3-Os/Reflexive Pedagogy

Reflexive Pedagogy
Application to facilitate synchronous online discussions in virtual classrooms/Web 2.0 social software

For use during online healthcare continuing professional development (OCPD) programmes to improve practice and patient care

A GUIDE FOR ONLINE FACILITATORS

Practice Points

 * Deploying a reflexive pedagogy in OCPD programmes focuses on developing professionals’ reflexivity and requires a skilled facilitator
 * The approach of reflexive pedagogy is to:
 * ensure facilitators have specialized competencies, experiential practice (i.e., doing-by-learning) and confidence to support reflexive online teaching and learning;
 * structure facilitated synchronous online discussions using Web 2.0 social software as social collaborative learning processes to solve problems, overcome barriers and improve practice and patient care
 * develop a strategic, transactional, immersive and dynamic practice environment (praxis)


 * Three modes of learning are typically used – literal, interpretive, reflexive – to critically connect professionals’ experiential knowledge with scientific knowledge in the context of professional practice
 * A variety of iterative learning activities and discursive prompts are used throughout the learning cycle
 * Reflexive pedagogy raises individual self-awareness (i.e., how thoughts, behaviours and practices are shaped by the social contexts, discourse and the influence of healthcare policy and research)
 * Reflexive pedagogy can support skills development; subject matter expertise; and enhance learners' reputations and value in reflexive networks without losing time trying to nurture high-trust enmeshed communities

What is the problem?
Synchronous online discussions using virtual classrooms and Web 2.0 social software are widely used in healthcare OCPD today, but challenges remain in structuring and facilitating discussions as social collaborative learning processes that improve impact on practice and patient care. While many researchers and educators have focused on improving learning online, there is little research regarding how to improve practice online. The artificial separation of learning delivered through stand alone modules and unstructured online forums from the issues and concerns of daily practice and daily use of technologies has hampered progress in the use of online discussions effectively to improve practice.

Effectively facilitating synchronous online discussions to improve practice is complex. Busy strategic healthcare professionals need to be engaged over time and distance with focused activities, discussions, projects and peers which are meaningful and relevant to their learning and practice goals. Yet dominant continuing medical education pedagogies are dominated by cognitive psychological theories that ignore the social and strategic nature of professional learning in the dynamism of practice (Schon, 1983; Bourdieu, 1978).

Further many online learning designs focus on building communities of practice that ignore the fact that health professionals are unwilling and unable to move beyond explicit knowledge sharing because of fears of breaching confidentiality. These communities also take a long time and a lot of effort to nurture and sustain trust and research has reported the problems of crossing boundaries to enable inter-professional knowledge creation.

In addition, despite the promise and popularity of Web 2.0 social networking technologies for health professional networking, education and information dissemination (Boulous & Wheeler 2007), how to design effective pedagogic approaches that leverage the opportunities for engagement, interaction and learner agency they offer to improve practice and patient care is absent in the literature.

What's more, today's professionals are not tied to one fixed way of learning that they are given by providers, but learn on their own through what Nardi (2002) has described as 'intensional NETworks'. This also reflects a post-modern perspective on society, by which people nowadays have working lives that are more fluid, risky, confused, and less stable and secure in traditional communities as in the past. As such, they act reflexively to navigate ever changing landscapes through their working lives. But at the same time, they also work within larger institutional and policy frameworks which regulate their practice and limit their autonomy over their work.

This perspective suggests that professionals build networks around their work of people and resources who can help them with their problems, share similar concerns, make deals and alliances to get on with what they want out of work and life when interacting with others across their careers.

The problem of OCPD to improve practice and patient care in this complex fragmented post-modern reality therefore becomes: individualised, flexible learning, ‘free’ from dominant structures that impose barriers on their agency to change practice, with increasing opportunities to critically reflect upon the self as a (non)learner with others in a safe space (Selwyn 2005), and with more choice to think and act differently?
 * how do we encourage professionals to develop their identities as learners rather than mere consumers of e-learning
 * how do we design pedagogies, programmes and Web 2.0 technologies that allows reflexive learning to take place:

To address these challenges, reflexive pedagogy can provide a useful approach to structure facilitated synchronous online discussions.

This guide on reflexive pedagogy provide practical activities and tips for healthcare educators to structure facilitated synchronous online discussions using virtual classrooms and Web 2.0 social software when delivering healthcare OCPD programmes to improve impact on practice and patient care.

''This guide is a first draft only and intended to kick-off an action learning process with interested online facilitators who wish to collaborate to develop, test and try out a reflexive pedagogy model for online facilitation using virtual classrooms and Web 2.0 social software. We wish to improve our understanding through inquiry if reflexive pedagogy is suitable and appropriate for structuring facilitated synchronous online discussions using virtual classrooms and Web 2.0 social software when delivering healthcare OCPD programmes to improve impact on practice and patient care to healthcare professionals across time and distance.''

Key Principle of Reflexive Pedagogy: Learning is Reflexive
Reflexive pedagogy takes a sociological perspective on professional learning. Practice happens across social contexts. In practice, continuous, iterative, overlapping and recursive cycles of thinking and doing occur. These cycles include formal courses as well as informal learning in the workplace through daily interactions with colleagues, patients, managers and technologies. All these forms of learning are intermingled. Together, these processes shape the choices and opportunities healthcare professionals have to change their behaviours and thoughts, thereby producing practice (Bourdieu, 1978). Practice changes when a new practice is gradually produced by a small group of people who try and change their thinking and actions in the social context that is a barrier to improving practice. As the new practice is done over and over again until it becomes regular and grooved, it is not considered new anymore and becomes a norm. But the direction and scope of change depends on who is transacting with who and for what purpose. These transactions depend on professionals sense of agency and their (power) capitals, which they exchange through strategic interactions to get ahead. As a result of these continuously turning processes, a sociological perspective proposes that professional learning, when situated in practice, is a combination of formal and informal, social, collaborative, active, reflective, critical and self-determined learning - it is reflexive.

In layman's terms, reflexive pedagogy means strategically supporting and enabling professional learners with the knowledge and skills to change their thinking and actions in the social context in which they learn and do their work so as to overcome barriers and improve outcomes. (increase capacity for agency)

We earn and learn not by keeping our knowledge and skills to ourselves, but building and sharing our knowledge and skills with each other strategically so that together we can learn smarter rather than harder and earn much more than we can alone. (exchange capitals)

