this case the students should, as a minimum, look at each other's conjunctival and practice checking for the other clinical signs. Ideally, they should then go on to examine patients. However, they could be asked to do exercises based on case-studies which describe different patients, some of whom have anaemia and some who do not. Role-playing exercises could also be used for the students to practice giving advice to mothers about anaemia.

It is also important to try to make the learning of facts as active as possible. This can be done very simply by setting a short test at the end of the session. Another and possibly better way is to ask the students questions during the session. Do not tell the students everything. Encourage them to think, deduce or guess what the facts are. The less the teacher tells and the more the students work out for themselves the better.

Incidentally, when you ask a question, it is much better to ask all students to write down their answer on a piece of paper than to ask only one student to speak the answer. This gives you a chance to look at all the answers and so judge how well the students are doing. It also makes every student active instead of just one.

10.6 Judging how much students have learned

An integral part of all teaching sessions should be some form of assessment. Teachers should not assume that everything they say has been learned. The activities described above also allow teachers to judge whether the students have achieved a good enough standard.

Ideally, you should only begin teaching a new group of topics when all the students have achieved all the learning objectives related to the previous session. This is rarely achieved in practice. However, the principle is clear and you should try to follow it as closely as possible. You will only know whether you are doing this if you assess what the students have learned.

10.7 Teaching people who cannot read

Many health workers cannot read or find reading and writing very difficult because they have had little or no schooling. The following points may help you to train people with such difficulties.

· Many people who cannot read are just as intelligent and capable of learning as other people. They simply did not have the chance to learn how to read and write when they were children. So they must not be treated as stupid or slow.

· There will be no point in providing these students with written textbooks or written handouts - or writing words on the board.

· The students may find pictures just as difficult to understand as words. However, pictures can be meaningful if they are explained. They can help students to remember what you have said.

· It is especially important to make learning as active as possible. You should draw on the experience and communication skills of the students. Keep asking them what they already know and what they would do in certain situations.

10.8 In-service training

The purpose of in-service training should be to improve the way in which health workers do their work. This is a fundamental point which is often ignored. As a result refresher training is given, which has no impact at all on the way in which the work is done. How can you avoid this problem?

First, you need to think carefully about exactly what improvement in working methods is required. You will need to talk to managers and supervisors. You will also need to go to the field and observe the way in which health workers do their work. In this way you can prepare a list of tasks that should be done differently. Then you should give some thought to the reasons why the tasks are being done badly.

· Is it because the health workers do not know what should be done?

· Is it because they do not have the necessary skills?

· Is it because they are being forced to work in the wrong way?

· Is it because they do not have the right equipment or supplies - or enough time to do the task correctly?

If the reasons are related to a shortage of supplies or other factors outside the control of the health workers, then in-service training for health workers will not improve the situation. Take a different situation. The health workers are giving antibiotics to children with a common cold. You find that they are doing this because the parents insist that their children should be given antibiotics and will make complaints if the children do not get them. To solve this problem, you might need to train the health workers in ways of explaining to the parents why antibiotics would be of no use. Certainly, just telling health workers when to give antibiotics would not have much impact.

This process of analysis will lead to a set of learning objectives. They should be very specific and designed to lead to changes in working methods that are realistic and that will improve the quality of health care. General refresher courses covering a lot of topics, but not dealing with anything in much depth, should not take place.

A final point about in-service training courses concerns the teaching methods. Most of the health workers will be experienced and already have a lot of knowledge and skill. This must be recognized. You should make a point of asking them what they would do to improve situations, rather than telling them. Health workers usually know much more than teachers about how health care can be provided in the field situation.

10.9 Working with groups of students

Much has been said and written about the advantages of smallgroup teaching. There are indeed many potential advantages. Unfortunately these advantages are not always apparent because teachers may not use the methods effectively.

One problem is that small groups are sometimes taught in exactly the same way as large groups. The same sort of lecturing style is used. The only difference is that fewer people hear the lecture. If this happens, very little benefit can be expected.

At the other extreme, some teachers have such confidence in the use of group discussions that they give the group a topic to discuss and leave them to discuss it in their own way. Usually this leads to a very disorganized discussion:

- nobody knows who is right and who is wrong,
- the confident, assertive students talk all the time while the shy students never speak,
- the students do not listen to what other students say,
- topics are changed more or less at random.

Where this happens, very little learning occurs.

In order to avoid these two extremes, you should:

· Have a very clear idea before the session begins concerning the topics to be discussed and the activities that the group will take part in.

· Control the discussion by encouraging the shy people to give their ideas first and by ensuring that all students have some chance to give their views.

· Control the discussion by ensuring that all students keep to the topic being discussed, by pointing out differences (or similarities) between the ideas given by different people, and by ensuring that the discussion is summarized in writing.

· Give feedback to ensure that all students know whether the opinions or ideas given are right or wrong.

· Tell students when they make points that are wrong. This must be done in such a way that they are not discouraged.

· Encourage a group spirit by setting tasks for the students to work on as a group.

If these rules are followed, small groups can learn quickly because all the students are actively involved in thinking and in expressing their ideas.