Chapter 1. Principles Of Adult Learning
Publication: Handbook of Psychiatric Education
In the late Middle Ages, doctors in training primarily acquired knowledge and skills through apprenticeship, a dyadic arrangement of novice learner and master physician for the transfer of information. In the half a millennium since then, medical education has dramatically evolved from textbooks, university lectures, and bedside teaching on academic wards to now instantly available innumerable online resources, videos, and modules. Concurrently, the field of psychiatry is rapidly expanding, with advances in neuroscience and genetics and new models for patient care delivery, such as integrated care and telehealth. Psychiatrists must navigate this ever-changing landscape and determine training priorities, identify resources, efficiently retrieve information, assess outcomes, and assimilate learning into clinical practice. The application of adult learning principles to clinical training in psychiatry is critical to help learners keep pace with this new “information age” and develop the skills necessary for lifelong learning.
FOUNDATIONS OF ADULT LEARNING
Andragogy, which is derived from the Greek andr-, meaning “man,” and agogos, meaning “to lead,” was popularized by Malcolm Knowles in the 1980s as a term referring to the principles of adult learning. Based on the premise that adults are intrinsically motivated and self-directed, he established four assumptions about adult learners, adding a fifth later (Knowles 1984):
1.
Self-concept: Adults are self-directed and take ownership of learning as they grow and develop a sense of self and individual preferences.
2.
Experience: Adults draw on varying degrees of accumulated knowledge and past experiences to enhance learning.
3.
Readiness to learn: Adults’ circumstances and developmental tasks often change as they progress through new social roles. They value learning knowledge and skills that are most applicable to their current stage of training and responsibilities.
4.
Orientation to learning: Adults desire immediate and practical application of information. They are problem oriented as opposed to content oriented.
5.
Motivation to learn: Adults are intrinsically motivated, for example, by purpose, job satisfaction, mastery, and a sense of relatedness or belonging.
These concepts may sound familiar given the inherent use of adult learning principles in our therapeutic work with patients. We deliver well-timed interventions when aligned with a patient’s intrinsic motivation, provide supportive interventions that promote autonomy, and adapt our approach based on thoughtful assessment of a patient’s individual needs, goals, and circumstances.
Although Knowles’s andragogical principles form the foundation for adult learning theory, these tenets lack substantial empirical support and are by no means all-inclusive. Extrinsic motivation, reflection, and sociocultural contexts also have a role in shaping how adults learn. Beyond andragogy, alternative theories of adult and general learning theory abound. Behaviorist theories of learning suggest that behavioral change is shaped by classical and operant conditioning (Mann 2004). Cognitive theories focus on the extent to which cognitive processes (e.g., registering, understanding, retaining, and recalling information) influence learning. Constructivism, a cognitive theory of learning described by Jean Piaget, suggests that learners process new information through pre-formed cognitive assumptions developed from past experiences (Powell et al. 2009). Relational theories, such as situated cognition, consider learning to be a social activity dependent on individualized context and environment (Brown et al. 1989). Other theories include transformative learning theory, a model that leverages critical reflection to change one’s perspective and worldview, and self-determination theory, which emphasizes the connection between motivation and expectation of learning in driving the pursuit of knowledge (Taylor and Hamdy 2013).
In the sections that follow, we link theory to practice and offer suggestions for incorporating adult learning principles into psychiatric education. Just as a firm grasp of psychotherapy theory grounds practice and guides effective treatment, application of adult learning theory can improve educational interventions. Adult learning principles can inform approaches to teaching and enrich teaching methods used in the classroom or clinical setting.
APPLYING ADULT LEARNING PRINCIPLES AT THE LEVEL OF EDUCATOR AND TRAINEE
In a review of 68 articles exploring what factors make “a good clinical teacher in medicine,” the five most commonly reported themes (Sutkin et al. 2008) were
1.
Medical/clinical knowledge
2.
Clinical and technical skills/competence and clinical reasoning
3.
Positive relationships with students and a supportive learning environment
4.
Communication skills
5.