Additional Principles of OCPD

 * 1) Starting from professionals own lived experience (valuing)
 * 2) Empowering professionals with connections and interactions that support them work through problems and get work done(agency)
 * 3) Reflecting on our values, beliefs and attitudes (psychology)
 * 4) Broaden the concept of learning from knowledge and skills training to processes, concepts and creative imagination, in order to transfer learning skills across current and future work-life challenges. This requires active participation and dialogue from policymakers, managers, educators and professional learners, not passive acquisition, to ensure programming connects from policy and research levels up and down through practice (participatory)
 * 5) Involve others – while self-directed learning is key to one's lifelong success, learning is too important to be left to an individual alone. Identify champions and supporters within and across social and institutional contexts. It requires cross-disciplinary pollination with mentors and experts to adapt evidence-based practices to another domain. Learning to improve practice is something that is collaborative, context-dependent and transactional (strategic collaboration)
 * 6) The content needs to come from groups/sources with the scientific and tacit knowledge; if this is about managing diabetes, then educators have got to get siloed scientific knowledge as well as tacit knowledge from experts, health professionals and community health groups involved; if you want people to learn, you need to think about education strategies; this leads to the idea of the “programme team”, made up of organizational leadership, educators, experts, mentors, professional learners and the patients working together (teamwork), and a systems perspective.
 * 7) Feedback mechanisms and learner support - there have to be ways to get learners to continuously link the online discussions to daily work, and for the programme to reach them outside the clinic or office, e.g. at home, iPad, Tablet, or on mobile phones, to maintain timely and regular contact and access rather than traditional one-off programmes. Smart apps could be developed for example to sustain conversations and bonding (dynamic)
 * 8) Fast turnaround and response time - rather than sitting around socialising an chit-chatting, time spent online is productive with clear objectives for each learner and for the group. The approach needs to be flexible to cater to different working hours and time zones, and combine individual chats with group chats as and when needed to keep on track, explore issues and work together to solve problems. (strategic)
 * 9) Learners must get something out of it that benefits them (relevance, capitals)

Pedagogic implications for OCPD: Developing Reflexivity
Professionals learn best and begin to know how to improve as they solve problems when immersed in the dynamism of practice across social contexts. In sociology, this is called 'praxis'. By discussing with peers and with guidance from mentors (online, in-person, blended), they learn to become more aware of the various conditions and contexts of their work, such as their projects, teams, departments, organizational structure, strategic plan, policy framework, funding environment, and the evidence base.

Effective pedagogy for OCPD thus needs to support professionals to weave and deploy appropriate actions (behaviours), thoughts, and feelings when relating professionally with their social networks across the contexts of practice. These networks include colleagues, managers, patients and community health stakeholders. They can be from the same organization and also link up with others in another organization across town, or across the country.

In addition, effective pedagogy should encourage professionals to develop reflexive awareness of peer and professional discourses and structures of healthcare policy, research, and organization when trying to address barriers / resistance to changing practice (i.e., self, team and organizationally, and for the profession).

Developing reflexivity is important because it can increase professionals’ ability to understand, contextualize and align the "what" and "why" of their learning - as it relates towards improving self-confidence, professional practice, better health outcomes and patient care.

Using Web 2.0 social networking technologies for OCPD
Web 2.0 social networking technologies have significant potential to support a reflexive pedagogy approach to facilitate synchronous online discussions. Web 2.0 software can include tools for collaboration such as Google Docs, Dropbox, and Slideshare. They can also include spaces where all professionals can meet together at the same time wherever they are around the world so that they can discuss problems and explore solutions with the support of a facilitator who helps them structure their learning. The most common type of such a meeting space these days are virtual classroom such as Adobe Connect. Because everyone meets online at the same time to learn, share and collaborate, this approach is called ''synchronous'.

Summary
Overall, effective OCPD pedagogy transitions professionals from a position of passive and active learners towards reflexive learners who not only consume or construct knowledge, but produce knowledge in practice to change practice strategically. And since practice is, by definition, situated across social contexts, producing new knowledge changes practice by changing the social context, culture and meaning of practice. Changing practice through problem solving is not only about using rational research methods to collect data and analyse results, it also requires creativity, imagination and a social worldview. These skills are needed to fire the minds of healthcare professionals so they begin to see the world differently and can consider new ways of thinking and action that improve their mental maps of 'practice'. Reflexive pedagogy thus can overcome the limits of 'scientistic' ways of seeing the world to build higher-order creative and social critical knowledge and competencies.

What is reflexive pedagogy?
Reflexive pedagogy is a pedagogy that develops learners reflexivity. It does this by teaching learners about practice while being immersed in practice. This is different from academic university approaches to professional practice because it is 'real'. So, learners learn not just academic knowledge and practical skills, but what practice is, why and how it is what it is, and what questions they need to ask when trying to solve problems by turning them into concepts that can be tested in real-life to see if and how these solutions can improve practice.

It can be used as a facilitation approach to structure synchronous online discussions using virtual classrooms and Web 2.0 social software among networks of healthcare professionals. The approach is cyclical through several key processes that include: identifying problems, goal-setting, group projects, analysing scientific knowledge to uncover key underpinning concepts of evidence-based medicine, linking it with personal knowledge from prior experience, exploring values, beliefs and assumptions, testing and trying out new thoughts and actions in work, reflecting critically in action and on action (Schon 1983), tapping into tacit knowing in action available from the network (Schon 1983), adapting behaviours and strategies to improve practice, and evaluating impact on patient care.

It is also a pedagogic approach by which online facilitators demonstrate self-reflexivity. Online facilitators are not only instructors but also give the gift of pedagogy to a network of learners to cultivate a cross-sector community so that online spaces are open for genuine critical inquiry (Bourdieu, 1990; Luke 2005). They demonstrate a sociological way of knowing, being and speaking by positioning themselves and locating their educational practice in the contexts of their local settings as well as the wider contexts of healthcare policy and programming, and of wider theoretical perspectives. They think about their concepts and what they bring to the learning situation, seek to learn from and understand professional learners’ social contexts, and create online spaces for producing practical knowledge that has relevance and application to improving practice and patient care for many types of professionals beyond a single programme.

Overall, reflexive pedagogy values the agency of learners and the facilitator in the learning process, as both learn from each other and develop individual and collective reflexivity. This approach ensures that facilitators support professionals strategically to co-design social collaborative learning processes that co-develop contextually appropriate theories of evidence-based practice, rather than simply take them as givens to be imported from outside and applied (Brookfield, 1995).

Compared to older pedagogies such as didactic teaching or group work alone, a reflexive pedagogy is better because it can affect the contextual barriers to changing practice through supporting learners to test and try out new ways of thinking and acting without the effort of building trust. Thus, reflexive pedagogy can respond more effectively and tactically to the problems of dynamism, and the problems of context, in an uncertain, unstable post-modern age.

Taking an ecological perspective, one can also imagine reflexive pedagogy as a process that strengthens the contexts and systems of practice with the appropriate discourses and capitals (power) with new practical knowledge grown in online discussions, and embedded into real-world practices. This processes of fertilisation, pollination,and harvesting may help more professionals access, create and use socially desirable norms, values and behaviours that are valued. Such 'soft' skills are often forgotten by traditional capacity building and CPD approaches focusing on 'hard' knowledge and skills, but are needed to transform practice to improve health care programme outcomes in the future.

The role of the Online Facilitator
The path towards greater reflexivity deals with the challenge whereby learners have been conditioned to think that learning-to-change practice is simply about individual change through reflection. The Online Facilitator has unique skills and competencies to support greater reflexivity and behaviour change in diverse contexts.


 * To develop and own an independent voice that can speak back confidently apart from the educators’ and the medical discipline,
 * To become aware of how their thoughts, actions, and behaviour relate to their social surroundings,
 * To actively create and contextualise the knowledge they are trying to gain, with others and in relation to policy and theory to improve practice,
 * To retain, own, and connect their online learning to their current and future lived experience,
 * To develop their choices and opportunities – their capacity for agency – to change their thinking and behaviours, and
 * To have more freedom and control over their practice.

