Principles of Adult Learning Theory: A Beacon in the Night

1. Principles of Adult Learning Theory: A Beacon in the Night Jennifer Kesselheim, MD, MEd Hematology Course Directors American Society of Hematology December 5, 2010 My first experience with teaching really did not come until I was an intern. Unlike my classmates who had done Teach for America or had other jobs in which teaching was an essential component, for me, I was a teaching novice until I began residency training. And I was so excited to enter this new role. That said, I distinctly remember teaching my first few medical students and being a bit of a disaster. Not only had I never taught before, but I had never been taught to teach…and it showed! Looking back on some of my earliest teaching encounters, I recognize now that what I lacked was some sort of framework, some conceptual model that could anchor my approach to teaching, thereby making it more effective. I am here with you this morning because I believe adult learning theory can be that anchor, that beacon in the night that will allow your teaching to feel less chaotic, more deliberate, and overall more useful, more satisfying, for you and your learners.My first experience with teaching really did not come until I was an intern. Unlike my classmates who had done Teach for America or had other jobs in which teaching was an essential component, for me, I was a teaching novice until I began residency training. And I was so excited to enter this new role. That said, I distinctly remember teaching my first few medical students and being a bit of a disaster. Not only had I never taught before, but I had never been taught to teach…and it showed! Looking back on some of my earliest teaching encounters, I recognize now that what I lacked was some sort of framework, some conceptual model that could anchor my approach to teaching, thereby making it more effective. I am here with you this morning because I believe adult learning theory can be that anchor, that beacon in the night that will allow your teaching to feel less chaotic, more deliberate, and overall more useful, more satisfying, for you and your learners.

3. Objectives Describe several essential educational theories relevant to the teaching of adult students Knowles concept of androgogy Self-directed learning Self-efficacy David Kolb’s cycle of experiential learning Reflective practice Millennial learner Identify classroom strategies to apply each theory Explore methods for ongoing inspiration in medical education Faculty development Educational research

4. Malcolm Knowles 1980 text: Modern Practice of Adult Education Androgogy Art and practice of teaching adult learners Distinct from learning in childhood Pedagogy There are many prominent leaders in adult learning theory, and we will not have time to discuss everyone. But I did want to mention Malcolm Knowles whose 1980 test entitled “Modern Practice of Adult Education” defines the terms ANDROGOGY. This refers to the art and practice of teaching adult learners, as a distinct concept from PEDAGOGY which focuses on the learning of childhood. There are many prominent leaders in adult learning theory, and we will not have time to discuss everyone. But I did want to mention Malcolm Knowles whose 1980 test entitled “Modern Practice of Adult Education” defines the terms ANDROGOGY. This refers to the art and practice of teaching adult learners, as a distinct concept from PEDAGOGY which focuses on the learning of childhood.

5. Androgogy vs. Pedagogy Pedagogy Formal Learners are dependent and directed by teacher Evaluation is external (teachers, tests) Learners extrinsically motivated (grades) Androgogy Informal and cooperative Learners are independent and self-directed Evaluation through self-assessment Learners intrinsically motivated In the next two slides, I hope to further distinguish these two terms for you, by contrasting pedagogy, the learning of childhood, with andogogy, which Knowles argues characterizes adult learning. Contrast lists….go back and forth Go to next page….In the next two slides, I hope to further distinguish these two terms for you, by contrasting pedagogy, the learning of childhood, with andogogy, which Knowles argues characterizes adult learning. Contrast lists….go back and forth Go to next page….

6. Androgogy vs. Pedagogy Pedagogy Learners inexperienced Value learning that is put upon them Learning centers on a particular subject Androgogy Learners have own rich experience, used as a resource Value learning that is relevant to every day life Learning centers on a particular problem Contrast lists….go back and forth These lists draw attention to an important theme which is that adult learners are truly autonomous and driven by their own aims Contrast lists….go back and forth These lists draw attention to an important theme which is that adult learners are truly autonomous and driven by their own aims

