What is a clinical skill? Searching for order in chaos through a modified Delphi process

Abstract

Background: Everybody seems to know what a clinical skill (CS) is but closer consideration shows that the concept of a CS is not as clear as might be assumed. Some seem to use “CSs” when just referring to physical examination skills, whereas others use the term to also include diagnostic, communication and practical skills. CSs are more than a simple performance, but clinicians are often not consciously aware of the complex interplay of different components of a CS that they are practicing and accordingly do not teach all these aspects to students.

Methods: A modified Delphi research was designed to explore concepts around the definition of a CS and its components for learning and teaching. The panel consisted of a group of British doctors, all involved in teaching CSs.

Results: One hundred and twenty-two items were identified and ranked through two rounds of a Delphi process, coded into thirty-seven codes and clustered into six principle themes: professional roles; components of CSs; performance; psychomotor aspects; educational environment; and teacher versus student centeredness.

Conclusions: A CS may contain one or several different domains such as: physical examination skills, practical procedure, communication skills, and management. Acquiring CSs includes three components: learning how to perform certain movements (procedural knowledge), why one should do so (underlying basic science knowledge), and what the findings might mean (clinical reasoning). If we are to teach CSs for clinical practice, we must take these three different components into account in our instructional design.

Introduction

Clinical skills (CSs) feature heavily in health professionals’ curricula, with dedicated curriculum time, specially designed CSs labs and a wide array of CSs assessment techniques and procedures. There are a wide range of CSs text-books, and there are even dedicated journals and conferences on the topic. Despite such a wide coverage, there seems little consensus as to what is, and what is not, a CS.

Different authors include different domains within their definitions of CS. These include physical examination skills, practical skills, communication skills, treatment skills, and clinical reasoning/diagnostic skills. Some texts only seem to refer to physical examination skills (Junger et al. 2005), whilst for others communication skills is seen as “a basic CS” (Kurtz et al. 1998). The British General Medical Council combines clinical and procedural skills but separates these from “diagnosis and treatment” and “communication skills” (General Medical Council 2004) in contrast to the Scottish Medical Schools who include diagnosis under CSs but separate this from practical procedures (Simpson et al. 2002). In its original document, the Royal College of Physicians and Surgeons of Canada does not use the term “CS” but lists all the procedures (from history taking to treatment) under the heading “diagnostic and therapeutic” skills (CanMEDS 1996), and in its updated version does mention, but not define, CSs, and the section “Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice”, is separate from patient assessment, communication, and from procedural skills (CanMeds 2005). The international curriculum for “Global minimum essential requirements in medical education” includes history taking, physical examination, practical skills, interpretation of results, and patient management under the heading of CSs, but separates these from critical thinking and problem solving (IIME 2002). Curriculum designers, therefore, seem not to agree as to which domains to include within CSs. We were interested whether we could build some consensus as to any common features across these various domains. We wanted to clarify the semantic representation that CSs teachers have when speaking about these skills.

Table

Practice points

Faculty should define what they mean when they speak about CSs. Which domain are they referring to? Physical examination, treatment skills, etc. Physicians involved in teaching do agree that the three components, procedural steps, underlying knowledge, and clinical reasoning, are part of CS learning and teaching. Skill analysis must be used to ensure that appropriate teaching methods are applied.

Within the literature on methods for skills training, most methods are clearly aimed at instruction within one domain, however some methods do cross across domains, using a common approach. Kneebone (2002), for example, describes a method of combining procedural and communication skills training and others have called for more integration of physical examination skills with clinical reasoning (Benbassat et al. 2005).

The wide range of different domains that may or may not be included under “CS” is not the only challenge in defining what we mean by this term. Different perspectives from educational philosophies, lead to very different concepts of how CSs are best taught and learnt. The behaviorist tradition sees learning as a change in performance; repetition and practice is important alongside behavioral feedback. Teaching, and the role of the teacher, is central to student learning (Ertmer & Newby 1993). Most existing methods of CSs teaching tend to follow this tradition (Van Dalen 2008). One widely used example is “the four stage approach to teaching skills” (Peyton 1998). In this method, the teacher demonstrates a skill, the teacher demonstrates the skill whilst giving a running commentary, the teacher demonstrates the skill whilst the student gives a running commentary and the student then performs the skill whilst giving a running commentary before receiving feedback.

