changing and learning in geriatrics/gerontology: a retrospective

The Journal of Continuing Education in the Health Professions, Volume 14, pp. 239-251. Printed in the U.S.A. Copyright 0 1994 The Alliance for Continuing Medical Education and the Society of Medical College Directors of Continuing Medical Education. All rights reserved.

Original Article

Changing and Learning in GeriatricdGerontology: A Retrospective

MALLORY R. HARVEY, PH.D. Faculty, St. Anthony Hospital Family Practice Residency Program Oklahoma City, OK

ROBERT D. FOX, ED.D. Professor and Director Research Center for Professional and Higher Education University of Oklahoma, Norman, OK

Abstract: The purpose of this study of health care professionals was to find answers to the following research questions: (1) What changes related to geriatricslgerontology occurred in the last year? (2) I f changes occurred, what factors caused or led to those changes? (3) Did learning play a part in the changes? Twenty randomly chosen participants in the First Summer Geriatric Institute were questioned using a semi-structured interview format. Data analysis was per- formed using the constant comparative methods. Changes were categorized by types (i.e., accommodations, incremental changes, and structural changes). Each change was then analyzed according to the model’s framework (i.e., forces for change, clarity of image of the fiture change, self-assessment of learning needs, and learning activities). One halfof the changes were found to be incremental changes, consisting of adjustments in some element of life or practice. The other half were structural changes involving complex additions, subtrac- tions, or reorganization of major elements. Participant responses indicated that multiple forces were involved in each change; change was a long process involving a series of interrelated experiences. Analysis of the forces initiating change revealed that professional forces were the strongest initial forces for change, followed closely by pro- fessionallsocial forces. Although learning accompanied every change, the change process varied according to the type of change (e.g., workshops or classes were chosen by those making incremental changes, while colleagues and experience were chosen by those making structural changes).

Key Words: Change, CME, forces for change, learning

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Continuing professional education is an expanding endeavor. Professionals are attempting to stay abreast of developments in their particular fields, as evi- denced by the fact that “one fourth to one half of the practicing professionals in the United States attended one or more formal continuing education activities in 198 1 .” ’ Researchers have attempted to verify the effectiveness of these educational activities by measuring the degree of change after each activity. However, research into Continuing Medical Education (CME) has failed to provide a clear picture regarding the efficacy of CME. Some research indicates that following a CME intervention permanent change occurs,* whereas other research suggests that the resultant change may be only ternp~rary,~ non- existent: or occurs only under certain circumstances.’

The fact that has been confounding CME practitioners, though, is that change obviously does occur and can be clearly seen in practice behavior.(‘ Researchers have continued to explore the role CME plays in these changes. Physicians have been reported to be making constant changes in their practice behavior,’ although in this study only 10% of the changes made by physicians involved CME. This paradox presents a dilemma: on the one hand, the results (changes in practice behavior) have been reported in research, but on the other hand, they have not been substantiated consistently with the traditional eval- uation tools of CME.

In an attempt to resolve this dilemma, Fox et al.* retrospectively analyzed cases of change and learning. Three hundred and forty physicians were interviewed regarding changes in their lives and practices. The analysis indicated that learning (formal CME and/or informal sources) was involved in change in almost 7 of 10 cases, but involvement varied with the type of change and with the forces that caused the change. From these data, the researchers developed a theory of change and learning and an accompanying model. Their theory presents a new perspective that may explain the earlier conflicting results.

Methods

This article presents a retrospective study of health care professionals that explores the usefulness of the change/learning theory reflected in the model developed by Fox et al.’ It examines the changes that resulted from the participants’ attendance at the Summer Geriatric Institute (SGI), a conference conducted in a southwestern state in June of 1990. The attendees were gerontologic/geriatric practitioners, administrators, and faculty from insti- tutions of higher education around the state. This group of health professionals was comprised of six administrators, six nurses, two pharmacists, two

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dentists, one occupational therapist, one physician, one psychologist, and one physician's assistant. They attended this conference to enhance their knowledge and skills in geriatrics/gerontology, teaching, and interdisciplinary teamwork.

This study attempted to answer the following research questions: (1) What changes related to geriatrics/gerontology, if any, have been made or have occurred? (2) What factors caused or led up to the changes that did occur? (3) What role did learning play in these changes?