This reflexive pedagogic role supplements the conventional roles of online facilitators to support effective online learning found in the literature. These roles include managerial, social and technical roles (see McPherson & Nunes, 2003). These also include the skills of e-moderation (see Salmon's 5 step process) and Anderson and Garrison's emphasis on teaching presence.

Within a reflexive pedagogic framework, all these 4 roles can be operationalised reflexively. That is, when performing their roles, it is essential that online facilitators open and share honestly with their learners how and why they manage, they socialise, they teach, and they offer technical guidance. After all, the online facilitator is learning 'with' the learners so that these roles become shared and owned. This will only happen if online facilitators consider the problems they and the group face by reflexively positioning themselves and their style in the unfolding learning process.

Applying reflexive pedagogy to structure facilitated synchronous online discussions: A Cyclical Process
Online facilitators applying reflexive pedagogy can develop professional learners’ reflexivity by structuring facilitated synchronous online discussions when delivering an OCPD programme through a cyclical process. I outline the process below, along with suitable activities.

At first glance, the cyclical process may remind readers of conventional action learning cycles used in healthcare CPD. Therefore, to distinguish reflexive pedagogy from action learning, online facilitators need to model and initiate reflexivity discursively during the synchronous discussions. What online facilitators say and what kind of talk is valued thus becomes a very important skill if we aim to change thinking and behaviours through dialogue that is critical and beneficial and not just banter or tedium.

In each of the stages of the process, I thus provide examples of suitable learning activities together with discursive prompts and cues that online facilitators can use through the cyclical process to focus and develop professionals’ reflexivity continuously.

Time and length of the facilitated synchronous discussions
The online discussions may begin at any time and last as long as they prove to be useful and successful in supporting professionals change practice.

The beginning of the discussions depends on how ready participants are to engage with Web 2.0 social software. The manager and facilitator need to be aware of, understand and accept the main principle of reflexive pedagogy. They may need to have some preliminary consultations with experts in online CPD, or even go through some training in using the software. These preparatory stage could also include a situation and needs analysis to develop the objectives and outcomes of the OCPD programme.

The manager and facilitator also need to be able to recognise when participants are ready to accept the Programme. The 'right time to begin' may come at a staff meeting or through an online survey that reveals a practice problem shared by healthcare professionals from different organizations. Professionals may also get involved in a genuine professional discussion on a blog or a discussion forum, which is followed by the identification of the problem. In such a situation professionals and management will be psychologically ready to accept an innovation because they will be looking for a solution to a problem which requires wider cross-sector perspectives. Then the online discussions may be offered in general and discussed in detail through e-mail, a blog or discussion forum. A draft syllabus for the programme may be posted online for review by interested participants, who can be invited to apply for the programme.

The schedule for the online discussions may depend on the facilitators' schedule, or participants' decisions, but it is advised that the group of participants be kept small (max. 10 students in a short programme), meet online approximately once a week to discuss for about two hours. In this case professionals will not be too overloaded and at the same time will be able to carry on their regular work, which is likely to promote productive work.

Most importantly, organizational support and protected time for online learning in practice will ensure greater uptake and less decline in attendance. To incentivise healthcare professionals, CPD validation points and credits can be offered for participating in facilitated synchronous discussions.

The OCPD programme thus is long-term. It can be broken up into sessions of 1-2 months, with weekly meetings, to pause to take stock and discuss ways forward. Reflexive seminars can take place during the implementation and evaluation stages of the curriculum.

Reflexive Social Collaborative Learning
The reflexive pedagogy cyclical process builds on and works through social collaborative learning. This is a combination of designed and emergent learning connected through a reflexive network (Singh, 2011). (Figure 1 needs to be added, don't know how to)

Healthcare professionals participate in collaborative work during the online discussions aimed at investigating their practice problems (connected and emergent learning). Online facilitators organise reflexive activities that focus professionals on their development and learning (designed learning). In the beginning reflexive activities take a significant part of the discussion time. Gradually, as professionals develop reflexivity and become more aware of the issues and strategies for online professional development to change practice, the time for designed learning may decrease as learning emerges reflexively 'in the moment'. In other words, the social collaboration becomes reflexive and less prescriptive. The aim is to transition from a tight structure to an immersive Web 2.0 ecology.


 * Add Figure 1 here

The content of the online discussions
In the activities with the focus on issues and concerns of practice (see Figure 1) it is the professionals who decide on the problems in practice they want to explore. While investigating their problems and developing their mini-projects in working groups, professionals explore the issues concerned. Online facilitators support professionals develop learning strategies as well as skills and strategies of practice during the process of collaborative work.

The themes for reflexivity seminars (see Figure 1) are chosen by the online facilitators and negotiated with the professionals. Reflexivity seminars help professionals contextualise their identity in their own professional development, raise professionals’ reflexive awareness about the issues of their online professional development, and equip professionals with necessary skills and strategies to develop reflexivity to change practice.

Programme evaluation tools could also suggest possible themes for reflexivity seminars, as well as for the working groups.

Assumptions
The reflexive pedagogic approach to facilitate synchronous online discussions described below is based on the assumptions:


 * 1) Healthcare professionals are dispersed in different organizations
 * 2) The online facilitator is from an educational provider independent from the organization where professional learners work. This is to ensure his neutrality and arbiter of conflicts.
 * 3) The programme is offered free to participants, who participate voluntarily for CPD credits
 * 4) The participants and online facilitators do not meet face to face and rely exclusively on meetings scheduled through the virtual classroom or the Web 2.0 social software. This is to reduce cost on hotels and flights for workshops and conferences.
 * 5) An overall goal for the OCPD programme is provided - 'to improve impact on practice and patient care' - so that specific objectives, content and outcomes can be negotiated with participants to ensure they develop their reflexivity as knowledge producers
 * 6) There is no time set for the number of synchronous discussion. But, if there are organizational constraints, online facilitators can suggest starting with weekly online discussions over 4-6 weeks.

Online facilitation materials

 * 1) Virtual classroom/ Web 2.0 social software with AV, chatroom, whiteboard, recording, internet access to the web
 * 2) Facilitators guide
 * 3) FAQ guide on the software
 * 4) Access to subject matter experts and subject content knowledge

Online facilitation methods

 * 1) Plenary discussions
 * 2) Question and answer
 * 3) Small Group discussion
 * 4) Facilitator exposition
 * 5) Plenary presentations
 * 6) Individual activities
 * 7) Group activities
 * 8) Reflexive seminars
 * 9) Guest lectures by experts
 * 10) Listening, watching, making videos and podcasts
 * 11) Digital storytelling

Aim
In Stage 1 of the reflexive pedagogic approach, we prepare to implement. Online facilitators use the synchronous discussion to co-design a curriculum that is relevant to professional learners concerns and contexts, and establish the norms, guidelines and etiquette for the group.

Activity 1 - Establish key concepts with self-study e-learning modules
Prior to the online discussions, facilitators begin the OCPD programme by requiring professionals to do a self-study e-learning module on the topic of the programme. This is necessary to provide learners with the basic definitions and concepts to ground the ensuing discussions. This module can include studying content packaged as clinical guidelines, videos, scientific journal articles, policy documents relevant to the topic, and taking a short multiple choice quiz to self-assess.