Enthusiasm
Not surprisingly, a natural connection occurs between what adults want from their teachers and adult learning theory. Proficient, competent educators model achievement and inspire attainment of excellence, motivating trainees to set increasingly higher goals. Enthusiastic and effective communicators expertly appeal to their trainees’ needs, show why material is relevant, and foster trainees’ personal connection to the subject matter by drawing on their personal experiences and prior knowledge. Using Knowles’s (1984) assumptions about adult learners, Table 1–1 lists implications for goals in teaching and practical applications for psychiatric education.
| Goals in teaching | Clinical educating methods |
|---|---|
Self-concept: Encourage individual inquiry and self-directed learning | Ask trainees to state their own goals and priorities for learning at the start of a class/rotation or before initiating a patient interview Use a graduated approach, offering more clinical responsibility and less direct supervision over time Challenge trainees to make decisions (e.g., regarding diagnosis or treatment choices) and discuss their rationale Ask for trainees’ input and opinions often Provide useful resources early on that trainees can access independently on their own time |
Experience: Acknowledge and validate learners’ individual backgrounds, experiences, and prior knowledge | Create a cooperative learning environment built on mutual respect Share past learning experiences as appropriate, and invite trainees to share their own as it relates to learning Facilitate reflection: ask trainees to compare prior experiences and knowledge to what they are learning Link learning material to trainees’ interests Universalize the concept that individuals hold implicit biases, and model ways to bring bias into awareness and to mitigate its impact on patient care Reassure trainees that there are many different approaches to subjective aspects of clinical practice and not necessarily any one right way of doing things |
Readiness to learn: Modify educational materials and content based on the learner’s level of training | Assess trainees’ needs List learning objectives at the start of every learning experience, whether it occurs more formally in a classroom or on bedside rounds Gauge receptiveness to learning by attending to trainees’ affect and cognitive-emotional state Consider how much time trainees can dedicate to self-study and adapt teaching methods accordingly (i.e., residents often lack time for class preparation given clinical duties compared with preclinical medical students) |
Orientation to learning: Prioritize relevant, practical, and problem-centered material that can be immediately applicable to real clinical scenarios | Start instruction by posing a problem and providing educational material for learners to solve it Provide or ask trainees to contribute personal examples and case studies that demonstrate practical application of theories and techniques Leverage unexpected “teachable moments” to deepen learning relevant to a distinct time, place, and situation Keep teaching points brief, succinct, and time limited Engage multidisciplinary staff in teaching trainees during their interactions (e.g., have social workers review disposition planning or nurses explain the floor protocol for admissions) |
Motivation to learn: Guide trainees in achieving competence while bolstering their intrinsic motivation and supporting self-esteem | Give specific and objective feedback that highlights strengths and offers suggestions for improvement Link learning objectives to trainees’ long-term plans and expectations Provide methods for self-assessment |
Stimulate interest by demonstrating genuine enthusiasm and excitement Diversify teaching methods (e.g., online applications, pair-sharing, writing exercises) and allow trainees’ flexibility in choice with regard to how they want to learn |
APPLYING ADULT LEARNING PRINCIPLES ACROSS VARIOUS SETTINGS
Adult learning principles support the notion that the process of achieving professional competence is adaptive and developmental and may be integrated into multiple teaching formats, including classroom, clinical setting, and self-study.
Classroom
A traditional classroom implies a formal frame, with a predetermined setting and topic and teacher-led learning. To embody adult learning principles, classroom teaching should engage the student as much as possible in the process of active learning.
LECTURES
The lights dim, a slide is enlarged on the screen, and a familiar yellow, serif font appears across a dark blue background. Stereotypically, lectures feature passive learners who face the educator and a static screen. Lectures are still the predominant method of teaching from preclinical years through residents’ didactic curriculum and have the advantages of disseminating knowledge from one to many, introducing or deepening learning on complex and difficult topics, and conveying the instructor’s personal perspective (Palis and Quiros 2014). However, lectures can and should employ adult learning principles to facilitate active learning. Engaging trainees in the interpretation and assessment of lecture content may potentially improve the knowledge retention rate, which is estimated at a disheartening 5% after traditional lectures (Masters 2013). Cooper and Richards (2017) outlined several active learning strategies that can be incorporated to improve lectures:
1.
Break long lectures into shorter segments with paired or group activities. The average adult learner’s attention span is estimated at 10–15 minutes (Jeffries 2014). Limits of working memory and decreased ability to meaningfully assimilate new information (also known as interference) detrimentally impact attention and retention. Implement think-pair-share activities every 15 minutes. These activities ask learners to think about content learned and questions raised, discuss and compare these concepts in pairs, and share their consensus with the entire group.
2.