The design of the study was naturalistic, and the methods used were qualitative. Volunteers for the study were randomly selected from 79 attendees of the SGI. After receiving an introductory letter that explained the study and assured them of confidentiality, selectees were contacted individually and asked if they would be willing to participate. The 20 individuals who agreed were interviewed in their work setting. A guided interview format9 that included probing and interactive dialogue was used. In a 1-hour session, two of these participants were able to discuss two changes, while the others recounted only a single change. Data were analyzed using the constant comparative method.'O Because the model developed by the change study offers a new perspective that could explain conflicting results in earlier CME stud- ies, it was chosen to serve as the organizational framework for the data. First, changes made by the participants were categorized according to the types of changes as described in the change study (ie., accommodations, incremental changes [adjustments], or structural changes [redirections and transformations]). Each type of change was then analyzed according to main points of the model's framework (i.e., forces for change, clarity of image of future change, self-assessment of need, and related learning activities). This article discusses each in turn. Other aspects of the change process not illustrated in Figure 1 but discussed in the change study were included (i.e., triggers, skills and information sought, purpose of learning, method employed, learning resources, and the prime learning resource). These aspects, with the exception of triggers, would fall under the heading of learning activities in the model (Fig. 1: Changing and Learning Model)!

Results

The participants described their changes and ranked them on Likert scales of 1-5 according to magnitude and complexity (Table 1). The types of change they described fell into the following categories: (1) attitudes toward the elderly, (2) teaching methods, (3) teaching materials, (4) interdisciplinary teamwork, ( 5 ) research topics, (6) educational endeavors, (7) communication

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Figure 1

Model of Learning and Changing

with patients, (8) service, (9) career goals, and (10) networking. After taking the participants’ descriptions into consideration, we categorized the changes as one of the three change types described in the change study. The type of change called accommodations was portrayed by Fox et al. as a small or simple change, usually made as an act of acceptance and often accompanied by neg- ative feelings; none of the changes in this study fell into this category. Incremental change (adjustments) was described as a change consisting of a proactive adding, dropping, or substituting of a major element. For example, one nurse/educator changed her teaching methods after experiencing these new techniques as a learner. One half, or 11, of the changes in this study were in this category. The third type of change, structural change (redirections and transformations), was described as a large, complex change involving change in one or more major elements of life or practice. For example, another nurse/educator lobbied for and received faculty agreement to design and teach an entire course on gerontology after she became strongly convinced of the need. Half of the changes (1 1) in this study were categorized as structural.

Trigger

The change study defined a trigger as an event that initiates a change. It may be caused by any of the forces for change, and it plays a significant role in the change process. Triggers were evident in 21 of the 22 changes. These trig- gering events arose from situations at work, new professional opportunities

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Table 1 Summary of Change Process

Change Process Incremental

(N = 11)

Forces Personal 6 PersonalProfessionaI 1 Professional Professional/Social Social

Trigger Clarity Discrepancy Learning activities-

skill/information Purpose

Method

Resources

Prime resource

12 11

1 11 2 3

10 Conceptual: 9 Problem specific: 2 Experiental: 4 Deliberative: 5 Mixed: 2 Informal: 6 Formal: 4 Equal: 1 Human: 3 Print: 1 Workshopslclass: 7

Structural

(N = 11)

3 1

13 6 1

10 7 6

9 Conceptual: 3 Problem Specific: 8 Experiental: 5 Deliberative: 4 Mixed: 2 Informal: 6 Formal: 3 Equal: 2 Human: 8 Print: 0 Workshops/class: 7 Experience: 3

or responsibilities, educational experiences, funding, new mformation, curricular changes, government regulations, or accreditation requirement changes. For one individual, the trigger was the acceptance of a new job, while for another, a dentist, it was a dental student’s remark, made while he was treating a 75-year- old as if he were an alien: “The oldest people I know are my parents and they’re forty.”

