Psychology’s top 20 principles for enhancing teaching and learning

Every once in a while an article is published that you know is Important and that you should take Note of, and in this post I’m going to summarise a paper that I think fits into that category. It’s a recent publication in Mind, Brain and Education that attempts to summarise and explain the Top 20 principles of teaching and learning, as determined by the last few decades of psychological research. The article is called Science Supports Education: The behavioural research base for Psychology’s top 20 principles for enhancing Teaching and Learning, and it’s by Lucariello, Nastasi, Anderman, Dwyer, Ormiston, and Skiba. See the bottom of this post for the abstract and citation information.

After a brief introduction and description of the Methods the article gets stuck into the principles, which I’ll list and describe below. For some reason, Principle 8 – on the development of student creativity – is not included in the paper and no explanation is given for the omission.


Principles 1-8: How do students learn?

1. Students’ beliefs or perceptions about intelligence and ability affect their cognitive functioning and learning: If students believe that intelligence has a fixed value, they are less likely to learn than if they believe that intelligence can be changed. Teachers should communicate to students that “…failure at a task is not due to lack of ability and that performance can be enhanced, particularly with added effort or through the use of different strategies.”

2. What students already know affects their learning: Students prior knowledge influences how they incorporate new ideas because what they already know interacts with the new material being learned. This is an especially important concept when considering students’ misconceptions and how those misconceptions impede new learning. Teachers could create tasks that give students an active role in confronting and then reducing their cognitive dissonance.

3. Students’ cognitive development and learning is not limited by general stages of development: Cognitive growth is uneven and not linked to stages. Therefore, teachers’ ideas around how, and what new material should be presented, are more effective when they can take into consideration the domain-relevant and contextual knowledge of their students.

4. Learning is based on context, so generalizing learning to new contexts is not spontaneous, but rather needs to be facilitated: In order for learning to be effective, it should generalise to new or different contexts and situations. However, student transfer of knowledge and skills is not spontaneous or automatic. Teachers could therefore teach concepts in multiple contexts so that students can recognise contextual similarities, and focus on the application of their knowledge to the real world.

5. Acquiring long-term knowledge and skill is largely dependent on practice: What people know is laid down in long-term memory and information must be processed before it can move from short-term to long-term memory. This processing is accomplished through different strategies, and practice is key. Teachers should consider a variety of frequent assessment tasks given at spaced intervals (distributive practice). In addition, interleaved practice (a schedule of repeated opportunities) to rehearse and transfer skills or content by practicing with tasks that are similar to the target task, or using several methods for the same task, is also recommended.

6. Clear, explanatory, and timely feedback to students is important for learning: Students should receive regular, specific, explanatory, and timely feedback on their work. Feedback is more effective when it includes specific information that is linked to current knowledge and performance to clear learning goals. Teachers should consider providing feedback on assessment tasks – particularly after incorrect responses – in order to improve classroom performance in the future.

7. Students’ self-regulation assists learning and self-regulatory skills can be taught: Self-regulatory skills include setting goals for learning; such as planning, and monitoring progress; and self-reflection, which consists of making judgements about performance and self-efficacy in reaching goals. Self-regulatory skills include the regulation of motivation, which consists of students’ knowledge, monitoring, and active management of their motivation or motivational processing. Teachers can teach these skills directly to learners, by modelling strategies or coaching on their effectiveness. Teachers can also provide opportunities for learners to set goals and manage their attainment and for self-appraisal. A reflective community also can be established by teachers.

8. Missing from this paper

Principles 9-12: What motivates students?

9. Students tend to enjoy learning and perform better when they are more intrinsically than extrinsically motivated: Learners who are intrinsically motivated engage in academic tasks for the pure enjoyment of such engagement, and are more likely to achieve at higher levels and to continue engaging with activities in the future. Intrinsic motivation is linked to effective learning because students persist longer at tasks, experience lower levels of anxiety and develop positive competence beliefs. Learners who are extrinsically motivated engage in tasks in order to receive a reward or avoid a punishment, and are at risk for a number of problematic long term outcomes. Teachers can facilitate intrinsic motivation by de-emphasising high-stakes assessment, by allowing students to engage in projects they are interested in, encouraging students to take academic risks and by ensuring that students have enough time to engage with tasks.

10: Students persist in the face of challenging tasks and process information more deeply when they adopt mastery goals rather than performance goals: When teachers emphasise test scores, ability differences, and competition, students are more likely to adopt performance goals. Moreover, when test scores and grades are presented publicly, students are encouraged to focus on performance goals. In contrast, when teachers emphasise effort, self-improvement, and taking on challenges, students are more likely to adopt mastery goals. At the same time, they are likely to use effective and more complex cognitive strategies, to persist at challenging tasks, to report being intrinsically motivated, and to report feeling efficacious. Mastery goals are therefore more likely to be adopted when grades and test scores are shared privately and not compared across individuals.

11. Teachers’ expectations about their students affect students’ opportunities to learn, their motivation, and their learning outcomes: In classroom settings, teachers’ expectations for students’ successes and failures influence student achievement and motivation. When educators hold high expectations for their students, they often rise to the occasion and achieve at high levels (provided that the necessary support structures are in place). In contrast, when teachers hold low expectations for student success, students may come to believe that they lack skills and abilities, and thus confirm the teachers’ expectations. It is important to understand that teachers may interact differently with students, and provide differential instruction, based on their expectations for each student’s success or failure, regardless of how accurate those expectations are.

12. Setting goals that are short term (proximal), specific, and moderately challenging enhances motivation more than establishing goals that are long term (distal), general, and overly challenging: Goal setting is the process by which an individual sets a standard of performance and is important for motivation because students with a goal and adequate self-efficacy are likely to engage in the activities that lead to achievement of that goal. Three properties of goal setting are important for motivation. First, short-term goals are more motivating than long-term goals because it is easier to assess progress toward short-term goals. Students tend to be less adept at thinking concretely with respect to the distant future. Second, specific goals are preferable to more general goals because it is easier to quantify and monitor specific goals. Third, moderately difficult goals are the most likely to motivate students because they will be perceived as challenging but also attainable.

Principles 13–15: Why are social context, interpersonal relationships, and emotional well-being important to student learning?

13. Learning is situated within multiple social contexts.

14. Interpersonal relationships and interpersonal communication are critical to both the teaching–learning process and the social–emotional development of students.

