1. A Look into Adult Learning Theory
24 January 2017
Scott Livingston & Karen Trimmer
Education Division Staff Training

2. OBJECTIVES
Describe the key findings from education literature that define Andragogy (Adult Learning Theory).
Discuss the relevance of the principles of Adult Learning Theory and the 6 key considerations for effecting behavior change in medical education programs, and apply these concepts to their scope of work in the DVBIC Education Division.

3. What is Adult Learning Theory?
Malcolm Shepherd Knowles (1913 – 1997) was an American educator well known for the use of the term Andragogy as synonymous to the adult education. According Malcolm Knowles, andragogy is the art and science of adult learning, thus andragogy refers to any form of adult learning. (Kearsley, 2010).
Andragogy– an equivalent term to the familiar pedagogy, which means, child-learning. Pedagogy dates back to the Greeks. The German educator, Alexander Knapp used the term Andragogy in 1833 to refer to adult learn as an intrinsically different way of learning. The American educator, Malcolm Knowles, articulated the most widely accepted theory of Adult Learning in the mid-20th Century.
Andragogy v. Pedagogy
Self-Concept– an adult is a dependent person and more self-directed whereas a learning child is going through stages of development that we might associate with the educational and learning theorists of the last 150 years Jean Piaget, Maria Montessori, B.F. Skinner, Erik Ericson, Carl Jung, Alan Bloom whose work was applied to the education of children. Throughout these stages, children are dependent on others and the community to form into well-balanced adults, socially, emotionally, cognitively.
The Brain itself—for the learning adult—there is an accumulated reservoir of knowledge, that should be honored and respected in the learning process, For youthful brain: concern about how the brain work and learns best to acquire necessary information: learn how we learn.
Readiness to learn —adults reach maturity and become invested in education; given there are no barriers to learning, usually adult education means advancement in a the community and most adults seek out that advancements. Children develop in an uneven, stratified manner, so they cannot often understand the purpose the specific aspects of education (why math (cognitive development) when playground (gross motor)?)
Application—adults want and need immediate application of what they learn, moreover, their life experience makes this application possible (job training, self-selection of classes). Children—also need immediate application, but unless their teacher constructs a learning environment that provides immediate application of content, they seldom get it.
Motivation—adults have a stronger motivation to learn as their motivation is internal. Young usually function via external rewards.

4. What is Adult Learning Theory?
Knowles’ 5 Assumptions of Adult Learners
Self-Concept
Adult Learner
Experience
Readiness to
Learn
Orientation
to Learning
Motivation to Learn
Andragogy– an equivalent term to the familiar pedagogy, which means, child-learning. Pedagogy dates back to the Greeks. The German educator, Alexander Knapp used the term Andragogy in 1833 to refer to adult learn as an intrinsically different way of learning. The American educator, Malcolm Knowles, articulated the most widely accepted theory of Adult Learning in the mid-20th Century.
Andragogy v. Pedagogy
Self-Concept– an adult is a dependent person and more self-directed whereas a learning child is going through stages of development that we might associate with the educational and learning theorists of the last 150 years Jean Piaget, Maria Montessori, B.F. Skinner, Erik Ericson, Carl Jung, Alan Bloom whose work was applied to the education of children. Throughout these stages, children are dependent on others and the community to form into well-balanced adults, socially, emotionally, cognitively.
The Brain itself—for the learning adult—there is an accumulated reservoir of knowledge, that should be honored and respected in the learning process, For youthful brain: concern about how the brain work and learns best to acquire necessary information: learn how we learn.
Readiness to learn —adults reach maturity and become invested in education; given there are no barriers to learning, usually adult education means advancement in a the community and most adults seek out that advancements. Children develop in an uneven, stratified manner, so they cannot often understand the purpose the specific aspects of education (why math (cognitive development) when playground (gross motor)?)
Application—adults want and need immediate application of what they learn, moreover, their life experience makes this application possible (job training, self-selection of classes). Children—also need immediate application, but unless their teacher constructs a learning environment that provides immediate application of content, they seldom get it.
Motivation—adults have a stronger motivation to learn as their motivation is internal. Young usually function via external rewards.

