Sot. SEI. & Med.. Vol. II. pp. 661 to 666. Pergamon Press 1977. Printed in Great Britain
CONTINUING
PROFESSIONAL
EDUCATION
STRATEGIES FOR HEALTH PROFESSIONALS PER G. STENSLAND New York University* Abstract-Recent
changes and pressures in the world of professional work have brought about a sharp increase in demands on continuing professional education. The health professions have been a special target of such demands. The paper examines the consequences of two systems meeting to influence continuing professional education: the action system of professional work, and the change system of professional learning. Against the background of past and present studies of professions and of adult learning, the author suggests teaching and learning strategies in five areas: the learner, learning goals, content, and methods of continuing professional education, and evaluation.
The recent concern for continuing education in the professions has its roots in the changing environment where the professionals work, and an explosive growth of knowledge, techniques and resources in the professions themselves. Nowhere is this more evident than in the health professions. Deepgoing changes inside and outside the health professions have given rise to doubts about permanence in qualifications for professional work. The threat of obsolescence has grown. Issues of quality and accountability have created performance demands for controls, for conditional certification and for mandatory continuing education whether the professional is a physician, a nurse, a dentist, a pharmacist, or a person in allied or related sections of the health sciences. Public legislation and organized professional regulations have sprung up all over the United States as well as in other developed countries. Sooner or later, this professional education storm will reach the so-called less developed nations and strike their professional world with even stronger force. Needs for continuing learning hit professionals almost as soon as they graduate. This sobering fact raises a number of questions about the relationship between theory and practice, word and work, education and action. Are there some special characteristics of professional work that call for special kinds of learning experiences? Is there something unique about continuing as compared to terminal education? What are the forces that motivate (or fail to motivate) professionals to continue learning? What new methods and techniques hold specific promise in the education of professional men and women? How can one capitalize on learning opportunities in the midst of practice and work? What new roles do professional men and women need to perform to meet the complex interprofessional task of service in our society? How might they best be trained for these new roles? What is the place of the “old professional schools” in the new picture of post graduate, often recurrent professional education? There is little chance in a brief paper to answer adequately this cluster of questions. What I shall
attempt to do is rather to examine the two sets of forces at work in continuing education of professionals, with special reference to the health profes sional [l]. The task will be to clarify the relation between profession as an action system and learning as a change system. The thesis is simple: the nature of the profession sets the parameter for professional learning, especially in postgraduate continuing education.
* The author has been retired since September 1976. At the time of submitting this article, Dr. Stensland was adjunct professor at New York University. 661
THETWO
SYSTEMS
(a) The setting The everpresent interplay between learning and action in professional life is conditioned by wnventions, agreements, commitments, and values. A professional works and performs in a certain area of knowledge and skill guided by attitudes and values and powerfully influenced by the environment (both in time and place). Professions have played distinct roles in society which set them apart from other workers and agents with values and behavior different from those of other citizens [2]. Nevertheless, for an analysis of professions and professional development to be meaningful, it has to be made not separately but in the context of the larger society. Any strategy to improve professional development must be part of overall social, economic, and intellectual strategies for the future. As Gunnar Myrdal puts it discussing economic assistance, “There is no health problem in our world nor education problem.. . there are only several parts of the overall social development problems” [3]. Early students of professions and professionalism, like Goode, Hughes, Parsons, and McGlothlin [4] were aware of the general forces that shape trends of professional work and weave the professional into the fabric of society. The reality they observed, some 25 years ago, has already been profoundly shaken and altered by such major facts as the emergence of a new world with global shifts in populations and resources, problems and policies, a dramatic increase in, and reordering of, scientific knowledge, a fundamental revolution in communications, and a sweeping reorganization and review of valuations that have created deepgoing fissures in families, groups, and nations. Professionals, often in the vanguard of action in the new world “beyond the stable state” as Donald
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Schon has put it [S], are more vulnerable than other occupational groups. Health professions have been radically affected by supermobility of patients. by the relentless pressure of new medical knowledge and inventions, by the altering patterns of communication and cooperation, by the profound change in basic human values-about health and illness, cure and care, life and death. Obviously, these macroforces have all had their deep impact on what is and what should be relevant continuing education of professionals. (b) The professional action system Behind the word “professional” there are several common sense everyday agreements: “That burglary was a real professional job”, meaning not done by an amateur. “Chris Evert is a professional tennis player”, meaning “she earns her living from tennis.” There are also certain generally recognized boundaries around “a profession”-these boundaries vary in character and in definiteness. In the health professions, as in other established professional work, there is considerable acceptance of six areas of concern: knowledge and skill, relations to the surrounding community, standards, controls, autonomy, and ethics. Rather than fixed boundaries in these areas, there is a dynamic process going on in each area determining how far professionalization has gone and what cohesion a group aspiring to professional status presents at a certain point of time [6]. First, there is a knowledge base for professional work, a specific body of understandings, skill, and attitudes acquired through intensive academic study. There are particular facts and concepts that “belong” to a professional, an intellectual possession, often refined, sharpened and augmented through various forms of internships and self-educational activities. A professional operates with technical competence in an area of human knowledge that has defined structure and clear boundaries. For example, a health professional gains qualification in the areas of medicine, health care, illness cure, biological, and behavioral sciences. Second, there is a special relationship between the professional and his community, largely aimed at service to clients, customers, patients. The health professionals offer their knowledge and skill to be used by people in need. Thus they are often legitimately described as belonging to “the helping professions” [7]. Third, the performance of a professional is guided by standards decided by the professional group. For example, members of a health profession through gradual refinements and compromises have agreed on criteria for judging professional acts. The standards are restrictive in the sense that they set-up barriers and boundaries, excluding those who do not meet the standards from professional work. In the health professions, at least in an optimum situation, criteria by which performance is judged are supposed to be definite, not vague, strict, not fluid. Fourth, the controls already mentioned are exercised by peers, often through organized groups. By agreement, professional organizations of physicians, nurses, pharmacists. dentists, etc. control what professionals are supposed to know, how they are supposed to relate to those clients they serve. what quality