Clarity of Image of Change

One of the questions on the researchers’ questionnaire was, “Did you start the change process before you had a clear image or idea of the kind of change you wanted?” Two of the 11 individuals making incremental changes and seven of the 11 making structural changes responded that they had clarity (a clear idea)

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before they started. For example, one individual reported having a clear image of what interdisciplinary teamwork should be and how it should be applied in the real world. He believed that real teamwork was not happening in his locale, despite the use of all the right “buzzwords.” Of the nine who reported no initial clarity for their incremental changes, six chose workshops as their prime resource. When further questioned about how they clarified the image and whether that was a problem for them, most reported that clarification was not a problem once they initiated the change. It makes intuitive sense that individuals who do not have a clear sense of what they want to do would tend to make less dramatic or incremental changes. For them, workshops could be a source of direction. For example, a pharmacist reported an attitudinal change after he was asked to be the key faculty representative to the Summer Geriatric Institute. He did not even desire a change initially, but came to appreciate the needs of the elderly through his conference attendance. He said, “I’m like I am now [new attitudes and awareness], but I didn’t try to get here. . . . No one fixed me, others provided the immersion.”

Self Assessment of Need/Skills and Information Sought

The individuals’ self-assessment of their need to learn consisted of their awareness of the gap between “what is” and “what ought to be.” When asked, “As you thought about the change, did you feel that you had the knowledge and skills necessary to make the change?”, eight individuals making incremental changes reported no discrepancy between the skills or knowledge they possessed and the skills or knowledge they needed to make the change. Only five of those making structural changes reported no discrepancy. It is interesting to note that while eight of those making incremental changes said that they had all the skills and information they needed, all but one of these individuals later reported seeking some information or skills. Five individuals who made structural changes felt that they had all the knowledge and skills necessary to make the desired change. With further questioning, two of these individuals agreed that they had learned new information or developed skills, thus bringing the total reporting seeking information or skills to nine. It may be that the respondents did not understand the original question as it was related in the interview. Ultimately, most individuals sought information or skills, regardless of change type.

Learning Activities

Purpose of learning. The purpose of learning is described as conceptual or problem specific. Conceptual learning focuses on general understanding and organizing thoughts, while problem-specific learning is directed toward resolv-

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ing a specific problem. With incremental changes, nine participants had a conceptual purpose. For example, one individual reported seeking “people skills,” while another sought information about the elderly. A possible relationship was found between conceptual learning and no clarity, although this may be a function of the way cases were analyzed. Nine individuals used conceptual learning, and two used problem-specific learning. For example, one individual with a problem-specific purpose used no outside learning and instead relied on her experience to redesign the curriculum (her problem). The other individual with a specific problem, who also said that he already had the necessary knowledge and skills, was seeking documentation. The purpose for learning in the group that made structural changes was found to be more problem specific than conceptual. Three individuals reported more global or conceptual learning. Eight individuals had a specific problem, although two of these individuals did not use any outside learning to accomplish their changes. Categorization of the learning purpose was difficult and arbitrary initially; however, the distinction became easier as the relationship to clarity of the image of change became evident.

Method employed to learn. Experiential methods are described as ways of ordering the learning resources to permit the learner to apply knowledge or skills. Deliberative methods are ways of structuring the learning resources in ways that foster contemplation and reflection. Participants used both experiential and deliberative methods relatively equally. With incremental changes, four individuals primarily used experiential methods, five individuals used primarily deliberative methods, and two individuals combined these methods. Both experiential and deliberative methods were also used by the individuals who made structural changes. Four participants used primarily deliberative methods, five individuals used primarily experiential methods, and two participants mixed these methods. For those making structural changes, experience was frequently listed as a resource, while it was not mentioned by those making incremental changes.

Learning resources used in the change. The learning resources used by the participants were classified as formal or informal. Participants were asked if they used any formal instruction or instructional materials; attended programs or lec- tures; enrolled in home study activities or self-assessments; etc. Participants were then asked about informal resources, which were described as self-directed or nonstructured learning. With all changes, informal resources were used most often. Six individuals who made incremental changes recounted using more informal learning resources. The mean number of hours for this group was around 670, with a range of 20 to 2080 hours reported. The mean number of hours reported by the four individuals who made incremental changes and related

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more formal learning experiences was approximately 60, with a range of 17 to 150 hours. One individual reported using both formal and informal resources for a total of about 20 hours each. The sum of all the hours reported by those making incremental changes was roughly 4600 hours. Ninety-two percent of these, or approximately 4200 hours, were described as hours of informal learning.

