Teaching and l earning in m edical e ducation: h ow t heory c an i nform practice

David M Kaufman and Karen V Mann

KEY MESSAGES • Understanding theory can enhance the use of effective • Learning is enhanced when it is relevant, teaching and learning strategies. particularly to the solution and understanding • The learner is an active contributor in the learning of real - life problems and practice. process. • Individuals ’ past experience and knowledge are critical • Learners interact actively with the curriculum, to how they learn. patients and teachers in a complex, changing • Learning has an emotional aspect to it that is often environment. under - recognised and can infl uence the learning • The entire context of learning is important, rather than signifi cantly. any single variable, and includes interactions of all the • Individual learners are capable of self - regulation, that variables. is, setting goals, planning strategies and monitoring • Values, attitudes and the culture of the profession are their progress. often learned implicitly and without explicit teaching • The ability to refl ect on one’ s practice (performance) is or awareness of learning. critical to lifelong, self - directed learning.

Introduction • adult learning principles (3) • social cognitive theory (4) How can educational theory inform our practice? • refl ective practice (5) Several writers have described a gap between theory • transformative learning (6) and practice. Indeed, this perception has led practi- • self - directed learning (7) tioners in many professions to conclude that theory is • experiential learning (8) in an ivory tower, not useful or relevant to those in • situated learning (9) practice. Educators are no exception.(1) However, as • learning in communities of practice. (10) professional practice is better understood, it is clear We selected these because we believe them to be par- that theory has the potential both to inform practice ticularly useful in the context of the issues facing and to be informed by it. medical education today. We will describe each theo- Our purpose in this chapter is to describe eight retical formulation, highlighting its major constructs, selected approaches to education theory and explore and present implications of the theory for educational their implications for the practice of medical educa- practice, followed by a specifi c example drawn from tion. We use the term ‘ theory ’ in a general sense, that medical education. We will conclude with a considera- is, as a set of assumptions and ideas that help to explain tion of the connections and commonalities among the some phenomenon. Knowles(2) put this succinctly eight theories, so that readers may make these connec- more than 25 years ago, defi ning a theory as: ‘ a com- tions within their own practice. prehensive, coherent, and internally consistent system of ideas about a set of phenomena’ . Each of the theoretical approaches we describe is Adult Learning Principles consistent with Knowles ’ defi nition. The eight theo- retical approaches discussed are: The purpose of adult education has been the subject of a number of typologies.(11 – 15) Generally, these accord with a list proposed by Darkenwald and Merriam, (15) Understanding Medical Education: Evidence, Theory and Practice namely: Edited by Tim Swanwick © 2010 The Association for the Study of • cultivation of the intellect Medical Education. ISBN: 978-1-405-19680-2 • individual self - actualisation

16 Teaching and learning in medical education 17

• personal and social improvement BOX 2.1 Andragogical assumptions(3,23) • social transformation • organisational effectiveness. 1 As a person matures, their self - concept moves from A number of theoretical frameworks have developed that of a dependent personality towards one of a around these functions, which Merriam (16) has self - directing human being. Adults are capable of grouped into three categories. The fi rst category is determining their own learning needs, and of fi nding based on adult learning characteristics , in which the the means to meet them. best - known framework is ‘ andragogy ’ . (3) Also in 2 An adult accumulates a growing reservoir of this group is Cross ’ (17) ‘ Characteristics of Adults experience, which is a rich resource for learning. This as Learners’ model, based on differences between experience can be brought to bear on new learning, adults and children across personal and situational and enhance the new learning signifi cantly. It can also characteristics. provide an effective context for the acquisition of new The second category emphasises the adult ’ s life situ- knowledge and skills. ation . Two theories have been proposed in this cate- 3 The readiness of an adult to lean is closely related to gory, Knox ’ s Profi ciency Theory (18) and McClusky ’ s the developmental tasks of their social role. Adults Theory of Margin. (19) The third category focuses on value learning that integrates with the demands changes in consciousness . Several models in this cate- placed on them in their everyday life. gory emphasise refl ection upon experience and envi- 4 There is a change in time perspective as people ronment. Mezirow ’ s Perspective Transformation (20) mature, from future application of knowledge to (discussed later) and Freire ’ s Theory of immediacy of application. Thus an adult is more Conscientization(21) are the best - developed models in problem centred than subject centred in learning. this category. Generally, adults value learning that can be applied Merriam and Caffarella (22) have provided an excel- to authentic problems that they encounter in everyday lent summary of the various theory - building efforts in life. adult learning. They conclude that no single theory 5 Adults are more motivated to learn by internal factors fares well when judged by the criteria of comprehen- rather than external ones. The internal desire to siveness (i.e. includes all types of learning), practicality succeed, the satisfaction of learning and the presence and universality of its application. They also assert of personal goals have a greater effect on maintaining that a phenomenon as complex as adult learning will [italics added] motivation than external incentives probably never be adequately explained by a single and rewards. theory. Although these theoretical frameworks provide implications for practice, few have actually been applied widely in adult education practice. Knowles’ (3) andragogy is the exception. The remainder of this criticism led Knowles to later modify his model by section focuses on and andragogy, its implications for describing andragogy and pedagogy as a continuum, practice and an example of its use in undergraduate and suggesting that the use of both teaching methods medical education. is appropriate at different times in different situations, regardless of the learner ’ s age. (23) Andragogy It is widely accepted that andragogy is not really a Malcolm Knowles (3) fi rst introduced the term ‘ andra- theory of how adults learn, the assumptions being gogy ’ to North America, defi ning it as ‘ the art and merely descriptions of the adult learner. (28) science of helping adults learn ’ . Knowles did not Furthermore, even the assumptions have been ques- present andragogy as an empirically based theory, but tioned as prescriptions for practice. simply as a set of four assumptions, (3) to which a fi fth Others argue that andragogy may in time become was later added ( see Box 2.1 ).( 23) a theory, but through empirical studies of the Andragogy has its roots in humanistic psychology assumptions. At least, andragogy captures general through the work of Maslow (24) and Rogers. (25) The characteristics of adult learners and offers guidelines core basis of andragogy is that the attainment of adult- for planning instruction with learners who tend hood is marked by adults coming to view themselves to be at least somewhat independent and self - directed as self - directed individuals. Knowles ’ ‘ model of (29) . assumptions’ has given adult education a ‘ badge of identity’ that distinguishes the fi eld from other areas Implications for e ducational p ractice of education, for example, childhood schooling. (26) There are several implications for practice that can be Bard (27) has asserted that andragogy ‘ probably more derived from the theories of adult learning which have than any other force, has changed the role of the at their heart the fact that an adult ’ s life situation is learner in adult education and in human resource quite different from that of a child. Merriam and development’ (p. xi). However, it has also caused enor- Caffarella (22) discuss these differences in three areas: mous controversy, debate and criticism. The early context, learner and learning process. 18 Chapter 2

Context BOX 2.2 Principles of adult learning(23) Children are dependent on others for their well - being, while adults have assumed responsibility for manag- 1 An effective learning climate should be established. ing their own lives. Typically, being a learner is only Learners should be comfortable, both physically and one of several roles played concurrently by adults. emotionally. They should feel safe and free to express Additionally, the principles that have guided themselves without judgement or ridicule. approaches to teaching children, and which have been 2 Learners should be involved in mutual planning of applied to learners of all ages, have focused on gener- methods and curricular directions. Involvement will alised learning in the school setting. (30) In contrast, help assure that collaboration occurs in the content adults generally learn and function in settings where and learning process. It will also increase the situation- specifi c skills are required to resolve relevant relevance to the learners ’ needs. problems. 3 Learners should be involved in diagnosing their own learning needs. Once again, this will help to ensure Learner meaningfulness and will trigger learners ’ internal As Knowles has described, (3) there are signifi cant dif- (intrinsic) motivation. It will also promote self - ferences between adults and children that must be assessment and refl ection, and effective integration of addressed in the learning process. These include the learning. need of adults to be self - directing, their large reservoir 4 Learners should be encouraged to formulate their of experience, the relationship of their readiness to own learning objectives. The rationale for this is the learn to their social role, their desire for knowledge same as for 3, above. Learners are thus encouraged to that can be immediately applied to current relevant take control of their learning. problems and their internal motivation to learn. 5 Learners should be encouraged to identify resources and to devise strategies for using them to accomplish Learning p rocess their objectives. This principle connects adult learning Three non - cognitive factors have been shown to affect needs to practical resources for meeting their adult learning: objectives, and also provides motivation for using • pacing (e.g. through deadlines for assignments or such resources for a specifi c and focused purpose. adhering to a schedule) 6 Learners should be helped to carry out their learning • meaningfulness plans. One of the key elements of motivation is • motivation. (22) expectancy of success. Learners will become Pacing of learning through deadlines or other pres- discouraged and lose their motivation if a learning sures may adversely affect learning, since adults have task is too diffi cult. Also, too much pressure without many competing demands. Also, adults tend to support can lead to a decrement in learning. perform poorly on learning tasks that are not meaning- ful, or which do not fall within their domain of 7 Learners should be involved in evaluating their own interest. learning. This is an essential step in a self - directed The ideas presented thus far can be formulated as a learning process that requires critical refl ection on set of principles to guide adult learning activities. experience, a specifi c example of which (5) is Several writers have proposed principles or ‘ tips ’ for discussed later in this paper. practitioners.(23,31) Knowles (23) himself drew seven principles from the assumptions of andragogy, which are presented here (see Box 2.2 ). dynamic, reciprocal interaction among three sets of determinants: personal, environmental (situational) and behavioural. Personal factors include the individ- Social Cognitive Theory ual ’ s attitudes, perceptions, values, goals, knowledge and all previous experience. Environmental factors Social cognitive theory (4) , formerly social learning encompass all those infl uences that may reward or theory(32) , acknowledges the social (interactive) aspect hinder actions and the achievement of goals. Bandura of learning and unites two approaches to understand- notes explicitly that ‘ personal and environmental ing learning. These are the behaviourist approach, factors do not function as independent determinants; which emphasises the infl uence of the environment on rather, they determine each other. People create, alter our actions, and the cognitive approach, which empha- and destroy environments. The changes they produce sises the importance of cognition in mediating our in environmental conditions, in turn, affect their learning and functioning. behaviour and the nature of future life ’ (p. 23). (4) These two approaches are united in a basic tenet of Bandura further states that behaviour, rather than social cognitive theory, which posits that our actions, being a ‘ detached by - product ’ of persons and situa- learning and functioning are the result of a continuous, tions, is itself an interacting determinant in the process. Teaching and learning in medical education 19