15. Emotional well-being influences educational performance, learning, and development.

These principles are interrelated and are represented in theory and research relevant to schools as systems that support psychological (social and emotional) well-being as well as cognitive development and academic learning. According to developmental–ecological theory, the child or learner is best viewed as embedded within multiple social contexts or ecosystems (e.g., school, family, neighbourhood, peer group), that influence learning:

  • Microsystem: student-teacher and student-student interactions influence learning
  • Ecosystem: microsystem interactions occur within a school where policies and norms (teaching and learning practices and organisational structure) influence learning
  • Macrosystem: ecosystems interact (e.g. school and families) within a society which reflects culture, values and norms

These interactions within and between systems influence students’ learning significantly, and are documented more extensively in the article (pg. 61-62).

Principles 16–17. How can the classroom best be managed?

16. Expectations for classroom conduct and social interaction are learned and can be taught using proven principles of behaviour and effective classroom instruction.

17. Effective classroom management is based on (1) setting and communicating high expectations, (2) consistently nurturing positive relationships, and (3) providing a high level of student support.

Classroom management is a fundamental, bedrock set of
procedures and skills that establish a climate for instruction and learning. Class and school rules must be positively stated, concrete, observable, posted, explicitly taught, frequently reviewed, and positively reinforced. This allows students to learn the social curriculum in each classroom and enables teachers to develop classroom climates that maximise student engagement and minimises conflict and disruption.

Classrooms that are structured to offer multiple opportunities for students to respond facilitate the development of quality teacher–student relationships, which in turn lead to fewer behavioural problems and increased academic performance. Students who are at risk for classroom disruption may need more attention to relationship-building in order to develop and maintain connections in the classroom.

Culturally responsive classroom management is an approach that aims to actively engage students by offering a curriculum that is relevant to their lives. Teachers demonstrate a willingness to learn about important aspects of their students’ lives and create a physical environment that is reflective of students’ cultural heritage. Culturally responsive teachers understand the ways in which schools reflect and perpetuate discriminatory practices of the larger society and are characterised as “warm demanders”; “strong yet compassionate, authoritative yet loving, firm yet respectful”.

Finally, a high ratio of positive statements / rewards to negative consequences, and nurturing an atmosphere of respect for all students and their heritage, builds trust in the classroom that can prevent behavioural conflict.

Principles 18–20: how to assess student progress?

18. Formative and summative assessments are both useful, but they require different approaches: Formative assessments are carried out during instruction and are aimed at improving learning in the classroom setting. Summative assessments measure learning at a given point in time, usually at the end of some period of instruction where they are used to provide a judgement about student learning. The goal of both formative and summative assessments is to produce valid, fair, useful, and reliable information for decision making. Teachers can also use their understanding of assessment information to decide whether they covered the material that they intended to cover, or to judge how effectively they met the objectives for student learning.

19. Students’ skill and knowledge should be assessed with processes that are grounded in psychological science and that have provided well-defined standards for quality and fairness: Valid and reliable assessments enable teachers to make inferences about what students are learning. To understand the validity of an assessment, there are four question that need to be considered:

  1. How much of what you intended to measure is actually being measured?
  2. How much of what you did not intend to measure actually ended up being measured?
  3. What consequences, either intended or unintended, occurred with the assessment?
  4. Do you have solid evidence to support your answers to the first three questions?

Validity is a judgement, over time and across a variety of situations, about what inferences can be drawn from the test data, and the consequences of using the test. Valid assessment entails specifying what an assessment is supposed to measure. Teachers can improve assessment quality by aligning teaching and testing. However, they should also:

  • Be mindful that valid tests in one context may not be valid for another
  • Ensure that high-stakes decisions be based on multiple measures, not on a single test
  • Examine outcomes for any discrepancies in performance among different cultural groups

20. Good use of assessment data depends on clear, appropriate, and fair interpretation: Effective teaching depends heavily on teachers being informed consumers of educational research, effective interpreters of data for classroom use, and good communicators to students and their families about assessment data and decisions that affect them. The interpretation of assessments involves addressing the following questions:

  1. What was the assessment intended to measure?
  2. On what are comparisons of the assessment data based? Are students being compared to one another? Or, are responses being directly compared to samples of acceptable and unacceptable responses?
  3. Are scores being classified using a standard or cut point, such as letter grades, or another indicator of satisfactory/unsatisfactory performance?How were these standards set?

Awareness of the strengths and limitations of any assessment is critical. Such awareness enables teachers to make others aware of important caveats, such as the imperfect reliability of scores and the importance of using multiple sources of evidence for high-stakes decisions.


And there you have it. Twenty principles (19 without the one on fostering student creativity) on how best to go about enhancing teaching and learning practices in the classroom. While I don’t think it’s feasible to try and incorporate all of these principles in every classroom session, it’s definitely worthwhile having these at the back of your mind when planning assessment tasks, assignments, lectures and activities in class. I also recommend reading the whole paper which provides additional insight and links to further reading that would be useful to dig into.

Abstract

Psychological science has much to contribute to preK-12 education because substantial psychological research exists on the processes of learning, teaching, motivation, classroom management, social interaction, communication, and assessment. This article details the psychological science that led to the identification, by the American Psychological Association’s Coalition for Psychology in Schools and Education, of the “Top 20 Principles from Psychology for PreK-12 Teaching and Learning.” Also noted are the major implications for educational practice that follow from the principles.

Citation: Lucariello, J. M., Nastasi, B. K., Anderman, E. M., Dwyer, C., Ormiston, H., & Skiba, R. (2016). Science Supports Education: The behavioural research base for Psychology’s top 20 principles for enhancing Teaching and Learning. Mind, Brain and Education, 10(1), 55–67.

Teaching physiotherapy in Kenya

A few weeks ago I visited colleagues in the Physiotherapy Department at Jomo Kenyatta University in Nairobi. I was invited as an external examiner and also to give advice on their developing MSc programme, which they are going to offer with both online and face-to-face components. This is just a short post of a few things that struck me about what it’s like trying to teach physiotherapy in Kenya.

Until recently, Kenya, like most other African countries, did not offer a 4 year Bachelor’s degree in Physiotherapy. Many countries on the continent still only offer physiotherapy as a 3 year diploma. Over the past decade or so my university has been one of the few institutions in Africa that has worked with our international colleagues to upgrade their degrees from Hon to MSc – and sometimes to PhD. Those colleagues have then gone back to their own countries and developed their local programmes to offer both the BSc (Physiotherapy) degree, as well as to upgrade local colleagues from their Diploma to BSc (Hon).

