Enhancing learning: How can learning theory help?

The Journal of Continuing Education in the Health Professions, Volume 10, pp. 177-186. Printed in the U.S.A. All rights reserved. Copyright 0 1990 The Alliance for Continuing Medical Education and the Society of Medical College Directors of Continuing Medical Education.

Theory and Practice

Enhancing Learning: How Can Learning Theory Help?

KAREN V. MANN R.N., PH.D. Director, Medical Education Unit Assistant Professor, Continuing Medical Education Faculty of Medicine Sir Charles Tupper Building Dalhousie University Halifax, Nova Scotia Canada B3H 4H7

Abstract: Learning theory provides a framework for understanding how individuals learn and function in their environment. These understandings offer important applications for research and practice in continuing education. Social Cognitive Theory (Bandura, 1986) describes an ongoing dynamic interaction of individual, environment and behavior. I t also describes five basic capabilities of individuals: symbolizing, forethought, vicarious, self-regulatory and self-reflective. These capabilities are considered as they affect human thought and action. Related theories are also discussed, as they help both to explain social cognitive theory and to translate theory into practice. Implications of these theories for practice and research in continuing education are explored.

Introduction As continuing educators, we are responsible for planning learning opportunities, for evaluating their effectiveness, and for exploring and testing new ways of assisting our learners. In our practice and our research we can benefit from incorporating a theoretical framework, which can. guide our activities so that they are both systematic and consistent with the goal of promoting and enhancing learning. Learning theory can provide such a framework.

Cognitive learning the07 is concerned with understanding perception and thinking, and with mental processes such as concept formation and acquisition of knowledge. These understandings are critical to those who seek to understand and promote learning. Unlike behavioral theorists, who believe that all learning can be inferred from observable 'behavior, cognitive theorists believe that learning involves a more complex process. Cognitive theorists further believe that the context of learning is important

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and that learning takes place in interaction with, rather than isolation from, the environment. The purpose of this article is to consider the contributions and implications of cognitive learning theory to continuing education practice and research.

To understand the contributions of cognitive theory, let us first consider how cognition contributes to human affect and action. This considera- tion includes describing the cognitive capabilities which enable individuals to learn and function in their environments; it also helps us to understand individual learners in the context of their environment, and of their unique perceptions, needs and goa1s.l

Cognition in Human Thought and Action The value of cognitive theory may be better understood when examined in the context of a larger more comprehensive theory of human functioning. The particular theory which seems best suited to continuing education in the professions is Social Cognitive Theory (formerly Social Learning The- ory) developed by Albert Bandura.*92

Social cognitive theory (SCT) has made several important contributions to our understanding of human thought and functioning. Firstly, it assumes that cognitive function cannot be separated easily from psychody- namic function. What we know is linked to and modified by our attitudes, values, motives, goals and perceptions. Secondly, SCT posits that persons are in constant, dynamic, reciprocal interaction with their environment. Factors within the person, individual behavior and factors in the environment all act as interacting determinants of each other. Personal factors, i.e., knowledge, beliefs, attitudes, values and perceptions, are of particular concern in discussion of cognitive theory. However, these factors interact with those in the environment, for example, the potential for reward, or the possibility for achievement of valued goals, to have an effect op cognitive processes. While most contemporary theorists subscribe to an interaction- al model in which behavior results from some type of interaction between personal and social factors, SCT views the three factors as continually interacting, although the relative strength and the temporal sequence of interactions will differ in different situations.

A common, everyday example illustrates the ongoing interactions. A person's desire for a particular goal may result in an action (e.g., renovat- ing the house) that will change the environment (e.g., increase the property value). However, the changed environment (increased value) has an effect on the individual, as the house is now more liveable, and therefore the de- cision to sell is reconsidered. It is also possible that the environment might change independently (e.g., market prices rise) thus affecting the individual's perception (e.g., achieving goal of some financial gain) and re-

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sulting in an action (e.g., the house being sold). This understanding of reciprocal determinism as described by Bandura is critical to our understanding of how individuals learn.

Social cognitive theory also sees the nature of man as determined by five cognitive capabilities. These are symbolizing, forethought, vicarious, self-regulatory and self-reflective capabilities. Each will be explained briefly.

Symbolizing Capability This capability enables individuals to take current, transient experience

and information, and to store it, in symbolic fashion, so that it can be drawn on as a guide to current and future action. From this store of information, individuals can create and test symbolically different courses of action. For example, health professionals may draw on previous experience in a particular situation or problem-solving occasion, to decide which course of action might work in the current situation.