7. Creating the Optimal Learning Environment* Create and environment where the learner is truly at the center Why is the learner here? What motivates her? What problems does she want to solve? What are her goals? How will she measure success in meeting those goals? What experiences will she bring to the process? Optimizing the practice of androgogy, rather than pedagogy, in your teaching is a lot about creating the right environment. The adult learner thrives when she is the center of attention. Too often, as teachers, we are concerned about ourselves. What are we going to say? How are we going to get the point across? But to create the optimal environment for adult learning, we must shift our focus and ask different questions: List the questions Optimizing the practice of androgogy, rather than pedagogy, in your teaching is a lot about creating the right environment. The adult learner thrives when she is the center of attention. Too often, as teachers, we are concerned about ourselves. What are we going to say? How are we going to get the point across? But to create the optimal environment for adult learning, we must shift our focus and ask different questions: List the questions

8. Creating the Optimal Learning Environment* Get to know your learner, shows respect Three questions What are you hoping to learn? Where will your future career likely take you? How can this course serve you in that future? Knowing your learner and his/her goals keeps the learning environment: Relevant Sparks internal motivation Adult learners are looking for a collaborative and respectful learning environment in which they exist as equals with their teachers. So, one of the best ways I have found to do this is to get to know your learners. When time is limited, you need to do this quickly. I recommend asking these 3 questions: List questions I have found this to be useful in many settings… I have used it in the clinical arena, like at the beginning of a multi-week rotation or a shared day in the clinic; but it is just as useful during an hour of small-group teaching. You could even ask a lecture hall full of learners to complete these questions on notecards at the start of the course or electronically before your course begins. I find that if I have an inkling about who this learner is and where he or she is going in the future, I can more easily craft a learning experience that will meet the learner’s needs. Not only does this show the adult learner respect, but knowing your learner’s goals also increases the chance that the teaching you provide is relevant and that you position the learner as a collaborative partner in what will happen. If the learner has a chance to reflect on his or her own needs, then this triggers internal motivation that is essential. Adult learners are looking for a collaborative and respectful learning environment in which they exist as equals with their teachers. So, one of the best ways I have found to do this is to get to know your learners. When time is limited, you need to do this quickly. I recommend asking these 3 questions: List questions I have found this to be useful in many settings… I have used it in the clinical arena, like at the beginning of a multi-week rotation or a shared day in the clinic; but it is just as useful during an hour of small-group teaching. You could even ask a lecture hall full of learners to complete these questions on notecards at the start of the course or electronically before your course begins. I find that if I have an inkling about who this learner is and where he or she is going in the future, I can more easily craft a learning experience that will meet the learner’s needs. Not only does this show the adult learner respect, but knowing your learner’s goals also increases the chance that the teaching you provide is relevant and that you position the learner as a collaborative partner in what will happen. If the learner has a chance to reflect on his or her own needs, then this triggers internal motivation that is essential.

9. Self-Directed Learning: a related concept Adult learners are autonomous and goal-oriented Come to educational experience with goals already in mind Teachers facilitate the meeting of those goals Strategy gives learner feeling of control, empowerment Learner accepts responsibility for learning When adults learn, they do so in a self-directed fashion. They are motivated by goals that they already have in mind and which they bring to the educational experience. They do not look to the teachers to create their goals (although their teachers do involve themselves in that process), but rather they view their teachers as facilitators who help learners to meet their own goals. When the learner’s goals are given a voice, the learner feels more in control and will be more likely to invest in the learning and accept joint responsibility for it. When adults learn, they do so in a self-directed fashion. They are motivated by goals that they already have in mind and which they bring to the educational experience. They do not look to the teachers to create their goals (although their teachers do involve themselves in that process), but rather they view their teachers as facilitators who help learners to meet their own goals. When the learner’s goals are given a voice, the learner feels more in control and will be more likely to invest in the learning and accept joint responsibility for it.

10. Optimizing Self-Direction* Allow learners time to ask questions Provide opportunity for building of theories and hypotheses Encourage critical appraisal of new information Force learners to identify gaps in their own knowledge and make plan for addressing those gaps Presentations and literature reviews To optimize self direction, you want to allow learners plenty of time to ask questions, and provide opportunities for them to build their own theories and hypotheses. Encourage critical appraisal of new information. Another strategy is to allow learners to assume more responsibility. This again shows them respect and allows them autonomy. This is what we are all getting at when we ask learners to make brief presentations on a relevant topic, when we encourage them to take on a leadership role in the class. Another way to get this effect is to ask the learner to engage in critical thinking and pursue independent research or a literature review to help solve a problem the class has encountered. To optimize self direction, you want to allow learners plenty of time to ask questions, and provide opportunities for them to build their own theories and hypotheses. Encourage critical appraisal of new information. Another strategy is to allow learners to assume more responsibility. This again shows them respect and allows them autonomy. This is what we are all getting at when we ask learners to make brief presentations on a relevant topic, when we encourage them to take on a leadership role in the class. Another way to get this effect is to ask the learner to engage in critical thinking and pursue independent research or a literature review to help solve a problem the class has encountered.