Figure 2.1 Diagrammatic representation of (a) reciprocal interaction among personal, situational and behavioural factors; (b) the same factors using a medical education example.

Figure 2.1 shows the interactions schematically and Symbolising c apability how these might apply to medical education. Almost every aspect of our lives is touched by our Bandura asserts that the relative infl uences exerted remarkable ability to use symbols to transform our by each of the three sets of factors will vary for experience into a form that can be internalised and different activities, different individuals and different serve as a guide to future actions. This ability enables circumstances. For example, when environmental us, when confronted with a new problem, to test pos- conditions exert a powerful infl uence they will prevail. sible solutions symbolically, rather than laboriously In a medical education example, when trainees are trying out each alternative. thrust into the busy environment of a clinical ward they will do what is required to get the job done and Forethought c apability to meet expectations. In other cases, the behaviour and Most of our behaviour is regulated by thought. We its feedback will be a major infl uence. For instance, anticipate the likely outcomes of our actions and plan when students are learning and practising a new skill, goals for ourselves and courses of action to maximise the feedback from this will have a strong infl uence. the likelihood of obtaining them. Also, as noted, Finally, in those instances where situational infl uences images of desirable future events can become motiva- are relatively weak, personal factors will exert the tors of our current behaviour. strongest regulatory infl uence. To complete our example, when not pressed by powerful environmen- Vicarious c apability tal forces students may choose to learn a new skill or If learning occurred only through performing actions to learn more about talking with patients. These and experiencing their effects, learning and develop- choices will be affected by the student ’ s own values, ment would be slow, tedious and enormously ineffi - perceived needs and individual goals. There may also cient. Fortunately, much learning that can be acquired be interaction within each factor as they exert an infl u- through direct experience can also be acquired or facil- ence on each other. The simple example provided here itated vicariously through observation of other peo- is not intended to convey lack of complexity; rather, it ple ’ s actions and their consequences. This applies to is to emphasise the ongoing, dynamic nature of our social development, especially where, in some situa- interaction with our environment. tions, new behaviours can only be conveyed effec- Environmental infl uences can affect people in ways tively by modelling. Even if learning can occur in other other than their behaviour, as when thoughts and feel- ways, the ability to learn vicariously distinctly short- ings are modifi ed through observing others ’ behaviour ens the process. (modelling), teaching or social persuasion. Thoughts do not arise in a vacuum. Individual perceptions and Self - r egulatory c apability understandings are developed and verifi ed through In social cognitive theory, the capability for self - regu- both direct and vicarious experience, judgements of lation is central. Much of our behaviour is regulated others and by inference from what is already known. (4) primarily by our internal standards and our evaluative (p. 27). reactions to our own actions. Any discrepancies between our actions and those standards activate a Basic h uman c apabilities self - evaluation, which will infl uence our subsequent Bandura views humans as possessing fi ve basic capa- behaviour. Self - evaluation is our personal guidance bilities that underpin our learning and functioning in system for action. We exercise self - regulation or self - all situations . directedness by arranging facilitative environmental 20 Chapter 2 conditions using our images of future events as guides Implications for e ducational p ractice and creating incentives for our efforts. Understanding the concepts of ongoing dynamic inter- actions, basic human capabilities and how people form Self - r efl ective c apability their conceptions of their abilities allows us to plan a Perhaps the most distinctive is the capability for self - learning environment that is most conducive to max- refl ection, whereby we can analyse our experiences imising each individual ’ s development. We will con- and think about our thought processes. Cognitive sider some implications of this theory for effective theorists refer to this as metacognitive capability. teaching and learning; in particular, fi ve learning proc- Through self -refl ection we gain understanding about esses (that build on the basic capabilities) that can be ourselves, our behaviour and the world around us. brought to bear in medical education: A central concept in social cognitive theory is • modelling or demonstration self - effi cacy ; the individual ’ s judgement about his or • a clear objective, goal or desired outcome her ability to carry out a specifi c task or activity • provision of task - relevant knowledge ( see Box 2.3 ). • guided practice and feedback • opportunities for learners to refl ect on their learning. BOX 2.3 Focus on: Self- effi cacy (33) Modelling or demonstration of the desired process or According to Bandura, a central type of thought skill facilitates vicarious learning through observation. that affects action is people ’ s judgements of their This opportunity not only shortens the learning capabilities to deal with different realities, or their process, it is often essential when new skills are being self - effi cacy . This judgement infl uences what people acquired. Demonstration can help students to form an choose to do, how much effort they invest in activities, image of the desired skill/behaviour, which can be how long they persist in the face of disappointment and used as a guide for action and as a standard of per- whether tasks are approached anxiously or assuredly. formance against which to monitor their personal Judgements about our personal effi cacy, whether progress. Finally, learner perceptions of effi cacy are accurate of faulty, arise from four main information increased by observing someone else perform sources. successfully. • Performance attainments – our own performance is A clear objective , goal or image of the desired outcome the most infl uential source of effi cacy because it is enhances learning. It builds on our capability for fore- based on authentic experience of mastery. Successes thought, providing a guidepost for monitoring and raise our effi cacy appraisals; failures generally have a directing our progress appropriately. Awareness of lowering effect, especially if they occur early in the the goal also increases expenditure of energy and learning and they do not refl ect lack of effort or effort and stimulates the development of strategies to diffi cult situations. Once strong positive effi cacy reach the goal. perceptions are developed, occasional failures do not Learners require task - relevant knowledge . They must have a marked effect. Feelings of capability are have the basic building blocks to use as a foundation generally task - specifi c, though they can generalise to for newly acquired knowledge and skills. It maybe other, similar tasks. knowledge related to content or process, but it must • Vicarious experience – observing other similar people be relevant to the individual ’ s prior knowledge and perform successfully can raise our own beliefs that skills, and to the current goal. Further, learners may we can perform similar tasks. This source of need stimulation and assistance to activate prior information is particularly effective when people are knowledge, to relate it to the new learning. This encountering new tasks and have little experience on knowledge promotes students ’ views of themselves as which to base their perceptions. capable of the task. Otherwise, their perceptions of • Verbal persuasion – we have all had the experience their effi cacy are likely to be low, which will affect both of trying to convince people that they possess developing effi cacy perceptions and their future capabilities that will enable them to achieve what performance. they seek. If the heightened effi cacy that the Guided practice of a new skill with feedback allows persuasion is attempting to achieve is realistic, it can learners to develop positive effi cacy perceptions about be infl uential, particularly in affecting the amount of the task, and to experience successes rather than fail- effort individuals put into a task. ures in that crucial early learning period. Practice pro- • Physiological state – people often judge their motes the internalisation of personal standards, which capability based on the messages received about can then be used in self - regulation and self - evaluation. their physiological states. We frequently interpret Corrective feedback is integral to effective learning. arousal in taxing situations as an ominous sign of Without feedback, the level of performance achieved vulnerability, and tend to expect more success when is lower. Similarly, feedback is less effective in improv- we are not tense and aroused. ing performance when it is not related to a goal or desired level of achievement. (33) Teaching and learning in medical education 21

