Using theory and research to shape the practice of continuing professional development

As research has expanded in scope and diversity, application of new ideas to the programs that facilitate learning and change should have grown accordingly. However, the gap between the theories of how and why physicians learn and change their practices and the practical application of these theories appears to be wider. The research component of research and development in continuing professional development appears to be strong, but the development function appears to be weak. This presentation will describe some of the factors that have led to this gap between theory and practice and suggest some actions that may be taken to reduce this gap. Among the factors leading to the gap are the different perspectives of practitioners and scholars as to the purposes of research, the appropriate foci of studies, and the attributes of quality of studies related to continuing professional development. A traditional model of research is discussed and analyzed for its strengths and weaknesses as they relate to writing research that is relevant to practitioners. The role and function of the research problem and the conclusions of studies are described in terms of how these two parts of a research report can assist in the translation of theory and evidence into the practice. In order to illustrate how theory may be translated into practical tools and procedures, the application of the theory of change and learning to the assessment of readiness to change is reviewed briefly. Implications of this experience are described and steps that may be helpful in bridging the gap between theory and practice will be proposed. Finally, a system of research and development that can ensure a tighter link between research and practice is proposed. The next steps to achieve this kind of system are suggested in the conclusions.     

Build-a-case: a brand new continuing medical education technique that is peculiarly familiar

An observation at a problem-based learning, case-building meeting prompted the realization that building cases might itself be an effective educational intervention. We developed a process for a new continuing medical education technique that is peculiarly familiar that we call "build-a-case." Build-a-case has now been used for teaching and learning in many clinical situations and with several kinds of health professionals. Subjective evaluations of the approach are consistently positive, and people feel that they learn from it because it prompts the discussion of practice as it is in their clinics and communities. In what follows, we describe the build-a-case process and our experiences with it and suggest several theoretical constructs that might be useful in promoting thoughtful research on what may become a useful new tool for continuing education.     

The longitudinal case study: from Sch?n's model to self-directed learning.

BACKGROUND: Rapid changes observed in information technologies, medical practice, and learning methods encourage physicians to develop new updating strategies. To test its feasibility and to help physicians devise new learning and updating strategies, the knowing-in-action model developed by Sch?n was applied in planning and evaluating an interactive workshop. Acquisition of knowledge was tested. METHODS: The office and hospital charts of a family physician were reviewed. They were used to prepare a longitudinal case study, based on the real-life story of a hypertensive patient followed by her doctor over a period of 15 years. The clinician's approach to solving clinical problems was triangulated for credibility with general practitioners, specialists, and the information available in the literature. This longitudinal case study was used to develop an interactive educational workshop. The workshop was presented to physicians who had registered in an accredited continuing medical education event. Changes in pre- and postevent knowledge among the participants were assessed using touch pad technology to evaluate the effectiveness of this approach on the acquisition of knowledge related to management of arterial hypertension and associated clinical problems. RESULTS: A comparison of pre- and post-test data showed a significant improvement in knowledge for participants who answered all questions on both questionnaires (n = 8/37). The average score of these participants increased from 5.5 of 10 before the workshop to 8.3 of 10 after the workshop (p < .05). Participants reported a high satisfaction rate for the event. FINDINGS: A workshop using the longitudinal case study enables physicians to perceive their daily practice through a continuing education activity in which they experience the processes of reflection in action and reflection on action described by Sch?n. It also increases awareness of the gap between current practice and experts' recommendations and provides an opportunity to evaluate the means for bridging or closing this gap. It sensitizes the physician to patients' changing needs and prompts the clinician to reflect on the who, what, when, where, and how of learning.     

The reflective experience and education

The reflective experience is proposed in this article as the way to approach the elaboration of knowledge. The concept of vital experience is proposed to make reference to the links with a great affective significance that characterizes each person in his/her relation with the world. Some considerations are made about perception with its affective, cognitive and evaluative components and its implications in the knowledge process. The idea of knowledge as the use and consumption of information is discussed. This idea that prevails at school corresponds with the passive perspective of education. We propose the idea of knowledge as an elaboration of the person in knowledge situation which originates the participative perspective of education. The characteristics of both perspectives of education are contrasted with respect to the role of theory and practice, the role of the professor and the student, the main purposes and the type of society that they aspire. The more relevant aspects of participative education are shown: the practice of criticism and self-criticism; the development of solid points of view about problem situations of experience, the development of methodological and practical aptitudes, with emphasis on medical education. Considerations are made about in what way the participative perspective concerns pre-graduate and post-graduate medical education and its possible incorporation to the programs.     