11. Self-Efficacy Learners make decisions about how much effort to give, how hard to work, in part due to their perceived likelihood of success Previous performance Observations of others Verbal persuasion

12. Set Them Up to Succeed* Set clear goals and expectations Model what you would like learners to do Allow learners to practice and receive feedback Promote reflection on learning process

13. Experiential Learning I wanted to share with you David Kolb’s cycle of experiential learning. This is a useful paradigm to be familiar with, especially as you consider teaching procedural knowledge. While most of us are neither intensivists nor surgeons, it may seem that we have very few procedures that fall into our practice. But I am talking about procedures like bone marrow biopsies, lumbar punctures, and in the setting of 2nd year medical students, this is applicable for analysis of a bone marrow or peripheral blood smear or for interpretation of lab results. So according to Kolb, the first step is concrete experience, when the learner, after hearing your instruction on this procedure, such as analysis of a peripheral blood smear, gets directly involved with the activity through concrete experience. After completing the activity, the learner delves into reflection, during which he thinks critically about the experience…what went well? At what point did I run into difficulty? If I misinterpreted the smear, what happened? The learner will then engage in abstract conceptualization, during which he tries to link your message from your teaching with what was just experienced. The learner may say “I remember my teacher telling me that it is important to discern what the dominant, or most common morphology is on a peripheral blood smear in order to interpret it correctly. I bet I should have remembered that when I saw just one target cell and wrongly diagnosed this patient as having Hb SC disease.” With these realizations in mind, the learner engages in experimentation where he tried to improve his performance now that he has better understood your lessons. I wanted to share with you David Kolb’s cycle of experiential learning. This is a useful paradigm to be familiar with, especially as you consider teaching procedural knowledge. While most of us are neither intensivists nor surgeons, it may seem that we have very few procedures that fall into our practice. But I am talking about procedures like bone marrow biopsies, lumbar punctures, and in the setting of 2nd year medical students, this is applicable for analysis of a bone marrow or peripheral blood smear or for interpretation of lab results. So according to Kolb, the first step is concrete experience, when the learner, after hearing your instruction on this procedure, such as analysis of a peripheral blood smear, gets directly involved with the activity through concrete experience. After completing the activity, the learner delves into reflection, during which he thinks critically about the experience…what went well? At what point did I run into difficulty? If I misinterpreted the smear, what happened? The learner will then engage in abstract conceptualization, during which he tries to link your message from your teaching with what was just experienced. The learner may say “I remember my teacher telling me that it is important to discern what the dominant, or most common morphology is on a peripheral blood smear in order to interpret it correctly. I bet I should have remembered that when I saw just one target cell and wrongly diagnosed this patient as having Hb SC disease.” With these realizations in mind, the learner engages in experimentation where he tried to improve his performance now that he has better understood your lessons.

14. Missed Steps Optimal learning requires time for all four steps Rushed learners often skip reflection and abstract conceptualization Oscillation between experience and experimentation is far less effective The challenge with this model is that optimal learning requires time be allowed for all four of these steps. So often our learners are as rushed as we are….and this often leads them to skip both reflection and abstract conceptualization. Without those, the learners is really just oscillating between concrete experience and experimentation…he is just bouncing around, trying and trying again, until something goes well. This kind of trial and error process is chaotic and may be upsetting for everyone involved which is why we as the teachers must make sure the learner takes the time to progress through all steps of active learning. The challenge with this model is that optimal learning requires time be allowed for all four of these steps. So often our learners are as rushed as we are….and this often leads them to skip both reflection and abstract conceptualization. Without those, the learners is really just oscillating between concrete experience and experimentation…he is just bouncing around, trying and trying again, until something goes well. This kind of trial and error process is chaotic and may be upsetting for everyone involved which is why we as the teachers must make sure the learner takes the time to progress through all steps of active learning.

15. Reflective Practice Formal theories inherent to training a professional tend not to apply to the messy reality of practice Learners reflect in these messy moments to compare or contrast theory and practice Reflection in action Learners also reflect after the fact to determine how to “do better” next time Reflection on action Through this reflection, learners develop “wisdom” and experience that enhances their performance Theory attributed to Donald Schon who studied a range of professionals.Theory attributed to Donald Schon who studied a range of professionals.