Finally, and arguably most critically, learners require analysed issues and programmes that encourage opportunities to refl ect on their learning, to consider refl ective practice in education. But it is Sch ö n who has their strategies, to determine whether new approaches perhaps been most infl uential in our understanding of are required to achieve their goal and to draw lessons refl ective practice. Sch ö n (5,38) summarises the need for future learning. Refl ection also allows the integra- for a new scholarship that recognises knowing - in - tion of new experiences into existing experience and action, on - the - spot experimentation (refl ection - in - knowledge. Finally, it allows the learner to build accu- action) and action research. rate and positive perceptions of effi cacy, based on their experience. Principles of r efl ective p ractice In summary, social cognitive theory provides us Sch ö n ’ s works (5,38,39) are based on the study of a with several important constructs that may inform our range of practice professions. Sch ö n argues that formal educational practice. They include the concept that theoretical knowledge, such as that acquired in the learners are constantly interacting with their environ- course of professional preparation, is often not useful ment and their actions and consequences. Many of the to the solution of the messy, indeterminate problems characteristics that we seek are present as basic capa- of real - life practice. Central to his premise is the need bilities common to all. Rather than creating these char- for professional scholarship and the recognition of an acteristics, learning opportunities can be created to epistemology of professional practice. The refl ective develop and build on them. Finally, we can have some practitioner incorporates these principles by relating confi dence that people are inherently self - directed. professional knowledge to practical competence and Given the appropriate conditions and support, they professional activity. By linking theory to practice, will set goals, develop strategies to attain them and both can inform each other. monitor their progress regularly. Professionals develop zones of mastery around areas of competence. They practise within these areas as if automatic . Sch ö n terms this a professional ’ s Refl ection and Refl ective Practice ‘ knowing - in - action ’ . Indeed, practising one ’ s profes- sion has been likened to riding a bicycle. Occasionally The concepts of refl ection and the refl ective practitioner the bicycle skids.(40) This occurs in response to a sur- are at the centre of the epistemology of professional prise or the unexpected. Two types of refl ection are practice. They borrow from and link three previously triggered at this time: ‘ refl ection - in - action ’ and well- established epistemologies: positivism, interpre- ‘ refl ection - on - action ’ . (5) tive theory and critical theory. (5,34) The positivistic Refl ection - in - action involves the three activities of view of science assumes that theory is a scholarly • reframing and reworking the problem from differ- pursuit that may be unrelated to practice. It is only the ent perspectives predictive value of theory that is of practical value. • establishing where the problem fi ts into learned Refl ection in professional practice extends this view by schema (i.e. already existing knowledge and proposing that theory and practice inform each other. expertise) As knowledge is embedded in practice, practitioners • understanding the elements and implications are positioned to test and revise theories through prac- present in the problem, its solution and tice. They do so by refl ection and action. The refl ective consequences. process, as such, serves as a bridge in the theory – Refl ection - on - action , which occurs later, is a process of practice relationship. thinking back on what has happened in the situation It ties the refl ection to the interpretive model. The to determine what may have contributed to the unex- interpretive epistemology proposes that theory is pected, and how this situation may affect future interpreted in light of personal current and past expe- practice. riences. Theory guides or enlightens action and under- Both are iterative processes whereby insights and standing. Lastly, the concept of refl ective practice learning from one experience may be incorporated shares with critical theory the observation that theory into future ‘ knowing - in - action ’ . (5,38) is intimately linked to practice through a process of Other approaches to refl ection and learning from critical thinking and examination. This process permits experience have also been infl uential. (40 – 42) Boud et professionals to break free from established paradigms al. (43) also outline an iterative process comprising and reformulate the ways in which practice, problems three main phases, beginning with the experience . The and problem solving are viewed. This reframing is second phase involves returning to the experience and, part of learning and change. It is how practice helps through refl ective processes, dealing with both nega- organise theory. (5,35) Refl ective practice then becomes tive and positive feelings about it, and re - evaluating it. a vehicle for learning effectively. The last aspect of the process Boud et al. labelled ‘ out- Al - Shehri et al. (35) and Moon (36) reviewed defi ni- comes ’ , in which new perspectives on experience can tions and approaches to refl ection and refl ective prac- lead to a change in behaviour and a readiness for tice found in the educational literature. Clift et al. (37) application and commitment to action. These authors 22 Chapter 2 view refl ection as the key to learning effectively. They BOX 2.4 Where ’ s the evidence: also emphasise the importance of recognising the emo- Refl ective practice tional aspects of experience that accompany effective learning from experience. Despite the observation that refl ection has been Moon (36) views refl ection as the catalyst that moves described in several different fi elds, and much has been surface learning to deep learning. Deep learning can written about it in the respective literatures, the research be integrated with current experience and knowledge, literature in the fi eld is relatively early in its resulting in rich cognitive networks that the individual development. A review (41) of the research across can draw on in practice. medicine, nursing and other health professions suggests Similar characteristics are found across a number of the following. refl ective models. • Refl ective thinking is seen in practising professionals • They describe refl ection as a series of iterative steps and in students across a variety of heath professions, or levels. including nursing, dentistry, medicine and health • They generally defi ne levels of refl ection, sciences. from superfi cial, descriptive levels to deeper • Refl ection appears to serve a number of purposes. In levels. medicine, it appears to occur most naturally in • Generally, the deeper refl ective levels are regarded response to complex and new problems. (42) as more diffi cult to achieve, although they hold However, it is also demonstrated in anticipation of greater potential for learning and growth. challenging situations.(47) There also appears to be a dynamic relationship • The phenomenon of refl ection is not unitary. Several between refl ective practice and self - assessment, both elements and aspects of refl ection have been explicitly and implicitly. The ability to self - assess demonstrated. The tendency to refl ect and refl ective depends on the ability to refl ect accurately on one ’ s ability vary across individuals and across situations. practice, and the ability to refl ect effectively relies • Attempts to measure and classify refl ective thinking heavily on accurate self - assessment. (44) have resulted in validated instruments which In the workplace, true professionals are known for demonstrate the differences exist and are measurable. their ability for on - the - spot experimentation and Generally, it seems that deeper levels of refl ection are improvisation, their commitment to ongoing practice - achieved less often and are more diffi cult to achieve. based learning and their self - directed refl ective learn- • It appears that refl ective ability can be developed. ing skills. It is these collective skills that permit Strategies associated with reported changes in professionals to continually and subtly learn from refl ective ability used small group resources and practice, adapt to change and maintain their compe- activities such as portfolio and journal keeping. tence. The core capabilities of professionals are tied to a number of essential skills. Professionals recognise • Several factors appear to constantly infl uence and value the traditional form of knowledge, that is, refl ection both negatively and positively. These that gained in school or in study, as well as experien- include environment, time, maturity, effective tial knowledge, that is, that gained through experience guidance and supervision, and the organisational and practice. In the context of their practice, they use culture. both these forms of knowledge to continually reshape • Refl ective practice appears to be linked to learning, their approach to problems, solutions, actions and out- particularly to deep learning, the development of comes. This creative process, sometimes called wisdom self - regulated learning and the development of or artistry, occurs in response to new meanings, professional identity. (36) insights and perspectives gained through refl ection on current and past experiences. It leads to continued learning and ongoing competence within a Implications for e ducational p ractice profession. (5) Refl ective practitioners are able to assess a situation Refl ection has frequently been viewed as an indi- from the perspectives of both theoretical background vidual professional activity. In some cases, refl ecting and practical experience. They must be able to bridge inadequately or inaccurately on one ’ s performance successfully the theory – practice gap and apply both can lead to circular, ‘ single - loop ’ learning, which can aspects of learning while examining the situation from often lead to confi rmation of current behaviours all perspectives. Refl ectivity in practice is a learned rather than to questioning and identifying areas for skill of critical thinking and situation analysis. learning.(45) For this reason, refl ection is increasingly As refl ection, practice - based learning and action suggested as a collective activity whereby individuals based on these are all skills to be learned and applied, can share individual insights and refl ections, and opportunities to acquire them must be available. increase their collective and individual learning. (46) The mentor or teacher models, shares and fosters The evidence surrounding refl ective practice is sum- this creative process in the presence of future and marised in Box 2.4 . current practitioners. The skills required for refl ection Teaching and learning in medical education 23 must be developed in professional courses within our authors described how to teach professional artistry. undergraduate, graduate, clinical and continuing They proposed that open learning environments medical education areas. Initially, the mentor or encourage a continual reshaping of practice - based teacher models, shares and demonstrates the skills. He learning, along with the development of continuous or she facilitates the learners ’ abilities to perceive competence. options and alternatives, to frame and reframe prob- Lockyer et al. (46) explored how refl ection could be lems. He or she also assists the learners to refl ect on used in both classrooms and practice, to enhance the the actions and options they chose, and on what integration of knowledge and its translation into pro- knowledge and values may have infl uenced their fessional practice. choice. Finally, teachers assist students to consider Palmer et al. (47) addressed curriculum design issues critically what they have learned and integrate it into specifi c to professional education and refl ection. Using their existing knowledge. the nursing profession as the context, they described Once the learner has gained suffi cient experience roles for lecture - practitioners, mentors (coaches) and and insight into the profession, the teacher ’ s role mentees. To defi ne the content or skill - set for a refl ec- becomes one of facilitating systematic experiential tive curriculum, they borrowed from Atkins and learning, on - the - spot experimentation, and refl ection Murphy. (44) They identifi ed fi ve skills as essential to on process, action and outcomes. Teachers observe partake in refl ection: and comment positively on situations in which the • self - awareness learner ’ s reframing has occurred. (40) This helps the • description learner to become consciously aware of the process of • critical analysis refl ection. • synthesis A dilemma in incorporating refl ective practices into • evaluation. our educational programmes is to select those strate- Palmer et al. (47) also provided guidance specifi c to gies that will facilitate its active development, and to assessing refl ective learning. select activities that are relevant to practice. Some lit- Crandall (42) notes the value of using Sch ö n ’ s model erature has addressed this issue when considering the for all levels of the medical education continuum. She merits of journals and portfolios. However, there has outlines how clinical teachers can use it to assist learn- been a move to incorporate more critically refl ective ers, and provides evidence through clinical teacher activities across the continuum. interviews that stages of Sch ö n ’ s model occur during Several authors (35,48 – 53) have linked refl ective effective clinical learning events. Specifi c evidence is practice to adult learning theory, self - directed learn- provided for all fi ve stages that Sch ö n recommends: ing, curriculum development, and effective profes- 1 knowing - in - action sional education and knowledge translation. 2 surprise Slotnick (41) linked Sch ö n ’ s work to how physicians 3 refl ection - in - action learn in practice. He emphasised the importance of 4 experimentation thinking while solving problems (refl ection - in - action) 5 refl ection - on - action. and thinking after problem solving (refl ection - on - Crandall offers strategies for implementing the refl ec- action). These two activities are required for clinicians tive practice across the medical education continuum, to gain new insights and perspectives around practice - and provides possible advantages for this. based problems, problem solving and practice itself. Al - Shehri et al. (35) described two roles for providers Ongoing learning, maintenance of competence and of continuing medical education in fostering self - improved practice will result. directed experiential learning, in which refl ection is Slotnick (41) outlined related principles and implica- core; to sustain motivation for such an approach in tions for learners and teachers in practice. established practitioners and to ‘ devise ways of sharing Parboosingh(54) adopted the Sch ö n model to assist in individual experience which both interpret and understanding how practitioners change and develop enhance learning’ (p. 251). The authors make a number professionally. According to Parboosingh, to remain of suggestions as to how these tasks may be accom- current, physicians require both an understanding of plished. Westberg and Jason (55) also offer practical their areas of competence (mastery) and the ability to approaches for fostering refl ection in medical educa- think refl ectively. These two concepts are embedded tion, before, during and following experience. They in the epistemology of professional practice. emphasise the importance of the learning environment Shapiro and Talbot, (40) , like Slotnick (41) and in effectively fostering refl ection. Parboosingh(52,54) , reinforced the importance of prac- Lastly, Moon (56) proposes a process of refl ection to tice context. They proposed that an understanding of promote transfer of new learning to practice. She artistry within the process of practice is required, and describes this four - phase framework in the context of adopted Sch ö n ’ s model (38) to aid in this understand- continuing education workshops and short courses, ing. Specifi cally, Shapiro and Talbot(40) applied the wherein participants are helped to address four refl ective practice model to family medicine. The questions. 24 Chapter 2

