Comment: Why South Africa will find it hard to break free from its vicious teaching cycle

There are standards that professionalise teaching and standards that simply manage teachers. While standards which professionalise create cultures of collegiality, expertise and pride among teachers, standards that manage can leave them feeling brow-beaten, untrusted, and demotivated.

Robinson, N. (2019). Why South Africa will find it hard to break free from its vicious teaching cycle. The Conversation.

While the article refers specifically to the primary and secondary teaching context in South Africa, the principles are relevant for a wide range of international higher education and professional contexts as well. The article differentiates between two types of standardisation; professionalisation and management.

Standards that aim to professionalise an activity invariably lead to virtuous cycles. From the article “…teaching [in Finland] is a prestigious and attractive profession which recruits the brightest and most motivated school graduates, who don’t require continual monitoring and oversight. Teachers instead enjoy professional autonomy; they are trusted in key decisions about their teaching and professional development.” You can easily see how this applies to any other profession as well when professionalisation standards are being applied i.e. the standards open up spaces and encourage autonomy as part of trusting relationships.

In contrast, management standards (especially when presented under the pretext of developing professionalism), can lead to vicious cycles. In these situations “…governments take it upon themselves to hold teachers accountable. Standards are used to manage teachers, and to protect students from the worst educators through supervisory surveillance and control. Invariably, the relationship between teacher unions and governments becomes antagonistic and generates feelings of fear and mistrust.” You can see how this could play out in the context of professional organisations tasked with developing cultures of professionalism. Instead of opening up spaces by trusting and supporting people who can make their own choices, organisations may use management standards that aim to close down space and control the people within them.

We need to ask if the standards we’re being asked to meet are aimed at developing cultures of professionalism, or whether they’re simply being used to manage us. One way of determining which standards are being used in your context is to ask how much autonomy you have to make decisions about the work you do.

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

PHT402 online course accreditation

The #pht402 Professional Ethics course has just been accredited by the South African Society of Physiotherapists and Health Professions Council of South Africa for 6 Level 2 Ethics CPD points. If you are a South African physiotherapist and would like to take part in the course, please register here before 9th August.

Image from opensourceway's Flickr stream
Image from opensourceway’s Flickr stream

Over the past few weeks I’ve been running an open, online course in Professional Ethics for my 3rd year students, in collaboration with Physiopedia. Check out the project page for the details of the course, including the context and background. I also received ethical clearance from our institutional review board to study the process and outcomes.

One of the major decisions we made was to invite qualified physiotherapists to participate as well. We wanted to encourage interaction between our students and the “real world”, that intangible place we say we’re preparing our students for. In return, participants external to the university would receive a badge from Physiopedia. These badges are compatible with Mozilla’s Open Badge standard and so have value outside of the Physiopedia ecosystem.

Until recently the course was only an interesting experiment among our 3rd year students and the 26 international physiotherapists who are also participating. However, I’m now very happy to announce that the SASP and HPCSA have accredited the course for 6 Level 2 Ethics CPD points. They had an additional requirement for participants to write a short test at the end but other than that, the course was accepted as is.

By accrediting the course the SASP and HPCSA have given this method of learning a degree of legitimacy that I find really exciting from two organisations that I think are traditionally quite conservative. It’s one thing for it to be recognised as an interesting research project and quite another for the professional bodies to recognise it’s potential to provide learning opportunities for geographically distributed professionals. A significant challenge for qualified South African physiotherapists obtaining their annual Ethics CPD points is that the courses are most often only offered in major city centres (requiring travel and sometimes overnight accommodation) and the registration fees are usually quite high. Our course is online and self-paced, which acknowledges the unique time constraints of individuals, and is free.

Now that we’ve set a precedent, we’ll offer the course every year and try to build a model for physiotherapy education for appropriate subjects through distance learning. This has potentially massive implications for the profession in terms of:

  • Moving learning away from the classroom, which will impact on physical space requirements
  • Connecting the university to health care professionals at a global level, bringing in many unique perspectives from “the real world”
  • Introducing a host of digital and information literacies for participants
  • Emphasising a student-centred, self-directed approach to learning that empowers learners to take control of their learning
  • Opening up further opportunities for collaboration between academia and the profession

Watch this space for further details. On a related note, I’ve also entered the course into the Reclaim Open Learning Contest, which is being run by MIT. I’ll be sure to post the outcome here.