STENSLAND
measures they have to meet. This gives a professional a unique power over work and hvmg conditions. The degree of power professionals hold over their ‘turfs” varies from the almost complete control by physicians to control-to-be-negotiated by the recently born allied health professionals. Fifth, power and control have given professionals monopoly, in many cases depending upon how strong the profession is and how much unprecedented occupational autonomy society permits. Through the ages physicians have acquired such a clear autonomy that Elliott Friedson makes it the substance of “professional dominance” [8]. Sixth, and finally, professions are guided by an overall commitment to special ethical principles. Professional ethics reflect as much past traditions and present behavior of leaders in the group as they reflect values in the surrounding society. In health professions, ethics are deeply influenced both by political and moral valuations and by the direction in which society is moving. Obviously professional ethics also have their very personal coloration in the helping professions where decisions and judgements concern “not only absence of disease but general social, physical and mental well-being.” all with bearing on not only means but on ends. (c) The
learning system
The learning required to prepare a person for professional work not only makes a professional but makes the profession itself. All six characteristics of professionals have their impact on what could and should be included. Part of the lifelong learning is the basic professional degree work, part of it the voluntary or required continuing education, which is the object of this essay. Just as professional action can be described as a system of forces, education can be so pictured. Being organized and purposeful learning, education as a system includes some obvious elements: a learner, something to be learned, learning goals, a process of Ieaming taking place in an environment. A meaningful model containing these elements must, however, include the unique circumstances of professional action which all create specific demands on continuing education. 1. The professional learner. The first consequence of a professional action system is that the person in the center of continuing education, the learner, is not Everyman, but a unique person. the practicing professional. This person intends to acquire not just general knowledge and skill but those understandings and abilities that distinguish people in the profession. The professional learner has to prepare for service relationships complying with professional standards and controls that have been set by peers. The learning has to bolster autonomy and clarify ethics, not just tool up for work. Like all other adults, the professionals in continuing education show enormous variations in learning. There are well-known differences among learners in speed, ability, retention, motivations, all accentuated by age [9]. Unlike other adults. however, the professional has brought to the teaching-learning situation professional motivations, insights. abilities. experiences. images of what the learning will be nbout-
Continuing professional education often mirroring what once did happen in graduate schools. but mainly geared to what should happen in the very specific professional world. Thus the professional more than others brings to learning a set of regulating mechanisms formed during previous years of education. preferences and biases with regard to learning and teaching styles and methods that have been reinforced in the unique (and sometimes isolated) environment of professional action. Obviously, there are individual differences within the professions. and; as some recent studies have shown, also among the professions. Motivations differ [lo], so do manners of dealing with new ideas and new information. Some professionals are innovators. others adopt new ideas more slowly, some lag far behind in adoption [1 11. Health professionals in their motivation to learn reflect such general differences. for example, in the uneven participation in continuing professional education. There is a small core of steady participants, but at times an amazingly large group of health professionals who do not respond to opportunities for learning. Vemer reports rates of participation in continuing education that vary from 30 to 50% among physicians, less than 30% for nurses, 25% for dentists, to around 11% for pharmacists [ 123. The choices open to the professional as a learner are not as voluntary and free as they are for other adult learners. Ultimately, they narrow down in response to requirements by the professional action system. The specific body of knowledge and skill essential for professional excellence changes with time and needs refurbishing. Quality control exercised by peer groups (and by licensing agencies), economic conditions. and ethical standards give the professional persuasive orders to continue learning, in spite of the vaunted autonomy. The professional patterns of continuous learning turn out to be far less voluntary and freely selected than in other forms of continuing education. 2. Lenrrring goals. Even more powerful in determining what happens in continuing professional education are the learning goals. Goals are always entry points into a learning process. What dynamic role goals play in learning processes, what nature they have, is still open to question [13], indeed still a matter of controversy. In this paper, the proposal is that two systems. the professional action system and the learning system, meet in the day-to-day work situation with inherent pressures and demands. Thus, learning goals to be relevant have to become professional action goals. A recent Regional Medical Program project on Continuing Education for Health Manpower reveals convincingly the continuous impact of the professional goals and objectives on the learning system: “The two main sources of objectives are information related to the health and illness of the patients and information related to the career”. A learning goal becomes realistic. “desirable.” to the extent that it relates to the health problems of the patient. The goal is to fill the gap between what the professional now knows and can do and what he would be able to do as a result of learning activities. In this meeting of two systems. learning goals are tied to the career facing the professional and are thus deeply imbedded in professional memberships [ 141.