Knowledge systems,health care teams,and clinical practice: a study of successful change

Clinical teams are of growing importance to healthcare delivery, but little is known about how teams learn and change their clinical practice. We examined how teams in three US hospitals succeeded in making significant practice improvements in the area of antimicrobial resistance. This was a qualitative cross-case study employing Soft Knowledge Systems as a conceptual framework. The purpose was to describe how teams produced, obtained, and used knowledge and information to bring about successful change. A purposeful sampling strategy was used to maximize variation between cases. Data were collected through interviews, archival document review, and direct observation. Individual case data were analyzed through a two-phase coding process followed by the cross-case analysis. Project teams varied in size and were multidisciplinary. Each project had more than one champion, only some of whom were physicians. Team members obtained relevant knowledge and information from multiple sources including the scientific literature, experts, external organizations, and their own experience. The success of these projects hinged on the teams' ability to blend scientific evidence, practical knowledge, and clinical data. Practice change was a longitudinal, iterative learning process during which teams continued to acquire, produce, and synthesize relevant knowledge and information and test different strategies until they found a workable solution to their problem. This study adds to our understanding of how teams learn and change, showing that innovation can take the form of an iterative, ongoing process in which bits of K&I are assembled from multiple sources into potential solutions that are then tested. It suggests that existing approaches to assessing the impact of continuing education activities may overlook significant contributions and more attention should be given to the role that practical knowledge plays in the change process in addition to scientific knowledge.     

Value of unstructured time (breaks) during formal continuing medical education events

BACKGROUND: Unstructured time (breaks) at formal continuing medical education (CME) events is nonaccredited in some jurisdictions. Program participants, however, perceive this time as valuable to their learning. The purpose of this research was to determine what activities occur during unstructured time in formal CME events and how these activities impact learning for physicians. METHODS: A qualitative method based on grounded theory was used to determine themes of behavior. Both individual and focus group interviews were conducted. Data were analyzed and coded into themes, which were then further explored and validated by the use of a questionnaire survey. RESULTS: One hundred ninety-seven family physicians were involved in the study. Several activities related to the enhancement of learning were identified and grouped into themes. There were few differences in the ranking of importance between the themes identified, nor were differences determined based on gender or type of CME in which the break occurred. FINDINGS: The results suggest that unstructured time (breaks) should be included in formal CME events to help physician learners integrate new material, solve individual practice problems, and make new meaning out of their experience. The interaction between colleagues that occurs as a result of the provision of breaks is perceived as crucial in aiding the process of applying knowledge to practice.     

Lost in knowledge translation: time for a map?

There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about planned-action theories to be better able to understand and influence change in practice settings.     

Practice guidelines, CME and epidemiologic research in general practice: a consistent triad?

A multidisciplinary effort involving epidemiologists, general practitioners and specialists is critical for finding valid and feasible answers, by asking the right questions through observational and experimental studies. Clinical practice guidelines may represent a good starting point of this research process, highlighting which information needs exist in everyday practice; logically, guidelines also represent an ideal end, as a means of transferring any useful knowledge produced into practice. In between, this research process may have an added educational value and represent an active and valuable means of achieving continuing medical education credits. Consistency of the research-education-guidelines triad is discussed in this paper by describing methods and results of a practical research experience--a cohort study for evaluating prevalence, incidence, chronicity and management of digestive disorders--involving epidemiologists, gastroenterologists and thirty-five general practitioners of the Emilia-Romagna region.     

Research to practice in The Journal of Continuing Education in the Health Professions: a thematic analysis of volumes 1 through 24

