The Fight Against Tick Boxing

This post is based on the talk I gave at EMEC 2019 on how to get more out of
Workplace Based Assessments.


There is little doubt that the reputation of Work Based Assessments (WBAs) is currently a little jaded. Whether it be Case Based Discussions (CBDs), Direct Observation of Procedural Skill (DOPs) or mini Clinical Evaluation Exercise (mini-CEX), they are often referred to as being just a ‘tick box exercise’ and if I’m honest, it isn’t that hard to see why. The ePortfolio training record and ARCP yearly sign off systems in particular seem designed to achieve quantity of assessments rather than quality, which hardly encourages a positive relationship with WBAs. Trainees and trainers who are struggling for time end up treating these assessments as a chore and aim to get them done as quickly and efficiently, rather than as effectively, as possible… the very definition of a tick box exercise.

So the problem I was wrestling with was what can we do as individuals to make a difference, given we are unlikely to be able to change the system in the short term? How can we fight back against the tick boxing? Here are six, simple ways that I think we, as trainers in particular, can make a significant difference to the quality of assessments.

 

1) Embrace Our Role

We are supposed to train, to educate, it is an essential part of who we are. Don’t believe me? Well, let’s look at the Hipporactic Oath. Written nearly two and a half thousand years ago it has formed the basis of how doctors have defined themselves ever since. Before any mention of treating everyone equally, doing no harm or the importance of confidentiality – ideals we hold to and guard so dearly – in fact before ANY mention of patients AT ALL, there is a section on teaching and training:

I will respect my teacher as I would a parent and promise, in turn, to teach others the art of medicine, without consideration of personal gain.

As trainers we need to understand and embrace this as part of our very being and we need to start behaving accordingly. Stop saying ‘I have to…’ or ‘We need to…’ about assessments and start saying ‘I want to…’ and ‘Wouldn’t it be good to…’ Stop acting like this is a burden thrust upon us and instead embrace our role as trainers. We can influence others in with the way we talk and act when it comes to assessments because if there is going to be a revolution, a fight back against the tick box culture, it will start with us and the way we behave.

 

2) Don’t Forget the Person

For assessments to be truly meaningful, trainers and trainees need to take a bit of time to get to know each other, get to understand each other and what it is they want to get out of their educational relationship. Now, I am not saying they need to become best friends and nor am I saying that a WBA with a relative stranger is without educational merit BUT if we consciously make an effort to build appropriate professional relationships between trainers and trainees, it gives us a foundation from which to build a more fulfilling assessment.

So, let’s work on our relationships outside of the assessments. Get to know each other a bit better. We can talk about work… What do we fear? What do we find hard? What do we think we are good at? Or we can talk about life… What do we do to relax? Where would we like to go on holiday? Is Love Island entertainment or just the start of the breakdown of civilisation? Whatever we talk about, let’s get to know each other as people and maybe then we can add some humanity to those tick box assessments.

 

3) It Takes Commitment

In the beginning, as a trainer, it can seem easy to get assessments done. Our motivation is high and we take the opportunity to do spontaneous WBAs whenever the situations arise. We wonder why it is other people seem to struggle to get their CBDs, ESLEs or DOPs done. However, as time passes it gets a bit more difficult. The waiting time plays on our mind, covering that night shift has left us tired and to be honest we’d rather spend an hour catching up with our emails than go to all the effort of doing an assessment.

Spontaneity might feel great, might feel more authentic but it is incredibly vulnerable to both our physical and emotional circumstances. Sometimes we need to make plans and commit to scheduling what we hope would happen spontaneously. Perhaps THAT is a more authentic demonstration of a commitment to education. We need to start creating space for assessments in our diary as a fixed commitment rather than relying upon spontaneity to see us through.

As trainers we need to consider where we can reclaim a fixed amount of time in our week to do these assessments and then we need to make it easy for trainees to access it. Personally I use a free piece of web software called youcanbook.me which reads my calendar and then creates bookable slots around times I have chosen to make myself available to do assessments. This allows trainees to access my diary 24/7 from home without having to play email or phone tag with me or a secretary. Simple.

And it isn’t just the responsibility of trainers either. Trainees, when you have the chance to speak with your trainers, ask gently but firmly, for a commitment to an assessment and have your diary ready with your rota to make it easier to confirm a suitable time.

Together, let’s commit to having a more mature attitude to the process and start planning these assessments in to our working lives.