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3. Educutioml roles. Just as goals and objectives are closely tied to the needs and unique make-up of the professional as learner, so are content and process. This close connection has its personal as well as its organizational side, illustrated by educational roles as much as by institutional arrangements. Up to fairly recently, educational roles have been fixed: a teacher-instructor-professor has performed the job of depositing knowledge, skills, and attitudes in a receiving student. in a bank, as Paulo Freire puts it [lS]. “The banking concept,” has so far been powerfully reinforced in professional education by the controls over professional knowledge and skill and by the self-regulating mechanisms. The profession of medicine has decided what should be taught and how it should be taught, not the medical student. Professional nursing regulates what the prospective nurse learns and how she learns. This one-way process of transmission has very likely been reinforced later in professional life, by hierarchical patterns of decision and work, and by power and control over professional communication and interchange. Profound changes in the world of professional practice may now force a change in this educational pattern. Future roles of physicians, nurses, pharmacists, dentists, allied health professional indicate an urgent need for un-learning old patterns or learning new ones. Productivity studies have shown that effective functioning of “health teams” builds on shared learning among the several health professions. On the scene are numerous cases where the producer of health care has to share the realities of planning, organization, and control with the consumer. In those new situations, new roles appear, at variance with the old traditional ones. To meet such new needs, the traditional “banking” of teacher knowledge and skill is less relevant than the discovery of themes around which the future professional will build their own learning, at their own pace, on their own terms [ 163. 4. Choice ofmethod. In the needed new professional learning system, the choice of method is as important as the decision over content, both determined by roles. Educators faced with an almost bewildering variety of methods must let professional practice be the measuring stick. Competencies to be learned must reflect the life tasks of the professional, the reality of diagnosing patient health problems, establishing priorities in cure or care, planning and organizing health actions, and evaluating the results. In professional learning, methods must fuse with life actions. 5. The learrkg environment. Learning and action most directly meet in the learning environment. Very likely this is the area where the most revolutionary change will take place in continuing professional education. Once professionals accept a lifelong pattern of recurrent education, they realize that their professional learning will continue in many environments. The “learning society” now widely discussed will become a network of “learning communities” [ 173. Some of these communities will naturally be the places of work, others the special facilities set up for education. The adequacy of either will depend on how close the connection between the two is. To illustrate. many have posed poignant questions about the adequacy of medical schools as learning environment for
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STENSLAND
future health professionals. Among them, Millis asks for a new intimate relationship of university medical centers, specialty societies, and community hospitals. He visualizes a learning environment placed out in the living community [18]. The well-known machinery for accreditation includes “site visits,” actually an assessment of the learning environment, whether this is acknowledged or not. It is very likely that “site visits” will be different in the future from what they are now. In addition to visiting peers assessing medical college or school of nursing, there will have to be reviews of various new nontraditional environments for continuing professional education [19]. The “site” may be the private office of a physician, the hospital ward, the living room with a television set, a community learning center, or the telephone network connected with that center. The most important learning environment will be the very world where professionals live and work, only occasionally where they once went to school. IMPLICATIONS
(a) The meeting of two systems Once the interrelationship between action and learning is recognized, continuing education has to include both the professional system and the learning system. A simple structure describing only the conditions and dynamics of professional work would not suffice. Neither would a simple learning flowchart illustrating the change a person experiences from a present stage of knowledge, skill, and attitude to a new future level. What is needed is a scheme where the two systems are related. The relationship between two worlds of activitieswork and education-is suggested through arrows and connecting lines. What cannot be shown effectively is the continuous dynamic interplay of forces at any given moment. Nor can one truthfully depict the constant impact of political, social, economic
-STRATEGY
forces by using a single word “system.” Least of all can one. except by inference. present the fact of time. What the scheme can attempt to show is the general factors at work; on the one side the profession with its controls, standards. priorities. and service action; on the other side professional education with its controls, learning needs, and priorities. Available to both are the general goals and means in society determined by values, such as science and technology and schools and societies. The end product is a professional with new knowledge, new skills, with changed attitudes and new values. The process connections loop back to a new basis level of knowledge, skill, and attitude to be used as springboard for further future professional learning. The framework of this model now permits a formulation of education strategies directed toward the learner, the goals, content, method, and evaluation. (b) Strategies for continuing professional educatiorl 1. The learner. The initial strategy has to be directed toward means and ways of providing for direct and active participation by the professional learner all through the learning sequence. Self-assessment of learning needs and personal setting of learning priorities are essential parts of the learner participation. The professional learner must be recognized as a person, as a learning agent, as a member of the several reference groups, and as a member of a particular professional culture. This professional has not just general “adult” characteristics, but has unique attributes that have to be analyzed as basic forces in all educational planning. 2. The goals. A second strategy calls for procedures and means to be developed for individual professionals to identify and clarify their own goals as persons, as learners, as group members, and as members of a profession. The matter for future negotiations and compromises will be to what extent professional controls and standards permit goals to be chosen and
FIVE
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Fig. 1. Continuing professional education-a
two system relationship.
Continuing professional education
formulated by individual professionals. Mandated continuing education for physicians. nurses, pharmacists. dentists. must then include provisions for leaming goals to be set not only from the outside. but by the individual. There must be ample opportunity for selection and continuous re-evaluation of goals. 3. The conre~~t. A third strategy should guarantee the continuous flow of “content.” the particular knowledge. skill. and attitude that is the unique “possession” of the profession. Within the accepted system of professional control over basic content continuing professional education must build on learning matter that is relevant to the learners, is within their reach, and useful in their work. The clinic and the surrounding community will become the true curriculum for education of the practicing health professional. This might call for new kinds of textbooks and new ways of including work experiences in the specified body of knowledge the professions build on. 4. Methods. A fourth strategy must concentrate on effective utilization of the great variety of methods and tools that now are available to educators. Informal as well as formal. traditional as well as non-traditional alternatives are at hand. There are well-known professional education methods: self-paced study, independent study, concentrated study, small group and seminar tutorials, project or problem-centered study, practical and clinical learning methods, work-study programs[20]. New dimensions have been added through the growing experimentation with electronic devices, with computerized instruction, communication satellites, and numerous quite personal methods of self-learning. 5. Eua1uation. A final strategy centers on evaluation [21]. In the professions, evaluation has hitherto meant post j&to surveys, inspections and supervisions, peer review, quality assurance schemes, and recertification procedures. Effective continuous professional learning builds on continuous evaluation of learner. of goals. content. and method, not episodic after-the-fact summations of pluses and minuses. Evaluation must be built into the total process in a series of takes and retakes, reviews and revisions, reconsiderations and restatements. As professions operate in a highly volatile and fluid society their learning depends on constant evaluation, steadily revitalizing those responsible for action. In a very real sense the five strategies together make the professionals as responsible for their own learning. as they have been responsible for their own actions [22]. REFERENCES I.