16. Opportunities for Reflection* Reflection as a group Good-spirited challenging of theories Debriefing Reflection as an individual Asking questions Practicing in safe environment Receiving feedback We need to intentionally create opportunities for reflection as we teach adult learners. Groups of learners can certainly reflect. They can do this with good-spirited challenging of one another’s concepts and ideas as they work on a common case, for example. They can promote one another’s reflection by asking questions that are left for the group to consider. Also, the group can debrief about their learning experience…what is working well, what would make things go better. In addition, each individual must have a chance to reflect. They can each do this by asking their own questions and by having opportunities to practice what they have learned in a safe environment where they can get feedback on their progress. Feedback is a very important step for enabling reflection and one that most of us underutilize. Learners have wonderful opportunities for reflection when they meet with an instructor to get feedback on their progress, their strengths, and their areas for improvement.We need to intentionally create opportunities for reflection as we teach adult learners. Groups of learners can certainly reflect. They can do this with good-spirited challenging of one another’s concepts and ideas as they work on a common case, for example. They can promote one another’s reflection by asking questions that are left for the group to consider. Also, the group can debrief about their learning experience…what is working well, what would make things go better. In addition, each individual must have a chance to reflect. They can each do this by asking their own questions and by having opportunities to practice what they have learned in a safe environment where they can get feedback on their progress. Feedback is a very important step for enabling reflection and one that most of us underutilize. Learners have wonderful opportunities for reflection when they meet with an instructor to get feedback on their progress, their strengths, and their areas for improvement.

17. Attend to the Millennial Learner Accustomed to group work Prefers active learning Multi-tasks with ease Expert in technology Requires structure Goal oriented As much as we need to attend to the adult learner, we also must focus on the special needs to the millennial learner. When we teach medical students, we have, for the most part, a room full of millennial learners. This can pose certain challenges because most medical school faculty are not millennial learners and there can be a bit of a culture clash at play. Read qualities of millennial learners….As much as we need to attend to the adult learner, we also must focus on the special needs to the millennial learner. When we teach medical students, we have, for the most part, a room full of millennial learners. This can pose certain challenges because most medical school faculty are not millennial learners and there can be a bit of a culture clash at play. Read qualities of millennial learners….

18. Attend to the Millennial Learner* Use the most updated references and keep technology current Allow for use of computer and other resources during learning Allow for small group learning and build structure Assign small group roles initially Rotate roles Require 100% participation Set clear expectations of each individual

19. Keeping it Fresh Teaching the same course can get monotonous Adherent to old methods If it’s not broken, don’t fix it Strategies for continual inspiration OK, I want to shift gears a little now. I have reviewed with you some of the major principles of adult learning and have tried to give you concrete applications of these for the classroom. I want to chat now about a different challenge for teachers. Teaching the same course, year after year, can get very monotonous and it is easy to slip into a rut. We become adherent to old methods and figure that things are going pretty well so, if it’s not broken, maybe there is no need to fix it. But actually, you as the teachers and course directors need to find a way to keep it fresh, so that you maintain your own motivation and that you can then motivate the other faculty in your course. It is important to develop some strategies for continual inspiration so that the course still challenges and excites you. Perhaps for some of you, incorporating and applying adult learning theory will be a way for you to reinvigorate your teaching. But I wanted to present a couple of other ideas too.OK, I want to shift gears a little now. I have reviewed with you some of the major principles of adult learning and have tried to give you concrete applications of these for the classroom. I want to chat now about a different challenge for teachers. Teaching the same course, year after year, can get very monotonous and it is easy to slip into a rut. We become adherent to old methods and figure that things are going pretty well so, if it’s not broken, maybe there is no need to fix it. But actually, you as the teachers and course directors need to find a way to keep it fresh, so that you maintain your own motivation and that you can then motivate the other faculty in your course. It is important to develop some strategies for continual inspiration so that the course still challenges and excites you. Perhaps for some of you, incorporating and applying adult learning theory will be a way for you to reinvigorate your teaching. But I wanted to present a couple of other ideas too.