What this means is that the four members of staff in this department run two curricula in parallel – one for the new BSc students and another for the Diploma upgrade students. There obviously isn’t enough time in the week for them to do this, which is why the Diploma upgrade programme runs on Friday evenings and weekends. Think about that. They’re so committed to improving the profession in their country that they work seven days a week. I wonder how that notion would be taken up by academic physiotherapists in South Africa.

Now, also consider the fact that they’re working on developing a new MSc programme. It’s not enough that they’re already working with two separate cohorts of students (BSc and Diploma-upgrade); they also want a group of postgraduate students…just to keep themselves busy in those few moments of the day when they’re not already teaching. And this is why they need to offer the course partly online; not be trendy or because “flipped classrooms” are in but because there simply isn’t enough space in the normal day for them to pack in more classes.

On one of the days I was there I spent an hour or so with their 3rd year class because the lecturers were still busy with a practical test that had gone on for more than 4 hours. The reason that it had gone on for so long is that there were only 2 lecturers available to do the test. They finished at 18:30. The attitude of the teachers in the department is that the work has to get done and that they’re the only ones to do it, so there’s no point in complaining because complaining just takes up more time. There simply is no other option. And this is not unusual in the African context. There is one other university in the country that offers physiotherapy, and their situation is no different to JKUAT. And, from what I understand, these two departments are better off than many others on the continent.

What really struck me when I left Kenya was the fact that, no matter what challenges we might face in my own department, we cannot really understand the difficulties that our colleagues across Africa are dealing with in their physiotherapy programmes. While we complain about the fact that our air conditioning unit is broken, they don’t have lights in some parts of the building. It really reminded me, in a very physical way, that teaching is not about the equipment or access to resources. Yes, those things are important but what matters most of all is the commitment of the teachers to the students, and their passion for the profession.

All in all, I had a wonderful time in Nairobi. Everyone was incredibly friendly and welcoming and made we feel so very welcome. But most of all I was impressed at the level of professionalism and motivation shown by my colleagues in the Physiotherapy Department at JKUAT. I look forward to going back next year.

Some thoughts on education from two interviews

I spend a lot of time listening to podcasts on my hour long commute to work every day. One of my favourite series is the Tim Ferriss Show, because I get a lot of insight into my own academic practices from listening to these high performers from other domains. Earlier this week I listened to Tim interview Chris Sacca and Eric Weinstein. The quotes from the interviews that resonated with me are presented below (note: listening to a few minutes of audio is very different to transcribing and reading that audio…this took much longer than expected).

Chris Sacca on Shark Tank, Building Your Business, and Startup Mistakes:

Question: If you were to start your own school to educate youth, how would you do it? What would you concentrate on? How much would you pay the teachers? Is education the answer to the world’s problems?

Answer: Presuppose that you weren’t using schools to just train your kids to be “successful”. Think about how the purpose of education up to this point has always been: Do well in school and you can get into a great college. Get into a great college and you can get into a great grad school and then you can get a great job. And that has been the baseline underlying assumption for our education system for at least a generation now…probably two.

And yet, imagine if that weren’t the case. I was lucky. I went to one of the most competitive schools in the country. Among my peers were kids who went to all the fanciest boarding schools, all the best prep schools, all the best high schools. I went to a public high school. I went there with trepidation, assuming that I would get trampled by these kids. And, while their life experiences were certainly more diverse and exciting than mine because they had money to do all kinds of cool things, and they had AP classes that I didn’t necessarily have, spending time with them I realised that their world views were incredibly narrow. Most of them had never lived or worked among poor people. Most of them hadn’t actually volunteered. Most of them hadn’t had service jobs, tipping jobs. They hadn’t worked manual labour. The same went on when I worked out in Silicon Valley with top Harvard and Stanford grads at Google and beyond, all across the valley. The same kind of thing…I found people who were incredibly “successful” and yet had very uni-dimensional lives.

So, back to your question: if I were to start my own school…What if you started a school that pre-supposed the goal was: Happy kids. And I mean Happy with a capital H. Balanced. Thoughtful. Compassionate. Do-ers. What if their resume would never matter. Some of you have heard me say before, that the only people who care about your GPA are people who you’ve given no other basis to evaluate you.

What if, instead you wanted to build an education that fostered: Interesting. Understanding. Action. Experience. I don’t know what that school looks like but that’s how my wife, Crystelle and I have been approaching raising our three daughters. I’ve yet to see test scores correlate with happiness. I’ve yet to even see test scores correlate with Learning, with a capital L. So I don’t know what I would do to re-invent the education system or any particular school, but it’s certainly top of mind for me.

 

Eric Weinstein on Challenging “Reality,” Working with Peter Thiel, and Destroying Education to Save It:

Question: If you had to create a class for any grade level from 9th grade to the end of college, what would the class be and when would you teach it?

Answer: Part of the problem surrounds, where would I be allowed to teach this class? The first question is: Are you really allowed to deeply question your teacher, or your school?…What you’re always looking for, is an education that makes students unteachable by standard methods. And this is where we get into the trouble, which is…we don’t talk about teaching disabilities, we talk about learning disabilities. And a lot of the kids that I want are kids that have been labelled learning disabled but they’re actually super-learners.

They’re like learners on steroids that have some deficits to pay for their super-power. When teachers can’t deal with this, we label those kids “learning disabled” to cover up for the fact that the economics of teaching require that one central actor – the teacher – be able to lead a room of 20 or more people in lock step. Well, that’s not a good model.

What I want, is to get as many of my dangerous kids out of that idiom, whether it requires dropping out of high school, dropping out of college…not for no purpose. Drop into something. Start creating. Build it. Join a lab. Skip college.

Note: Eric Weinstein works at Thiel Capital, which is linked to the Thiel Foundation that provides a fellowship for students to drop out of college and work on projects they care about. So, his point about dropping out of, or skipping college, needs to be considered in that light.

Introducing the Humanities into physiotherapy education

This post has been modified and published on The Conversation: Africa as Physiotherapy students have much to learn from the humanities.

Selection_018I’m increasingly drawn to the idea of integrating some aspect of the Humanities into undergraduate physiotherapy education. We focus (almost) all of the curriculum on the basic sciences and then the clinical sciences, which has a certain pragmatic appeal but ignores the fact that a person is more than an assemblage of body parts. We spend a lot of time time teaching anatomy and biomechanics (i.e. bodies as machines), and then exploring what we can do to bodies in order to “fix” them. While we pay lip service to the holistic management of the patient, there is little in our curriculum that signals to the student that this is something that we really care about.

“Science is the foundation of an excellent medical education, but a well-rounded humanist is best suited to make the most of that education.”