They can also take a second module to acquire the requisite networked information and literacy skills for participating effectively in online social interaction, negotiation and collaboration (McPherson & Nunes, 2003).

However, these abstracted concepts and skills rarely connect with professionals’ personal experience. These preparatory steps thus open the way to involve learners further in curriculum design.

Activity 2 - Engage learners in designing the Web 2.0 learning environment
The OCPD curriculum includes the use of Web 2.0 technologies for facilitating synchronous discussions. Various kinds of Web 2.0 tools can be trialled and tested with professionals. In our current study, we are using Adobe Connect virtual classroom, but Skype, Moodle, Elluminate, 3-D immersive environments and smart phone applications could work as well. Professional learners can participate in usability testing to assess the features of the tool, such as ease of use, interactivity, and accessibility. (Sandars & Lafferty 2010)

Activity 3 - Reflexive Seminar 1 - Ask open-ended questions and pose problems for investigation
Once the Web 2.0 tool has been selected, the first 2-3 synchronous discussions are used to develop the ethos of the programme.

The aim of reflexive seminar 1 is:
 * To get to know one another
 * To introduce professionals to the importance of reflexivity in OCPD through engaging in a reflexive learning process.
 * To raise awareness of the main issues of OCPD, especially the added value of social collaborative learning
 * To identify mutual problem areas, choose focus problem areas and form working groups (or one group).

Reflexive Seminar 1 involves all professionals that have decided to participate in the programme. It can take 2-3 hours, with breaks.


 * 1) The online facilitator opens the discussions by proposing the aims of the programme for discussion – to improve practice and patient care.


 * 1) Engage learners to develop reflexivity - ask them to suggest modifications to the aims, agree to a shared agenda.


 * 1) Contextualise the learning environment and the process - keep providing support to resolve glitches and the dialogue moving (use software self-study guide and FAQs)

Note that facilitators should select a video that stresses the importance of the social aspects of improving patient care and of inter-professional collaboration.
 * 1) Watch a video on improving healthcare in the topic area. (10 mins)


 * 1) After the video, facilitators ask open-ended questions that pose problems for discussion to the group.


 * 1) To begin, you can ask: Having watched a video, what questions arose for you? Does it relate to your work?


 * 1) Record the key points of their answers to these questions on the whiteboard. Keep relating what they say to the video, but this is not the time yet to probe deeper.


 * 1) Next ask: What problems do you have about improving (topic) in your context?


 * 1) Discuss this question using breakout groups (15 mins) as described in Activity 3.1 below.

Activity 3.1
It is important that from this very stage professionals began to feel they are a network and not just representatives of separate organizations. That is why it is recommended that professionals form mixed groups with peers from different organizations/regions in each group.
 * Participants form small groups of 4 – 5. They should appoint a rapporteur (Note-taker) and a moderator. Give them some guiding notes on their roles as below:
 * In groups participants discuss the problems every member of the group has listed and identify common problems areas.
 * Each group makes a list of the problems identified in the group and ranks them beginning with the most urgent.

Activity 3.2
As groups report their findings, one of the discussion leaders can take notes on the whiteboard at the same time checking that problems are not repeated. To do this, some rewording will be needed and sometimes clarifying what professionals mean under this or that term such as 'reflection' and 'community'. This is the beginning of the process of creating the ‘common language’ between the participants. It is important, therefore, that all professionals agree on one formulation of the problem that will focus their collaborative group work to improve practice.
 * Group representatives report their findings for all the participants.
 * A common list is made on the whiteboard.
 * Together professionals rank the problems.

Help participants with prompts like: Is your problem-
 * Specific
 * Not to narrow
 * Meaningful and significant; one for which the answer "makes a difference"
 * Open-ended
 * Grounded in your own practice & has the potential to help you learn and grow
 * Feasible; you are likely to obtain at least a partial answer to your question(s)

At the end, this list can be saved online, e.g. on a blog. Creating these learning artefacts and teaching professionals how to record and structure their learning so they can find and refer to it is very important. ALso it is important to write so they have a record and not just spend their time 'airing opinions'.

Activity 3.3
The facilitator's role is very important at this stage in developing learner reflexivity. To overcome resistance and create a collaborative atmosphere among participants, facilitators can use discursive cues to prompt:
 * Individually professionals decide what problem they would like to investigate.
 * Professionals state their names by the problem they would like to investigate. This is how working groups begin to be formed.


 * Among all these problems we have identified, what are the problems we can realistically explore in the time we have together?
 * What specific goals shall we set for ourselves during this programme?

This can help focus learners to think reflexively by relating their exploration of problems to the time and contextual constraints they face. It also helps develop reflexivity by allowing the participants to accept and adopt the idea that they will benefit most in solving problems in cooperation with their colleagues from other organizations who are facing similar problems.

At the same time, the working groups formed at Seminar 1 may be reformed with the course of time. This should be considered as an acceptable option to overcome habits that can become grooved in over time and result in low effectiveness of the working groups.

Save the responses to these questions in a shared space, e.g. blog or wiki, that everyone can access.

Activity 3.4

 * In their new working groups participants brainstorm possible ways to address the problem they have chosen.
 * Working groups decide on possible schedules of work and decide on the next online discussion, and the preparation that they might want to do for the discussion.

Activity 3.5: Preparing for Stage 2
The facilitator explains to the participants that the aim of the working groups is to attempt to find a solution to the problem by investigating the problem, researching the causes of the problem, the consequences, possible ways to solve the problem, and possible projects that may develop as a result of the work of the working groups. Then the working groups focus on their problem and discuss how they can begin their work. The groups decide on their working schedule. It is important that the schedule suits all the group members and does not impede their daily work.

However, this is a risky process because experience shows that they will always be some who are lurkers and unwilling to engage in group work, perceiving it as irrelevant. There are also those who would rather hoard knowledge rather than share it, and keep wondering, 'what's in it for me?' Professionals can be guarded, as they will take time to develop trust when sharing online, and they will also be worried about revealing too much in case they are 'found out'. A lot of professionals can come across as cynical and alienated from positive discourses about 'lifelong learning' and such, having seen through these gimmicks of management. It is important to create a safe space, ensure confidentiality of discussions, and accept that pedagogy affects different learners differently.

To overcome this problem, online facilitators need to give something personal to the learners to 'hook' the online group work to the issues and contexts of their daily work, and position themselves within the evidence-based medicine concepts they learnt in the self-study module. This is called thinking 'relationally' about the learner identity, the practice contexts, and the OCPD curriculum.

Therefore, after the working groups are formed, the facilitator can say:

''Thanks everyone for brainstorming ways to address the problems you have chosen. It's really great to read and see all your mind maps. Before we close today's session, I want to check: Did everyone do the self-study module on (topic) at the beginning?''

Check for responses. If some have not done it, remind them to look at it as it is important to improving practice.

Now, here are some things for you to think about when trying to solve the problem in your groups:

* What caused/ causes the problem? * What is needed to solve the problem? * What action can the working group undertake to solve the problem? * What will be the challenges?

''Please think about these questions over the next week. I will email these questions to you as well. We'll discuss them when we return next week.

Also, I was wondering if you have any resource on improving practice that you have found useful. It can be an article, a Powerpoint slide, a report, a video, a blog, etc. If you could share this next week, it would be great so we can all learn.''