Forethought Capability This capability enables us to plan courses of action for the future. It is

the ability to bring the future and future events into our present, and to use them to set courses of action and goals for the future. This ability to for- mulate images of desirable future events can serve as a powerful motivat- ing force. For example, the image of more success in counselling patients and the satisfaction which that would provide may motivate a health professional to embark on a learning project which will improve skills in counselling. Another example may be seen in the image held of a finan- cially comfortable and trouble-free retirement. The vision of that future desired event can act as a powerful motivator to work long hours, or to choose a remunerative area of practice, or to sacrifice earlier comforts, along the way to that goal. Among the most powerful motivators is the image we hold of ourselves and of the capabilities and attributes which we would like to possess.

Vicarious Capability The ability to learn from observing others' behavior and the conse-

quences of that behavior for them allows an invaluable abbreviation of the learning process. According to Bandura, virtually all learning phenome- na can occur in this way. Obviously, the more costly the potential mis- takes from learning by one's own actions, the greater the importance of learning vicariously. We are all aware that both desirable and undesirable behaviors are learned in this way; for example, those attitudes that chil- dren learn from those modelled by their parents. Another example is re- flected in our concern about the violence which is commonly seen on tele- vision, and its effect on those who view it. Some behaviors, especially

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those that rely mainly on social cues for their learning, can only be learned vicariously. Many interactions with clients are learned by health professionals from the modelling of these encounters by their teachers. Similar- ly, teachers model attitudes and skills and their students can observe the utility of these actions when taken by others.

Self- regulatory Capability The ability to set standards for one’s own behaviors and goals, to direct

one’s actions toward achievement of those goals, and to evaluate one’s own action is key to our understanding of how individuals learn and function. It is this ability that allows us to be self-directed, and to influence the external environment so that it is most conducive to the achievement of our goals. We also create strategies to assist us in attaining our goals, and reward ourselves on their achievement. It is self-regulatory capability that we rely or build upon when we speak of self-directed lifelong learning in the professions. This ability relates closely to the forethought capability described above: it involves setting goals related to future envisioned events. In the case of improving the individual’s counselling skills, the future event may be made more likely, by the setting of specific goals and the development of strategies to acquire more skills. In our personal, professional and social actions and interactions, we set certain personal standards of performance. It is the discrepancy between those standards, and our assessment of our own behavior in relation to them, that motivates and directs our action. It is the achievement of our goals that provides us with satisfaction and reward.

Self-reflective Capability This capacity is distinctly human: the capacity to reflect on and ana-

lyze our experience and our thought processes. According to Bandura, “Among the types of thought that affect action, none is more central or more pervasive than people’s judgments of their capabilities to deal effec- tively with different realities”.l* One key aspect of this judgement is our perception of our competence to perform a particular task or our self- efficacy. This expectation is separate from our belief that our actions will have any effect on outcomes, or our outcome expectations. Bandura suggests that this perception of self-efficacy is a major determinant in peoples’ choice of what to do, how long to persevere, how much effort to expend, and whether tasks are approached anxiously or assuredly. How we perform on these tasks determines our reflection on our successes, and this reflection in turn affects our view of ourselves.3~4 Successful execution of tasks we undertake increases our self-efficacy, which increases the likeli- hood of our taking on other, more challenging tasks.

Individuals’ perceptions of themselves and of their abilities are developed through four different processes. In order of the strength of their ef-

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fect, these are 1) direct experience, 2) vicarious experience, 3) the judgement of others, and 4) individuals’ inference from what they already know. Our perceptions of our competence are most strongly affected when we actually experience directly the success of accomplishment; we also form judgments about our abilities from observing others, especially others like ourselves, and the consequences of their actions. Persuasion and exhorta- tion are less powerful effectors of self-efficacy.

Health professionals’ perceptions of their own competence may readily affect their actions. For example, if a health professional does not feel competent to deal with terminally ill patients and the emotional and social issues involved, he or she may avoid engaging in discussion with dying patients, or perhaps even relinquish their care to others. However, with direct, guided experience in addressing these issues, the individual may gain confidence, increased views of personal efficacy, and may be more willing to form helping relationships with patients. The adage that “success breeds success” is as true here as in any situation.

Social cognitive theory then sets a context for our understanding of the manner in which humans learn and function in interaction with their environment. It also underlines the uniqueness of individual learners which results from these capabilities. It provides a framework for the types of learning experiences that we provide, and enhances our understanding of the context within which learning, including that enhanced by our educational programs, occurs.