20. Faculty Development Teach the teachers! Adult learning theory Assessment and feedback Small group dynamics Simulate small group sessions Observed teaching with feedback from peers Share course and teacher evaluation data I encourage you to hold meetings with the other teachers in your course. I suspect many of you already do this, mostly for administrative purposes. But consider adding faculty development to these meetings, or hold separate meetings that aim to teach your teachers. You can share with your faculty some of what you learned today about adult learning theory. You could also review principles of assessment, feedback, and small group dynamics. You could simulate small group teaching session and allow a couple of faculty members to practice facilitating and getting feedback from the group about their performance as a facilitator. You could use this as a time to review evaluations you received from the course and about teachers. Don’t be afraid to invite experts from your medical school to speak to your group or provide resources to allow for ongoing faculty developmentI encourage you to hold meetings with the other teachers in your course. I suspect many of you already do this, mostly for administrative purposes. But consider adding faculty development to these meetings, or hold separate meetings that aim to teach your teachers. You can share with your faculty some of what you learned today about adult learning theory. You could also review principles of assessment, feedback, and small group dynamics. You could simulate small group teaching session and allow a couple of faculty members to practice facilitating and getting feedback from the group about their performance as a facilitator. You could use this as a time to review evaluations you received from the course and about teachers. Don’t be afraid to invite experts from your medical school to speak to your group or provide resources to allow for ongoing faculty development

21. Education Research New focus on measuring outcomes creates new opportunities for research Internal, QI Publish Which methods lead us to the outcomes we desire? Will achieving the outcome lead to meaningful improvement in learner’s experience? Another way to refresh your interest in your teaching is to engage in education research. Hematologists have such a magnificent track record and are really leaders in medical research so there is not reason we can not apply those same skills to our teaching. I encourage you to begin identifying the outcomes of your course that are most important to you and to begin measuring them. This can be done for internal purposes, as a kind of QI, but this can also be written up and published. We should ask ….Another way to refresh your interest in your teaching is to engage in education research. Hematologists have such a magnificent track record and are really leaders in medical research so there is not reason we can not apply those same skills to our teaching. I encourage you to begin identifying the outcomes of your course that are most important to you and to begin measuring them. This can be done for internal purposes, as a kind of QI, but this can also be written up and published. We should ask ….

22. Research Questions Will an electronic image bank allow students to perform better on the hematopathology portions of the exam? Will more small group sessions increase students’ ratings of our course? Will more exposure to hematology research increase medical students’ interest in scholarly pursuits with our faculty? Here are some examples of research questions that might emerge in your courses:Here are some examples of research questions that might emerge in your courses:

23. Share Your Innovations Curricula Evaluation instruments Use of technology to enhance learning Plan to collect data as you make improvements in your teaching

24. Share Your Innovations Hematology literature Pediatrics and internal medicine journals Medical education Academic Medicine Medical Education Journal of Graduate Medical Education Med Ed Portal www.aamc.org/mededportal Make sure to share what you have learned. This work can be published in the hematology literature, in pediatric or internal medicine literature, or in the medical education literature. Also, curricular innovations or learning tools can be published online at Med Ed Portal. If you don’t know about med ed portal, you should check it out. This is a peer reviewed, online repository of educational materials sponsored by AAMC and it is a great way to disseminate what you are working on and get academic credit for it.Make sure to share what you have learned. This work can be published in the hematology literature, in pediatric or internal medicine literature, or in the medical education literature. Also, curricular innovations or learning tools can be published online at Med Ed Portal. If you don’t know about med ed portal, you should check it out. This is a peer reviewed, online repository of educational materials sponsored by AAMC and it is a great way to disseminate what you are working on and get academic credit for it.

25. Conclusion Adult learners are… Millennial Self-directed Experienced Reflective Self-assessed Problem-centered Self-motivated

26. Also…. Adult learners are all of the people in this room! While you are brought here because you are teachers, don’t forget that you are also adult learners. Directing your course is a learning opportunity that will be most successful when seen through the lens of adult learning theory. Notecard Whatever you wrote on that notecard is your self-motivating force, your relevant problem or challenge, and the thing that you will evaluate yourself by. So make sure to keep whatever is on your notecard in mind as you direct your course so that you can continue to learn, even as you teach. I wish you much luck and I am happy to take your questions!Whatever you wrote on that notecard is your self-motivating force, your relevant problem or challenge, and the thing that you will evaluate yourself by. So make sure to keep whatever is on your notecard in mind as you direct your course so that you can continue to learn, even as you teach. I wish you much luck and I am happy to take your questions!