Online facilitators can use creative learning activities such as brainstorming and mind mapping to work through the questions above.

See Figure 2 below for an example of a possible mind map to explore the metaphor of 'how to improve practice and patient care' (need to add, otherwise put it on Slideshow/PPT). Other mind maps could be add to explore the metaphor of 'online learning' 'collaboration' and so on.

These problem posing questions and creative learning activities can be used throughout the online discussions to ensure participants keep being reflexive. What we are gradually building up is a new valuable social practice, valuable resources and a valuable context for connecting and problem solving. It is a 'social glue'. It is not a permanent home, but something professionals can turn to and be a part of to turnaround deficit thinking in daily life.

Stage 1 Outcomes

 * Learners become partners in the curriculum design
 * Web 2.0 learning environment functions
 * A shared agenda and goals for discussions agreed
 * Working groups are formed for problem solving.
 * Learners know they are crucial to the success of the programme

Aims

 * To synthesise the answers from the homework task
 * To learn the 3 modes of learning
 * To critique scientific knowledge and reframe concept of 'evidence' in the social context within which participants work.
 * To situate the initial solutions from Stage 1 in light of their social context and theory.
 * To support professionals position themselves in a more reflexive way when solving problems.
 * To come up with new actions to test and try out in daily life to redesign practice.

Activity 1: Situate Problem Solving in Practice
This step is an attempt to change learners perceptions' of the problem and the experience of daily practice by moving away from relying solely on 'importing' evidence-based medicine concepts while making the online discussions and problem solving relevant to learners' daily lives and their social contexts.

This step is a plenary discussion where the online facilitator is an instructor telling participants what is going to happen.

1 Gather up participants' answers from the homework task, and make a neat matrix for the participants. If they have not done their homework, then provide them a short time in breakout groups to consider the issues again. The matrix should have 4 components:


 * Cause of problem
 * What is needed to solve problem
 * Possible Solutions
 * Challenges

2 Thank participants for contributing.

3 Inform participants that problem solving to improve practice must connect and compare evidence-based medicine concepts learnt earlier with daily practice.

4 Tell learners that the projects they do to solve problems will be interwoven into the online discussions and their daily work.

5 Clarify issues and concerns about this reflexive pedagogy strategy with participants. Ensure that learners are aware of the purpose and intention of situating problem solving in daily practice through testing and trying out new actions. Stress the added value and fun of making new practical knowledge together.

Activity 2: Direct Instruction of 3 modes of learning scientific knowledge
In this step, the online facilitator instructs the learners in the three modes of learning - literal, interpretive, reflexive.

This step aims to teach professionals how to engage with and articulate concepts from scientific knowledge critically and reflexively. This 3 modes are necessary to ensure professionals recognize how knowledge of evidence-based medicine is embodied by each and everyone of us. Moving through the 3 modes when engaging with scientific knowledge such as clinical guidelines highlights the importance of context, perspective and identity. Therefore, when trying to produce new practical knowledge that is relevant to changing practice, learners' identity, perspective and context are important frames to consider.

This approach is based on Mason (2002) for researcher reflexivity, which I am adapting for professional learners reflexivity.

Activity 2.1: Plenary discussion

 * 1) Ask question - how does one understand 'evidence'?
 * 2) Gather up answers and post on the whiteboard. Thank participants.
 * 3) Say - now I am going to teach you how to understand 'evidence' in 3 ways. This will take 20 minutes max.
 * 4) Say - "New research shows that early HIV treatment reduces transmission of the virus, and doctors should recommend HIV positive patients to start HIV treatment as early as possible"
 * 5) Ask - Is this true? - 5-10min open dialogue. Allow learners to express their views, let it flow, don't interrupt, don't judge.
 * 6) Say - thank you for these ideas. Let us consider how we can perceive evidence critically.
 * 7) Way 1 - The evidence shows 'what has been proven' by research. It is evidence because it follows the scientific style, structure and form of doing healthcare research. So, we just need to take it and use it directly.
 * 8) Way 2 - It may not be true in all cases. We should interpret the evidence, compare with what we are doing already, and discuss with the manager/our peers if it can work in our context for our patients.
 * 9) Way 3 - I am not sure. I need to change my thinking and actions by trying out this evidence for myself to see if it can work for me and my patient, and work with others who want to solve this problem.
 * 10) These are the 3 modes of learning to improve practice:
 * 11) Draw a table on the white board showing these 3 modes of learning.

Table: Connecting Evidence to Solving Problems and Improving Practice Evidence               <--->    Practice Text                   <--->    Con-text Level 1 Take it as it is        <--->    Just do it  Level 2  It depends              <--->    Put it in my context Level 3 I need to do it and     <--->    Change my thinking and actions see what happens                & discuss (insert here)


 * 1) Tell them that Level 1 is the most basic. When you want to improve practice, you need to move through the 3 ways to think about how your perspective and context affect how you use the evidence. This process enables you to think about the relationship between evidence, your practice, who you are and your context. In this way, you can make gradual adjustments to improve practice.
 * 2) Ask them what they think of the 3 modes of learning.


 * Potential conflicts for dialogue:


 * 1) I am afraid to step outside the clinical guidelines because I am not an expert, just a GP.
 * 2) I am conflicted between my professional judgement of what the patient wants and what the evidence says.
 * 3) I tried it before and it did not work.
 * 4) I spoke to others who tried it and they said the same thing.
 * 5) It depends on how confident I am around different areas of care and treatment. If I am used to long term care and have previous experience, then I am more confident than someone who is outside of that and only has initial training and will be more likely to stick rigidly to the guidelines.
 * 6) Discuss - it's never easy to get a 'fix' on good practice is it? Why do you think so? What factors define good and bad practice in your work?
 * 7) The actions we take have consequences on patients. Is it possible to make a different choice, to choose another way of thinking and behaving? Could you try it? What would you consider?


 * These dialogues can be excellent at encapsulating the choices between evidence and daily work, the influence of others, the context, how nothing is black and white, how there is never a perfect solution, and we can try to make small changes.


 * After teaching each of these ways, be sure to allow time for learners to ask questions and explore deeply. Keep the dialogue on track. When openings in the discourse emerge, weave in the next way of learning to support the dialogue. The result should be a clear understanding of the importance of reading evidence in 3 ways when trying to solve problems and improve practice. Stress that the more you learn this way, the easier it will become over time, and we can do it together. Always check for meaning, and elicit questions. This will be difficult as most healthcare professionals are trained to think and learn reflectively, not reflexively. Take as much time as needed. Use more examples of evidence familiar to learners, invite them to explore 'evidence' they know about and have tried to use.


 * Issue handout with the 3 modes of learning. This can be a PPT slide, or a blog entry.


 * Say - we now have a learning strategy that can help us analyse evidence as we try and improve practice. Let's try it!