Earlier general studies and reports, for example on medical education. do not mention continuing education: the AMA Commission on Medical Education, reporting in 1932: the Commission on Graduate Medical Education set up by the then Advisory Board for Medical Specialties. reporting in 1940; the Commonwealth Funds study of Teaching of Social and Environmental Factors in Medicine. reporting in 1948. are cases in point. Slowly the picture changes. In the AAMC Coggeshall Report of 1965. the committee sees the need for looking at medical education as a continuum. It deplores that. while “it is recognized that the doctor is
665
not fully qualified to practice when the M.D. degree is earned, it is here that the traditional medical school abandons him and relinquishes responsibilities.” It recommends that “the influence of the university should extend beyond the campus and beyond grdduation to support the practitioner throughout his career and wherever he shall render his services.” Coggeshall L. T. Planning jtir Medical Progress Through Educatiorz. Association of American Medical College. Evanston, 1965, pp. 39-40. During the last half dozen years, reviews and surveys, as well as special studies have begun to include specific views and recommendations about continuing professional education, especially referring to physicians and nurses See especially the research and overview studies referred to below, and Benton J. G. and Gubner R. S. (Consulting Ed.) Education in the health-related professions, Annls N.Y. Acad. Sci. 166, 821 ; Millis J. A Rational Public Policy for Medical Education and its Financing, The National Fund for Medical Education. New York, 1971; and Schechter D. S. and O’Farrell’T. M. Universities, CoC leges and Hospitals: Partners in Continuing Education,
A Study Report for the W. K. Kellogg Foundation, Battle Creek, undated; “Continuing medical education” in the Education Number of J. Am. med. Ass. 218, 1258; and Continuing Education: Agent of Change, Proc. of the National Conferences on Continuing Education in Mental Health, National Institute of Mental Health, Rockville, MD., 1971. Only recently has there been any substantial effort to inventory and assess continuing education of health professionals. Some recent works are worth notice. Elliott Freidson in Professional Dominance (New York, 1970) has explored the special dynamics surrounding the medical profession. Jerome P. Lysaught in the report from the National Commission for the Study of Nursing Education and Nursing, An Abstract ,for Action, and Daniel Schechter in Agendafor Continuing Education for the Hospital Research and Educational Trust (Chicago, 1974) have added dimensions to professional definitions. In assessment of medicine, nursing, dentistry, and pharmacy, Coolie Vemer and Jane Nakamoto in their Continuing Education in the Health Professions (Washington, 1973) with a bibliographic survey have thrown new light on educational needs and professional demands. With special reference to regional health developments in the United States, Robert Blakely and Alexander Charters with several collaborators have delved still further into the questions of unique professional learning conditions in Fostering the Growing Need to Learn (Washington, 1974). 2. Hughes E. C. Men and Their Work. The Free Press,
Glencoe, Ill., 1958; Parsons T. The Social System, ibid., 3. 4.
5.
6.
1951; Schein E. Professiona/ Education. McGraw Hill, New York, 1972. Myrdal G. On Reforming Economic Aid. Center Report. Center for the Study of Democratic Institutions, Santa Barbara. February, 1975. Goode W. J. Community within a community: the professions. Am. social. Rev. 22, 1957; McGlothlin W. J. The Professional Schools, The Center for Applied Educational Research, New York. 1964. Schon D. Beyond the Stable State. Random House, N.Y. 1971: cf. Stensland P. G. Old Professionals in a New World, Adult Leadership, Washington, April 1974. Edgar Schein in his Professioual Education has made a synthesis of numerous early and recent definitions ending with a composite list of ten criteria: full-time occupation. strong motivation. socialized body of knowledge. decision-making on basis of general principles. service orientation. service based on objective client needs. autonomy of judgement. certification and
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7.
8. 9.
10. 11. 12. 13.
PER G. STENSLAND licensing based on profession organization judgment, specific expertise knowledge, and stricture against advertisement. Schein E. Professional Education-Some New Directions, McGraw-Hill, New York, 1972. See for example, Frank L. K. Fragmentation in the helping professions, in Bennis. Benne, and Chin. The Pla;u&~g~of Change, New York, 1964. Freidson E. Professional Dominance. Atherton, New York, 1970. . See, for example Thomdike E. L. Adult Learning, MacMillan, New York, 1928; Lorge I. The influence of the test upon the nature of mental decline and the function of age. J. educ. Psychol. 27, February 1936; Brunner E. deS., Wilder D., Kirchner C. and Newberry J. Jr. An Overview of Adult Education Research, Adult Education Association of the USA, Chicago, 1959; Kidd J. R. How Adults Learn, Association Piess, New York, 1959; and 1974, Johnstone J. W. C. and Rivera R. J. Volunteers for Learning, Aldine, Chicago, 1965; Houle C. The Inquiring Mind. University of Wisconsin Press, Madison, Wisconsin, 1961. Cf. Knox A. B. Lifelong self-directed education. In Charters and Blakely, op. cit., 1965. See Rogers E. Diffusion of Innovations. Free Press, Glencoe, 1962. Nakamoto and Vemer, op. cit. Among psychologists, the controversy between stimulus-response and inner-drive groups has by no means abated. Either explanation of goals may fit into the professional learning frame of reference. Professionals may well be examples of learners who have a particularly clear wish to achieve-illustrating McClelland’s classic n-factor in motivation. There may be especially strong forces in professional life establishing disequilibrium and tension creating strong inner drives toward homeostasis or reduced tension. On the other hand, there may be as good a case for suggesting that professional life presents an unusual amount of outside incentives and operants working to facilitate stimulus-response learning. The professional matrix seen in this light provides explanations for goal
setting that are determined very much by “pay-off”. the concrete results of professional learning. For useful summaries of theories of learning. see e.g. Hilgard E. Tlteories of Learuing. New York. 1956. and Kidd J. R. How Adults Learn. Association Press. New York. 1974. 14. Charters and Blakely. op cit.. p. 94. 15. Freire P. Pedagogy for the Oppressed. Seabury Press. New York, 1970. 16. Husen T. Tire Leamirrg Society. Methuen. London. 1974. 17. Schon, op. cit. 18. Mills J. A Rational Policy for Medical Educotiort md its Financing. National Fund for Medical Education. New York, 1971. 19. Much organized and purposeful learning is going on without being formal or recorded. Recent surveys of non-traditional studies reveal that most adults engage in more self-directed, personal learning activities than is reflected in registration figures. Canadian reports on “the adult’s learning project” confirm this individualized, highly diversified, mostly unreported learning that adults take part in. See, for example, for the United States, Gould S. and Cross P. K. Esploratiort in Non-Traditional Study, Jossey-Bass. San Francisco. 1972: for Canada Tough A. The Adult Learrtirta Projects, Ontario Institute for Education. Toronto: 1962. 20. Schein, op. cit. 21. A recent research study brings into focus the many difficulties and uncertainties in the area of evaluation of professional preparation: Menges R. J. Assessing readiness for professional practice. Rev. Educ. Res. 45 (No. 2), 1975. 22. Ideas similar to those explored in this paper have been presented earlier in Stensland P. G. Education continua de profesionales de1 salud, Education Medico y Mud, November, 1973, Pan-American Health Organization, Washington, D.C., 1974; also in Convergence. Education de profesionales de salud, No. 2, 1974, International Council on Adult Education, Toronto, Canada, 1974.