Insights from cognitive psychology bring a different perspective. This paradigm places the learner at the centre of the learning process, and has shifted the emphasis from what the students can do, to what they know (Ertmer & Newby 1993). Aspects such as prior knowledge and its activation, the structuring of knowledge, the use of contextual cues, and techniques for maximizing intrinsic motivation have been shown to improve retention and recall of factual knowledge (Schmidt 1993). This approach is seen as more student-centered. Whilst it has increasingly featured in the learning of knowledge, it is rare to find cognitivist approaches to CSs learning. One notable exception is Gagné's instructional events, as modified by O’Connor (2002).

Models of CSs learning are predominantly based on the wider skills learning literature (how we learn to walk, drive, and fly a plane). However, as we have seen above, there may be more to a CS than learning a procedure, other forms of knowledge rather than just what steps to take may be required if we are to expect, for example, clinical reasoning. Knowledge can be classified as declarative (factual knowledge, knowing what), procedural knowledge (knowing how to perform certain tasks), and conditional knowledge (knowing when and why to apply declarative or procedural knowledge) (Bruning et al. 2004). The behaviorist approach to skills learning discussed above emphasize behavior and performance of simple steps for learning CSs, relating to development of procedural knowledge. Anderson's influential ACT model (Patrick 2002; Bruning et al. 2004) for skills learning is one of the few approaches that links declarative knowledge to procedural knowledge through an “if … then …” algorithm, but this generic model is rarely referenced in CSs training outside of clinical reasoning training. It is not clear, therefore, whether CSs relate only to the development of procedural knowledge, or whether integration with declarative and conditional knowledge should be considered. Clearly the conception of what knowledge is required for CSs learning (procedural alone or integrated) is crucial for the planning of skills teaching.

CSs, therefore, appear to mean different things to different people, with a lack of clarity as to what is, and what is not, a CS. In addition the literature on training CS is unclear as to whether training should be within or across domains, and whether more behaviorist, teacher centered models, or more cognitivist student-centered models are best employed in its delivery. By the way of the knowledge required for learning CS, there seems little consensus as to whether CS are procedures requiring procedural knowledge, or whether they involve complex interactions of procedural, declarative, and conditional knowledge. This lack of clarity is surprising, as without defining what learning is expected, we cannot select an appropriate instructional methodology: “… the analyse of a task is to identify the types of learning which are involved … . types of learning require different training methods of strategies” (Patrick 2002, p. 281)

We therefore decided to try and build a consensus through investigating the following areas: What is a CS, which are its sub-domains? Which are the different components or elements involved in learning a CS? Which are the different components or elements involved in teaching a CS?

There are various methods for gaining a consensus between opinions (Evans & Estcourt 2007). We chose to utilize a Delphi approach (given in Delphi flow chart). This is a widely recognized method for gaining consensus at a distance between a group of experts (Gordon 1994; Stewart et al. 1999). However, there is no uniformity about how to conduct a Delphi, as the number of rounds and the panel size fluctuate a lot in the literature (Gene & Gordon 1999). Most of the papers refer to a group of experts who express their opinion and comment on the statements of the other panel members in order to reach a consensus. The strengths of this approach lie in the expertise of the participants and the anonymity which allows to express their opinion without being influenced and permits as such a controlled feedback mechanism (Stewart 1999).

Methodology

Participants

Potential participants were suggested by two UK medical educationalists working in different London medical schools. The inclusion criteria were an expertise in teaching CSs and being a medical graduate. Twenty-six doctors agreed to participate in the Delphi process, and included representatives teaching principally in general practice, hospital settings (at least five different hospitals) and skills lab settings. All except one had more than five years’ experience of teaching CS and the majority had more than 10 years’ experience. These panelists taught students from at least three different medical schools (Flow chart).

Generation of round 1 items

Questions used in the first round were generated through discussion between four health profession educationalists and a statistician, followed by a pilot round with two of the participants. The final open-ended questions used are given in Table 1.

Table 1  Initial trigger questions for the Delphi process

• What is a CS, which are the sub-skills?

• Which are the different components or elements involved in learning a CS?