Empathy is critical to the development of professionalism in medical students, and the humanities – particularly literature – have been touted as an effective tool for increasing student empathy. In addition, there is some evidence that training in the Humanities and liberal arts results in health professionals with improved professionalism and self-care. In other words, health professionals who are exposed to the arts as part of their undergraduate education may demonstrate an increased ability to manage themselves and their patients with more care.

Hilary Allen_Artist in Residence 2015_1000

The relationship between emotion and learning has also been explored, with findings from multiple disciplines supporting the idea that emotion is intimately and inseparably intertwined with cognition in guiding learning, behaviour and decision making. The introduction of the Humanities in health professions education therefore has another potential impact; by using the arts to develop an awareness of emotional response, educators and students may find that exposure to the Humanities might lead to improvements in learning.

As I started looking into these ideas in a bit more detail, I realised that there are several examples of how art and literature are being explored formally by some very prominent medical schools.

dancingwheelsI was disappointed – although not surprised – not to find any good examples of physiotherapy departments who have formally integrated the Humanities into their curricula. However, I did find several papers (all by the same author with various colleagues) that describe a process of integrating these concepts into an undergraduate physiotherapy programme over a period of time, and these are listed in the references below.

avery_hosp_ward_low_resOver the past year or so, I’ve tried to bring some of these ideas into my Professional Ethics module, using the assignments for students to explore the Humanities (art, literature, theatre, music, dance, etc.) as a process of developing a sense of awareness of empathy in the context of clinical education. They can interpret the assignment in any way they want, for example, by writing a poem, drawing a picture, taking a photo, or re-interpreting a song. However, the important part is the reflection that they attach to the piece. Here are some examples of previous student work in this module, without the more personal reflections that accompany them.

  • Eleven hundred hours – poem by a student
  • The mind of the innocent – poem by a student
  • I’ve had two students provide videos of interpretive dance sessions used as methods to try and present an embodied experience of what it might be like to live with a disability.
  • Photovoice assignments (see below for examples): in these assignments students took photos of people and places and then reflected on how those experiences had informed their personal and professional development as ethical practitioners.

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I’m hoping to get some experience with this process as part of these little experiments I’m running in the classroom, and that over time we can start building something more formal into the curriculum. Watch this space.

Additional readings

Technology will make lecturers redundant – but only if they let it

Technology will make lecturers redundant — but only if they let it

This article was originally published on The Conversation. Read the original article.

A teacher walks into a classroom and begins a lesson. As she speaks, the audio is translated in real time into a variety of languages that students have pre-selected, so each can hear the lecturer’s voice in their own language. It can even be delivered directly into their auditory canal so that it does not disturb other students. The lecturer’s voice is also transcribed in real-time, appearing in a display that presents digital content over the students’ visual field.

As the lesson progresses, students identify concepts they feel need further clarification. They submit highly individual queries to search engines that use artificial intelligence algorithms to filter and synthesise results from a variety of sources. This information is presented in their augmented reality system, along with the sources used, and additional detail in the form of images and animations.

microsoft-hololens-medical-studies

All of the additional information gathered by students is collated into a single set of notes for the lesson, along with video and audio recordings of the interactions. It’s then published to the class server.

This isn’t science fiction. All of the technology described here currently exists. Over time it will become more automated, economical and accurate.

What does a scenario like the one described here mean for lecturers who think that “teaching” means selecting and packaging information for students? There are many excellent theoretical reasons for why simply covering the content or “getting through the syllabus” has no place in higher education. But for the purposes of this article I’ll focus on the powerful practical reasons that lecturers who merely cover the content are on a guaranteed path to redundancy.

The future isn’t coming – it’s here

The technology described above may sound outlandish and seem totally out of most students’ reach. But consider the humble – and ubiquitous – smartphone. A decade ago, the iPhone didn’t exist. Five years ago most students in my classes at a South African university didn’t have smartphones. Today, most do. Research shows that this growth is mirrored across Africa. The first cellphones were prohibitively expensive, but now smartphones and tablets are handed out to people opening a bank account. The technology on these phones is also becoming increasingly powerful, and will continue to advance so that what is cutting edge today will be mainstream in about five years’ time.

This educational technology can change the way that university students learn. But ultimately, machines can’t replace teachers. Unless, that is, teachers are just selecting and packaging content with a view to “getting through the syllabus”. As demonstrated above, computers and algorithms are becoming increasingly adept at the filtering and synthesis of specialised information. Teachers who focus on the real role of universities – teaching students how to think deeply and critically – and who have an open mind, needn’t fear this technology.

Crucial role of universities

In a society where machines are taking over more and more of our decision-making, we must acknowledge that the value of a university is not the academics who see their work as controlling access to specialised knowledge.

Rather, it’s that higher education institutions constitute spaces that encourage in-depth investigation into the nature of the world. The best university teachers don’t just focus on content because doing so would reduce their roles to information filters who simply make decisions about what content is important to cover.

Digital tools are quickly getting to the point where algorithms will outperform experts, not only in filtering content but also in synthesising it. Teachers should embrace technology by encouraging their students to build knowledge through digital networks both within and outside the academy. That way they will never become redundant. And they’ll ensure that their graduates are critical thinkers, not just technological gurus.The Conversation

What does it mean to be a book?

Recently I’ve been thinking about what it means to be a book. What makes a book, a “book”? I’m willing to bet that when you see the word “book” you think of a physical container for words that are printed on paper, bound within covers and sits on a bookshelf. Wikipedia agrees with you:

A book is a set of written, printed, illustrated, or blank sheets, made of ink, paper, parchment, or other materials, fastened together to hinge at one side. A single sheet within a book is a leaf, and each side of a leaf is a page.

It seems that the physicality of a book has a lot to do with its book-ness. In other words, when we think of a book it’s usually as something that we can hold. This makes sense in a historical context because writing in books was an evolution of previous systems that allowed the recording of words and ideas onto some kind of natural material e.g. tablets (clay, not Apple). When you actually think about it, maybe the only reason we think of books as printed collections of words is because for the past several hundred years that’s all they were. Maybe we think of a book as a collection of words printed on bound paper because that is all we have ever known a book to be.

If we consider the design principle that form should follow function we see that the purpose of a thing should define it’s form. In other words, if the purpose of a book is to record and preserve ideas with the intent of sharing them at scale with others, then we should choose a form that allows us to most effectively achieve that function. For most of our recent history, printing words onto paper was pretty much the only way that complex ideas could survive the death of a person. While oral traditions of preserving and sharing ideas are also valid, they don’t scale when it comes to sharing with very large numbers of people.