CONTINUING
PROFESSIONAL
EDUCATION
STRATEGIES FOR HEALTH PROFESSIONALS PER G. STENSLAND New York University* Abstract-Recent
changes and pressures in the world of professional work have brought about a sharp increase in demands on continuing professional education. The health professions have been a special target of such demands. The paper examines the consequences of two systems meeting to influence continuing professional education: the action system of professional work, and the change system of professional learning. Against the background of past and present studies of professions and of adult learning, the author suggests teaching and learning strategies in five areas: the learner, learning goals, content, and methods of continuing professional education, and evaluation.
The recent concern for continuing education in the professions has its roots in the changing environment where the professionals work, and an explosive growth of knowledge, techniques and resources in the professions themselves. Nowhere is this more evident than in the health professions. Deepgoing changes inside and outside the health professions have given rise to doubts about permanence in qualifications for professional work. The threat of obsolescence has grown. Issues of quality and accountability have created performance demands for controls, for conditional certification and for mandatory continuing education whether the professional is a physician, a nurse, a dentist, a pharmacist, or a person in allied or related sections of the health sciences. Public legislation and organized professional regulations have sprung up all over the United States as well as in other developed countries. Sooner or later, this professional education storm will reach the so-called less developed nations and strike their professional world with even stronger force. Needs for continuing learning hit professionals almost as soon as they graduate. This sobering fact raises a number of questions about the relationship between theory and practice, word and work, education and action. Are there some special characteristics of professional work that call for special kinds of learning experiences? Is there something unique about continuing as compared to terminal education? What are the forces that motivate (or fail to motivate) professionals to continue learning? What new methods and techniques hold specific promise in the education of professional men and women? How can one capitalize on learning opportunities in the midst of practice and work? What new roles do professional men and women need to perform to meet the complex interprofessional task of service in our society? How might they best be trained for these new roles? What is the place of the “old professional schools” in the new picture of post graduate, often recurrent professional education? There is little chance in a brief paper to answer adequately this cluster of questions. What I shall
attempt to do is rather to examine the two sets of forces at work in continuing education of professionals, with special reference to the health profes sional [l]. The task will be to clarify the relation between profession as an action system and learning as a change system. The thesis is simple: the nature of the profession sets the parameter for professional learning, especially in postgraduate continuing education.
* The author has been retired since September 1976. At the time of submitting this article, Dr. Stensland was adjunct professor at New York University. 661
THETWO
SYSTEMS
(a) The setting The everpresent interplay between learning and action in professional life is conditioned by wnventions, agreements, commitments, and values. A professional works and performs in a certain area of knowledge and skill guided by attitudes and values and powerfully influenced by the environment (both in time and place). Professions have played distinct roles in society which set them apart from other workers and agents with values and behavior different from those of other citizens [2]. Nevertheless, for an analysis of professions and professional development to be meaningful, it has to be made not separately but in the context of the larger society. Any strategy to improve professional development must be part of overall social, economic, and intellectual strategies for the future. As Gunnar Myrdal puts it discussing economic assistance, “There is no health problem in our world nor education problem.. . there are only several parts of the overall social development problems” [3]. Early students of professions and professionalism, like Goode, Hughes, Parsons, and McGlothlin [4] were aware of the general forces that shape trends of professional work and weave the professional into the fabric of society. The reality they observed, some 25 years ago, has already been profoundly shaken and altered by such major facts as the emergence of a new world with global shifts in populations and resources, problems and policies, a dramatic increase in, and reordering of, scientific knowledge, a fundamental revolution in communications, and a sweeping reorganization and review of valuations that have created deepgoing fissures in families, groups, and nations. Professionals, often in the vanguard of action in the new world “beyond the stable state” as Donald
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Schon has put it [S], are more vulnerable than other occupational groups. Health professions have been radically affected by supermobility of patients. by the relentless pressure of new medical knowledge and inventions, by the altering patterns of communication and cooperation, by the profound change in basic human values-about health and illness, cure and care, life and death. Obviously, these macroforces have all had their deep impact on what is and what should be relevant continuing education of professionals. (b) The professional action system Behind the word “professional” there are several common sense everyday agreements: “That burglary was a real professional job”, meaning not done by an amateur. “Chris Evert is a professional tennis player”, meaning “she earns her living from tennis.” There are also certain generally recognized boundaries around “a profession”-these boundaries vary in character and in definiteness. In the health professions, as in other established professional work, there is considerable acceptance of six areas of concern: knowledge and skill, relations to the surrounding community, standards, controls, autonomy, and ethics. Rather than fixed boundaries in these areas, there is a dynamic process going on in each area determining how far professionalization has gone and what cohesion a group aspiring to professional status presents at a certain point of time [6]. First, there is a knowledge base for professional work, a specific body of understandings, skill, and attitudes acquired through intensive academic study. There are particular facts and concepts that “belong” to a professional, an intellectual possession, often refined, sharpened and augmented through various forms of internships and self-educational activities. A professional operates with technical competence in an area of human knowledge that has defined structure and clear boundaries. For example, a health professional gains qualification in the areas of medicine, health care, illness cure, biological, and behavioral sciences. Second, there is a special relationship between the professional and his community, largely aimed at service to clients, customers, patients. The health professionals offer their knowledge and skill to be used by people in need. Thus they are often legitimately described as belonging to “the helping professions” [7]. Third, the performance of a professional is guided by standards decided by the professional group. For example, members of a health profession through gradual refinements and compromises have agreed on criteria for judging professional acts. The standards are restrictive in the sense that they set-up barriers and boundaries, excluding those who do not meet the standards from professional work. In the health professions, at least in an optimum situation, criteria by which performance is judged are supposed to be definite, not vague, strict, not fluid. Fourth, the controls already mentioned are exercised by peers, often through organized groups. By agreement, professional organizations of physicians, nurses, pharmacists. dentists, etc. control what professionals are supposed to know, how they are supposed to relate to those clients they serve. what quality