Elicit responses from the audience. Pose questions to listeners throughout the lecture using technological platforms (e.g., online polls or “clickers”), paper, or a show of hands. Responses obtained with a preassessment offer the opportunity to tailor the material to trainee needs. Assess past experience as well; ask if trainees have encountered similar problems before and how they handled them. For example, during a lecture on the management of alcohol withdrawal, residents may have experience using chlordiazepoxide but have not yet treated alcohol withdrawal with intravenous benzodiazepines. A trainee who is asked and is unsure about benzodiazepine equivalents conversions may review and bookmark resources for later reference. Questions asked during and after the lecture stimulate interest, self-assessment, and motivation to reinforce learning lecture content.
3.
Be ACTIVE. A group of residents and faculty developed ACTIVE, a structured lecture format that incorporates principles of adult learning. Trainees Assemble into small groups. The educator Conveys three to five learning points and Teaches a limited amount of content. The educator then Inquires about how the material applies to a clinical scenario, Verifies learning after discussion of each group’s answers, and Explains and educates how the answer choices reflect the learning points (Sawatsky et al. 2014). Discussion of a clinical scenario makes learning problem centered rather than content centered, which is appealing to adults who require immediacy of application.
FLIPPED CLASSROOM
Traditionally, trainees learn from teachers in a classroom and bring materials home to study and review. In a flipped classroom model, trainees learn material on their own and build on what they learned in the classroom through individual exploration or group activities. For example, rather than learning about prescribing practices for antidepressants in a lecture, residents might complete a preclass worksheet focused on the indications, adverse effects, and dosage recommendations of the antidepressants. Residents then come to class, break into small groups, and roleplay as prescribers and patients who are initiating treatment for depression (Kavanagh et al. 2017).
Teachers who use a flipped classroom approach facilitate learning rather than directly instructing, encouraging trainees to move at their own pace. A meta-analysis published in 2018 found that students favor a flipped classroom over a traditional classroom and that the flipped classroom model was more effective in increasing student learning (Hew and Lo 2018). Residents and medical students have little free time to study outside of rotations, especially for topics that do not pertain to their immediate clinical needs. Thus, the flipped classroom model may be modified to include a “prelearning” period during allotted class time rather than outside of class. Alternatively, preclass material such as video clips, podcasts, or Web-based modules should be limited (lasting no longer than 10–15 minutes), and learners should be given an estimate of how long this preparatory work will take. Done well, a flipped classroom approach may accelerate mastery through imminent transfer to practice and bolster intrinsic motivation as trainees progress toward competency (Persky and McLaughlin 2017).
SIMULATION AND STANDARDIZED PATIENTS
Residents’ clinical experience is tied to the presentation and pathology of their assigned patients. Given the 250 psychiatric disorders listed in DSM-5 (American Psychiatric Association 2013) and the myriad available treatments, it is impossible to cover the breadth of psychiatric diagnosis and treatment solely through direct clinical practice. Simulations, defined as “approximations to reality that require trainees to react to problems or conditions as they would under genuine circumstances” can fill this gap (Tekian et al. 1999). Simulations broaden exposure to clinical material and provide opportunities for immediate feedback and reflection that are not possible in every patient encounter (Abdool et al. 2017). Experiences with standardized patients may shift trainees’ perspectives on bias, stigma, and capacity for empathy. In a safe, trusting, and collaborative simulation environment, transformative learning is promoted through trial and error and reflection (Clapper 2010).
Clinical Settings
As trainees transition from the classroom to clinical practice, learning shifts from theoretical knowledge to clinical reasoning and practical application. Miller’s pyramid (Miller 1990) may guide planning and assessment of clinical competence. In clinical training, students build from a base of knowledge (“knows”) and applied knowledge (“knows how”) to a demonstration of skills (“shows how”) before reaching the apex at which their knowledge and skills are consolidated into clinical practice (“does”). The clinical setting lends itself to informal teaching and numerous opportunities to apply adult learning principles. We focus on bedside teaching and clinical rounds in the following section; supervision is discussed later in Chapter 4.
BEDSIDE TEACHING
The traditional model of apprenticeship—“see one, do one, teach one” —carries into modern-day medical education. Given the affective, subjective, and personalized aspects of psychiatric care, skills are not transferable by passive observation. Active engagement before, during, and after patient interaction is required. Lokko et al. (2016) underscored the importance of keeping bedside teaching “both learner centered and patient centered” and provided a comprehensive overview of how adult learning principles can be incorporated into psychiatric “pre-bedside encounters, bedside encounters, and post-bedside encounters”:
1.