Transformative Learning Mezirow (6) explains that discourse is a crucial process, and refers to a special kind of dialogue in Mezirow ’ s concept of transformative learning has which the focus is on content and attempting to justify developed over 20 years into a comprehensive and beliefs by giving and defending reasons, and by exam- complex theory. (6,48,51) Transformative learning ining the evidence for and against competing theory defi nes learning as the social process of con- viewpoints. structing and internalising a new or revised interpreta- Transformative learning is a complicated, emotional tion of the meaning of one’ s experience as a guide to process requiring signifi cant knowledge and skill to action. In other words, transformative learning implement effectively. (53) A new paradigm emerges involves helping adults to elaborate, create and only after the old one becomes dysfunctional, and it is transform their meaning schemes (beliefs, feelings, the task of the transformative educator to challenge the interpretations, decisions) through refl ection on learner ’ s current perspective. A paradigm shift will their content, the process by which they were occur only if the learner perceives the existing para- learned and their premises (social context, history and digm to be signifi cantly inadequate in explaining his consequences).(51) Transformative learning can be or her experience. However, the new paradigm contrasted with conventional learning that simply appears only after a period of disorientation during elaborates the learner ’ s existing paradigm, systems of which no clear paradigm remains. It is typical for the thinking, feeling or doing, relative to the topic. learner to resist letting go of the old paradigm and Although learning is increased, the learner ’ s funda- beginning the transition to the new one. During this mental structure is maintained. Transformative learn- process, the teacher – learner relationship may intensify ing changes the learner ’ s paradigm so radically that, enormously because the learner may begin to resent although it may retain the old perspective, it is actually the teacher or feel anger towards him or her. Often a new creation. Critical refl ection and rational dis- learners feel a complex love – hate for the teacher who course are the primary processes used in learning. intentionally assisted in the collapse of their existing The core of transformative learning in Mezirow ’ s (51) paradigm. view is the uncovering of distorted assumptions or Successful transformative learning questions errors in learning. assumptions (this is a key to the process), provides Empowerment of learners is both a goal and a condi- support from others in a safe environment, provides tion for transformative learning. An empowered challenge, examines alternative perspectives and pro- learner is able to participate fully and freely in critical vides feedback. New assumptions are tested in the discourse and the resulting action. This requires authentic settings or in discussion with others. freedom and equality, as well as the ability to assess evidence and engage in critical refl ection. (48) Refl ection Implications for e ducational p ractice is a key concept in transformative learning theory. How can educators promote and support transforma- Mezirow (51) defi nes it as the process of critically tive learning? First, educators need to take a reformist assessing the content, process or premises of our perspective, rather than a subject - centred or consumer - efforts to interpret and give meaning to an experience. oriented perspective. (57) In a subject - centred perspec- He distinguishes among three types of refl ection: tive, the educator is the expert authority fi gure and • content refl ection – an examination of the content or designer of instruction. In a consumer - oriented per- description of a problem spective, the educator is a facilitator and resource • process refl ection – examination of the problem - solv- person. In a reformist perspective, essential to trans- ing strategies being used formative learning, the educator is a co - learner and • premise refl ection – questioning the problem itself, provocateur; they challenge, stimulate and provoke which may lead to a transformation of belief systems. critical thinking.(53) Box 2.5 illustrates Cranton ’ s (53) Perspective transformation may be the result of a stages before, during and following transformative major event in one ’ s life, or the cumulative result of learning. related transformations in concepts, beliefs, judge- Cranton (53) provides the following guidelines for ments or feelings. The most signifi cant learning transformative educators. involves critical refl ection around premises about • Promote rational discourse. Remember that rational oneself. This kind of learning is triggered by a disori- discourse is a fundamental component of trans- enting dilemma that invokes self - examination and a formative learning and part of the process of critical assessment of assumptions. Through a process empowering learners. of exploring options for new roles, relationships and • Promote equal participation in discourse. This can actions, new knowledge and skills are acquired. This be done by stimulating discussion through a pro- leads to planning and implementing a new course of vocative incident or controversial statement. action, provisionally trying new roles, renegotiating • Develop discourse procedures (e.g. stay on topic, relationships and forming new ones, and building summarise) and avoid using own position to make competence and self - confi dence. dismissive statements. Teaching and learning in medical education 25