INTRODUCTION: Authors have stressed the importance of the broader contextual influences on practice improvement and learning and have expressed concern about gaps between research and practice. This implies a potential expansion of the knowledge base for continuing education in the health professions (CEHP) and an increased emphasis on research evidence for that knowledge. How has the content of The Journal of Continuing Education in the Health Professions (JCEHP) reflected those changes? What are the implications for CEHP practitioners? METHODS: Based on all abstracts, tables of contents, and editorials, a thematic analysis was completed for volumes 1 through 24 of JCEHP. All texts were downloaded into qualitative analysis software and coded. Main code categories included demographics of articles, concepts relating to CEHP as a discipline, knowledge translation and outcomes-oriented continuing education, and theories and frameworks. Key themes were identified. RESULTS: Key themes include categories of topics included in JCEHP over the years, the increased prominence of research in JCEHP, a dual research evidence-to-practice gap, the professionalization of continuing education providers, and interdisciplinarity and the links with broader frameworks that have been proposed for CEHP. DISCUSSION: Two sets of research-to-practice gaps are portrayed in the journal: the gap between clinical research and practice and the gap between research and practice in CEHP. To close the first gap, authors have asserted that the second gap must be addressed, ensuring that CEHP practices themselves are evidence based, driven by theory-based research. This is a variation on prior debates regarding the need to define CEHP as a discipline, which uses the language of professionalization. The increased focus of continuing education on the contexts of health care providers' practices has multiplied the topics that are potentially relevant to CEHP practice.     

The continued evolution of the credit system

In its ongoing support of continuous physician professional development, the American Medical Association (AMA) for use in the AMA Physician's Recognition Award has adopted 2 new learning platforms: Performance Improvement (PI) and Internet Point of Care (PoC). This article highlights the process that led to their adoption and places these new forms of continuing and physician professional development in the framework of existing continuing medical education (CME). The article calls for new research that revisits existing data on physician learning and prepares to incorporate provider experience with "practice situated" forms of CME. The Conjoint Committee on CME may serve as an important contributor to this process by enabling valuable dialogue among stakeholder organizations.     

Reframing risk management in dementia care through collaborative learning

Risk management is a complex aspect of practice which can lead to an emphasis on maintaining physical safety, which impacts on the well-being of people with dementia. Education for practitioners in risk management is particularly challenging because of its conceptual nature and diverse perceptions of risk between and within professional groups. The practice development research reported here formed one part of a multisite study and contributed to developing a risk assessment and management framework for use by practitioners in partnership with people with dementia and their families. Practice development research uses learning theories in the process of the research, and in so doing its intent is to not only create new knowledge but to view the research process as also a process of learning for those involved. Twenty practitioners from varying professions participated in five Collaborative Learning Groups, each of at least 2 hours duration, which were held over a 7-month period. Data analysis highlighted contradictions in the care system and in the professional's intention to practice in a person-centred way. These were expressed through the themes of: Seeking Certainty; Making Judgements; Team Working; Managing Complexity; Gathering and Using Information.     

Satisfaction and Job Stress in General Practice

This paper investigates sources of job satisfaction and dissatisfactionin general practice and identifies pressures and difficultiesexperienced by general practitioners in their work. The studyrevealed wide spread job satisfaction based on three separate(but independent) aspects of general practice: clinical, psychosocialor managerial. Despite this, significant pressures were experiencedand, in common with previous studies over the last 20 years,this research found continuing problems affecting young generalpractitioners in particular. The main pressures currently experiencedwere uncertainty and insecurity about work, isolation, poorrelationships with other doctors, disillusion with the roleof the general practitioner, and an awareness of changing demands.These pressures were related to experience in general practice,amount of study leave and practice organization. Like previousstudies, it also appears from this research that continuingeducation could play an important role in attenuating thesediffi culties. It is argued that the emphasis should be on developingsupport, confidence and better contacts between general practitioners,as well as teaching knowledge and skills.     

Using problem-based learning to improve educational outcomes

As the health care industry and the occupational therapy profession experience rapid change and growth, our professional preparation and continuing education must prepare graduates and therapists for an evolving practice environment. By exploring and evaluating alternative teaching methods and their impact on educational outcomes, occupational therapy educators demonstrate their commitment to improving the quality of student education. This article proposes that the traditional educational paradigm prepared clinicians for the old health care environment, and that problem-based learning (PBL) is an educational strategy that could prepare occupational therapists for success in a new practice environment that values cost, quality, and customer satisfaction. The PBL approaches used by various international occupational therapy educators are reviewed to highlight the strategies that have been implemented to achieve educational objectives that parallel the requirements of this new practice environment. Copyright © 1996 Whurr Publishers Ltd.     

The role of educational theory in continuing medical education: has it helped us?