Before seeing the patient: Engage your trainees by asking them to set learning objectives before meeting the patient; refine as necessary. Define a time frame and specific expectations for the interaction. Assign active roles to each participant, depending on level of training and learning goals. For example, the medical student interviews the patient, and a resident observer develops a biopsychosocial formulation.
2.
During the patient encounter: Capitalize on “teachable moments.” Demonstrate an examination skill or ask trainees to do so, model parts of the interview as appropriate, offer affirmation in real time, and give gentle redirection.
3.
After seeing the patient: Debrief the patient encounter away from the bedside. Encourage reflection and a discussion of “sensitive or affectively charged aspects of the encounter.” Explore transference and countertransference to promote transformative learning. Give specific feedback and ask for trainees’ feedback on what and how they learned during the patient interaction. Deliver teaching points succinctly and leave trainees with a clinical pearl that they can apply in the future.
CLINICAL ROUNDS
During clinical rounds, trainees may synthesize information by presenting cases and demonstrate competence by sharing input and rationale on diagnostic impressions and treatment decisions. To employ adult learning principles, consider rounds from the learner’s perspective with regard to environment, learning objectives, and educational methods. Does the environment feel safe and welcoming of diverse opinions? Invite trainees to sit at the table when presenting a case, to bolster their self-confidence. Ask for their input when staff ask how to respond to a clinical situation. Are trainees’ needs and learning goals known? Ask what questions came up during their assessment or presentation. Socratic questioning may identify the extent of trainee knowledge but must be used with care; learners are often frustrated by Socratic questioning that appears as “guess what I’m thinking,” and it often implies a performative aspect with a risk of humiliation. Deliver teaching points effectively and timely, with context. Demonstrate respect by acknowledging time constraints and trainees’ clinical duties. If rounds end before questions can be discussed, set a convenient time to reconvene.
Self-Study
In line with the adult learning principle of self-direction, learning is increasingly taking place outside of the classroom. According to a report by the Association of American Medical Colleges (2018) that surveyed second-year students, nearly one-quarter of subjects reported “almost never” attending in-person preclerkship courses or lectures, and the majority (42.4%) reported attending virtual pre-clerkship courses and lectures “most of the time.” Educators teaching preclinical courses should consider providing multimedia materials to offer students a choice in learning, for example, lecture slides with audio to teach the mental status examination, along with a video clip of a psychiatrist conducting the examination and related reading materials.
Trainees and practicing psychiatrists must independently determine when acquisition of facts is most useful versus a deeper exploration of concepts, given the overwhelming amount of available content. Studies suggest that problem-based learning can facilitate self-study; trainees are presented with an open-ended problem and subsequently set their own learning objectives and pursue an answer via self-directed learning or group discussion (Wood 2003). Residents who are exposed to problem-based learning dedicate more hours to independent study, have more discussions with co-residents outside of scheduled classes and rounds, and perform more computer literature searches each week (Ozuah et al. 2001). Teaching through problem-based learning models being faced with a clinical problem that requires selection of research materials, independent investigation, and assimilation of knowledge, which furthers lifelong learning.
CONCLUSION
A practical understanding of adult learning principles lays the groundwork for psychiatric education and facilitates one’s development as a clinical educator. Teaching that takes an adaptive, learner-centered, and problem-oriented approach promotes trainees’ advancement in self-directed learning, evoking meaning and purpose. Their growth and accomplishment makes teaching generative and immensely rewarding.
— KEY POINTS —
•
Adult learners are self-directed, problem oriented, and intrinsically motivated.
•
Trainees use past experiences and knowledge to enhance learning and value relevant, immediate, and practical application of skills and concepts.
•
General learning theories, such as humanistic, cognitive, behavioral, and relational models, may be used to understand how trainees learn and to adapt teaching methods accordingly.
•
Active learning strategies improve students’ engagement in traditional models of teaching, such as lectures and bedside rounds.
•
Self-study promotes independent inquiry and lifelong learning skills required by the rapidly evolving advances in psychiatric research and knowledge.
REFERENCES
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Handbook of Psychiatric Education
Pages: 1 - 14
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Published in print: 8 March 2021
Published online: 5 December 2024
© American Psychiatric Association Publishing
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