direction as a goal towards which individuals BOX 2.5 Stages of change in strive, refl ecting a humanistic orientation such as transformative learning (53) that described by Maslow (58) and Brockett and Hiemstra.(59) These models imply achievement of a Stage of change Through level of self - actualisation, along with the acceptance of Initial learner Freedom to participate personal responsibility for learning, personal auton- development Comfort omy and individual choice. Learner decision making The second line of development has framed SDL as a method of organising learning and instruction, with Learner critical Questioning assumptions the tasks of learning left primarily in the learners ’ self - refl ection Consciousness raising control. Early development included linear models, Challenging assumptions where learners moved through a series of steps to Transformative Revision of assumptions reach their learning goals (e.g. Knowles (60) ). Later learning Educator support models have described the self - directed learning Learner networks process as more interactive, involving opportunities in Action the environment, the personal characteristics of learn- Increased Critical self - refl ection ers, cognitive processes, the context of learning and empowerment Transformative learning opportunities to validate and confi rm self - directed Autonomy learning collaboratively. Examples of this are seen in several models clearly described by Merriam and Caffarella. (61) This line of development also includes • Develop group facilitation skills (e.g. dominant par- models of instruction such as those of Grow (62) and ticipant, silent participant). Hammond and Collins, (63) which present frameworks • Encourage decision making by learners. This can be for integrating self - directed learning into formal edu- done by making the process open and explicit. cational settings. • Encourage critical self - refl ection. This can be accom- Candy (7) has clarifi ed the fi eld of SDL signifi cantly, plished by challenging learners, asking critical ques- bringing educators closer to understanding the spe- tions and proposing discrepancies between learners ’ cifi c characteristics to identify, develop and evaluate experiences and new or confl icting information. To in the self - directed learner. Candy (7) identifi ed be successful here, a climate of openness and sup- approximately 100 traits associated with self - direction, portiveness needs to be established. clustered around four dimensions: • Consider individual differences among learners. • self - directedness, including personal autonomy Learners should be assisted in becoming more • self - management in learning aware of their own learning styles and preferences. • learner control of instruction The educator needs to develop a strong awareness • the independent pursuit of learning. of how learners vary in the way they think, act, feel Self - directed learning is an integral aspect of several and see possibilities. theoretical approaches, including the cognitive, social • Employ various teaching/learning strategies. Many learning, humanist and constructivist. As noted earlier, strategies are effective, for example: role playing the social learning approach views individuals as (with skilful debriefi ng), simulations and games, life inherently self- regulating, with self - direction as a histories or biographies, exposure to new knowl- natural activity. The humanist approach views self - edge, journal writing (with self or others ’ feedback) direction as evidence of higher levels of individual and critical incidents arising in the practice setting. development. The cognitive perspective recognises the need to build rich, interconnecting knowledge structures, Self - d irected Learning based on existing knowledge, which allow continuing incorporation of new learning. The constructivist per- Self - directed, lifelong learning (SDL) is increasingly spective recognises the unique personal and social essential in the development and maintenance of construction of knowledge that occurs in different professional competence and is a hallmark of best learners. Self - directed learning elements can also be practice. seen in the ability to learn from experience through Those responsible for professional education, critical refl ection, which allows learners to identify including that of physicians, are challenged to create their personal learning needs and to be aware of, curricula that ensure the development of these skills monitor and direct the growth of their knowledge, and the evaluation methods needed to ascertain their skills and expertise. achievement. Generally, self - direction is a natural human process The literature on SDL has developed along two that can occur inside or outside of formal settings. SDL overlapping pathways. The fi rst has framed self- does not exclude formal activities such as lectures or 26 Chapter 2 courses. It is the learner ’ s choice of activities to meet in learning over time, through a variety of learning and manage a particular learning goal that denotes modes. self - direction. A number of factors in the learner and The ability to self - assess is critical to effective self - in the environment will affect the learner ’ s ability to directed learning. To properly direct one ’ s ongoing be self- directing. learning, and to assess where and what learning is • The learners ’ view of themselves as learners is also required, the individual must be able to assess his or an infl uencing factor. Learners who view them- her current practice with reasonable accuracy. A recent selves as competent, with the skills to learn in a review of the self - assessment literature suggests that variety of situations, are more likely to be self - our current understanding of self - assessment is insuf- directed and independent. fi cient and that our ability to assess our own perform- • Sometimes the demands of the learning situation ance is limited. Eva and Regehr (66) suggest that infl uence the capacity for self - direction. Where the accurate self- assessment requires a knowledge of situation demands that certain (particular) knowl- appropriate performance, and of the criteria by which edge and skills are non - negotiable, or where the to judge it. They further suggest that several sources situation requires the learner to reproduce exactly of information may be necessary for accurate self - what has been taught, the capacity for self - direction assessment, including feedback from others about may be obscured. one ’ s performance. It is also important to better under- • Self - direction is, to some degree, a function of stand the cognitive, affective and psychomotor bases subject matter mastery. As the learner builds a of self - assessment to effectively promote the develop- base of relevant knowledge and skills, the capacity ment of self - assessment capacity. to be self - directed is enhanced. This basic knowl- A more detailed look at self - assessment and self - edge is held by some to be essential for effective regulated learning is provided elsewhere in this book. SDL. For others who promote learning based on activation of prior knowledge, there are few learn- Implications for e ducational p ractice ing situations where the learner is completely There are a number of important implications for cur- lacking relevant knowledge to engage a learning ricula, teaching and learning in medical education, all task. of which are facilitated by the creation of a supportive • Much of professional learning is situated learning; learning environment where learners feel safe to ask that is, the learning is inseparable from the situation questions and to admit to not understanding. Learners in which the knowledge is used. Similarly, profes- must have the opportunity to develop and practise sional knowledge and acumen become embedded skills that directly enhance effective SDL. These include in practice, and part of the professional ’ s ‘ knowing - competency at asking questions and a critical appraisal in - action ’ . (38) Learners may require a cognitive of new information. guide and opportunities to participate in their com- Learners also need to acquire multiple approaches munity of practice and the knowledge embedded in to learning, along with the ability to decide when each it. (60,61) is appropriate. For ongoing SDL, however, deep learn- • Knowledge is also socially constructed, in that it is ing skills, (67) which involve understanding principles built from mutually understood perceptions and and concepts, and elaborating the relationships among assumptions. Learners ’ participation in the social them, are most likely to support self - direction. Making construction of knowledge through discussion and use of learners ’ existing knowledge structures, and participation provides a cultural basis for their assisting them to add to and enrich those structures self - direction. and understand similarities and dissimilarities, • Knowledge is dependent on context for its meaning, encourages the individual to understand his or her its structure in memory and its availability. knowledge base and to identify gaps. A fundamental Understanding and experience of a broad range of skill in self - direction is that of critical refl ection on discipline- relevant contexts encourage self - direction one ’ s own learning and experience. Learners must in transferring knowledge to other appropriate practise and develop skills at refl ecting on all aspects contexts. of their learning to determine additional learning Comprehensive measures of self - directedness are few. needs and to set goals accordingly. Mifl in et al. (68) Two scales have been used suffi ciently to have describe an attempt to introduce SDL into graduate achieved validation.(64,65) The Self - Directed Learning medical education in a university in Australia. Lack of Readiness Scale (SDLRS) was developed by clarity of what constitutes self - direction forced a recon- Gugliemino(64) as a tool to assess the degree to which sideration of the curriculum. people perceive themselves as possessing the skills Critical to the achievement of both explicit and and attitudes conventionally associated with SDL. The implicit curriculum goals is congruence between the Oddi (65) Continuing Learning Inventory is a 26 - item goals and the assessment methods.(19) Assessment scale that purports to identify clusters of personality will invariably drive learning and give the strongest characteristics that relate to initiative and persistence messages to learners about the real goals of the cur- Teaching and learning in medical education 27 riculum. Although there are genuine attempts to do otherwise, too frequently assessment methods reward teacher - directed, fact - oriented learning, and do not reward or evaluate the learners ’ achievement of self - directed learning.