Despite the existence of many approaches to understanding learning and change and attempts to incorporate these into continuing education research and practice, the search continues for a comprehensive understanding of how learning is engendered in professional practice and the processes by which learning and change occur. This article considers four broad questions in relation to the practice of continuing education: (1) What can be expected of theory? (2) How does theory relate to the educational practice of those in continuing education and the goals of continuing medical education ? (3) How have practice and theory mutually informed our current understandings? (4) How can theory serve the field more effectively in the future? Broad orientations to understanding learning provide a framework for examining the contributions of theory and practice. The orientations include behaviorist, cognitivist, social learning, humanist, and constructivist; for each, an example is presented. Newer understandings also are introduced. The article concludes by considering reasons as to why theory appears not to have served us better and by offering ways in which those in continuing education can ensure greater usefulness of theory while contributing to its continued development.     

Education for navigating "permanent white water:" establishing a bachelors program for Canadian health services managers

A rapidly changing health services environment challenges educators to critically assess what they do, and what they should do, to prepare managers to survive and grow professionally and to contribute to clients, organizations and the health system. In this paper we describe the establishment of an undergraduate degree-completion program in Health Services Management at Ryerson Polytechnic University in Toronto, Canada. In contrast to traditional programs which begin the process of education as the basis for later practice, this program, the first of its kind in a Canadian university, is designed to develop management skills and competencies on an existing base of professional experience and practice; it offers practitioners with 3-year diplomas in a health technology or allied health field the opportunity to complete an undergraduate degree on a part-time basis. Sections of the paper outline the multidisciplinary and multi-stage process of program development which took place outside of traditional departmental lines and involved a partnership of academics and practitioners; and the curriculum design, which integrates knowledge specific to the field of health administration, relevant knowledge from other professional fields, and liberal studies. In a final section we discuss the ongoing development of the program and factors contributing to its success.     

Didactic CME and practice change: don’t throw that baby out quite yet

Skepticism exists regarding the role of continuing medical education (CME) in improving physician performance. The harshest criticism has been reserved for didactic CME. Reviews of the scientific literature on the effectiveness of CME conclude that formal or didactic modes of education have little or no impact on clinical practice. This has led some to argue that didactic CME is a highly questionable use of organizational and financial resources, and a cause of lost opportunities for physicians to engage in meaningful learning. The authors' current program of research has forced them to reconsider the received wisdom regarding the relationship between didactic modes of education and learning, and the role frank dissemination can play in bringing about practice change. The authors argued that the practice of assessing and valuing educational methods based only on their capacity to directly influence practice reflects an impoverished understanding of how change in clinical practice actually occurs. Drawing on case studies research, examples were given of the functions didactic CME served in the interest of improved practice. Reasons were then explored as to why the contribution of didactic CME is often missed or dismissed. The goal was not to advocate for a return to the status quo ante where lecture-based education is the dominant modality, but rather to acknowledge both the limits and potential of this longstanding approach to delivering continuing education.     

Primary care education for the new NHS: a discussion paper

CONTEXT: The White Paper, The New NHS: Modern, Dependable, once again heralds change and new expectations of primary care in the UK. OBJECTIVES: This discussion paper aims to encourage reflection on the implications for primary care teams of current governmental strategy, and to address the pivotal role which education can play in equipping practitioners for their roles. KEY AREAS: The paper examines the opportunities and threats for primary care in the new NHS developments, the strengths and weaknesses of the role that education currently plays in primary care, and how recent innovations might be used to give a more holistic approach to the needs of practitioners. The challenges for clinical governance of lay engagement and ethical decision making are seen as two crucial outcomes for an educational strategy which must be practice-led, and must interface individual practitioner education with the needs of the team and the community as a whole. I draw on a range of policy documents and educational literature to alert the reader to the different choices which can be made when thinking about appropriate educational models and methods; and offer a detailed structure for a practical educational strategy that may effectively unite theory and practice. The key elements are a three-tier link between practices, primary care groups, and district-level resources for all educational and training activity, and the aim of continuing multiprofessional development which will underpin the new NHS.     

Re-envisioning paradigms of education: towards awareness,alignment, and pluralism

In this article we introduce a synthesis of education “paradigms,” adapted from a multi-disciplinary body of literature and tailored to health professions education (HPE). Each paradigm involves a particular perspective on the purpose of education, the nature of knowledge, what knowledge is valued and included in the curriculum, what it means to learn and how learning is assessed, and the roles of teachers and learners in the learning process. We aim to foster awareness of how these different paradigms look in practice and to illustrate the importance of alignment between teaching, learning and assessment practices with paradigmatic values and assumptions. Finally, we advocate for a pluralistic approach that purposefully and meaningfully integrates paradigms of education, enhancing our ability to drive quality in HPE.