Related Theories and Models Social cognitive theory allows us a broad, comprehensive approach to understanding how humans learn and function. Specific aspects of the theory, however, need further explication to be useful to us in planning the learning opportunities we provide. Certain related theories and models offer more specific guidelines for our educational ap roaches. Those that

standing learning and change in physician beha~ior ;~q~ and 3) models of physician functioning which incorporate cognitive elements. Each of these theoretical and/or empirical approaches is consistent with what we know about the role of cognition in human functioning.

will be described here briefly include 1) goal theory; P 2) models for under-

Goal Theory Bandura’s SCT elucidates the important capacity we have for envision-

ing future events, setting personal standards and goals, and evaluating our progress towards them. Goal theory, as originally described by Locke and associates, assumes also that human behavior is purposive, that action is regulated by our goals and intention^.^ As with SCT, goal theory postu-

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lates that certain factors initiate formulation of the goal and of goal- directed action; additional factors maintain the process. The individual’s perception of existing and anticipated incentives and outcomes affects de- sires; combined with the judged utility of any action in achieving the desired outcome, this will affect the goals set and subsequent action taken. In SCT, individual perceptions of efficacy are the key determinant in the goals individuals set.

Social cognitive theory and goal theory posit consistent and similar effects of goal setting on performance. Locke and Lathamlo state the effects as follows: 1) goals direct action and attention; 2) they mobilize energy and effort; 3) they increase persistence, and 4) they encourage the development of strategies for goal attainment.

Based on a comprehensive review of goal theory5 the following summary describes the characteristics which are relevant to its role in learning and change:

a) Specific and challenging goals lead to higher performance than easy goals, “do your best” goals or no goals.

b) Given sufficient ability, the more difficult and challenging a goal, the greater the effort the individual will expend to achieve it, and the higher the resulting performance.

c) Dissatisfaction with one’s perceived performance motivates the desire to change in the direction of the goal.12

d) Short-term or subgoals appear to have greater impact on performance than long-term goals. l3

e) There is evidence for an interaction between goals and knowledge of the level of one’s performance. Goals plus knowledge of results appear to have a greater effect upon performance than either goals or knowledge of results alone.14

f) External incentives may increase the beneficial effect of goals upon performance, but they are probably linked to the value the individual plac- es on the activity and amount of effort e ~ p e n d e d . ~ ? ~

g) Goals which are accepted are most likely to affect performance ben- eficially. Participation in goal setting may be important, but the fact that the goal is set seems to be more important.1°

There is also a suggested link between the individual’s perceived self- efficacy and goal-performance, l5 in which ability, past performance and self-efficacy appear to be major predictors of goal choice. For moderate to difficult levels of performance, individual levels of self-efficacy may be the best predictors of performance. In fact self-efficacy is suggested to be the major unifying mechanism between goal theory and social learning (cognitive) theory.16

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The PRECEDE Framework Other models which attempt to explain the role of cognition in behav-

ior have emerged. Originally developed as a model of health education di- agnosis and evaluation, the PRECEDE framework6 has recently been suggested as an appropriate model for viewing physician behavior.’ The model defines three groups of factors which may modify the effect of educational interventions upon behavior. The first of these factors are called predisposing factors, or those factors which predispose an individual to take action. These are essentially personal determinants, and largely cognitive, and they include individuals’ knowledge, attitudes, beliefs, values and perceptions. The second type of factor is enabling, as these factors enable behavior change and learning to occur. Included are environmental or sit- uational factors such as the availability or accessibility of resources, both human and material. The final group of identified factors are reinforcing factors, which determine the initiation and maintenance of a behavior. At- titudes of professionals, peers, patients, and other forces in the environment which may or may not reward or reinforce a behavior are included in this group. The PRECEDE model, like SCT, acknowledges both personal (predisposing) and environmental (enabling and reinforcing) determinants of action. It also acknowledges that cognitive factors are only one compo- nent of interacting factors which must be addressed in the context of pro- viding for learning and change. A survey of physicians1’ has confirmed that these factors exist, and that their influences interact in the determina- tion of behavior.