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measures they have to meet. This gives a professional a unique power over work and hvmg conditions. The degree of power professionals hold over their ‘turfs” varies from the almost complete control by physicians to control-to-be-negotiated by the recently born allied health professionals. Fifth, power and control have given professionals monopoly, in many cases depending upon how strong the profession is and how much unprecedented occupational autonomy society permits. Through the ages physicians have acquired such a clear autonomy that Elliott Friedson makes it the substance of “professional dominance” [8]. Sixth, and finally, professions are guided by an overall commitment to special ethical principles. Professional ethics reflect as much past traditions and present behavior of leaders in the group as they reflect values in the surrounding society. In health professions, ethics are deeply influenced both by political and moral valuations and by the direction in which society is moving. Obviously professional ethics also have their very personal coloration in the helping professions where decisions and judgements concern “not only absence of disease but general social, physical and mental well-being.” all with bearing on not only means but on ends. (c) The
learning system
The learning required to prepare a person for professional work not only makes a professional but makes the profession itself. All six characteristics of professionals have their impact on what could and should be included. Part of the lifelong learning is the basic professional degree work, part of it the voluntary or required continuing education, which is the object of this essay. Just as professional action can be described as a system of forces, education can be so pictured. Being organized and purposeful learning, education as a system includes some obvious elements: a learner, something to be learned, learning goals, a process of Ieaming taking place in an environment. A meaningful model containing these elements must, however, include the unique circumstances of professional action which all create specific demands on continuing education. 1. The professional learner. The first consequence of a professional action system is that the person in the center of continuing education, the learner, is not Everyman, but a unique person. the practicing professional. This person intends to acquire not just general knowledge and skill but those understandings and abilities that distinguish people in the profession. The professional learner has to prepare for service relationships complying with professional standards and controls that have been set by peers. The learning has to bolster autonomy and clarify ethics, not just tool up for work. Like all other adults, the professionals in continuing education show enormous variations in learning. There are well-known differences among learners in speed, ability, retention, motivations, all accentuated by age [9]. Unlike other adults. however, the professional has brought to the teaching-learning situation professional motivations, insights. abilities. experiences. images of what the learning will be nbout-
Continuing professional education often mirroring what once did happen in graduate schools. but mainly geared to what should happen in the very specific professional world. Thus the professional more than others brings to learning a set of regulating mechanisms formed during previous years of education. preferences and biases with regard to learning and teaching styles and methods that have been reinforced in the unique (and sometimes isolated) environment of professional action. Obviously, there are individual differences within the professions. and; as some recent studies have shown, also among the professions. Motivations differ [lo], so do manners of dealing with new ideas and new information. Some professionals are innovators. others adopt new ideas more slowly, some lag far behind in adoption [1 11. Health professionals in their motivation to learn reflect such general differences. for example, in the uneven participation in continuing professional education. There is a small core of steady participants, but at times an amazingly large group of health professionals who do not respond to opportunities for learning. Vemer reports rates of participation in continuing education that vary from 30 to 50% among physicians, less than 30% for nurses, 25% for dentists, to around 11% for pharmacists [ 123. The choices open to the professional as a learner are not as voluntary and free as they are for other adult learners. Ultimately, they narrow down in response to requirements by the professional action system. The specific body of knowledge and skill essential for professional excellence changes with time and needs refurbishing. Quality control exercised by peer groups (and by licensing agencies), economic conditions. and ethical standards give the professional persuasive orders to continue learning, in spite of the vaunted autonomy. The professional patterns of continuous learning turn out to be far less voluntary and freely selected than in other forms of continuing education. 2. Lenrrring goals. Even more powerful in determining what happens in continuing professional education are the learning goals. Goals are always entry points into a learning process. What dynamic role goals play in learning processes, what nature they have, is still open to question [13], indeed still a matter of controversy. In this paper, the proposal is that two systems. the professional action system and the learning system, meet in the day-to-day work situation with inherent pressures and demands. Thus, learning goals to be relevant have to become professional action goals. A recent Regional Medical Program project on Continuing Education for Health Manpower reveals convincingly the continuous impact of the professional goals and objectives on the learning system: “The two main sources of objectives are information related to the health and illness of the patients and information related to the career”. A learning goal becomes realistic. “desirable.” to the extent that it relates to the health problems of the patient. The goal is to fill the gap between what the professional now knows and can do and what he would be able to do as a result of learning activities. In this meeting of two systems. learning goals are tied to the career facing the professional and are thus deeply imbedded in professional memberships [ 141.