Activity 2.2 : Try doing the 3 modes of learning

 * 1) Select a news clip, health fact sheet, magazine article, webinar which discusses a piece of evidence relevant to the topic of the programme e.g. "Research shows that using (treatment) can reduce (disease) by 40%". Let the learners browse through it for a few minutes.
 * 2) When they return, ask them: Is this true?
 * 3) Tell them to use the 3 modes of learning to answer the question.
 * 4) Break them out into small groups for 15 minutes.
 * 5) Bring them back into plenary.
 * 6) Gather up their responses and post on the whiteboard.
 * 7) Give them some time to read through all the small groups' answers. Help them refine and synthesise.
 * 8) Facilitate the discussion and shape the dialogue by asking:


 * So how did it go?
 * Could you differentiate the 3 modes of learning?
 * You are right, its hard to separate the 3 ways of learning isn't it? They are interconnected.
 * What did the article leave out?
 * Have you seen/heard such things at your own workplace?
 * Do you know of any other examples? Have you heard such things from the media?
 * Is there an alternative opinion?
 * Do you think there is a hidden ideology behind it?
 * Should we believe all the 'evidence' we are given and told to use?
 * Could you use the 3 modes of learning when trying to solve problems?
 * what else do we need?
 * 1) Thank everyone. Inform them that by using the 3 modes of learning, they become reflexive learners of evidence-based medicine who can solve practical problems to improve practice.

Activity 2.3: Investigate the Problem using the 3 modes of learning
In this activity, learners apply the 3 modes of learning to revisit their problems. The goal is to teach them how to critically frame their problem, the evidence based concept, and their social context.They also explore their values, beliefs and assumptions. By sharing knowledge with each other, collaborating in small groups,and using a new learning strategy, they are making the first step to redesign their practice reflexively.


 * 1) Bring up the matrix from Step 1.
 * 2) Say - earlier, we made this matrix about the problems you want to solve. As you can see, it has 4 section - cause, need, solution, challenges.
 * 3) Check everyone is on the same page.
 * 4) Now, you have learnt the 3 modes of learning, and can think critically about how you can think about new evidence.
 * 5) Check if everyone gets this.
 * 6) Now, you are going to explore the problem again, except now, try and analyse the problem using the 3 modes of learning. And see if you could bring the new evidence to help you solve the problem.
 * 7) Check this instruction is clear.
 * 8) Break them out into 4 small groups. Each group will work on one section of the matrix.
 * 9) Do not set a time limit as this is a challenging task.
 * 10) At this stage, it is advisable to bring in mentors and experts to work with small breakout groups.
 * 11) Move through the breakouts to support their meaning making.
 * 12) Help them interpret the problem at 3 levels. Make them move through the 3 levels slowly. Do not rush into 'brainstorming' all over the place. Give them structure, use the matrix.
 * 13) Help them to 'read' their problem by bringing in the evidence, their social context, and their self. Draw a diagram to show what this looks like.
 * 14) Ask questions like: Is the evidence important? What is left out? How does it compare with what I do? What is my context like? Does the problem look different? How come - support them think differently. Make them write and say the 'difference' they perceive.
 * 15) Bring back small groups into plenary.
 * 16) As you dialogue, say things like, Hmm, yes, its difficult to put aside blaming, naming and shaming when trying to solve problems isn't it?
 * 17) Ask - do the 3 modes of learning make you feel more empowered about solving problems?
 * 18) Show the matrix again. Compare different groups' matrices and ask them to ponder, explore what differences they see.
 * 19) Invite group representatives to feedback to the plenary how they used the 3 modes of learning.
 * 20) Help them by taking notes on the matrix.
 * 21) The matrix should now have a 'reflexive' edge to it because participants have framed the problem they face through the 3 modes of learning.
 * 22) Summarise the relationship between learning, change, practice, evidence, context. Draw a concept map.
 * 23) Ask - is learning separate from practice? Discuss and debate.
 * 24) Pause. Say well done to the group. Give them time to digest.

Reflexive Seminar 2: Planning new thinking and action to test and try out

 * Now, what strategies can you use to solve this problem?


 * With the 3 modes of learning, you can research your problem at a social level.


 * Show them a diagram of what this means - use AMEE slides of doctor immersed in praxis across contexts.


 * Task - Let's explore now what new thinking and actions we can take when we go back to our work to try and solve your problems in small steps.


 * Breakout into small groups.


 * Discuss how they are going to change their thinking and action.


 * Plan how they are going to research the changes they make.


 * Come back into plenary.


 * Share suggestions from each small group.


 * Discuss. Query, prompt, elicit, synthesise. Keep asking how they are going to try and use the new evidence to do things differently. Respect disagreement. Deal with potential misunderstandings, discomfort, uncertainty. Explain that a little dis-ease is natural when trying to change thinking and actions. Say "If we don't do it, how will we know?"


 * Suggest using a blog to record the changes they make, and using audit tools such as self-assessment checklist, patient care audit.


 * Share these tools with participants, ask if they'd be OK with trying these out.


 * Ask them to be specific about the new thinking and new action.


 * Also ask them to be realistic. Keep it small at first. It could be something as simple as 'Asking my patient about his life'.


 * Suggest making a plan of how the new action will unfold. Maybe with a time line over 1 week. Describe what you will do.


 * Do they need to include anyone else in changing their action?


 * Could they collect some simple data of what happened? Maybe keep a journal?


 * Encourage them to think outside the box. Be free and creative. Small changes can make a big difference.


 * Ask - can I change how I understand my practice now?


 * This testing and trying in real life is their homework.


 * Check everyone is clear. Do they need e-mail reminder? How could the facilitator and mentors support them next week?


 * Close seminar.

Stage 2 Outcomes

 * Learners have learnt & practiced the 3 modes of learning
 * Learners can critique scientific knowledge and reframe concept in the social context within which participants work.
 * Learners have come up with ideas of new thinking and new actions to test and try out in daily life to redesign practice.
 * Learners have developed reflexivity.

Aim
This monitoring and evaluation stage can be held one week after the experimental stage of testing and trying out new actions and thinking.The aim is to recall what happened when professionals tried to use a reflexive learning approach to change practice in their various contexts, and learn lessons to move forward in small steps.

Activity 1 Recall
Process:
 * Welcome learners to the virtual classroom.
 * Ask them how their experiences of changing their thinking and actions went.
 * Allow for open discussion for 10 mins. Notice their views and perceptions.
 * Write down points you find ambiguous and ask the participants later in the discussion for clarification. These points will provide further openings for meaning making.
 * Ask - Why did you decide to do...? Why do you think patients like/dislike…? I noticed that you said/did… why was that? What was your colleagues reaction when you suggested that?
 * At this evaluation stage, the facilitator needs to go beyond asking factual questions.
 * Remind them that they have been through the goal setting, trailing and planning phases in the last stage. * Stress that the focus now is on moving forward what to do next as a result of the experiment.
 * Discursive prompts that confront and challenge learners are very useful to bring an aspect of behaviour on the surface and to help the professionals develop reflexive thinking. Some examples of prompts you can weave in are given below in Section 4 of this guide.
 * Tell learners Thank you for sharing. Our aim is to support you improve practice, and collaborate online. These are new experiences. You are doing great so far. I know its hard, and I'm wondering if we'd like to make a simple powerpoint show to tell our change stories creatively?
 * Gather feedback, gain consensus.
 * Segue into Activity 3.2 gradually

Activity 2 Digital Storytelling

 * However, professional learners may be reluctant to share 'honestly' what happened for fear of losing face in front of peers. They may also be cynical that they actually can do much to affect 'the way things are done around here.'
 * One of the best ways to combat cynicism is through storytelling. In this activity, online facilitators encourage learners to re-present what they did and come up with a story of their own making.
 * By sharing a story, this approach gets professionals to realize how they've transformed self, and others - without even recognizing it, or giving it a name!
 * This activity is something non-threatening that all learners could all relate to.
 * Research on the Reflect 2.0 project at University of Leeds for medical students digital storytelling shows that facilitators should be aware that they learners find sharing their stories with each other valuable. Students reported that the use of images helped them to feel more engaged in other’s experiences. Sharing and discussing stories allows further opportunities for reflection and engagement as opposed to text-based assessment such as reflective journals. These journals are also known to cause professionals to 'fake it' since they are seen as a burden that someone else is checking and judging them on.