• Which are the different components or elements involved in teaching a CS?

Round 1

Participants were asked to answer and comment with free text to each of the three open-ended questions (Table 1). These free text comments were separated into statements, each with one theme, and listed for each of the three questions. These lists of statements were then used for round two as follows.

Round 2

Respondents to round 1 (n = 22) were asked to rate each statement on a 4-point Likert scale (strongly agree, agree, disagree, or strongly disagree), and return this to the investigator. These ratings were collated to produce a score for each statement, indicating the level of agreement for that statement. Three researchers were asked to look for themes, grouping similar statements, and providing headings for these groups. After an individual interpretation, the three researchers met and discussed their clustering; this led to a further round of independent recoding and a second meeting and discussion where consensus was reached between the three researchers.

Round 3

All respondents of round 2 (n = 20) received the new questionnaire, which consisted of the group headings, each one listing its referring statements. The panel was encouraged to comment whether these headings were representative of the group of statements listed underneath or not. Over the three rounds, six participants dropped out due to competing pressures on their time.

Post-study analysis

Despite two rounds of coding by three independent researchers, the panel's level of agreement (percentage either agreeing or strongly agreeing) with the clusters ranged from 56% to 94%. It was felt that this may have resulted from cultural differences or nuances in language (the three researchers involved in the initial analysis practiced in three different countries, all outside the UK) or from the coding process. The round 2 data were therefore re-coded and re-analyzed by two researchers, including a native English speaker, using a thematic analysis approach, facilitated by the Computer Assisted Qualitative Data Analysis Software Atlas.ti (version 5.2). Statements from each of the three questions (Table 1) were pooled and coded together, in order to provide insights of what a CS is, from the perspectives not only of a definition, but also the perspectives of teaching and learning. Notably, there was considerable overlap in answers from the different sections. Consensus was reached between the two researchers after two rounds of coding and discussion. Codes were clustered into further themes with iterative attention to the original quotations. The final analysis was presented to a different panel of CS teachers, working in a medical school that had been unrepresented in the original Delphi process, and there was strong agreement with the findings of the analysis.

Results

Round 1 generated 49 statements for question 1, 48 statements for question 2, and 29 statements for question 3. All statements were offered for voting in round 2.

One hundred and twenty-two quotations were identified from round 2 which were coded into 37 codes within Atlas.ti. Each statement was associated with the level of agreement as identified by the panelists in round 2 of the Delphi. The statements are listed in Table 2.

Table 2  Statements generated by round 1 of the Delphi, with scores expressed as percentage of the panel voting strongly agree or agree out of a four point Likert scale