5. What is Adult Learning Theory?
Knowles’ 4 Principles of Andragogy
Adults need to be involved in the planning & evaluation of their instruction
Experience (including mistakes) provides the basis for learning activities
Adults are most interested in learning subjects that have immediate relevance & impact to their job or personal life
Adult learning is problem-centered rather than content-oriented [Kearsly, 2010]
Andragogy– an equivalent term to the familiar pedagogy, which means, child-learning. Pedagogy dates back to the Greeks. The German educator, Alexander Knapp used the term Andragogy in 1833 to refer to adult learn as an intrinsically different way of learning. The American educator, Malcolm Knowles, articulated the most widely accepted theory of Adult Learning in the mid-20th Century.
Andragogy v. Pedagogy
Self-Concept– an adult is a dependent person and more self-directed whereas a learning child is going through stages of development that we might associate with the educational and learning theorists of the last 150 years Jean Piaget, Maria Montessori, B.F. Skinner, Erik Ericson, Carl Jung, Alan Bloom whose work was applied to the education of children. Throughout these stages, children are dependent on others and the community to form into well-balanced adults, socially, emotionally, cognitively.
The Brain itself—for the learning adult—there is an accumulated reservoir of knowledge, that should be honored and respected in the learning process, For youthful brain: concern about how the brain work and learns best to acquire necessary information: learn how we learn.
Readiness to learn —adults reach maturity and become invested in education; given there are no barriers to learning, usually adult education means advancement in a the community and most adults seek out that advancements. Children develop in an uneven, stratified manner, so they cannot often understand the purpose the specific aspects of education (why math (cognitive development) when playground (gross motor)?)
Application—adults want and need immediate application of what they learn, moreover, their life experience makes this application possible (job training, self-selection of classes). Children—also need immediate application, but unless their teacher constructs a learning environment that provides immediate application of content, they seldom get it.
Motivation—adults have a stronger motivation to learn as their motivation is internal. Young usually function via external rewards.

6. Hallmarks of Adult Learning Effective learning design strategies
Interactive learning
Problem-based
learning
Simulation
Reinforcement
Differentiation
Problem-based learning – learners work together—can be collaborative to solve a real problem/issue occurring in community, society. Used often in science and medicine because of the nature of seeking resolution to scientific mystery, very collaborative, requires time and integration.
Simulation—modeling or representing a real-world event or action to learn or understand the situation and its impact or possible impact.
Reinforcement– any multitude of ways to enable learners to review content at their own pace or via knowledge checks.
Differentiation—instruction that takes into account the various ways that individuals learn.
All of these hallmarks call the designer to create learning instruments and modules that are interactive, integrating the principles of Adult Learning Theory

7. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Traditional CME, in the form of lecture presentations, may improve knowledge, skills and attitudes, but not performance.
Interactive interventions are impactful in changing outcomes (i.e. behaviors):
Case discussions
Practice simulations
Roundtable discussions
Interactive presentations
Sequenced sessions
Enabling materials
According to the focus of the study presented here: while undergoing annual continuing medical education, physicians are more likely to change their behavior in practice when exposed to Adult Learning Theory (ALT), which improves patient outcomes. Traditional CME programs, with little interaction or attention to ALT, may increase knowledge and skills, but these programs do not change provider behavior towards patients.
The key findings of the study fall around 6 points:
1. Traditional educational methodologies do not improve physician performance
2. Provider behaviors toward patients change as a result of good instructional design and best educational practice
3. Active participation is more impactful than passive learning
4. Adult Learning methodologies must be used in instructional design to succeed in changing provider behavior.
5. Adult learners respond positively to reinforcement and feedback, which is often not available through traditional instruction methods
6. All effective learning design measures outcomes

8. Key Findings [Mayer-Mihalski & DeLuca, 2009]
The use of Adult Learning Theory in continuing medical education can lead to a beneficial change in provider behavior that improves & optimizes patient outcomes.
According to the focus of the study presented here: while undergoing annual continuing medical education, physicians are more likely to change their behavior in practice when exposed to Adult Learning Theory (ALT), which improves patient outcomes. Traditional CME programs, with little interaction or attention to ALT, may increase knowledge and skills, but these programs do not change provider behavior towards patients.
The key findings of the study fall around 6 points:
1. Traditional educational methodologies do not improve physician performance
2. Provider behaviors toward patients change as a result of good instructional design and best educational practice
3. Active participation is more impactful than passive learning
4. Adult Learning methodologies must be used in instructional design to succeed in changing provider behavior.
5. Adult learners respond positively to reinforcement and feedback, which is often not available through traditional instruction methods
6. All effective learning design measures outcomes

9. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Behavior change is a dynamic process resulting from effective design & implementation of education.
Elements of effective learning design include:
Curriculum
Enablers
Application
Media

10. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Elements of effective implementation are based on adult learning principles that:
Include varied learning methods (multiple interventions)
Guide participants through learning process (facilitate vs. instruct)
Provide a comfortable learning environment
Stimulate cognitive (intellectual), psychomotor (skill), & affective (emotional) behaviors

11. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Active involvement
The act of doing versus passive participation results in 90% retention rate two weeks post program.
Passive involvement results in a 10% retention rate two weeks post program
Consistent with concept of, “see one, do one, teach one” learning method used in physician medical training programs.

13. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Utilize effective learning methodologies
In order to achieve a behavior change, effective learning methodologies must be incorporated into the program design, including blended learning, problem-based learning, & simulation.

14. Effective Learning methodologies
Blended Learning
Includes mix of CD-ROM video streaming, virtual classrooms. Voic , , conference calls, online text animation
Traditional classroom training
Problem-Based Learning
Places learner in active role as problem solver
Provides interactive format for learning
Uses case studies, medical teaching rounds
Simulation
Immediate feedback motivates learners to transfer skills taught
Validated as method to measure quality of care by MDs

15. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Reinforcement strategies are important interventions that can be used to enhance the learning effectiveness & establish appropriate behavior.
Effective reinforcement strategies include:
Academic detailing (outreach visits)
Audit & feedback (summary of clinical performance)
Commitment to change instruments
Communities of practice
Patient mediated interventions (educational materials, counseling sessions)
Reminders (manual or computerized)

16. Key Findings [Mayer-Mihalski & DeLuca, 2009]
Performance metrics must be incorporated into all learning interventions.
Pre- and post-test to assess knowledge & skills acquired
Action plan or commitment to change instrument
Follow-up surveys (at various intervals post-learning event – to determine extent of behavior change)

17. Adult Learning in Medical Education
According to medical literature, traditional medical education (including continuing medical education activities) is effective in the transfer of knowledge & skills, yet is inadequate in changing behavior.
Physicians spend approx. 50 hours per year in CME activities, geared toward improving & optimizing patient outcomes
Do healthcare professional who participate in CME activities improve clinical practice skills? Does this improve patient outcomes?
Formal CME has minimal to no effect on changing clinical practice [Davies, 1999]

18. Adult Learning in Medical Education
Medical and allied healthcare education & CME programs with little interaction improve knowledge & skills but DO NOT change behavior
Majority of medical/allied health professions educational programs & CME-accredited programs are didactic lectures (live or virtual).
A paradigm shift to a more interactive approach is needed
Where’s the evidence?

19. Summary & Conclusions
6 key concepts define effective educational programs & provide framework for medical education that can change providers’ behavior
Effective education for healthcare providers can be accomplished using:
Interactive, problem-based learning
Use of simulation w/case-based scenarios
Reinforcement strategies & performance metrics

20. Sources
Davis D, et al. (1999). Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior on health care outcomes? JAMA, 282(9):
Mayer-Mihalski, Nanci & DeLuca Marc, J. (2009). Effective Education Leading to Change. ParagonRx. May 2009.
Mazmanian PE & Mazmanian PM. (1999). Commitment to change: theoretical foundations, methods, and outcomes. J Contin Educ Health Prof, 19:
Pappas, Christopher The Adult Learning Theory: Andragogy. eLearning industry: Instructional Design. 9 May. Retrieved from:

21. Sources
Todesco A. (1997). From training evaluation to outcome assessment: What trends and best practices tell us. The Research Center.
Zeitz HJ (1999). Problem-based learning: Development of a new strategy for effective continuing medical education. Allergy & Asthma Proc, 20(5):
Zemke R. (2002) Who needs learning theory anyway. Training, September 2002, 85, 87-88