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3. Educutioml roles. Just as goals and objectives are closely tied to the needs and unique make-up of the professional as learner, so are content and process. This close connection has its personal as well as its organizational side, illustrated by educational roles as much as by institutional arrangements. Up to fairly recently, educational roles have been fixed: a teacher-instructor-professor has performed the job of depositing knowledge, skills, and attitudes in a receiving student. in a bank, as Paulo Freire puts it [lS]. “The banking concept,” has so far been powerfully reinforced in professional education by the controls over professional knowledge and skill and by the self-regulating mechanisms. The profession of medicine has decided what should be taught and how it should be taught, not the medical student. Professional nursing regulates what the prospective nurse learns and how she learns. This one-way process of transmission has very likely been reinforced later in professional life, by hierarchical patterns of decision and work, and by power and control over professional communication and interchange. Profound changes in the world of professional practice may now force a change in this educational pattern. Future roles of physicians, nurses, pharmacists, dentists, allied health professional indicate an urgent need for un-learning old patterns or learning new ones. Productivity studies have shown that effective functioning of “health teams” builds on shared learning among the several health professions. On the scene are numerous cases where the producer of health care has to share the realities of planning, organization, and control with the consumer. In those new situations, new roles appear, at variance with the old traditional ones. To meet such new needs, the traditional “banking” of teacher knowledge and skill is less relevant than the discovery of themes around which the future professional will build their own learning, at their own pace, on their own terms [ 163. 4. Choice ofmethod. In the needed new professional learning system, the choice of method is as important as the decision over content, both determined by roles. Educators faced with an almost bewildering variety of methods must let professional practice be the measuring stick. Competencies to be learned must reflect the life tasks of the professional, the reality of diagnosing patient health problems, establishing priorities in cure or care, planning and organizing health actions, and evaluating the results. In professional learning, methods must fuse with life actions. 5. The learrkg environment. Learning and action most directly meet in the learning environment. Very likely this is the area where the most revolutionary change will take place in continuing professional education. Once professionals accept a lifelong pattern of recurrent education, they realize that their professional learning will continue in many environments. The “learning society” now widely discussed will become a network of “learning communities” [ 173. Some of these communities will naturally be the places of work, others the special facilities set up for education. The adequacy of either will depend on how close the connection between the two is. To illustrate. many have posed poignant questions about the adequacy of medical schools as learning environment for
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future health professionals. Among them, Millis asks for a new intimate relationship of university medical centers, specialty societies, and community hospitals. He visualizes a learning environment placed out in the living community [18]. The well-known machinery for accreditation includes “site visits,” actually an assessment of the learning environment, whether this is acknowledged or not. It is very likely that “site visits” will be different in the future from what they are now. In addition to visiting peers assessing medical college or school of nursing, there will have to be reviews of various new nontraditional environments for continuing professional education [19]. The “site” may be the private office of a physician, the hospital ward, the living room with a television set, a community learning center, or the telephone network connected with that center. The most important learning environment will be the very world where professionals live and work, only occasionally where they once went to school. IMPLICATIONS
(a) The meeting of two systems Once the interrelationship between action and learning is recognized, continuing education has to include both the professional system and the learning system. A simple structure describing only the conditions and dynamics of professional work would not suffice. Neither would a simple learning flowchart illustrating the change a person experiences from a present stage of knowledge, skill, and attitude to a new future level. What is needed is a scheme where the two systems are related. The relationship between two worlds of activitieswork and education-is suggested through arrows and connecting lines. What cannot be shown effectively is the continuous dynamic interplay of forces at any given moment. Nor can one truthfully depict the constant impact of political, social, economic
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forces by using a single word “system.” Least of all can one. except by inference. present the fact of time. What the scheme can attempt to show is the general factors at work; on the one side the profession with its controls, standards. priorities. and service action; on the other side professional education with its controls, learning needs, and priorities. Available to both are the general goals and means in society determined by values, such as science and technology and schools and societies. The end product is a professional with new knowledge, new skills, with changed attitudes and new values. The process connections loop back to a new basis level of knowledge, skill, and attitude to be used as springboard for further future professional learning. The framework of this model now permits a formulation of education strategies directed toward the learner, the goals, content, method, and evaluation. (b) Strategies for continuing professional educatiorl 1. The learner. The initial strategy has to be directed toward means and ways of providing for direct and active participation by the professional learner all through the learning sequence. Self-assessment of learning needs and personal setting of learning priorities are essential parts of the learner participation. The professional learner must be recognized as a person, as a learning agent, as a member of the several reference groups, and as a member of a particular professional culture. This professional has not just general “adult” characteristics, but has unique attributes that have to be analyzed as basic forces in all educational planning. 2. The goals. A second strategy calls for procedures and means to be developed for individual professionals to identify and clarify their own goals as persons, as learners, as group members, and as members of a profession. The matter for future negotiations and compromises will be to what extent professional controls and standards permit goals to be chosen and
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Fig. 1. Continuing professional education-a
two system relationship.
Continuing professional education
formulated by individual professionals. Mandated continuing education for physicians. nurses, pharmacists. dentists. must then include provisions for leaming goals to be set not only from the outside. but by the individual. There must be ample opportunity for selection and continuous re-evaluation of goals. 3. The conre~~t. A third strategy should guarantee the continuous flow of “content.” the particular knowledge. skill. and attitude that is the unique “possession” of the profession. Within the accepted system of professional control over basic content continuing professional education must build on learning matter that is relevant to the learners, is within their reach, and useful in their work. The clinic and the surrounding community will become the true curriculum for education of the practicing health professional. This might call for new kinds of textbooks and new ways of including work experiences in the specified body of knowledge the professions build on. 4. Methods. A fourth strategy must concentrate on effective utilization of the great variety of methods and tools that now are available to educators. Informal as well as formal. traditional as well as non-traditional alternatives are at hand. There are well-known professional education methods: self-paced study, independent study, concentrated study, small group and seminar tutorials, project or problem-centered study, practical and clinical learning methods, work-study programs[20]. New dimensions have been added through the growing experimentation with electronic devices, with computerized instruction, communication satellites, and numerous quite personal methods of self-learning. 5. Eua1uation. A final strategy centers on evaluation [21]. In the professions, evaluation has hitherto meant post j&to surveys, inspections and supervisions, peer review, quality assurance schemes, and recertification procedures. Effective continuous professional learning builds on continuous evaluation of learner. of goals. content. and method, not episodic after-the-fact summations of pluses and minuses. Evaluation must be built into the total process in a series of takes and retakes, reviews and revisions, reconsiderations and restatements. As professions operate in a highly volatile and fluid society their learning depends on constant evaluation, steadily revitalizing those responsible for action. In a very real sense the five strategies together make the professionals as responsible for their own learning. as they have been responsible for their own actions [22]. REFERENCES I.