Experiential Learning

Kolb ’ s experiential learning theory (8) is derived from Figure 2.2 Kolb learning cycle. the work of Kurt Lewin, (69) John Dewey (70) and Jean Piaget. (71) Lewin ’ s (69) work in social psychology, group dynamics and action research concluded that learning methods and procedures are bridges connect- learning is best achieved in an environment that ing a learner ’ s existing level of understanding, phi- considers both concrete experiences and conceptual losophies, affective characteristics and experiences models. with a new set of knowledge, abilities, beliefs and Dewey (70) constructed guidelines for programmes values. Second, in experiential learning the learner of experiential learning in higher education. He noted adopts a more assertive role in assuming responsibility the necessity of integrating the processes of actual for his or her own learning. This leads to a shift in the experience and education in learning. Piaget ’ s (71) power structure from the traditional relationship research regarding cognitive development processes between teacher and learner. Last, experiential learn- constituted the theory of how experience is used to ing involves the transfer of learning from an academic model intelligence. Abstract thinking, including the mode to one that involves more practical content. use of symbols, is closely linked to learners’ adaptation More specifi cally, in the affectively oriented envi- to their environment. Thus, Kolb ’ s experiential learn- ronment, learners experience activities as though they ing theory is a model of learning based on research in were professional practitioners. (8,74) The learner ’ s social, educational and cognitive psychology and present values and experience generate information. education. In the symbolically oriented environment, the learner Kolb ’ s theory can be used as a framework in inter- uses experiences to develop skills or concepts that can preting and diagnosing individual learners, as well as provide the right answer or the best solution to a designing learning environments. (72) Kolb ’ s four problem. (8,74) The source of information is primarily learning environments are conceptual. In the perceptually oriented environment, • affectively oriented (feeling) the learner views concepts and relationships from dif- • symbolically oriented (thinking) ferent perspectives.(8,9) • perceptually oriented (watching) Behaviourally oriented activities focus on specifi c • behaviourally oriented (doing). (73) problems or practices to which learners apply their Within these environments, grasping and transform- competencies.(8,76) ing experiences are the two constituent activities of learning tasks. (74) There are two components of the Teachers grasping phenomena: concrete experience, which The roles and actions of teachers depend on the par- fi lters directly through the senses, and abstract concep- ticular learning context. (8,76) In the affectively ori- tualisation, which is indirect and symbolic. The trans- ented environment they act as role models and relate forming experience also consists of two processes: to the learner as friendly advisors. They deliver infor- refl ection and action. One, or a combination of the four mation quickly and tailor it to the needs and objectives activities (concrete experience, abstract conceptualisa- of individual learners. Teachers monitor progress by tion, refl ection and action) may be used in learning.(8) encouraging ongoing discussion and critique without Learning is enhanced if students are encouraged to use constricting guidelines to inhibit students. all four components ( see Figure 2.2 ). In the symbolically oriented environment: ‘ The This section explores Kolb ’ s learning environments teacher is accepted as a body of knowledge, as well as in more depth by presenting practical implications for a timekeeper, taskmaster, and enforcer of events ’ , (8) in planners of educational programmes, teachers and order for the learner to reach a solution or a goal. (8,76) learners. Educational formats for delivering experien- Success is compared against the correct or best solu- tial learning activities are also included. tion by objective criteria. The teacher provides guide- lines regarding terminology and rules. Implications for e ducational p ractice In the perceptually oriented environment, teachers Programme p lanners act as process facilitators, emphasising process rather There are three major guideposts for directing experi- than solution. They also direct and outline connections ential instructional activities.(75) First, experiential between discussions. Learners evaluate answers and 28 Chapter 2 defi ne concepts individually. Performance is not meas- In contrast to some of the theoretical models already ured against rigid criteria but by how well learners use discussed, where learning is a one - sided process in predetermined professional criteria. which either the teacher or the learner is responsible, In the behaviourally oriented environment, teachers situated learning is about participation . Learning occurs act as mentors and refl ect on their background when through collaboration with other learners and more giving counsel. There are a few guidelines. Learners senior community members in carrying out activities manage their own time and focus on ‘ doing ’ . (8,76) It with purposes connected explicitly with the history is essential that the learner complete the task using and current practices of the community. (78) New professional standards. learners enter the community of practice and learn through a process of legitimate peripheral participa- Learners tion in which they perform the less vital tasks of In the affectively oriented environment the learner the community. As they take on more responsibility must work with people, be perceptive to encompass- learners move towards the centre. As they participate ing values and feelings, and become engaged in a increasingly in the community’ s practice they come to learning group in a concrete experience. understand the particular knowledge that distin- In the symbolically oriented environment learners guishes that community from others. study quantitative data to test their theories and pos- A central tenet of situated learning is then that learn- tulations.(74,76) Using unique ideas and action plans, ing occurs through social interaction. Learners acquire learners develop and conceptualise their experiences knowledge from talk of the community. They also and models. This relates to the experience of abstract learn to talk to and participate in the community. The conceptualisation. community offers a variety of relationships and exem- The perceptually oriented environment encourages plars from whom to learn, including masters, more the learner to analyse and manage data with an open advanced apprentices and fi nished products. Learners mind. (74,76) The learner must learn to see things with learn how masters walk, talk and conduct their lives; a broad point of view, compose complete plans of observe what other learners are doing and what is action and conjecture about the implications of ambig- needed to become part of the community. Through uous circumstances. The learner undergoes the trans- this participation they learn about the values and formative experience of refl ective observation by shared knowledge and practices of the community. openly approaching the learning activity. They learn how people in the community ‘ collaborate, In the behaviourally oriented environment learners collude and collide, and what they enjoy, dislike, must make their own choices in order to locate and respect and admire ’ . (78) exploit potential opportunities, committing them- For Lave and Wenger, the opportunity to learn selves to meet predetermined goals and objectives. around relationships with other apprentices and to They are encouraged to adapt to uncertainty and observe the masters ’ (senior practitioners) practice shifting circumstances, and to guide others. This creates the curriculum in the broadest sense. Learners relates to the transforming experience of active can develop a view of what the whole enterprise is experimentation. about, and what there is to learn. ‘ Engaging in practice, Caffarella (75) describes a number of formats for rather than its object, may be a condition for the effec- experiential learning activities in medical education in tiveness of learning ’ . (78) a variety of settings, from practical clinical environ- What is the relationship of situated learning to other ments to strictly academic arenas. Depending on the learning theories? Situated learning allows a broad view format, the teacher may form a strict regimental rela- of learning that relates to several other conceptions of tionship with the learner or may foster a caring bond. learning, both long - standing and more recent. Learners along the medical educational continuum Situated learning shares with social cognitive use various experiential learning methods. These may theory(4) the view that learning occurs in a dynamic include apprenticeship, internship or practicum, men- interaction between the learner and the environment. toring, clinical supervision, on -the - job training, clinics Situated learning suggests that learning is not separate and case study research. from social infl uences. The context in which teaching and learning occur is critical to learning itself, and learning is culturally and contextually specifi c. (79) Situated Learning Learning occurs within social relations and the prac- tices that occur there. Situated learning belongs to those theories of learning Situated learning also holds that some knowledge that have a socio - cultural basis, which view learning related to a task is only present in the context or loca- and development as occurring via transformation tion of the task. Brown et al. (80) described situated through participation in community activities. cognition and emphasised the idea of cognitive Learners transform their understanding, roles and apprenticeship. Cognitive apprenticeship supports responsibilities as they participate. (9,76,77) learning in a domain by enabling students to acquire, Teaching and learning in medical education 29 develop and use cognitive tools in authentic domain ing beyond the individual learner, as it views the activity. This happens in practice as teachers guide learner as contributing to, and participating in, the learners through processes of framing problems and shared experience of the community. applying disciplinary knowledge to their solution. In addition to all the above theoretical relationships, In the process, teachers provide a scaffold for the situated learning is entirely in keeping with construc- learner ’ s development, which can be withdrawn grad- tivism. Constructivism views learning as a process of ually as the learner gains more knowledge and active participation in problem solving and critical experience. thinking. Through these processes, learners construct Situated learning as described by Lave and their own knowledge and understanding of the world Wenger(9) extends beyond the acquisition of concepts based on their previous knowledge and experience. and structures by the individual and includes all Knowledge is integrated into previously existing con- of the learning in the learning environment. It cepts and schemata, which gradually become richer views the community and learning opportunities as a and more connected. way of structuring learning resources, with pedagogi- Postmodern constructivist approaches do not view cal activity (teaching) as only one resource among the locus of knowledge as in the individual. Rather many. they view learning as a social constructivist process. Situated learning theory was originally a means for Learning and understanding are social; cultural activi- studying the learning that occurs through apprentice- ties and tools are essential to conceptual development ship. (9) Traditionally, apprenticeship has been viewed that will allow learners to develop the skills and stand- as a relationship between the master or senior practi- ards that are valued by the community. (79) In the tioner and the novice or learner. Through apprentice- context of situated learning, knowledge may be con- ship, the learner comes to understand the content and structed not only individually, but jointly by commu- process of professional practice. Situated learning pro- nities and the individuals who are members. vides a way of understanding the process whereby apprentices acquire knowledge and skills through fol- Implications for e ducational p ractice lowing and attempting to be like the master. In the Situated learning is relevant to medical education in situated learning model, the apprenticeship is actually many ways and at all levels of the continuum of educa- to the whole community, and much of the learning tion. Apprenticeship remains a pervasive teaching and occurs in the relationships between people, rather than learning method in physician learning. Learners in inside the individual learner ’ s head. undergraduate and postgraduate medical education Situated learning also relates closely to notions of programmes are assigned to various clinical and com- informal learning. According to Eraut, (81) informal munity sites where they are immersed, to a greater or learning is a signifi cant dimension of the learning that lesser degree, in the work of the community, perform- occurs in the course of our work. He suggests that it is ing minor tasks and striving to learn from the more implicit, unintended, opportunistic and unstructured, advanced learners and mentors in the community. and often occurs in the absence of a teacher. Learning Increasingly, medical and health professional edu- about how things are done, exposure to a variety of cations are recognised as a process of professional different approaches and practical approaches to prob- socialisation. Hafferty and Franks (84) articulated the lems occur daily. There is still much to understand notion of three levels of curriculum as including about it; however, the evidence that informal learning formal, informal and hidden. The formal curriculum and learning from others in the workplace occurs is represents that which is stated. The informal curriculum convincing. This is in contrast to the image of inde- may include both explicit and serendipitous goals, and pendent learners that is embedded in much of formal is found in the interaction between teachers and learn- medical education. ers, and clinical environments, other students, per- Informal learning with its corollaries of implicit sonal interests and goals. Part of the informal learning – ‘ the acquisition of knowledge independent curriculum may also be what Hafferty termed the of conscious attempts to learn and in the absence of hidden curriculum , which may be seen in the practices explicit knowledge about what was learned ’ (82) – and and routines of the community, particularly in relation tacit knowledge – ‘ that which we know but cannot