Six participants who made structural changes related spending more hours in self-directed or informal learning. Their mean number of hours was approximately 220, with a range of 10 to 520 hours. Three individuals reported using more formal than informal resources. Their mean number of hours spent in formal education was roughly 150, with a range from 20 to 364 hours. Two participants reported using formal and informal learning equally, one using 30 hours and the other using 50 hours. The sum of the hours reported by those making structural changes was approximately 2440. Sixty-seven percent of these, or approximately 1650 hours, were used in the informal learning resources category.

Prime learning resource chosen. The group who made incremental changes had difficulty in selecting one prime resource. When forced to do so, seven listed workshops/classes/meetings, three listed human resources, and one listed print materials. Interestingly, in looking at the seven who reported workshops as their prime resource, six reported no clarity at the onset, and four reported using more formal resources than informal. None of the others making incremental changes reported using more formal resources than informal. The individuals who had made structural changes were, for the most part, very clear in their preference of learning resources. Three individuals reported experience as their prime resource and eight indicated human resources. Analysis of structural changes revealed that individuals who did recognize a discrepancy were more likely to choose human resources over experience; and although those who did not recognize a discrepancy chose humans more frequently than experience, they did so less often. Of the three who felt experience was their prime resource, two described no discrepancy in their knowledge and skill. All of those who felt experience was their best resource used experiential rather than deliberative methods. For those who felt humans were their best resource, half used informal methods, while the remainder were split equally between formal and mixed methods. Both individuals who reported seeking no skills or information had a problem-specific purpose.

Forces for change. Although the change study model starts with forces for change, for the purpose of discussion, they are included at this point in the sequence, because their discussion involves all other aspects in the process. In order to understand the role of forces initiating change, the participants were asked to rank them on a Likert scale of 1-5, . . .“according to how strongly they

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Table 2 Forces by Type of Change* (N = 55)

Forces for Change Incremental Structural

Personal 19% 13% PersonalProfessional 3% 4% Professional 39% 52% Professional/Social 35% 26% Social 3% 4%

* Table 2 was constructed to facilitate understanding of the changes and the alignment of the various components of the changes. For each change, only the highest ranked forces for change selected by each individual were included. These rankings ranged from 3 to 5 on the Likert scale. The number listed in the specific forces for change category (e.g. personal, professional, etc.) equals the number of times forces from that category were ranked as the strongest force chosen.

relate to the reason you made the change.” The discussion of forces includes only the most highly ranked forces chosen by each participant, a total of 55 forces. These forces were examined individually even though they often occurred in tandem. The average number of forces described in a change was six. These forces were extremely useful in analyzing the differences in the types of changes. They provided the organizational framework for analysis within each change. With reference to Table 2, professional forces, such as a sense of professional competence or needs of the work environment, were the strongest initiating forces for both types of changes. Professional/social forces, such as needs of colleagues or needs related to professional association, were second for both types of changes. Professional forces played a larger part in structural changes than they did in incremental changes. Professional/social forces played a larger part in incremental changes. With both types of changes, social forces, such as needs related to family or community responsibilities, and personal forces, such as curiosity and sense of personal well-being, were approximately equal and in last place.

When the changes were sorted according to forces for change, the following differences were observed. The categories of social and personal/professional were largely ignored in the analysis because of their small number (i.e., only two each).

Analysis of the 55 highest ranked forces chosen by each individual yielded these results:

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1. Changes initiated by personal forces used more experiential learning (70%) than those initiated by professional forces (45%), while changes arising from professional/social forces appeared to use even less (29%) experiential learning.

2. With both incremental and structural changes, purely professional forces were most likely to lead to change (i.e., 39% of incremental and 54% of structural). These forces were followed closely by professional/social forces, which initiated 35% of the incremental changes and 26% of the structural changes. Since these changes were related to professional endeavors, it follows that professional forces would be involved in initiating the changes.The importance of professional/social forces may coincide with new association requirements and other changing regulations in this field.

3. Human resources were the prime resource used in 56% of those changes initiated by professional forces, 47% of those changes initiated by professional/social forces, and 22% of those changes initiated by personal forces.

4. Most individuals who recognized a discrepancy between their current skillshowledge and the skillshowledge needed to make the change were making structural changes based on professional and professionalfsocial forces for change. Perhaps respondents had a better understanding of their need for skill and knowledge in these professional areas, and structural changes are larger, complex changes.