 * Suggest a structure for their digital stories. Use the matrix from Stage 1 and 2 since they know it already.
 * Ask them to make a PPT slide show in their small groups (if they are more experienced, they can use Flash or Prezi as well) of 5 mins showing:


 * Cause of problem
 * What is needed to solve problem
 * What I changed
 * What worked and didn't work
 * What I learned about myself, the evidence, and my context
 * Next steps/Lessons for others
 * Check if everyone is clear on the process.
 * Say we will now break into small groups and you can spend the time discussing your stories. You don't have to finish it now but you should start having an idea of your overall story.
 * Break them out into small groups.
 * Allow them 20 mins to discuss their stories.

Reflexive Seminar 3
In this, the 3rd reflexive seminar in the programme, the aim is to help professionals develop reflexivity by becoming aware of the complexity of daily practice through cycles of thinking/doing that they have gone through.

Activity 3.1 Share digital stories
-improved your self-confidence? -learned new information about evidence-based practice? -mastered new techniques? -developed new skills? -developed new strategies? -reconsidered your beliefs about changing practice? -changed your behaviour in the workplace?
 * Gather back small groups from Activity 2 into plenary.
 * Invite each small group to present their group work for everyone.
 * They can post their digital stories on the blog, on YouTube or simply share their individual screens with the group.
 * After all the stories have been shown, thank them.
 * Ask them to discuss:
 * How did your joint work with colleagues influence you as a professional? As a learner?
 * In what way have you changed as a professional during these discussions ?
 * Have you:


 * What role do your context and your emotions play for you at work?
 * Is it always easy to control them? Do you try to hide your negative emotions at work? Why? Why not?
 * Has your approach to deal with the problems in practice changed? If yes, how? If not, why?
 * Can you now deal with the problems in practice better?
 * Does our network help you cope with problems?


 * Facilitators should note that these are vital prompts to develop reflexivity. The overall goal is that we need professionals to be constantly questioning and making sense of praxis and that they constantly integrate a wide range of inputs – information, opinion and support – in an attempt to improve praxis.
 * By reflexive learning, they are mixing all these factors together – taking actions/reflecting/new actions.
 * This more effectively occurs in a wider reflexive social collaborative learning environment situated in a network. This is active and authentic learning as opposed to simple and vain attempts to try and make the information traditionally provided by online CPD fit their practice. This is at the heart of the Reflexive Networking model used for this study's online CPD programme to improve practice.

Activity 3.2 Develop evaluation tool

 * Next ask them how we should evaluate the impact of the changes made - did it improve patient care?
 * Gather feedback. Prompt them with ideas of self-assessment and patient care audit tool.
 * Have they used them before? Could they work? Suggest working together to develop something that works for all of us and will please the boss that we've achieved something.
 * If they'd rather have existing tools, facilitators can suggest using a self-assessment checklist (available) and a validated patient care audit tool from the national health system.
 * They could also use goal attainment scaling to set goals and work towards them as a network. The facilitator can introduce examples of performance and audit checklists to consider and learn from before they proceed to design their own. The goal is to come to a principled rationale for changing practice as a collective network geared towards improving healthcare. This is a key skilled for online facilitators and requires reflexivity towards healthcare policy and research for impact on patient care.
 * Break them out into groups for the design work.
 * Say - in your groups, collaboratively develop a self-evaluation checklist to monitor their performance outcomes.
 * Give them 20 mins or so to brainstorm the categories they would use to evaluate if the programme helped them improve practice and patient care.
 * Return to plenary.
 * Invite groups to share their ideas on what categories the tool should include.
 * The facilitator helps the group to refine the categories and make a self-assessment checklist that everyone can accept.
 * Discuss the benefits and challenges of using the self-assessment checklist when applyinng online learning to monitor their performance and evaluate impact.
 * If the group is comfortable, the checklist can be shared with the wider network as an example of effective collaborative learning to improve practice. This can be through a blog, a flyer, or other dissemination tools that demonstrate participants' engagement with and ownership of the process of change.
 * Be sure to stress that these kinds of tools are powerful only when they are aligned with the national and organizational policy and research guidelines. The programme, their small projects, and the outcomes are aligned. Say this tool helps make them reflexive learners so they can make changes. They can also adapt the tool over time.
 * Tell them that using the checklist is optional, it is for their benefit.


 * If the group comes up with an evaluation tool collectively, this will mark a great leap forward in increasing their capacity for agency to change.
 * Rather than have guidelines imposed on them, they would now have had the opportunity to integrate such received knowledge with their prior experiences. Through group supported reflexive learning, they become confident enough in their own thinking ability to examine the assumptions behind health care practice, and the roles of policy, managers, professionals, and patients within it. This process thus continues a long and penetrating syringe of immersion in praxis, through multiple doses, to create a product for all members of the network to identify with and contribute to. This product is the evidence of co-constructing knowledge and practices through online collaborative learning.

Activity 3.3 Moving into the Future: Action Planning
It is at the action planning stage of the 3rd reflexive seminar that online facilitators invite participants to project themselves into the future and to achieve some sort of closure on the current online CPD course.
 * Invite participants to decide on what action they wish to take, on the basis of the shared experiences up to this point in the cycle. These plans could include testing the value of the self-evaluation checklist on improving practice.
 * Facilitators should anticipate that participants face difficulties in implementing any change in their thinking and practice.
 * It is thus the facilitators ethical responsibility to provide support and assistance for participants in achieving change. Reflexive pedagogy, as mentioned earlier, involves giving a 'gift' and not just 'dishing out knowledge and skills'.

End of 1 reflexive pedagogy cycle
At the end of these 4 synchronous web-chat sessions, a reflexive learning cycle has been completed. Working from experience through critical reflection to creating meaning, and finally planning for action, participants’ thinking and actions will in some small way have been transformed. We have moved through the filters of individual and group talk on this journey and engaged in different activities at each stage to develop reflexivity to support the self-determination for change.

The group can decide to continue to test and try out new thinking and actions and whether it makes any difference with the support of their self-assessment checklist.

Online facilitators agree a date and time with the group to reconvene in a few weeks to evaluate together whether this approach had empowered them to improve practice in the problem area they began with.

Such regular facilitated synchronous discussions will be crucial in maintaining the sense of belonging to a social network that is transforming care together across contexts. Such continuous discussion also keeps removing the blockages in thinking that can dilute the commitment to change once they end the course and are safely ensconced back in their existing communities of practice.