We should be asking what technology currently exists that enables books to take on a form that allows them to better achieve the function of storing and sharing ideas at scale over extended periods of time? Why do we still think of a “book” as a thing that sits on a shelf, when digital tools enable us to create new forms of books that are better suited to achieving their function. And I’m not talking about PDFs as digital versions of books. The PDF version of a printed book differs only in degree from the printed version and its fundamental properties are generally the same. For example, the PDF is “better” than the print version because we can make more copies at a lower cost. This property makes the cost of distribution (i.e. copying) of PDFs essentially zero. But besides decreasing the cost of efficient distribution, how else is the PDF of a book different to a printed book?

digital-book

What if “books” could be more than a collection of printed pages (whether the “print” and “page” is ink- or pixel-based)? What if, instead of thinking of books in terms of their physical properties (i.e. what they look and feel like) we think of them in terms of collections of ideas that are stored and shared over time (i.e. what books are for)? Now we’re talking about separating the function of a book from its form, and digital technology is inherently suited for this. In the default idea of “book”, form and content are intricately tied together. Words are collected into sentences, paragraphs and chapters, and printed onto pages. The words and the pages are inseparable.

“Digital” allows us to abstract ideas out into smaller collections (much smaller than chapters), which can be shared, modified and repurposed far more easily than 20 printed pages collected into a chapter. Instead of thinking of words, sentences and paragraphs as collections in a chapter, we can think of them as discrete ideas – down to the “word” level – which can then be categorised and presented as such. It means that we could, for example, allow for readers to search for ideas and abstract concepts, rather than just words. Imagine putting together a custom textbook that is made of excerpts or ideas from a variety of other books that are created this way, in a similar process to what we can currently do with books created in Wikipedia. Imagine if readers could download and share, not only single chapters of a book, but single ideas?

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“Digital” means that we can separate the form and content of writing so that we can focus on creating content leaving computers to focus on form. Machine readability is what allows me to write a blog post in plain text and leave the formatting and presentation of my content to the WordPress theme that I have installed on my blog. It’s what allows my content to show up, stripped of formatting and design, in your Pocket reader when you save it to read later. It’s what allows you to subscribe to my posts and have my content show up in whatever format and device you choose to receive it in.

Machine readability allows affordably serving the information to a wider variety of users (in a presentation that they can understand), where users may be humans or machines. This requires the ability to recast abstractions in new instances quickly and cheaply (that is, without time-consuming reworking), which generally requires automation rather than person-hours of labor.

Responsive design is the idea that content will take the form of whatever device you’re using to access it, and has become a foundational principle of modern digital design. If you’re a content creator, you need to ensure that your work is going to take whatever form the content consumer requires it to. If they’re on a 20 inch monitor, it needs to look as good as it does on a 4 inch phone screen. Try making a PDF do that.

triveo-media-responsive-design

This is the power of separating out content and presentation. How a thing looks is different to what it does. So we come back to the idea that a book is a container of ideas, not words, which means that the way in which the ideas are expressed, stored and shared need have nothing to do with the ideas themselves. A book therefore, does not actually need to be a book.

Now that we’ve separated form from function, what does that allow us to do with the “collection of ideas” (i.e. the book)? Well, for one thing, it removes the requirement that ideas are presented linearly. When you can break up the ideas into discrete items, they can be remixed, distributed and presented in non-linear ways e.g. using hyperlinks to connect different ideas in different places. It also means that the “book” can be presented and shared as either a physically printed volume, an ebook, an audiobook, a website, an RSS feed or an email newsletter.

By using digital tools, we lose nothing (we can still print the book) and gain several advantages that print simply cannot provide. For example, you could make sections of the book available to be distributed as embedded content or as streams of content (via RSS) rather than PDF pages. One practical benefit of this is that further distribution is possible in very simple ways. Just like a tweet can be embedded in any website, a section of content from the book could be embedded into any other media. Think what this would mean for generating discussion and debate around your content, as opposed to emailing a PDF of a whole book around.

cards_image_976x298

Finally, on a more pragmatic level publishing a book – not just as an ebook but also as a website, RSS feed, or mobile app – provides the following benefits:

  • You can include animations, audio interviews, linking out to external content, and embedding videos.
  • Digital text can be converted to audio via text-to-speech software, creating access for people with disabilities.
  • The separation of content and presentation means that you could edit and update content via a content management system, which means that errors can be corrected at no cost, and the updated content is propagated through the system, changing automatically whenever it is viewed.
  • New chapters could be added or modified over time at no cost. There would be no need for updated editions that are distributed in cargo containers to other countries because every instance of the “book” is the most up-to-date version.

Taking all of the above into account, what is the value of publishing a physical book in hard copy? I honestly can’t think of any reasons that are not rooted in legacy or simple momentum, for us to seriously consider printing words onto paper, binding them together and shipping them around the world. I think that in order for us to most effectively share our ideas with others is to ask what it means – in a digital age – to be a book?

First draft of article on Informed Consent for the Clinical Teacher

Featured image “Diverging paths” by SDJ on Deviant Art.

I’ve just finished the first draft of my 13th article in the Clinical Teacher mobile app. It’s been a LONG time since I’ve managed to put some effort into this project, mainly for personal reasons (my second daughter was born in March last year and we moved house in September) but also because I found 2015 to be a very challenging year in terms of prioritising my writing projects (I have another post in progress where I talk about some new strategies for prioritisation in my workflow).

Anyway, here is the draft of my article on Informed Consent, which I’ll be publishing in the app within the next couple of weeks.

Introduction

A successful relationship between patient and health care practitioner is based on trust, which is developed partly by respecting the autonomy of the patient i.e. their right to make their own decisions about their bodies. Informed consent is the exercise of informed choice by a patient who has the capacity to give consent and is therefore a component of developing a trusting relationship between patient and therapist (Wilders, 2013). Patients need complete and honest information about various aspects of their health care, including diagnosis, prognosis, treatment options, likely treatment outcomes, common or serious side effects, and the timescale of the treatment in order for them to give their informed consent (Tippet, 2005).

Informed consent

The patient is the one who determines what is in their best interests, not the practitioner. Practitioners may recommend a course of action but should not pressurise patients to accept their advice. The practitioner must ensure that their opinion is a balanced point of view, providing the patient with enough detail from the various perspectives that they are able to give their own, voluntary consent. It is possible for patients to nominate a third party (provided they are still competent to make such a decision) to give consent on their behalf. This must be provided by the patient in writing.