Physician Learning and Change Fox, Mazmanian, and Putnam* have developed a theory of learning

and change in the lives of physicians which was grounded in the experience of 340 physicians who contributed information about 775 changes in their lives and practice. The authors identified three different forces for change: professional, personal and social. They identified different types of change ranging from small minor accommodations to more fundamen- tal structural changes. Different amounts of learning were associated with different types of change, with larger amounts of learning being associated with larger changes. The theory also underlined the importance of individual self-directedness for change and of incentive to change as a moti- vating factor in learning. Additionally, learning and change always oc- curred in interaction with the environment. A particularly important aspect of the change process appeared to be the image of change held by the physician, i.e., the clarity with which the future consequences of the change could be viewed. This concept of the image of change relates to capabilities of forethought, self-reflection, and future thought described in SCT. It suggests to us the importance of helping to clarify and understand

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the learner’s image of change and of the instrumentality of that change in achieving personally desired goals. The presence of both external and in- ternal motivators in learning and change was confirmed, as was the fact that the latter motivation exerted the stronger effect. Study physicians re- ported the use of multiple resources in learning, and the tendency to utilize deliberative and experiential methods of learning preferentially for different types of tasks. The use of experiential learning methods when the change involved the acquisition of new skills is very consistent with Ban- dura’s view that the most effective means to increase self-efficacy, and thereby to gain confidence and competence, is through direct experience.

Schon9 has described the characteristics of professional life and learning as a process of “reflection in action.” This ability to both act in certain situations and to reflect on one’s actions during and following is consistent with the social cognitive approach to an individual’s self-reflective and self-evaluative capabilities.

Other workers in professional education underline the importance of practice knowledge, gained through actual practice, again consistent with the concept of ongoing interaction with the environment and with the importance of the mastery which is acquired through direct experience in the “real” world, rather than the world of abstract k n ~ w l e d g e . ’ ~ ~ ~ ~ Nolen19 also posits that individuals’ performance is based on not only their knowledge, but on the whole background of cultural, personal, individual determinants which are brought to and which affect practice.

All of these theories and models confirm the importance of several key factors which relate to the theoretical foundations of continuing education. These include 1) the ongoing and dynamic reciprocal interaction with the environment, 2) the unique knowledge, perceptions and personal determinants brought by each learner to the learning environment, and 3) the individual’s capabilities for self-direction, self-reflection and self-evaluation.

Implications for Practice The existence and explanation of these factors have clear implications

for our understanding of learners in continuing education, and for our practice.

1. Continuing education planners must understand the importance of those factors in the environment which are most salient for the individual. Understanding and identifying them will assist in enhancing individuals’ learning, and in identifying particular incentives for change. Context assessment must accompany need assessment.

2. The abilities to be self-directed and to set goals exist in all of us. We need to assist learners to identify their own goals, and to help them develop strategies to attain them. In some cases, it may be necessary to help learners visualize the future consequences of their learning, so that goals may be based on these images.

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3. We need to devise learning experiences which will build on the individual’s sense of self-efficacy. This can occur when learners have the op- portunity to practice new skills and receive feedback on their performance. Self-efficacy can be gained by watching others model behaviors and skills. It can also occur when learners are helped to set realistic goals, from which they can experience success and, therefore, greater self-efficacy.

Implications for Research 1. Learning theory provides a framework which can unite our research

activities. Many research questions are complex; answers are sought from different perspectives; knowledge may be accumulated gradually from different sources. Through the understanding and use of a theoretical framework, different but complementary understandings may be meaningfully related.

2. The understanding and use of the theoretical framework provides us access to what is known in other disciplines, allowing us to draw on that knowledge to plan our own research activities. Even those situations which do not seem to pertain to our learners directly offer important in- sights and understandings as we plan our own activities.

Research interventions which address only one factor, e.g., those determinants within the learner, such as knowledge and skills, may not be sufficient to bring about change at the level we or the learners desire. Theory allows us to understand better both the factors which must be addressed to promote change in the learner and the natural processes at work so that our research and practice interventions may build on them.

Summary We have considered the contributions of learning theory to continuing education. Regarding the effect of cognition in human affect and action we have considered particularly social cognitive theory, and we have discussed the ongoing interaction with the environment, and the importance of our individual perceptions. We have also considered briefly some related theories and models which can help to translate the theory to practice. The concepts of basic capabilities which influence human learning and function are critically linked to practice and research in continuing education. These concepts help us to create learning environments to enhance individuals’ existing abilities as lifelong, self-directed learners.

Research and practice sometimes appear unrelated; research is seen as “ivory tower” and not useful to us in practice. By understanding the theoretical foundations of research and practice we provide a framework for our activities in both areas. We are then able to plan, implement and evaluate interventions which are consistent and which increase our opportunities for success.

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Enhancing learning: How can learning theory help?