Earlier general studies and reports, for example on medical education. do not mention continuing education: the AMA Commission on Medical Education, reporting in 1932: the Commission on Graduate Medical Education set up by the then Advisory Board for Medical Specialties. reporting in 1940; the Commonwealth Funds study of Teaching of Social and Environmental Factors in Medicine. reporting in 1948. are cases in point. Slowly the picture changes. In the AAMC Coggeshall Report of 1965. the committee sees the need for looking at medical education as a continuum. It deplores that. while “it is recognized that the doctor is
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not fully qualified to practice when the M.D. degree is earned, it is here that the traditional medical school abandons him and relinquishes responsibilities.” It recommends that “the influence of the university should extend beyond the campus and beyond grdduation to support the practitioner throughout his career and wherever he shall render his services.” Coggeshall L. T. Planning jtir Medical Progress Through Educatiorz. Association of American Medical College. Evanston, 1965, pp. 39-40. During the last half dozen years, reviews and surveys, as well as special studies have begun to include specific views and recommendations about continuing professional education, especially referring to physicians and nurses See especially the research and overview studies referred to below, and Benton J. G. and Gubner R. S. (Consulting Ed.) Education in the health-related professions, Annls N.Y. Acad. Sci. 166, 821 ; Millis J. A Rational Public Policy for Medical Education and its Financing, The National Fund for Medical Education. New York, 1971; and Schechter D. S. and O’Farrell’T. M. Universities, CoC leges and Hospitals: Partners in Continuing Education,
A Study Report for the W. K. Kellogg Foundation, Battle Creek, undated; “Continuing medical education” in the Education Number of J. Am. med. Ass. 218, 1258; and Continuing Education: Agent of Change, Proc. of the National Conferences on Continuing Education in Mental Health, National Institute of Mental Health, Rockville, MD., 1971. Only recently has there been any substantial effort to inventory and assess continuing education of health professionals. Some recent works are worth notice. Elliott Freidson in Professional Dominance (New York, 1970) has explored the special dynamics surrounding the medical profession. Jerome P. Lysaught in the report from the National Commission for the Study of Nursing Education and Nursing, An Abstract ,for Action, and Daniel Schechter in Agendafor Continuing Education for the Hospital Research and Educational Trust (Chicago, 1974) have added dimensions to professional definitions. In assessment of medicine, nursing, dentistry, and pharmacy, Coolie Vemer and Jane Nakamoto in their Continuing Education in the Health Professions (Washington, 1973) with a bibliographic survey have thrown new light on educational needs and professional demands. With special reference to regional health developments in the United States, Robert Blakely and Alexander Charters with several collaborators have delved still further into the questions of unique professional learning conditions in Fostering the Growing Need to Learn (Washington, 1974). 2. Hughes E. C. Men and Their Work. The Free Press,
Glencoe, Ill., 1958; Parsons T. The Social System, ibid., 3. 4.
5.
6.
1951; Schein E. Professiona/ Education. McGraw Hill, New York, 1972. Myrdal G. On Reforming Economic Aid. Center Report. Center for the Study of Democratic Institutions, Santa Barbara. February, 1975. Goode W. J. Community within a community: the professions. Am. social. Rev. 22, 1957; McGlothlin W. J. The Professional Schools, The Center for Applied Educational Research, New York. 1964. Schon D. Beyond the Stable State. Random House, N.Y. 1971: cf. Stensland P. G. Old Professionals in a New World, Adult Leadership, Washington, April 1974. Edgar Schein in his Professioual Education has made a synthesis of numerous early and recent definitions ending with a composite list of ten criteria: full-time occupation. strong motivation. socialized body of knowledge. decision-making on basis of general principles. service orientation. service based on objective client needs. autonomy of judgement. certification and
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7.
8. 9.
10. 11. 12. 13.
PER G. STENSLAND licensing based on profession organization judgment, specific expertise knowledge, and stricture against advertisement. Schein E. Professional Education-Some New Directions, McGraw-Hill, New York, 1972. See for example, Frank L. K. Fragmentation in the helping professions, in Bennis. Benne, and Chin. The Pla;u&~g~of Change, New York, 1964. Freidson E. Professional Dominance. Atherton, New York, 1970. . See, for example Thomdike E. L. Adult Learning, MacMillan, New York, 1928; Lorge I. The influence of the test upon the nature of mental decline and the function of age. J. educ. Psychol. 27, February 1936; Brunner E. deS., Wilder D., Kirchner C. and Newberry J. Jr. An Overview of Adult Education Research, Adult Education Association of the USA, Chicago, 1959; Kidd J. R. How Adults Learn, Association Piess, New York, 1959; and 1974, Johnstone J. W. C. and Rivera R. J. Volunteers for Learning, Aldine, Chicago, 1965; Houle C. The Inquiring Mind. University of Wisconsin Press, Madison, Wisconsin, 1961. Cf. Knox A. B. Lifelong self-directed education. In Charters and Blakely, op. cit., 1965. See Rogers E. Diffusion of Innovations. Free Press, Glencoe, 1962. Nakamoto and Vemer, op. cit. Among psychologists, the controversy between stimulus-response and inner-drive groups has by no means abated. Either explanation of goals may fit into the professional learning frame of reference. Professionals may well be examples of learners who have a particularly clear wish to achieve-illustrating McClelland’s classic n-factor in motivation. There may be especially strong forces in professional life establishing disequilibrium and tension creating strong inner drives toward homeostasis or reduced tension. On the other hand, there may be as good a case for suggesting that professional life presents an unusual amount of outside incentives and operants working to facilitate stimulus-response learning. The professional matrix seen in this light provides explanations for goal
setting that are determined very much by “pay-off”. the concrete results of professional learning. For useful summaries of theories of learning. see e.g. Hilgard E. Tlteories of Learuing. New York. 1956. and Kidd J. R. How Adults Learn. Association Press. New York. 1974. 14. Charters and Blakely. op cit.. p. 94. 15. Freire P. Pedagogy for the Oppressed. Seabury Press. New York, 1970. 16. Husen T. Tire Leamirrg Society. Methuen. London. 1974. 17. Schon, op. cit. 18. Mills J. A Rational Policy for Medical Educotiort md its Financing. National Fund for Medical Education. New York, 1971. 19. Much organized and purposeful learning is going on without being formal or recorded. Recent surveys of non-traditional studies reveal that most adults engage in more self-directed, personal learning activities than is reflected in registration figures. Canadian reports on “the adult’s learning project” confirm this individualized, highly diversified, mostly unreported learning that adults take part in. See, for example, for the United States, Gould S. and Cross P. K. Esploratiort in Non-Traditional Study, Jossey-Bass. San Francisco. 1972: for Canada Tough A. The Adult Learrtirta Projects, Ontario Institute for Education. Toronto: 1962. 20. Schein, op. cit. 21. A recent research study brings into focus the many difficulties and uncertainties in the area of evaluation of professional preparation: Menges R. J. Assessing readiness for professional practice. Rev. Educ. Res. 45 (No. 2), 1975. 22. Ideas similar to those explored in this paper have been presented earlier in Stensland P. G. Education continua de profesionales de1 salud, Education Medico y Mud, November, 1973, Pan-American Health Organization, Washington, D.C., 1974; also in Convergence. Education de profesionales de salud, No. 2, 1974, International Council on Adult Education, Toronto, Canada, 1974.