Question: what is a CS, which are the sub-skills?	%SA + A
4) CS includes -practical procedures:	100%
5) CS includes-examination skills:	100%
6) CS includes -the use of instruments required to examine	100%
16) CS can be diagnostic:	100%
46) CS can be acquired:	100%
3) CS includes -communication skills (verbal-non verbal):	95%
17) CS can be treating:	95%
42) CS is an acquired/learned/taught ability to perform them:	95%
43) CS is gained through experience:	95%
44) -CS is gained through training:	95%
7) CS includes -observation:	90%
10) CS includes -specialist skills:	90%
13) CS includes-implementation of appropriate management:	90%
18) CS is an ability which can be technical or cognitive:	90%
29) CS is a competency:	90%
38) I use a CS when I do something – When I employ an ability in which I apply my knowledge	90%
8) CS includes-core CS:	85%
40) each clinical group has its own specific CSs:	85%
9) CS includes -generic CS:	80%
14)CS includes -thinking skills (but those are not confined to the health professionals:	80%
20) CS is a task performed by a practitioner in relationship with their patients:	80%
25) CS is a tool of the work as doctors:	80%
30) CS define the clinical competence/the clinical ability:	80%
45) CS can be natural:	80%
12) CS includes-attitudinal skills:	75%
15) in most but not all cases CS requires interaction of observational/verbal/diagnostic and treatment skills:	75%
22) CS is a technique required to perform a clinical activity:	75%
37) CS is the foundation of the professional life:	75%
19) CS is the ability to carry out a task required form clinical professionals:	70%
23) there is a distinction between a CS and a technique:	70%
31) CS is an action between the health care professional and patient:	70%
33) CS is an action/ability not only done by a health professional:	70%
36) CS is working out what is going on with a patient:	70%
39) each profession develops its own vocabulary and way of arguing (belief system) →different med professionals give different advices to the same problem:	70%
48) contributes to the well being of the patient:	70%
49) a CS includes a degree of interpretation:	70%
21) a skill is a practical activity with motor component and supported by cognitive and attitudinal components	65%
26) CS is a craft:	60%
35) CS is a behavior that allows diagnosis:	60%
41) clinical: to do with medicine:	60%
1) CS is any defined component of an interaction between a patient and a clinician:	55%
11)CS includes review success:	55%
34) CS is a procedure:	55%
27) CS is an accomplishment:	50%
2) CS is performed around the bedside:	45%
28) CS is an aptitude:	35%
32) CS is an action/ability only when done by a health professional:	35%
47) the clinical context and the clinical knowledge make the ability specific to the medical profession (e.g.: a stitch):	35%
24) CS is an art required to perform a clinical activity:	30%
Which are the different components or elements involved in learning a CS?	%SA + A
L1) relevant to the context so the student knows why to learn it:	100%
L2) relevant to the context so the student knows when they should need to use it:	100%
L2) relevant to the context so the student knows when they should need to use it	100%
L5) understanding of what is required:	100%
L6) understanding the skill to be learned:	100%
L7) understand why you are doing it:	100%
L8) to see the usefulness/need of the CS in practice:	100%
L10) the opportunity to ask questions:	100%
L18) demonstration (modeling):	100%
L22) opportunity to use the skills taught:	100%
L23) repeated practice:	100%
L24) repeated practice under supervision:	100%
L25) reflection on one's own skill:	100%
L27) understanding of the limitation of the skill and when not to use it:	100%
L29) feed back:	100%
L39) opportunities to reinforce learning:	100%
L47) good teaching technique:	100%
L48) an open mind: which is a mind receptive to examination of new ideas and facts	100%
L9) to see the importance of learning the CS:	95%
L11) working from where the student is:	95%
L16) clear objectives and outcomes so the student knows what is required:	95%
L26) critical evaluation:	95%
L33) physical ability to perform:	95%
L34) the ability to adjust to individual variations between patients:	95%
L37) having sufficient time:	95%
L12) related to knowledge and understanding of the student:	90%
L13) relevance to current stage of training:	90%
L28) assessment in the clinical environment as to whether CSs can be appropriately be employed and carried out:	90%
L38) being allowed to get it wrong at first:	90%
L46) competence of teacher:	90%
L4) theoretical foundation:	85%
L21) move only to the next level if judged competent to do so:	85%
L32) skill labs but not that important if sufficient real life opportunities exist:	85%
L36) offer the deconstructed elements to the learner:	85%
L3) the learning should be based on medical knowledge:	80%
L14) prior knowledge:	80%
L17) observation of an expert:	80%
L31) a non threatening encouraging surrounding:	80%
L35) the ability to deconstruct and reconstruct:	80%
L44) ability:	80%
L40) follow excepted methods:	75%
L15) previous skills:	70%
L20) helpful text:	65%
L45) depends on learning styles:	65%
L42) objectivity:	60%
L19) description of the skill (book):	55%
L30) understanding of the framework of the medical model:	55%
L43) humility:	55%
L41) learn how to use the CS only if put in context:	50%
Which are the different components or elements involved in teaching a CS?	%SA + A
T1) being competent in the skill being taught:	100%
T6) to understand the theory behind the practice:	100%
T10) as safe environment to demonstrate and observe practice:	100%
T11) clinical environment to observe the use of CS on real patients:	100%
T12) feed back of students abilities in the clinical environment:	100%
T15) anticipation of the learner's potential difficulties:	100%
T23) understand the learner:	100%
T25) enthusiasm of the teacher:	100%
T3) being familiar with the theoretical basis:	95%
T5) how to convey the knowledge:	95%
T8) teach why you are doing it:	95%
T9) a structured easy to follow method which can be modified with experience:	95%
T14) adapt to students needs:	95%
T16) reflection on the context of the task:	95%
T20) setting appropriate expectations:	95%
T4) knowledge:	90%
T13) a small number of students:	90%
T21) allow the learner to suggest ways to improve the skills:	90%
T24) interested and enthusiastic students:	90%
T26) ability to make it interesting:	90%
T19) various methods of teaching the skill:	85%
T22) teach each other:	85%
T7) teaching based on anatomy and physiology:	80%
T29) the ability to direct learning:	75%
T2) the person who is teaching should be actively involved in clinical practice:	70%
T27) teach GSOH (good sense of humour)	50%
T28) students initiated teaching:	50%
T17) teaching script:	35%
T18) different teachers should teach the skill in the same way:	10%