Health care professionals must be confident that they have received consent from a patient – or other valid authority – before they perform an examination or investigation, provide treatment, or involve patients in teaching and research (General Medical Council, 2008). It should be based on the sharing of correct information, appropriate communication, and understanding and agreement on the part of the patient. In order for the process of informed consent to be correct and legal, the patient must have (Wilder, 2013):

  1. Knowledge of the nature or extent of the harm or risk
  2. Appreciated and understood the risk
  3. Consented to the risk
  4. The consent must have been comprehensive

All aspects of health care involves decision-making by patients and healthcare providers and the principles of informed consent apply to those decisions, from the treatment of minor conditions, to major interventions with significant risks or side effects. Whatever the context in which medical decisions are made, the health care professional must work in partnership with patients to ensure appropriate care. In order to achieve this, you should (General Medical Council, 2008):

  • Listen to patients and respect their views about their health
  • Discuss patients’ diagnosis, prognosis, treatment and care with them
  • Share the information that patients want or need in order to make decisions about their health
  • Maximise patients’ opportunities, and their ability, to make decisions for themselves
  • Respect the decisions that patients make

Written consent

Patients can express consent either orally or in written form. However, it is strongly recommended that consent be obtained in writing. This can be done either in the case notes, or on a specific consent form. The consent form should contain the information provided to the patient, specific requests by the patient and the scope of the consent given.

Once written consent has been given once, the practitioner can simply remind patients of the initial instance, if they present at a later date with a similar condition. However, this consent should be revisited regularly to ensure that the patient is still comfortable with the procedure. Verbal reminders and responses should still be noted in writing in the patient’s file. When a patient presents with a new condition, fresh consent must be obtained and appropriately documented.

Implied consent

Practitioners should use caution if relying on a patient’s compliance with a procedure as an indicator of consent because submission in itself may not indicate consent (Wilder, 2013). Just because a patient goes along with what is happening, does not mean that they understand the nature, extent and risks that are associated with it. Consent must be expressed explicitly at all times.

Sharing information

Informed consent is premised on the concept of sharing information with the patient. There is no single approach that will suit every patient, or apply in all circumstances. Some patients may want more or less information or involvement in the decision making process, depending on their needs. In addition, some patients may need additional support to understand information and express their views and preferences (General Medical Council, 2008).

The way you choose to discuss the various aspects of a patient’s condition, including diagnosis, prognosis and the treatment options that are available, can be just as important as the information itself (General Medical Council, 2013). When sharing information with a patient (or their family), you should:

  • Share information in a way that the patient can understand and when possible, in a place and at a time when they are best able to understand and retain it.

  • Be considerate when sharing information that the patient may find distressing.

  • Involve other members of the healthcare team in discussions with the patient, if this is appropriate.

  • Give the patient time to reflect, before and after they make a decision, especially if the information is complex or what you are proposing involves any risk.

  • Make sure the patient knows if there is a time limit on making their decision, and who they can contact if they have any questions or concerns.

  • Give information to patients in a balanced way. For example, if you recommend a course of action, you should explain your reasons for doing so but also be aware of putting unnecessary pressure on a patient to accept your advice.

  • Support your suggestions with written material or other visual aids (make sure the information is accurate and up to date).

  • Check to determine if the patient needs any additional support in order to understand the information you shared, to communicate their wishes, or to make a decision.

Bear in mind that some barriers to understanding and communication may not be obvious. For example, a patient may have certain anxieties that they have not mentioned before, or may be affected by pain or other underlying problems. Support for patients might include using an advocate or interpreter, asking those close to the patient about the patient’s communication needs, or giving the patient a written or audio record of the discussion and any decisions that were made.

The information provided to the patient should include the following:

  • The nature and extent of the procedure, using language that the patient understands
  • Whether students will be involved in the procedure, and the extent to which they will be involved
  • Reminders that the patient can withdraw consent at any time i.e. change their minds
  • Reminders that the patient can seek a second opinion
  • Details of the costs applicable (if relevant)

Possible reasons for not sharing information

Remember that patients are vulnerable and that overzealous truth-telling may be harmful to them. As a result they have an equal right to refuse to receive information about themselves and their condition (Tippet, 2005). From the General Medical Council (2008): “You should not withhold information necessary for decision making unless you judge that disclosure of some relevant information would cause the patient serious harm”.

If a patient has the capacity to make their own decisions but appears to not want to have relevant information shared with them, the health care practitioner should consider the following steps (General Medical Council, 2008):

  1. No-one else can make a decision on behalf of an adult who has the capacity to give their consent. If a patient asks you to make decisions on their behalf or wants to leave decisions to a relative, partner, friend, carer or another person close to them, you should explain that it is still important that they understand the options open to them, and what the treatment will involve. If they do not want this information, you should try to find out why.

  1. If, after discussion, a patient still does not want to know in detail about their condition or the treatment, you should respect their wishes, as far as possible. But you must still give them the basic information they need in order to give their consent to a proposed investigation or treatment.

  1. If a patient insists that they do not want even this information you must explain the potential consequences of them not having it, particularly if it means that their consent is not valid. You must record the fact that the patient has declined this information making it clear to them that they can change their mind at any time.

  1. You should not withhold the information that is necessary for making decisions for any other reason, including when a relative, partner, friend or carer asks you to, unless you believe that giving it would cause the patient serious harm. In this context serious harm means more than the patient simply becoming upset or deciding to refuse treatment.

  1. If you withhold information from the patient you must record your reason for doing so in the patient’s medical records and be prepared to explain and justify your decision. You should regularly review that decision and consider whether you could give information to the patient later, without causing them serious harm.

Obstacles to sharing information

Because of time or resource limitations, it might be difficult to give patients as much information or support in the decision making process as you, or they, would like. To help with this, consider the role that other members of the healthcare team might play and what other sources of information and support are available. For example, do you have access to patient information leaflets, advocacy services, expert patient programmes, or support groups for people with specific conditions?

Do your best to make sure that patients with additional needs, such as those with disabilities, have the time and support they need to make a decision. In all cases, treat patients fairly and make sure that you do not discriminate against them by providing them with less detailed information than you might do for others. If you believe that limits on your time or the information that is available for patients is compromising their ability to make an informed choice, you should raise your concerns with your line manager or other authority (General Medical Council, 2008).