to coping and thriving. The hidden curriculum often tell’ (83) – will be covered in more detail in the context teaches values and moral judgements, and may be of the medical apprentice elsewhere in this book. found especially in the institutional policies, language, Situated learning also relates to experiential learn- assessment strategies and allocation of resources of an ing, or learning by doing. Experiential learning has as institution. Clearly, these curricula all exist and are its goal the integration of conceptual models and con- enacted in the context of situated learning in medicine. crete experience, (8) and of actual experience and edu- Not all messages of the hidden curriculum are nega- cation. Again, situated learning extends the concept to tive. Both negative and positive aspects have been include the experiential learning as occurring within a described. Often these are unintentionally imparted context. It also extends the notion of experiential learn- through actions, discussions and relationships among 30 Chapter 2 members of the community. This relates the notion of Communities of Practice situated learning closely to role modelling, as the senior members of the community enact through their Lave and Wenger (9) fi rst proposed the term community behaviours, both tacitly and explicitly, how problems of practice (CoP) to capture the importance of activity of the discipline are approached, how colleagues are in integrating individuals within a community, and of regarded and how knowledge is built. a community in legitimising individual practices. When learners are involved in clinical placements, Within this context, they described a trajectory in participation in the actual daily round of activities is which learners move from legitimate peripheral par- important in enhancing the effectiveness of their learn- ticipant to full participation in the CoP. The concept of ing. Clearly, the longer the engagement in a commu- legitimate peripheral participation means that access nity, the greater the opportunity to participate to a CoP, its resources and activities provides a means meaningfully. Where attachments are short, learners for newcomers to learn through observation and grad- may remain at the periphery and feel little participa- ually deepen their relationship to the CoP. Barab et tion in the community. Special attention may be al. (86) defi ned a CoP as ‘ a persistent, sustaining social needed to identify how their participation can been network of individuals who share and develop an sured and enhanced. overlapping knowledge base, set of beliefs, values, Faculty (teachers) enact several roles concurrently. history and experiences focused on a common practice As in the perspective of social learning theory, they are and/or mutual enterprise ’ . modelling skills, knowledge, values and attitudes that Wenger (10) proposed three constituent parts of a learners observe, along with how those actions are CoP: mutual engagement , joint enterprise and a shared received in the community. repertoire . Mutual engagement involves both work - Beyond role modelling, faculty are also demonstrat- related and socio - cultural activities, achieved by inter- ing how knowledge is built, understood and how action, shared tasks and opportunities for peripheral practices evolve. This aspect of talk offers both chal- participation. Joint enterprise refers to the need for the lenges and advantages. group to respond to a mandate for itself, and not Learners who participate in and listen to the talk of simply an external mandate. Finally, a shared reper- the community are able to learn in a contextualised toire involves the ‘ routines, words, tools, ways of doing way. However, the nature and content of the talk things, stories, gestures, symbols, genres, actions or become important considerations. As teachers, we concepts that the community has adopted in the course need to be mindful of our talk, and open to refl ecting of its existence’ . (10) Wenger (10) summarised his con- on it with learners. Learning through observation is ceptual framework for a social theory of learning com- also vulnerable to misunderstanding, as learners will prising four components that are ‘ deeply interconnected interpret what they observe in light of their current and mutually defi ning ’ . All of these should be present experience and understanding.(85) It is important to in a true CoP. The components include the following: fi nd opportunities and demonstrate willingness to • Meaning – learning as experience. Members talk discuss and refl ect on experience with learners. about their experience and create shared meaning. Participation in the work of the clinical site or com- • Practice – learning as doing. Members talk about the munity is a key to this understanding of learning. shared ideas and resources that can sustain action. Situated learning suggests that all members of the • Community – learning as belonging. Members talk community are involved. In the case of medical educa- about the community process and how they are tion this means that more senior learners and other learning and developing competence. health professionals can all enhance the learners ’ • Identity – learning as becoming. Members talk about participation. how learning changes who they are. Different fi elds of medicine have distinct knowledge Therefore, we can see that the concept of a CoP is and skill bases. However, there will still be some complex and multidimensional, serving multiple pur- aspects that are common to all, including communica- poses both for individuals and the subcommunities tion with patients, ethical approaches and grounding that participate in the full community. of actions, basic clinical skills, etc., in which learners The primary purpose of CoPs is knowledge transla- can participate across their fi elds of experience As tion. Knowledge translation has been defi ned as ‘ the faculty, we need to think carefully about how we can exchange, synthesis and ethically sound application of promote participation among learners. knowledge – within a complex system of interactions Building on the advantage of situated learning, among researchers and users – to accelerate the capture we have the opportunity to rethink our students ’ of the benefi ts of research … through improved health, experience and consider all the ways we have more effective services and products, and a strength- available to promote their learning. However, this ened health care system ’ (87) . involves thinking of learners as part of our learning More recently, other terms have been proposed for environment, rather than as temporary adjuncts essentially the same broad concept. These terms to it. include knowledge mobilisation, (88) knowledge utili- Teaching and learning in medical education 31 sation,(89) knowledge exchange, (90) knowledge man- • What value will members and their organisations agement(91) and knowledge brokering, (92) all of receive? which involve an active exchange of information Others have suggested principles for cultivating among various stakeholders, such as researchers, CoPs. (97) CoPs are dynamic entities and need to be healthcare providers, policy makers, administrators, designed for adaptability and large growth. They private sector organisations, patient groups and the should combine the perspectives of both insider general public. Partnerships are at the heart of all members and outsider participants, and all members knowledge translation activity, (87) and effective should be valued regardless of their level of participa- knowledge translation is dependent on meaningful tion. Both public and private spaces are necessary and exchanges among network members for the purpose need to be related. A critical principle is that the CoP of using the most timely and relevant evidence - based, must provide value to its members, otherwise partici- or experience- based, information for practice or deci- pation will be minimal or absent. Although familiarity sion making. is important, challenge and excitement need to be pro- In the fi eld of continuing medical education, the vided to keep the energy high. Finally, CoPs have a limitations of traditional workshop/presentation rhythm they need to settle into, one that works for its models are becoming apparent. (93) It is now recog- members ( see Box 2.6 ). nised that there is a need for continuous learning to occur in the context of the workplace, and for refl ec- Virtual c ommunities of p ractice tion- in - practice and refl ection - on - practice to be sup- Virtual (online) communities play a socialisation role ported.(5) Knowledge translation is essential to to the same extent as real communities do. (98) The shortening the path from evidence to application of theoretical foundation of virtual communities is based that evidence in practice, and CoPs provide an oppor- on social cognitive theory and situated learning. Henri tunity to embed learning within a clinical context. A and Pudelko(98) have proposed three components of highly effective way to learn about complex issues is the social context of activity in virtual communities – through experience, application and discussion with the goal of the community, the methods of initial mentors and peers in the same or similar contexts. group creation, and the temporal evolution of both the Relevant learning occurs when the participants in the goals and the methods of the group – leading to the CoP raise questions or perceive a need for new knowl- development of four different types of community. edge. Using Internet technology enables these discus- Figure 2.3 illustrates that a CoP requires a highly cohe- sions to occur in a timely manner, and records of these sive group with a clear goal. can be archived for later review or by those who Box 2.7 dissects the characteristics of these four missed the discussion. types of community further. It demonstrates that There are a number of key factors that infl uence the although many types of virtual community can exist, development, functioning and maintenance of they may not be true CoPs. The virtual CoP generally CoPs. (94) The legitimacy of the initial membership is arises from an existing, face - to - face CoP in which important. Commitment to the desired goals of the professional practice is developed through sharing CoP, relevance to members and enthusiasm about the potential of the CoP to have an impact on practice are also key. On the practical side, a strong infrastructure BOX 2.6 Factors for success of a and resources, such as good information technology, community of practice useful library resources, databases and human support, Lave and Wenger (9) suggest that the success of are essential attributes. community of practice depends on fi ve factors: Skill in accessing and appraising the knowledge • the existence and sharing by the community of a sources is important, as is the skill in bridging this common goal knowledge to practice. Providing the above - mentioned key factors requires strong, committed and fl exible • the existence and use of knowledge to achieve that leaders who can help guide the natural evolution of goal the CoP. If professional learning is to fl ourish, it is • the nature and importance of relationships formed critical that a blame - free culture is established in which among community members community members can learn from positive and neg- • the relationships between the community and those ative experiences. (95) outside it Some writers have outlined some key questions to • the relationship between the work of the community address in establishing a CoP. (96) and the value of the activity • How will the community be formed and evolve? Wenger (10) later added the idea that achieving the • How and when will members join? shared goals of the community requires a shared • What do members do and how will they interact? repertoire of common resources, e.g, language, stories • How will the CoP be supported by the members ’ and practices. organisation(s)? 32 Chapter 2 knowledge among members. Through this interaction, been carried out. Parboosingh (100) advocates conduct- new practices may be developed and identifi cation ing evaluation studies that focus on how the CoP takes with the community can occur. advantage of the technology, rather than how the tech- Some writers have distinguished ‘ soft ’ from ‘ hard ’ nology affects the CoP. knowledge.(99) Soft knowledge can be gathered in a domain through sharing solutions to a particularly dif- Implications for e ducational p ractice fi cult problem, describing idiosyncrasies of particular This chapter integrates the concepts of knowledge tools, equipment or processes, and recounting and translation and CoPs. These ideas have many obvious refl ecting on challenging events (i.e. recounting war applications in the medical education arena, and a stories). This refers to the implicit or tacit knowledge number of these CoPs are emerging in various special- in a domain. CoPs are central to the creation and main- ties. The application outlined in this section is a CoP tenance of soft knowledge. Hard knowledge, in con- for palliative care practitioners and students. This is an trast, is stored in databases and documents. It is highly excellent application because palliative care is a truly explicit and codifi ed. A key question is whether a interdisciplinary fi eld that involves subcommunities virtual CoP can effectively share soft knowledge, of various specialties, including oncologists, family which tends to be situated in specifi c contexts. This is physicians, nurses and social workers. These subcom- a question that requires further research. munities need to interact in CoPs, but the various pro- Virtual CoPs are a recent phenomenon, and studies fessional groups also need to interact with each other on their effectiveness to enhance learning have not yet around specifi c topics and cases. This provides an excellent model for continuing medical education, and also provides an environment for training residents, interns and medical students. Since many participants are acquiring and applying new knowledge in this fi eld, scaffolding learners through an evolving con- tinuum from simulation to participation to codeter- mined interactions is an effective instructional approach. (101) For example, family physicians, resi- dents and nurses who have trained with oncology spe- cialists may begin with simulated cases. They then learn to participate in real cases supported by learning materials and/or clinicians until they are able to operate as full participants. The scaffolding process proposed here uses a staged approach for bridging from a learner (knowledge) identity to a participant (practitioner) identity. This approach is consistent Figure 2.3 Different forms of virtual communities of practice with the constructivist (102) view of learning that according to their context of emergence. Adapted from Henri espouses the learner as central in the educational and Pudelko(98) (p. 476). process. The advantages of the situated learning