Five main themes relating to the definition of a CS and two main themes relating to teaching and learning a clinical emerged from clustering the coded data. In describing these themes below, we use quotations to give an indication of representative statements within each cluster. Each statement is followed by the percentage of respondents agreeing or strongly agreeing with that statement in round 2 (n = 20)

Defining a CS

Domains

The concept of CS appear to include the domains of physical examination skills, practical procedures, communication skills, and treatment/therapeutic skills. There was a high level of consensus on these domains.

• □ “CS includes-examination skills” 100%

• □ “CS includes -practical procedures” 100%

• □ “CS includes -communication skills (verbal-non verbal)” 95%

• □ “CS includes-implementation of appropriate management” 90%

Interaction between these domains was also highlighted, although only in one statement, which received a relatively low level of agreement from the panel.

• □ “In most but not all cases CS requires interaction of observational/verbal/diagnostic and treatment skills” 75%

Professional roles

A frequent theme (17 statements) was around how CSs relate to professional roles, and clearly there was a perception of a strong association for many respondents, but not all, as there were not high levels of consensus.

• □ “CS is a tool of the work as doctors” 80%

• □ “each clinical group has its own specific clinical skills” 85%

• □ “CS is the foundation of the professional life” 75%

Patients featured in eight additional statements, with an emphasis on their central role to CSs.

• □ “[the most important factors for teaching a CS include the] clinical environment to observe the use of clinical skills on real patients” 100%

• □ “[in learning a clinical skill it is important to consider] the ability to adjust to individual variations between patients” 95%

Components of a CS

Three components of a “CS” that cut across all domains seem to come out of the data; these are aspects of procedure, knowledge, and clinical reasoning. Procedure relates to the sequence of performance within the skill, and was valued highly, particularly in considering teaching and learning of CS.

• □ “[in learning a clinical skill, it is important to have] a structured easy to follow method which can be modified with experience” 95%

• □ “[in learning a clinical skill, it is important to] follow expected methods” 75%

Underlying knowledge was also seen as important (13 statements with high levels of agreement).

• □ “[the most important factors for teaching a CS include] to understand the theory behind the practice” 100%

• □ “[the most important factors for teaching a CS include] being familiar with the theoretical basis” 95%

• □ “I use a CS when I do something – when I employ an ability in which I apply my knowledge” 90%

Various aspects of clinical reasoning were expressed as being important to any CS. This included diagnostic reasoning, but went further to include aspects of clinical decision making.

• □ “CS can be diagnostic” 100%

• □ “[in learning a clinical skill, it is important to have an] understanding of the limitation of the skill and when not to use it” 100%

• □ “A CS includes a degree of interpretation” 70%

Technique, procedure, or performance

Thirteen statements related to perceptions of CSs as a technique, a procedure, or a performance, with varied levels of agreement, and some apparent conflicting statements

• □ “CS is a technique required to perform a clinical activity” 75%

• □ “there is a distinction between a clinical skill and a technique” 70%

Psychomotor aspects

Only two comments seemed to touch on the aspects of psychomotor learning and co-ordination of physical movements.

• □ “[in learning a clinical skill it is important to have] physical ability to perform” 95%

• □ “a skill is a practical activity with motor component and supported by cognitive and attitudinal components” 65%

Approaches to teaching and learning a CS

Educational environment

The data confirms previously recognized important aspects of the educational environment for learning, these included realistic contexts, safety to experiment.

• □ “[the most important factors for teaching a CS include] a safe environment to demonstrate and observe practice” 100%

• □ “[in learning a clinical skill it is important to be] allowed to get it wrong at first” 90%

However, out of 16 statements relating to learning environment and context of learning, only one (below) made mention of skills labs.