Conditions for consent

In order for a patient to give valid informed consent, there are three components that must be present; disclosure, capacity and voluntariness (Faden & Beauchamp, 1986). Disclosure requires the therapist to provide the patient with the necessary information to make an independent decision. However, it is not enough that the therapist merely provides the information; they must also ensure that the patients have adequate comprehension of the information they provide. This latter aspect of the process implies that the consent form be written in language that is understandable by the general population, in addition to determining the level of the patient’s understanding during the initial assessment. Capacity refers to the ability of the patient to both understand the information provided and to subsequently form a reasonable judgement of the potential consequences of their decision. Finally, voluntariness refers to the patient’s right to freely exercise their decision-making without being subjected to external pressure such as coercion, manipulation, or undue influence (Beauchamp & Childress, 1994).

Capacity to give informed consent

In order to give consent patients must be able to understand the procedure that is being recommended, apply reasoning to consider the consequences of the procedure and its alternatives, appreciate the way in which this information applies to them, and be able to make a subsequent logical choice. Although psychiatric illness, in and of itself, does not change the presumption that an individual is competent, a patient’s ability to appreciate the consequences of a particular decision maybe shaped by specific mental symptoms. Thus, cognitive deficits (e.g., due to dementia or associated with depression) can impair the ability to recall and understand information about the procedure, suicidal ideas can affect perceptions of mortality risks, and the ambivalence and indecision that often occurs with depression can limit patients’ ability to make a choice about treatment. If a patient lacks decisional capacity, substituted consent (possibly by a family member) or a judicial hearing may be necessary (Lapid, Rummans, Pankratz & Appelbaum, 2004).

Therapists must always work from the premise that every adult patient has the capacity to make decisions about their health. This includes the ability to make decisions about whether to agree to, or refuse, an assessment, investigation or treatment. You should only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes. It is essential that the therapist does not make the assumption that a patient lacks the capacity to make a decision because of their age, a disability, their appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with (General Medical Council, 2008).

If patients are not able to make decisions for themselves, the health care professional must work with those who are close to the patient and with other members of the team. They must take into account those views or preferences that were expressed by the patient and must also be aware of the legal context when a patient lacks the capacity to make their own choices (General Medical Council, 2008).

Children and informed consent

As children often lack the ability or legal power to provide true informed consent for medical decisions, it falls on parents (or legal guardians) to provide permission for medical assessments or procedures to be conducted on children. This “consent by proxy” usually works reasonably well but can lead to ethical dilemmas. This is particularly true when the judgement of the guardians differ with the therapist with regard to what constitutes an appropriate decision.

Children who are legally emancipated and unemancipated minors who are deemed to have medical decision making capacity, may be able to provide consent without the need for parental permission, although this depends on the laws of the country the child lives in (Committee on Bioethics, 1995).

Children are usually presumed to be incompetent to consent, but depending on their age and the influence of other factors, they can sometimes be asked to provide Informed assent.

Informed assent means a child’s agreement to medical procedures in circumstances where he or she is not legally authorised or lacks sufficient understanding for giving consent competently.

De Lourdes Levy, Larcher & Kurz (2003)

Medical professionals are advised to seek the assent of older children and adolescents by providing age appropriate information to these children to help empower them in the decision-making process (Committee on Bioethics, 1995). It should be noted that only legal guardians are able to provide informed consent for a child, and not adult siblings. In addition, parents may not order the termination of a treatment that is required to keep a child alive even if they feel it is in the best interests of the child.

Responsibility for seeking consent

It is the responsibility of the practitioner who will be providing the treatment, to obtain consent, since they will have a comprehensive understanding of the process, how it is to be carried out and the risks involved. In cases where the responsibility to obtain consent must be delegated to another party, they must ensure that the person they are delegating to:

  • Is suitably trained and qualified to take on the responsibility
  • Has sufficient knowledge of the investigation or treatment, and understands the risks involved
  • Understands, and agrees to act in accordance with established guidelines and legal frameworks that are related to issues of informed consent

If you delegate the responsibility of seeking consent to another party, you are still responsible for ensuring that the patient has been given enough time and information to make an informed decision, and has given their consent, before you start any investigation or treatment (General Medical Council, 2008).

Informed consent in research

Medical research is overseen by an institutional ethics committee that usually also oversees the informed consent process as part of any research project involving human beings or animals. Ethics clearance is applied for by researchers via a detailed proposal document, that lays out in detail – among other things – the ways in which the ethics inherent in the project are being considered.

Differences in local contexts (e.g. language and social norms) make the issue of informed consent in research a complex topic. There are five benchmarks for evaluating informed consent procedures in local contexts, with particular reference to developing countries (Emanuel, Wendler, Killen & Grady, 2004):

  1. The community should be involved in drawing up recruitment and incentive procedures that are consistent with local cultural, political and social practices. For example, in some cultures an incentive might be expected, while in others it could be considered offensive.

  2. Disclosure of information should be sensitive to the local context, using local languages, culturally appropriate idioms, and analogies that the local population will understand.

  3. Researchers may need to obtain consent from a range of different “spheres”, including community leaders, elders or other respected community members, and the heads of family. Note that this is not to imply that these individuals grant consent on behalf of other adults, only that they give permission for the researchers to enter the community.

  4. Researchers should use informed consent procedures that are contextually acceptable within a community but which also enable independent observers to verify that voluntary consent was obtained.

  5. Individuals must be made aware that their right to refuse to participate, or to withdraw from the study is actually enforced. Community or familial coercion or retribution needs to be guarded against, especially if compensation for participation is offered.

The World Health Organisation (WHO) has published a series of templates for Informed Consent in a variety of contexts, including research that involves children requiring parental consent, qualitative and clinical studies. These templates may be used to guide principal researchers as they develop an approach to informed consent in their research practices.

Seeking consent in the research process brings with it another set of challenges, especially in the social sciences where there is often little or no risk to participants. In addition, the fact that participants are aware that they are involved in a study may cause them to change their default behaviour (the Hawthorne Effect). In cases where the researcher is concerned that seeking consent will modify the outcomes of the study, the requirement for consent may be waived. However, this is only done after an Ethics Committee has weighed the possible risk to the study participants versus the benefit to society, as well as whether participants are present in the study of their own will and that they will be treated fairly.

Reviewing consent

Informed consent – especially in the clinical context – should be thought of as an ongoing dialogue between patient and healthcare practitioner (Emanuel, et al., 2004). The decision made by the patient should be reviewed at different points before treatment begins, to ensure that the patient’s point of view is consistent and can therefore be relied on. Before beginning treatment you or a member of the healthcare team should check that the patient still wants to go ahead and you should respond to any new or repeated concerns or questions they raise. This is particularly important if:

  1. A significant amount of time has passed since the initial decision was made.
  2. There have been material changes in the patient’s condition, or in any aspect of the proposed investigation or treatment.
  3. New information has become available, for example about the risks of treatment or other treatment options.