 

4) Preparation Matters

When it comes to delivering great WBAs, preparation is essential. Trainees may seem grateful when we offer to do a WBA at short notice but it rarely gives a truly satisfactory outcome… and I’m not sure that they always feel able to say ‘No’ if they’re not in the right frame of mind at that point. Prior to an assessment we need to take some time to consider what it is that the trainee wants to get out of the experience. Are they looking for advice on history taking in general or perhaps a specific aspect of that which they feel they are struggling with? Is there an exam approaching and they want to understand whether they are practicing at the required standard? Or maybe they are looking to revisit a previous assessment and the feedback received then, wondering if they have made progress in that area or not. Remember too that it isn’t always about trying to identify weak spots that need to be brought up to standard, sometimes it’s about consolidating the satisfactory to build confidence or pushing what is already good towards excellent.

This type of dialogue not only helps guide the feedback to come, it also ensures the collaborative nature of the assessment. Assessments should never be done TO a trainee, they should be done WITH a trainee and preassessment conversations help them to feel in control of the situation. As trainers we may help clarify the goals of the assessment, or even make suggestions, but the trainee should usually take the lead when discussing what they really want to get out of this encounter.

Feedback may be the pinnacle of our assessment, but it is essential to create a receptive place for that feedback to land.

 

5) Deliver Great Feedback

Training is about feedback… that’s all there is to it. Without this none of us are able to improve. All of our work based assessments are designed around a trainer giving feedback so there is nothing worse than a failure to deliver on that. How depressing for a trainee to look for feedback and get ‘Well done. See more patients.’ or ‘You did that skill well. Take opportunities to do more of them’.

Having gone to the effort of finding out what the trainee wants from the assessment, now is the time to deliver on that. We should concentrate our feedback on the areas that will satisfy them and not get carried away talking about some particular educational fetish of ours or overwhelm them with ten different learning points: this is not about us and what we want it is about them.

What is more, if we have taken the time to build a good relationship, we will find it easier to deliver feedback about areas of poorer performance and the trainee will be more likely to accept it. WHERE the standard is set in an assessment is often less important than WHO is setting that standard. If trainees think we have no interest in them and are out of touch with their experiences of work, they will ignore our advice and the whole assessment has been a waste of time for everyone… just a tick in a box. If, however, they understand that we are trying to help them and that we have ideas and experiences in common, they will respect what we are trying to do and take the feedback on board. Additionally, if we have good feedback to give, a positive relationship multiplies the impact for both of us: they feel built up by a respected colleague and we can take pride in a fellow clinician become the colleague we know they want to be.

AND while it is all still fresh in your mind FILL IN THE FORM!!! Yes, I know it’s not much fun and the systems can be incredibly frustrating but if we don’t do it now, we’ll only have to do it later… and it doesn’t get any more pleasant with the passage of time. Trainers in particular, not filling in the forms on the same day leaves the trainees in an awkward situation, having done an assessment but having no proof of it in their portfolio. Let’s be better colleagues and do the forms there and then, it’s a part of the whole experience after all.

So, can we make sure that we have the IT or the paperwork ready to go BEFORE we start because in this case, the box DOES actually need ticking!

 

6) Improve Yourself

It might seem an awkward or even intimidating thing to do at first but if we are to develop as educators we need to be getting feedback on our performance. How else are we to become the trainers that trainees deserve and we want to be?

Once the assessment is completed and the forms are filled in, it’s time to ask the trainee, ‘How did I do?’ Making this effort to ask the trainee for some feedback is important to help us improve and models to trainees a commitment to long term, continuous development. It might be necessary to leave it to a later date, a separate meeting altogether, but feedback from our trainees is essential to helping us improve. Not only that, positive feedback can also help sustain us, keeping us going when we feel we are struggling to make a difference or concerns of inadequacy start to play on our minds.

Aside from feedback, let’s also make sure we are learning in other ways too. We need to keep up to date with our clinical knowledge, obviously, but also to make the effort to learn around education, particularly on how to give feedback. We must clearly demonstrate to trainees that they are not the only ones trying to improve because whilst the tick in the box might mark the end of the learning event for the trainee, for the trainer it is probably only just getting started.

 

And finally, whilst I can only speak as a doctor, I have been fortunate to have learned from many different staff groups over the years… nurses, paramedics, physiotherapists and porters to name a few. We deliver healthcare as a multi professional group and we should deliver training in the same way. There is no good reason why we shouldn’t carry out these assessments across roles, learning from each other to gain insights in to our practice that will make us better clinicians. So, if we aren’t doing so already, perhaps we could start to encourage some diversity in assessments, explicitly demonstrating that we value the experiences and opinions of our colleagues in other roles rather than treating ‘multi-professional training’ as just another tick in the box as well.

 

Simon

 

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