5. Of the three individuals making incremental changes and mentioning only one force, two mentioned professional/social forces and one mentioned professional forces. In contrast, five of the six individuals mentioning one force while malung structural changes reported professional forces, and one individual mentioned professional/ social forces. In other words, when only one force motivated the change, it was usually from professional or professional/social needs. If motivated by just one force, larger changes were generally motivated by needs in the professional area, which tended to be problem specific. Incremental changes (less complicated) that were motivated by just one force tended to be from professional/social needs and more conceptual in nature. This corresponds to all the comments about new regulations and needs of professional associations.

Discussion

Responses to interview questions indicated that most of the people were not prone to change quickly. Most were concerned specifically with the plight of the elderly in this country; they expressed a personal commitment to the elderly and were in the forefront in advocating the changes they felt were needed. For

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example, they mentioned their professional experience with the elderly, their own family, population demographics (“the graying”) of America, college courses, their own age, background, and “a morbid fascination with mortality based on an awareness of the preciousness of life.” They reported changes related to the study of geriatrics/gerontology within their professional associations, among their colleagues, and within their work environments. Job descriptions, professional association requirements, or government regulations changed or were currently in the process of changing for many individuals. Their age or career stage also appeared to play a major role in initiating change. Age or stage of life (personallprofessional force) was mentioned as a force for change in 15 of the 22 changes. Many individuals were at a time in their lives when they were beginning to prepare for their own retirement or were dealing with elderly family members.

The change process employed by these individuals varied. Interestingly, most of these changes had a trigger associated closely with the change. Those making larger or structural changes reported more clarity initially, but less awareness of the discrepancy between their present skills and knowledge and those needed to complete the change. The needed skills or knowledge may have fallen into the area of customary gaps,” where the individual did not perceive a need to learn because of the small gap between their perceived skills and the actual skills that were needed. Typically, those making structural changes had a problem to solve, while those making incremental changes sought more conceptual learning. The methods chosen were divided fairly evenly between the groups. Both groups strongly favored informal learning resources. The prime resource used by those makmg structural changes was humans, while those making incremental changes used workshops/classes/meetings.

Multiple forces were involved in each change; change was a long process involving multiple experiences. While many of these individuals talked about previous parallel changes that had started as early as 1986, they also reported that they had begun seeking information or developing skills many years earlier that later proved useful in this specific change. One participant recounted that he began seeking information for a change 24 years previously. Many individuals seemed to have had their own agenda and chose their own curricula for change from among the resources available to them, in three quarters of the cases choosing both formal and informal resources. This finding agrees with the idea of self-directed curricula for change, as postulated by

One of the most obvious findings was the importance of colleagues and other informal learning resources. GoldfingeI-6 mentions that those analyzing CME have tended to ignore informal peer contacts as a part of the learning process.

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In half of these changes, humans were listed as the prime resource. Another intriguing finding was the role of learning by experience (i.e., as in both experiential learning and the part the wealth of professional experience played in the augmentation of new learning into the professional’s pre-existing body of knowledge without outside learning. In one such change, the individual reported incorporation of new information concerning the value of reminiscence, which was adapted to form a communication tool. This individual said her experience allowed her to adapt and then incorporate this new information. She reported that she did not know how it would work until she tried it. She called it emo- tional learning rather than intellectual learning.

Conclusions

The findings of this study reinforce the need for further research into the changing and learning process. The design of continuing education programs could benefit from more information about many aspects of this process. Important information could be identified about why a particular trigger initiates the change process; the nature or image of change and the part it plays in the subsequent stages of change; the stage of change at the time of participation in continuing education; and if particular types of resources are favored at certain stages of change. The reported length of time the participants of this study had been involved in making their changes indicates that longitudinal analy- ses should be conducted on the changing and learning process.

Another area of interest involves the finding that many of these individuals used colleagues and networking to complete their changes. Continuing professional education could benefit from a better understanding of this process. The large number of informal education resources used by these participants seems to indicate that more thoughtful use of informal learning resources might enhance continuing education programs. For example, ongoing learning contracts could be designed to allow professionals to fulfill their continuing education requirements. Individuals would be encouraged to identify personal goals or areas of need and be assisted in utilizing multiple resources to fulfill their learning needs. Finally, some of the changes described a process similar to the reflective practice model. This information about the use of experience should be utilized in educational programs to help professionals learn to recognize and apply this reflective process in their practices.

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