The strategic online social support enhances the reflexive aspect of the network – valuing each other and increasing confidence and control over learning while immersed in praxis together, no matter what the workplace is like.

To close:


 * Say - we can always rely on and turn to one another.


 * Provide them an email address where they can contact the facilitator to keep asking questions.


 * Ask if they want to share their email with one another.


 * Say that the blog will be kept going, and they are welcome to keep sharing.


 * Ask if they wish to meet again to see what happens.


 * Remind them that they will get an email to fill out an evaluation form.


 * Thank them and wish them well on their learning journeys.

Stage 3 outcomes

 * Participants have reflected critically on their experience of trying to change thinking and actions
 * Participants have understood how to act reflexively in daily practice.
 * Participants are confident they can turn to a network to access information, advice and opinion to support change
 * Participants have developed and shared digital stories
 * Participants have developed a self-assessment checklist
 * Participants have agreed to test out new thinking and actions.
 * Participants may have agreed to meet again.
 * Participants may have agreed to submit outcomes evaluation.

Further prompts to develop reflexivity in the moment of online discussions

 * Have you tried to change practice?
 * What led you to try and change practice?
 * What happened?
 * What was easy and what was difficult?
 * Were others involved?
 * Is it possible to change practice alone?
 * What new questions arose?
 * Did you ask for support from management or your colleagues?
 * Did you get any support?
 * What is your organizational culture/workplace community like?
 * Shall we explore why the old practice is ineffective to improve patient care?
 * What is needed to change this practice?
 * Let’s explore the problem – how does it relate to the concept we learnt in the module?
 * Does this concept relate to your practice?
 * Does this concept make sense?
 * Could you apply it in your daily life?
 * Do others at your work use evidence-based medicine?
 * Could our group try and solve the problem to change this practice using this new concept?
 * Do you see any problem with the concept?
 * If we use this concept, what does practice look like to you now?
 * How should we try and apply it?
 * Shall we work in small groups of 3?
 * OK, what process shall we follow?
 * What else do we need to know first?
 * How can we get this?
 * Are we confident?
 * Who else can support us - mentors, experts?
 * What questions and concerns do you have about learning together in this way?
 * How does it compare to how you usually learn online?
 * How could our online discussions become meaningful and relevant to improving the practice of (topic)?
 * What does being a good health professional involve?
 * Have you changed as a health professional over the years? How?
 * What issues and relationships in the social context affect the choice and opportunity you have to change practice?
 * What's your strategy to improve practice?
 * In your work, do you have any opportunity to sit together with the staff to discuss about improving practice? How often?
 * Who usually organises such meetings? And why?
 * If you find some problems in your work, whom do you prefer to talk to? Why?
 * Out of work, how often do you see your colleagues in social settings? What issues do you usually raise?
 * Write a list factors you think are obstacles to work collaboratively and improve practice
 * Do you and your colleagues share ideas you read in journals?
 * Do you follow what's happening in the policy side of things?

How online facilitators can demonstrate self-reflexivity
Throughout the process of facilating synchronous discussions, online facilitators need to be aware of their own social position in the teaching process and publicly reflexive about this. For instance, they can share by saying things like:


 * Like you, I am here to do new things by learning so that we can all improve in how we spend our time online
 * I am also critical about what online learning can and cannot do but I think we can make it better.
 * I believe strongly in positive thinking and cooperation
 * I learn best by practice, practice and reflection with people I can trust
 * I choose the content and the learning process together with you
 * I think social context is very important in affecting what I think and how I behave. I think and behave differently when I am in a university, in a clinic, or in the private sector.
 * We can become more socially aware so that we can be more sensitive to how to change practice slowly.
 * Slowly, I am becoming more aware of how I can change my surroundings to improve my work
 * I think we can support one another to change our behaviours to testing and trying out new ways

These statements may be seem awkward at first, but educators should try it. My experience is that dropping such statements into the flow of online discussions creates trust and bonding and reduces the teacher-learner hierarchy.

Furthermore, if by doing reflexive pedagogy, our intention is to support learners become sociologically aware, then it is requires online facilitators to be more reflexive in our facilitation practices.

Closing Remarks
In this guide, I have developed a 3-stage reflexive pedagogy model for facilitating synchronous online discussions with Web 2.0 social software to deliver OCPD programmes to improve practice and patient care for learners dispersed across contexts. To summarise, the main point is that changing professional practice with a reflexive pedagogy approach is likely to work because it develops the reflexivity of professionals with the support of a network. The approach supports professionals productively contest existing practices, and tentatively adopt new practices by allowing the space to think and act differently and trying out new actions in real-life contexts. However, online facilitators need to be trained to think reflexively, and this is a core competence for facilitators who wish to use this approach. After all, how can educators expect to change the behaviours and practices of others if we ourselves don't change our behaviour and practices?

To see reflexivity as intertwining and intersecting with improving professional practices is to recognise that learners first need access to socially available resources from peers, mentors and experts for shared meaning making. Consequently, in order to provide learners with access to creative and critical practices required to make and remake meaning, arguably a core aspect of health professionals work, then online professional learning and online CPD development must focus on solving professionals' own problems of practices, conceptions of practice and subsequently, evidence based medicine by taking an 'interactive worldview'. This approach makes OCPD programmes not just a choice between the practical or conceptual, but both at the same time. Curriculum is then re-oriented to solving problems. What we will really gain is that professional learners will get both intuition and experience by participating.

Nevertheless, the problematic of pedagogy will remain – this approach will be helpful for some and not for others. Social networks can tend to conformity. Educators will have to keep juggling a variety of activities, roles, and power relations with learners to cater to the variety of habits and conditionings present as they shape the network towards improving practice and care. Hence, the critical and financial value of maintaining a reflexive awareness of healthcare, educational and technological contexts is necessary for programme managers who want to make impact. This is a serious problem because of the pressures of accountability, results, performance, that led to a rush towards standardised efficiency CPD models. Such models don't have the culture, the depth, and the real stories that make professional learning rich and engaging conversations.

Overall, coming to terms with different responses to shared problems in their small groups, professionals may learn that healthcare practice is a creative and critical act. Negotiating meaning with their peers will teach them to value differing interpretations and enable them to reflect on how they might entertain these differences in their practice. Seeing that patient care and their own learning are fundamentally intertwined, participants may become more reflexive about their practices and appreciate the practices and resources they can access from patients, peers, mentors, experts. We believe that the practices developed in the facilitated synchronous discussions will be incorporated into professionals' planning, building a pedagogy and curriculum that encourages professional learners to engage creatively and critically with the widest range of scientific texts to improve practice. We also expect that participation in the online discussion will allow them to discuss in more detail the impact of their learning on practice at their appraisal, allowing them to claim for higher CPD revalidation points.

Developing an interactive worldview to solve problems and improve practice is something we as educators are trying out as well. Upon reading this, please do not assume that we have already changed our worldviews and want to impose them. Instead, we are in transition and sharing our social perspective because we think it can help address a common problem we all face today - how to design OCPD that works. This guide marks our attempt to change the way we teach and the way we learn so as to achieve individual and social change.

Links & Resources

 * http://chronicle.com/blogs/profhacker/reflexive-pedagogy/22939
 * http://wikieducator.org/Category:Facilitation
 * IICD Facilitator Manual