• □ “[in learning a clinical skill it is important to have] skill labs but not that important if sufficient real life opportunities exist” 85%

Teacher-centeredness versus student-centeredness

Twenty statements (the largest cluster) with strong agreement (12 > 90% agreement, a further four >80%), were associated with teacher centered concepts (Peyton 1998). These included the

• □ “[the most important factors for teaching a CS include] the teacher being competent in the skill being taught” 100%

• □ “[in learning a clinical skill it is important to have] clear objectives and outcomes so the student knows what is required” 95%

• □ “[in learning a clinical skill it is important to have] demonstration (modelling)” 100%

In contrast 13 statements were more associated with student centered concepts (Sweeney 1986; Spencer & Jordan 1999), with more mixed levels of agreement (only five finding >90% agreement).

• □ “[the most important factors for teaching a CS include to] adapt to students needs” 95%

• □ “[the most important factors for teaching a CS include to] allow the learner to suggest ways to improve the skills” 90%

• □ “[learning a clinical skill] depends on learning styles” 65%

Discussion

Contrary to the published literature discussed at the beginning of this article, the participants of this study showed marked agreement that “CSs” included the domains of examination skills, practical procedures, communication skills, and management skills. Despite almost complete integration of these domains in clinical practice, the importance of this integration within an educational environment was not as clear to our respondents. This may reflect the current trend of segregation of these domains in both teaching and assessment (for example, different domains assessed in different stations in OSCEs). Different domains certainly require different teaching strategies, and so it is clearly important to identify which domain(s) are intended to be taught within a teaching session.

The relationship of CSs to professional identity is rarely mentioned in the skills literature. However it does reflect the wider literature on professionalization, with general consensus that a profession is usually characterized by a special skill or a number of skills, often skills that require extensive training and adapted application case-to-case (Abbott 1988; Cruess & Cruess 1997).

Mirroring the descriptions of declarative, procedural, and conditional knowledge, and in line with the concepts of CSs as a professional characteristic, the results of this study show that a CS contains more than simply the steps of how to perform the skill, but also both the underlying knowledge on which those steps were based and reasoning skills – both diagnostic reasoning and clinical decision making, that allow the CS to be applied meaningfully. If the skill is to be adapted “case–to-case” then the underlying knowledge to understand the procedure, and the clinical decision making skills to apply that knowledge are essential.

These findings are relevant to teaching. If CSs include declarative knowledge and clinical reasoning components in addition to procedure, then we must include these components in our plans for instruction. This in turn may require a shift away from the more traditional, process-driven approaches to teaching that are still in common use today.

The predominant theme in statements on CSs teaching and learning in this study was coded as “teacher-centered concepts”, which may be at odds with the current prevailing cognitive-constructivist conception of adult learning within higher education (Kaufman 2003). We wonder if a similar study were to look at learning of declarative knowledge, words such as “collaboration”, “facilitation”, “experiential”, “experimentation”, “self-directed,” and “reflection” would be more common.

Conclusions

The term CSs are perceived as including physical examination skills, practical procedures, communication skills, and treatment/therapeutic skills, with or without integration across these domains. It seems that CSs also form part of the professional identity of health professionals, and this may warrant further research.

For a CS to be learnt, or undertaken, there needs to not only be procedural knowledge (how to perform the skill), but also declarative knowledge that justifies this procedural knowledge (such as underlying anatomy and physiology) and clinical reasoning (including, but not limited to, diagnostic reasoning and clinical decision making). Without these three components, CSs become a “mechanical performance” which has limited diagnostic value, and cannot be adapted for different patients and different situations.

Teaching CSs requires first a clear decision as to which domains are to be addressed, as clearly different domains require different types of training based on educational theory. Secondly, attention must be given not only to training a task/performance/procedure, but to integrating this with both underlying knowledge and clinical reasoning skills. How these components are best taught, and at what stage of learning warrants further research.

Acknowledgments

We would like to thank all the participants of the Delphi study and all the people who were involved in clustering the statements, in giving precious feedback about the methodology and all the people who have provided useful productive feedback on earlier manuscripts. We would particularly like to thank the reviewers of this article for their encouragement and highly detailed feedback

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.