There is a great deal of turbulence and disruptive change across the massage education landscape lately.
What should be taught in massage school, and how students' learning of those skills should be evaluated, are two of many big questions facing educators and students alike.
Part of the problem is that massage is so experiential, much more so than, say, administering an injection. So there is a certain amount of overlap in what we do and what healthcare professions do, as well as major differences in how the client perceives those procedures, respectively.
But as difficult as it is, healthcare professions have to evaluate students' proficiency at the procedures that make up the job that they are training for--sometimes for much higher stakes than for massage, such as life-or-death emergency room procedures, or even day-to-day personal care in a skilled nursing facility. Even though it's hard to measure competency at a subjective skill, they still have to do it, to assure their patients of a sufficient number of skilled providers to meet the population's needs.
So perhaps in their investigation of how to meet these needs for evaluating the skill of students at carrying out professional procedures, they have developed techniques and methods that would be useful to us--that we can adapt, instead of having to re-invent the wheel all over again.
The article we'll look at in this post comes from a group of physician-educators in Ontario, Canada. They examine how to develop objectives for evaluating students' skills in family-medicine procedures.
Wetmore S, Laughlin T, Lawrence K, Donoff M, Allen T, Brailovsky C, Crichton T, Bethune C. Defining competency-based evaluation objectives in family medicine: Procedure skills. Can Fam Physician. 2012 Jul;58(7):775-80. PMID: 22798466PMCID: PMC3395528 Free PMC Article
OBJECTIVE: To develop evaluation objectives for assessing competence in procedure skills using a key-features approach. This was part of a multiyear project to develop competency-based evaluation objectives for Certification in Family Medicine.
DESIGN: Nominal group technique.
SETTING: The College of Family Physicians of Canada in Mississauga, Ont.
PARTICIPANTS: An expert group of 7 family physicians and 1 educational consultant, all of whom had experience in assessing competence in family medicine. Group members represented the Canadian context with respect to region, sex, language, community type, and experience.
METHODS: Using a nominal group technique, the expert group developed the general key features for procedure skills. The expert group also linked the key features to already established skill dimensions in the domain of competence, to the 4 principles of family medicine, and to the CanMEDS roles.
MAIN FINDINGS: The general key features were developed after 5 iterations. Ten key features were outlined and were shown to reflect all the essential skill dimensions in the domain of competence for family medicine. The key features were linked to 2 of the 4 principles of family medicine and to 4 of the CanMEDS roles.
CONCLUSION: The general key features for procedure skills were developed to assess competence in procedure skills in family medicine.
They describe what they mean by a "key features approach":
The key-feature approach is a practical method of defining competence for the purposes of assessment, first described by Bordage and Page. Page and Bordage described a key feature as a critical point in the resolution of a problem, where examinees are most likely to make errors and which is a difficult aspect of the identification and management of the problem in practice. The overall objective of the key feature approach is 2-fold. The first aim is to identify these essential or critical steps specific to the problem; the second is to determine why they are difficult and what processes are involved in successfully completing them. Page and Bordage identified that key features for a given problem are not typically generic; they vary according to the clinical presentation of the problem relative to other issues, such as age and sex. A general skill might be used in any given key feature; however, an individual key feature is problem specific. Generally, key features are observable actions; they are not simply knowledge. They are generated from practical experience, not theoretical analysis or published references. Key features are pragmatic, suggesting where assessment should be concentrated in order to be both effective and efficient. They are useful tools when planning assessment.
What this means, if such an approach is useful for us, that we should look at what points in the massage procedure call for decision-making, and on what basis. Those are the key features that it would be important to evaluate, during the entire course of testing, as well as for practical testing for licensure or certification.
Table 1 in their article describes the general key features, and what skill aspects they connect to. I think the skill aspects are worth developing further in a later post, so let's just look at the key features now, and we'll connect the other dots soon.
Table 1. The general key features for procedure skills
To decide whether you are going to do a procedure consider
- The indications and contraindications to the procedure
Testing this key feature will give an indication of how well the student or test candidate understands massage indications and contraindications.
- Your own skills and readiness to do the procedure (e.g., your level of fatigue and any personal distractions)
This key feature is a good point to evaluate the student or test candidate's level of understanding of their own learning, as well as ethical aspects of honest self-representation and not practicing while impaired.
- The context of the procedure, including the patient involved, the complexity of the task, the time needed, the need for assistance, and the location
This key feature is a good point at which to test the student or test candidate's understanding of the integration of anatomy, physiology, pathology, methods and techniques, and other practical factors that come into the delivery of massage in real-life practice settings.
Before deciding to go ahead with the procedure
- Discuss the procedure with the patient, including a description of the procedure and possible outcomes, both positive and negative, as part of obtaining consent
- Prepare for the procedure by ensuring appropriate equipment is ready
This key feature tests the student or test candidate's skill at history-taking, foundational knowledge, and clinical decision-making in forming a treatment plan in communication with the client.
- Mentally rehearse the following:
- The anatomic landmarks necessary for procedure performance
- The technical steps necessary in sequential fashion, including any preliminary examination
- The potential complications and their management
Visualization of what techniques you are going to perform with the client, and stepping through the rationale for them, are a good habit to form and encourage while in massage school, but the take-home point from this key feature is that you never stop doing so. Even when you're an experienced practitioner, mentally rehearsing in advance is a very useful technique for both working with familiar clients and conditions, and for being prepared and confident when you're encountered by the unfamiliar.
During performance of the procedure
- Keep the patient informed to reduce anxiety
This key feature is a good point at which to observe and evaluate how the student or test candidate communicates with the client. The right balance to strike is one of informed consent, but where there is not too much unnecessary conversation. Letting the client direct the conversation is the right thing in most situations, but this can also be a good point for evaluating how the student or test candidate handles clients with poor boundaries or communication skills.
- Ensure patient comfort and safety always
This key feature is a good point for evaluating how the student or test candidate handles letting the client undress before and dress after the massage, as well as how privacy and comfort is maintained during draping, turning, and remedial gymnastics.
When the procedure is not going as expected, reevaluate the situation, stop, or seek assistance as required
This key feature is useful for evaluating how flexible and knowledgeable the student or test candidate is--if something is not working, are they stuck in a rote sequence that they know? Or are they able to assess the situation on the fly, and make good change decisions in the moment?
Develop a plan with your patient for aftercare and follow-up after completion of a procedure
This key feature is useful for evaluating how well the student or test candidate carries out and evaluates their own treatment, communicates with the client about the client's experience, communicates any necessary or appropriate client education follow-up, and continues to carriy out the agreed-upon treatment plan.
There is no denying that massage is complex, and, in large part, subjective and experiential. Even so, there are principles of what constitutes good service and professionalism, and healthcare professionals are tested on those skills and procedures everyday.
Reaching out to other healthcare professions to learn from them, and to build on their validated methods in order to improve the skills we need to develop for our clients, is an excellent way of building bridges and of communicating our interest in being an integral part of a unified and client-centered healthcare team.