You need to make sure that patients are kept informed about the progress of their treatment and that they are able to make decisions at all stages, not just in the initial stage. If the treatment is ongoing you should make sure that there are clear arrangements in place to review decisions and if necessary, to make new ones (General Medical Council, 2008).

Conclusion

Informed consent is an essential aspect of clinical practice and medical research. The process of sharing relevant information with a patient to ensure that they can make an informed choice about their bodies and their health, is a central principle of ethics. Patient autonomy is premised on the idea that they – not the healthcare practitioner – are best positioned to make decisions about the relative risks and benefits of choosing a particular course of action.

Sharing information is an important aspect of consent, although what information to share, how much and when, are sometimes difficult to determine, especially in cases where patients are not competent. It is the responsibility of the healthcare practitioner to ensure that consent is obtained before proceeding down a particular path of management, and in cases where the actual process is delegated, it is the practitioners responsibility to ensure that the person the task is delegated to is trained to carry it out.

Seeking informed consent is complex, time consuming, possibly frustrating, and may even require health professionals to reconsider the role of power in their patient relationships. However, not only is it a legal requirement to involve the patient in decision-making around management, but it is a foundational ethical principle to adhere to in clinical practice.

References

Beauchamp, T.L. & Childress, J.F. (1994). Principles of Biomedical Ethics (4th edition). New York: Oxford University Press.

Committee on Bioethics (1995). Informed consent, parental permission, and assent in pediatric practice. Pediatrics, 95(2):314-7.

De Lourdes Levy, M., Larcher, V., & Kurz, R. (2003). Informed consent / assent in children. Statement of the Ethics Working Group of the Confederation of European Specialists in Paediatrics. European Journal of Pediatrics. 2003 Sep;162(9):629-33.

Emanuel, E. J., Wendler, D., Killen, J., & Grady, C. (2004). What makes clinical research in developing countries ethical? The benchmarks of ethical research. The Journal of infectious diseases, 189(5), 930–7.

Faden, R.R. & Beauchamp, T.L. (1986). A History and Theory of Informed Consent. New York: Oxford University Press.

General Medical Council (2008). Consent guidance: patients and doctors making decisions together.

Health Professions Council of South Africa (2008) Ethical rules, regulations and policy guidelines: Informed consent.

Lapid, M.I., Rummans, T.A., Pankratz, V.S. & Appelbaum, P.S. (2004). Decisional capacity of depressed elderly to consent to electroconvulsive therapy. Journal of Geriatric Psychiatry and Neurology, 17(1):42–46.

Spandorfer, J., Pohl, C. A., Rattner, S. L., & Nasca, T. J. (2010). Professionalism in medicine: A case-based guide for medical students. Cambridge University Press.

Tippett, V. (2005). “Trust me…I’m a medical student”: Truth and trust for student doctors. The Clinical Teacher, 2(1), 21–24.

Wilder, C. Seeking patients’ informed consent: The ethical considerations. Health Professions Council of South Africa news bulletin, March, 2013

World Health Organisation (n.d.). Informed Consent form templates.

Knowledge translation frameworks: Narrowing the gap between evidence and practice

There is a large gap between what we know and what we practice and the way to narrow that gap is not always clear, especially in the context of clinical practice where clinical guidelines are often ignored by healthcare professionals. There is often considerable time that elapses before research findings are transferred to common practice.

Various strategies are used to try and bring about a movement towards evidence-based practice and associated change in practitioners’ behaviour. These include Continuing Medical Education (CME), Continous Professional Development (CPD) and Knowledge Translation (KT). KT has been positioned as a construct that subsumes and builds upon CME and CPD, minimising the limitations of those approaches, as well as offering new insights into behavioural change (Davis, et al., 2003). See pg. 34 of Davis, et al. (2003) for a table comparing the basic characteristics of CME, CPD and KT.

For example, workshops are often suggested as possible ways to help implement change by inviting stakeholders and getting them to participate in discussion around the change. However, workshops in the context of CME and CPD are either teacher- or learner-focused and relatively rarely include the patient or health systems context. In addition, change is a process and not an event, which may be another reason for why workshops often don’t work in this context. It seems clear that logic and pragmatism are not necessarily the best way to implement and drive change in clinical practice and knowledge translation frameworks show some promise as potentially useful tools to help guide the process.

The effectiveness of strategies that aim to bring about behavioural change is highly variable and dependent on the setting, and success is often determined by whether or not the strategies have been appropriately tailored to the unique context of the setting (Santesso & Tugwell, 2006). The Ottawa Model of Research Use (OMRU) is one example of a KT framework that incorporates this concept, as well as having an interdisciplinary focus. It consists of six elements:

  1. Setting the stage
  2. Specify the innovation
  3. Assess the innovation, potential adopters and the environment for barriers and facilitators
  4. Select and monitor the knowledge translation strategies
  5. Monitor innovation adoption
  6. Evaluate outcomes of the innovation

Underlying the OMRU model is the idea that success rests with tailoring the KT strategies to the relative barriers and supports that are found within the setting in which behavioural change is sought (Santesso & Tugwell, 2006).

Knowledge translation encourages the integration of insights and experiences from many disciplines, including informatics, social and educational psychology, organisational theory, and patient and public education. This means that the approach incorporates a range of perspectives beyond what healthcare professionals are able to provide on their own, with the possibility for more diverse and creative solutions to arise. This seems prudent since the most effective strategies for behavioural change tend to be those that are more active in nature, and which incorporate multiple interventions (Davis, et al., 2003).

Graham et al., (2006, pg. 22) offer the following practice points regarding KT:

  1. Knowledge translation is about turning knowledge into action and encompasses the process of both knowledge creation and knowledge application.
  2. Knowledge translation subsumes and builds on continuing education and continuing professional development.
  3. Healthcare professionals need to learn about planned-action theories and frameworks so as to be able to understand and influence change in their practice settings.
  4. Continuing education should be based on the best available knowledge, whether in the form of knowledge tools (e.g. practice guidelines), knowledge syntheses, or primary knowledge enquiries.
  5. Continuing education should apply strategies known to be effective at transferring knowledge.

It should be noted that, while KT seems to show some promise for changing clinician behaviour when it comes to adopting evidence-based practices in healthcare, there are some limitations to the approach, including the fact that the approach remains largely intuitive and untested in large-scale, rigorous studies (Davis, et al., 2003).

Resources and references