Adopting a learning stance

Distinction between ES and LS

The distinction between an ES and an LS was described by Giroux and Girard at the conclusion of a 15-year participatory action research project conducted at the University of Sherbrooke in Quebec.⁸ The LS and ES represent a series of ideas, emotions, behaviour, and attitudes adopted by learners in their relationships with their supervisors, based on their needs and motivations. It emphasizes the fact that some learners focus on the goal of “becoming a good family physician” while others are mostly driven by the goal of “getting good grades.” One student will see clinical situations as opportunities for real learning, openly talking about the challenges he or she is encountering and looking for answers. By contrast, another student will seek to impress, avoiding situations that could lay bare his or her weaknesses. Through their attitudes, remarks, and supervision strategies, supervisors play a crucial role in shifting the focus to an LS. If they judge a student for the difficulties he or she is encountering, that student might never voice them again.²

Clearly, evaluation is an essential part of medical training—one that coexists with the reality of learning. The LS and ES are part of a continuum, as represented in Figure 1. Students move back and forth along this continuum every day in their interactions with their supervisors. Where they are at any given moment depends on the learning situation, the students (eg, the emotions that the learning situation brings up for the student, past experiences, etc), the attitudes of their supervisors, and the teaching culture in the setting. By the very nature of their role as assessors, preceptors need to take the initiative to create an atmosphere of trust and encourage learners to adopt an LS.

• Download figure
• Open in new tab

Figure 1.

Continuum from an evaluation-focused stance to a learning stance

Many supervisors across Canada try intuitively to encourage their students to adopt a learning stance, to varying degrees of success. Giroux and Girard describe different strategies to help both students and preceptors adopt an LS rather than an ES on a daily basis (Table 1).⁸

Workshop to foster the adoption of an LS

In the 1990s, the University of Sherbrooke introduced a workshop on the LS in an effort to encourage residents to adopt attitudes and strategies for making the most of their residency. Because they were unsure whether their supervisors shared this vision, the residents were initially reluctant to expose themselves and risk bad evaluations. The workshop was re-introduced, this time with the participation of the supervisors.⁸

The first part of the workshop introduces the notion of LS-ES. Participants are asked to come up with possible strategies, first individually and then in groups. Two actors then simulate a typical supervision session and those watching are instructed to suggest specific strategies favourable to an LS. The actors then play out the scene again, incorporating the suggestions that have been made. The result is a very convincing demonstration of active learning and the LS.

Laval University in Quebec began to use this workshop in 2010 in its efforts to find tools to support competency-based learning. Response to the workshop was so positive that Laval University decided to adopt the concepts and materials that had been developed at the University of Sherbrooke. Since 2013, all of its teaching sites have offered a 2-hour workshop at the beginning of the year that is attended by first- and second-year residents, preceptors, and other professionals involved in teaching.

Each workshop is led by 2 facilitators, 1 of whom is from outside the teaching centre. This facilitator encourages the residents to express themselves, reassuring them that their comments, which are often very emotional, will be treated confidentially. To ensure that the workshop is delivered consistently, a facilitator’s guide has been developed and workshop facilitators meet annually.

The residents and supervisors reported that they really liked the workshop and that it has had lasting and positive effects. Supervisors are more focused on learners’ needs. As one resident put it, “This is the course that has had the most impact on how I behave during supervision. I realized that my supervisors were there to help me. This was the opposite of my experience as a clerk, where I learned to hide certain things.” Second-year residents reported that attending the workshop again at the beginning of their second year was really valuable.

Tips for teaching

The LS involves a reciprocal, explicit responsibility that is shared by the learner and the supervisor; both work together to create conditions conducive to optimal learning. For example, they agree together on a strategy for discussing cases that will meet “real” needs expressed by the learner.

Both benefit when they take an honest look at where they are along the LS-ES continuum. The supervisor also benefits from adopting the LS; a proactive attitude, self-examination, collaboration, open dialogue, and feedback loops are all important aspects of lifelong learning.⁹ A supervisor’s commitment to ongoing improvement will be a source of inspiration for his or her residents.

For maximum benefit, the LS should be adopted throughout the program. Those in charge in the various rotation settings should ensure that the atmosphere and relationships are conducive to the LS and that learners will be able to trust that they have more to gain by sharing their fears and concerns than by hiding them. The general observation is that the shift results in a healthier, more constructive work environment and learning environment for all.

Tools and resources

The workshop⁸ can make it easier to apply these concepts on a daily basis and to transform the culture of teaching settings. Based on the experiences of residents and teachers in the field, a list of strategies has been developed for optimizing the LS in clinical supervision (Table 1).⁸ Supervisors will find that paying attention to the LS will be especially helpful for supervising residents who are struggling.

Adopting the LS and proactive supervision strategies will help you to make the most of what little time you have for supervision. As your clinical load gets heavier and the number of residents grows, these tools might help you to optimize your supervision time.