BOX 2.7 Principal descriptors of the four types of virtual communities (adapted from Henri and Pudelko)( 98, p. 485)

Community of Goal - oriented community Learning community Community of interest practice

Purpose Gathering around Created to carry out a Pedagogical activity Stems from an a common topic specifi c task proposed by the existing, real of interest instructor community Activity Information Sharing of diverse Participation in Professional practice exchange perspectives and production discussions of collective development through of objects commissioned by topics sharing knowledge the mandate among members Learning Knowledge Knowledge construction Knowledge construction Appropriation of new construction for from diverse knowledge by carrying out social practices and individual use systems towards collective situated activities development of use involvement Teaching and learning in medical education 33 approach over the traditional didactic approach are is transmitted to, or acts upon, the students, be they discussed above in the section on situated learning. undergraduate, postgraduate or practising physicians. A CoP implemented in a community - based learning There is an important element of human agency. environment could include specialist and non - special- Moreover, in practice, the physician - learner is stimu- ist practitioners in palliative care, as well as residents lated to learn through interactions in the practice and medical students (clerks). It would aspire to environment. achieve a number of different aims, based on the chal- The entire context of learning is more important than any lenges by Richardson and Cooper. (103) one variable alone. The learning environment is complex. • Engage all trainees in a research culture (i.e. encour- It includes learners, faculty, patients, colleagues, age evidence- based practice). resources and other workers. It is both the interacting • Provide an opportunity for participants to identify and the independent effect of all these variables that with their peers and supervisors. result in the learning environment, whatever the level • Encourage cross - site discussion to explore shared of learner. Learning is accomplished both through theory, methodological and practical issues. direct experience and vicariously, and from many • Provide a forum for discussion and a recognised interactions in this complex system. Consequently, we channel for communication and collaboration. must analyse as many factors in the environment as • Facilitate high - quality supervision to ensure ade- possible when planning, implementing and evaluating quate access to teaching and learning for all our educational programmes. In learning from prac- practitioners. tice, physicians solve complex problems that occur in • Foster scholarly interaction and good supervisory the environment of the patient, family, physician and practice to stimulate dialogue among students and community. All of these infl uence the effectiveness, supervisors across sites. nature and outcomes of learning. We are asserting that linking medical students, their Learning is integrally related to the solution and under- community preceptors and medical school specialists standing of real - life problems. For adult learners, learning in an online CoP can greatly enhance the learning and is most effective and motivating when it is relevant to practice experience of all participants. A recent the solution of real - life needs or problems. This is study (104) demonstrated that students assigned to obvious in the learning that occurs in refl ective prac- community practices for their paediatric clerkship tice, where the new learning is triggered by the sur- perform as well as, or better than, students assigned to prise encountered in a problem in practice. Experiential academic medical centres in written examinations. An learning in real - life problems leads to ongoing mastery online CoP approach can build on this positive fi nding and competence. Similarly, learning around clinical and perhaps provide an even more effective commu- problems, both in the clinic and in the classroom, rep- nity experience for medical students. A side benefi t resents learning to solve the authentic tasks of the pro- could be the improvement in teaching and supervisory fession and of future professional practice. methods used by their preceptors. Individuals ’ past experience and knowledge are critical in learning, in actions and in acquiring new knowledge. At all levels, learning must be connected to relevant experi- Connections ence, or compatible with the learner ’ s existing knowl- edge. Past experience and knowledge will affect In this paper, we have presented eight theoretical perceptions of self - effi cacy, which will, in turn, affect approaches to learning, each of which has the potential the choice of new experiences and goals. Learners ’ past to inform our practice as educators. Fo reach theoreti- experience is important in providing a framework for cal approach we have set out the underlying frame- acquisition of new knowledge. In practice, the new work and principles and provided examples of its learning opportunities identifi ed will depend substan- application. The application of educational theory to tially on the individual ’ s existing experience and practice has always been somewhat eclectic. This is not knowledge. unusual in applied sciences such as education. To Learners’ values, attitudes and beliefs infl uence their make this exposition of theory as useful as possible to learning and actions, and building learners ’ self - awareness our educational practice, it is helpful to consider the in this area is important for their development. These relationships among the theoretical frameworks, and values, attitudes and beliefs are central to learners ’ the consistency of messages and themes that can be willingness to attempt new actions. They affect virtu- drawn from all of them to inform teaching and learn- ally everything that learners think, as well as their ing. Some of these common themes are presented here. interactions with mentors, peers and patients. Various All theoretical frameworks view the learner as an active processes exist to modify these, such as refl ective contributor in the learning process. In each of the theoreti- observation, perspective transformation, role model- cal approaches discussed here the learner actively ling and feedback on action. interacts with a changing, complex environment. The Individuals as learners are capable of self - regulation, that curriculum can no longer be viewed as something that is, of setting goals, planning strategies and evaluating their 34 Chapter 2 progress. Adult learners are viewed as self - motivated 9 Lave J and Wenger E ( 1991 ) Situated Learning: legitimate periph- and directed, pursuing those learning objectives rele- eral participation . Cambridge University Press , New York . vant to personal goals. They are inherently self - regu- 10 Wenger E ( 1998 ) Communities of Practice: learning, meaning, lating, and the process of refl ection implies a learning and identity . Cambridge University Press , New York . 11 Selman G and Dampier P ( 1990 ) The Foundations of Adult that arises directly out of experience. 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