Translating health professional education research evidence into effective continuous professional development

Biases and assumptions often arise from past experiences and, when unquestioned, can negatively influence the development of effective educational strategies

Knowledge is frequently considered as the panacea for all ills, and its acquisition is often proposed as the solution for ensuring we deliver the best quality health care. For example, training and continuing professional development (CPD) have been proposed as the first steps for medical colleges to address some troubling variations in health care practice in Australia.1 However, while proposing educational strategies to address health outcomes is logical, appropriate and defensible, it is well established that “knowing” something is quite different from “doing” something.2 Nevertheless, CPD curricula are frequently limited to “knowing”.3 While knowledge is a key prerequisite to transforming practice, how do we maximise CPD effectiveness as a strategy to improve care? And is changing individual practice through education all that is needed to change health practices and outcomes?4

CPD should be based on the best available evidence for high quality health professional education (HPE). This evidence should inform the design and application of education strategies and, thus, enable learners to transform knowledge into a tool for best practice in their particular team and organisational context.4 It is clear that the field of medical education research, with its primary interest in generating evidence to inform effective teaching, learning and assessment, is central to this endeavour. Evidence‐informed educational strategies can extend CPD past simply using factoids and evidence updates,5 which, while beguilingly easy to introduce, are limited in their capacity to optimise clinical practice. However, although medical education research and educational research as a whole have developed rapidly over the past 50 years,6 there can be a mismatch between research that is done and actual practice, resulting in a lag in translating research into actual practice.5

Understanding the lag

There are several reasons for this lag in research translation. First, we all have a lay understanding of learning and we value education practices that were meaningful to us, and, thus, we are subject to our own cognitive and personal biases. Biases and assumptions, when unquestioned, can negatively influence the development of effective educational strategies. Second, it is assumed that it is the individual's competence that is critical and that, therefore, this should be the educational target. Finally, evidence‐based practice in HPE has challenges that are specific to the nature and accessibility of the evidence generated in this research field.

Lay theories of learning and their influence on educational practices

We all have personal theories and understanding of what constitutes good education.7 These theories can lead to persistence of educational strategies by individuals and groups that intuitively match that understanding — even in the face of evidence to the contrary. This is demonstrated, for example, by the persistent practice of teaching to individuals’ learning styles (or preferences) on the assumption that this will enhance their learning when in fact no relationship has been found.8

All cultures have pervasive and unconsciously held lay theories about learning that are strongly supported across the community. These theories have significantly influenced the way in which CPD in the western medical education tradition is designed and delivered. Learning is generally conceptualised as a product rather than a process and the mind as a container into which knowledge is deposited.7 As a result, the focus is all too often on the individual endlessly accumulating pieces of knowledge, usually as part of formally accredited CPD. Content is delivered on the assumption that learners will acquire and transfer it to the practice context and thereby improve outcomes.3,9,10

These metaphors of acquisition and transfer and the assumption that learning is a one‐way transfer from experts to learners lead to CPD curricula characterised by reductionist “chunks” of pre‐specified knowledge delivered to individual learners in formal contexts separate from practice. This persistent mental model of learning neglects the complexity of competent performance that arises from individuals integrating different types of knowledge (propositional, craft and emotional) and skills (practice, cognitive and emotional) with their personal predispositions (cognitive and interpersonal styles).9,11 Therefore, learning that changes practice needs more than a single inoculation of an individual with specific propositional knowledge or practical skills training. This is why, for example, understanding germ theory and knowing how to wash one's hands does not automatically lead to optimal hand hygiene compliance.

Individual, team and organisational learning

While an individual's ability to perform competently is important, health care is delivered by teams in complex contexts in which the individual may not be the key influencing factor for good outcomes. It is entirely possible to have an incompetent team that is composed of competent individuals.10 Therefore, education that is directed not only to individuals but also to all health team members and is supported by a learning oriented culture is a necessary requirement for effective CPD.9 A learning oriented culture will, for example, ensure that adverse or near miss events are responded to as an opportunity to learn and improve practice rather than to blame and punish, leading to a reduced likelihood of event reoccurrence.12 Learning in this context will not occur through unidirectional content delivery, but, rather, it will arise from individual and collective reflection along with review of current best practice, related skills and knowledge. This learning will also need to be cyclical; that is, new skills and knowledge applied and then reviewed for impact on health outcomes.

Therefore, CPD is likely to have more impact if it is designed from a different mental model that includes individuals, teams and the organisation itself and considers the way in which knowledge and skills also arise from the interaction of these elements. The ways in which newly learnt knowledge and skills are prevented from being applied due to organisational culture and team behaviour need to be understood. For example, the World Health Organization's recommendations for a multimodal approach to ensuring implementation of effective hand hygiene practices were found to have significant and enduring impact.13 Of these recommendations, only one specifically related to training and education of health care workers, with the remaining five including attention to organisational culture, ensuring availability of hand rub, visual reminders, and compliance monitoring and feedback.

Nature of health professional education research evidence

Schuwirth and Durning6 have highlighted that the nature of evidence in HPE research is counterintuitive for practitioners who are more familiar with health research whose aim is to produce solutions that can be applied regardless of the context. HPE research generates evidence about why an educational approach may or may not work, and builds or enriches learning theories that can, in turn, be applied to the various contexts and combinations of individuals, teams and organisational cultures to maximise educational effectiveness. Furthermore, the focus needs to be balanced between the “how” of CPD when we seek to locate and apply a ready‐made solution and the understanding of “why” we should select particular strategies.

For example, cognitive load theory has integrated understandings of how short and long term memory functions and how competing elements may affect educational learning.14 Applying this theory to analyse the cognitive and situational demands of a particular task in combination with an understanding of the learner's stage in developing a skill (eg, novice or expert) will more effectively guide educational design decisions. Therefore, it might be appropriate to use low fidelity simulation techniques to train novices on partial processes (eg, practising resuscitation techniques on a simulation model) and a high fidelity approach that integrates all aspects of practice for more expert learners (eg, full team based emergency resuscitation scenario in a simulated ward). However, this requires a considered application of theory to the learners and learning context and is more challenging than finding and applying an attractive solution used elsewhere.

Effective continuing professional development

We have argued that CPD should be informed by translating current HPE research evidence into effective design and implementation of CPD. Designers should be alert to and challenge pervasive simplistic mental models or theories of learning and related biases. Consideration should be given to individual, team and organisational learning needs and focus should be placed on “how” as well as “why”. Effective CPD requires careful definition of the desired behavioural change as well as identifying opportunities and barriers that are amenable to educational strategies. This approach needs a more nuanced understanding of learning and is founded on a deeper engagement with and application of the evidence generated through HPE research to the specific context and issue at hand. This requires a willingness to grapple with more diverse methodologies and epistemologies than the more familiar logical positivist paradigm prevalent in health research.6

Education is an important tool for health care change and should be subject to the same evidence‐based practice and quality improvement principles. A landmark book for teachers on the evidence for teaching strategies for 6–20‐year‐old students describes the recovery of a 10‐year‐old student from leukaemia.15 It highlights the process of monitoring the dosage and treatment against clear criteria for success that was central to the effective outcome, and urges teachers to adopt these strategies and “Know thy impact”.15 Given the distinguished history of evidence‐based practice in health care, we should expect no less of ourselves and apply the same care to our educational strategies.