Learning theories represent an ideology surrounding the art and science of learning. Pedagogy, the art and science of teaching children, had its origins between the seventh and 12th centuries modeled on the approach used in monastic and cathedral schools where priests taught basic skills to young people. This teacher-centered approach was largely unchanged for much of recorded time and is still evident in most traditional educational settings. This teacher-centered learning assumes that the learner has a need to know and is dependent on the teacher to fulfill that need [3].
Self-directed learning
While the term andragogy was in use in Germany in the early 1800s, it is Malcolm Knowles who popularized the concept in the United States after introducing the term and the concept that children and adults learn differently in the late 1960s [4]. In Knowles’ view, andragogy, the art and science of helping adults learn, is the antithesis of pedagogy in that it is student-centered and it relies on the teacher as a facilitator of learning [5].
Knowles identified six core principles of adult learning that place the learner at the center of the learning process and exhibit basic respect for the inherent worth and dignity of each individual learner [6].
- Learners need to know the reason for learning. This concept is easily related to EMS education as the provider must know and understand not only the what but also the why and how of all aspects of prehospital medicine.
- Self-concept of the learner. Autonomy and self-direction are essential aspects of adulthood in our society. Adult learners need to be responsible for their educational decision making and when possible, should be included in planning (identifying learning needs and setting goals) and evaluation (evaluating learning outcomes).
- Prior experience of the learner. Prior experiences, both positive and negative, serve as a foundation for learning; this is particularly true of the experienced EMS provider.
- Readiness to learn. Adults tend to be most interested in learning subjects that have immediate relevance to their work and/or personal lives.
- Orientation to learning. Adult learning is problem-centered rather than subject-oriented, which speaks to the immediacy for application of new learning.
- Motivation to learn. As people mature, the motivation to learn is internal.
These principles should be taken into account when planning adult learning activities [7]. However, it is critical to remember that educational planning is a dynamic process and depending on the goal or purpose of an educational activity, some of these principles will be of lesser importance. As always, situational awareness is a necessity; for instance, when conducting classes for initial certification of EMS providers, prior experience will have less significance than when conducting continuing education activities for experienced providers.
Social learning theory and self-efficacy
In social learning theory, Albert Bandura states that behavior is learned through the process of observational learning and imitation, and is influenced by being rewarded and/or punished for these actions. Effective modeling teaches general rules and strategies for dealing with different situations [8]. Just as children learn by modeling the behavior of those around them, so too do adults learn in a similar fashion. This model has been replicated time and again in medical education as “see one, do one, teach one.”
The seminal research in social learning theory, proposed by Neal Miller and John Dollard, posits that learning relies heavily on modeling performance for learners as an integral component of the learning process. Their operating premise was that if one was motivated to learn a particular skill or behavior, learning could be enhanced through clear observation of that skill or behavior, and by imitating the observed behavior the individual would solidify the learned behavior and be rewarded by positive reinforcement [9].
While the visual model of effective performance is foundational to social learning theory, Bandura embellished the Miller and Dollard model by adding the relationship of model to the learner (symbolic coding), more robust practice, and a rich feedback component. Bandura also noted that people’s beliefs about their ability to deal with different situations affect learning by influencing their actions – what they choose to do, how much effort is invested, how long they persist in an activity when faced with adversity, and how they approach challenges. Self-efficacy, the belief in one’s own ability to complete tasks and reach goals, arises from four primary sources: mastery experiences, social modeling, social persuasion, and psychological state [10].
It is not surprising that success enhances self-efficacy, while failure tends to diminish it. Failure is particularly likely to lower self-efficacy when it occurs early in learning new skills and behaviors. Seeing others perceived as similar to one’s self or one’s circumstances succeed enhances self-efficacy, as does positive external reinforcement. A person’s perception about his or her emotional state or physical reactions and stress level can also affect self-efficacy in certain situations.
Theory of margin
Howard McClusky, an educational psychologist at the University of Michigan, described the theory of power-load margin in the 1960s [11]. The formula (margin = load/power) states that the key components of adulthood are load (the internal and external demands made upon the learner by self and society) and power (a combination of interacting support and coping factors and strategies that the individual possesses to sustain the load) [12]. This formula clearly suggests that the greater the power in relationship to the load, the more margin will be available, and the greater the margin, the greater the likelihood the learner will be able to manage the load. This model is particularly relevant in adult education as it focuses on the pressures that may affect the individual during the learning process, the competing demands for one’s time and attention that can distract the learner from learning [13].
An area of study that has emerged from McClusky’s theory is the degree to which adult educators increase learner load, pioneered by Michael Day and Jim James at the University of Wyoming. Their qualitative analysis categorized instructor-generated load into four areas: attitude, behavior, tasks (structure and content), and classroom environment [14].
Transformative learning theory
Central to Jack Mezirow’s work in developing the transformative learning theory is the belief that “a defining condition of being human is that we have to understand the meaning of our experience” and that learning is a change process [15]. His premise is that meaningful learning occurs most readily when learners are actively engaged and use critical reflection and discourse to challenge their frames of reference, and that adult educators have an obligation to facilitate such understanding and encourage autonomous thinking.
Frames of reference (mind schemes) are the structures or assumptions through which we understand our experiences. Based on the totality of an individual’s experience over a lifetime, there are three components that serve to set and shape one’s expectations and attitudes: cognitive (perception, knowledge, memory, judgment, reasoning), conative (drive, impulse, action), and emotional (expression, feelings, beliefs, attitude). We tend to reject ideas that fail to fit our frames of reference. Transformation is the “process by which we transform our taken-for-granted frames of reference (meaning schemes, habits of mind, mindsets) to make them more inclusive, discriminating, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action” following an activating event that exposes the limitations of one’s current knowledge or approach [16].
The adult educator can foster transformative learning in professional training programs by creating an open and safe environment that in the face of an activating event allows the learner to identify and assess current assumptions, encouraging critical reflection and discourse, giving students an opportunity to test new perspectives and fostering openness [17].
Context-based learning
The core principle of context-based learning is that adult learning takes place in context where tools and the context intersect with interaction among people. Devised at McMaster University in Hamilton, Ontario, in the 1960s, context-based learning (formerly known as problem-based learning) was initially used to prepare medical students by replacing the traditional lecture approach to teaching with a student-centered approach that emphasizes self-directed learning, placing the adult educator in the role of facilitator [18].
Context-based learning is a teaching strategy organized around scenarios that are relevant to desired learning outcomes, but it is not organized by topics or disciplines. Students work in groups to resolve real-life scenarios or situations. Through a student-led process, the group identifies relevant learning needs, which are then explored by the students using current research and resources to consolidate information and develop a strategy to resolve the situation based on the necessary concepts and principles. Clinical scenarios processed in this manner encourage research, critical thinking, and the development of lifelong learning skills.
Evidence-guided education
While Glick’s model for evidence-guided education is not truly an adult learning theory, it does warrant inclusion as foundational material for the EMS physician. Glick’s concept builds on earlier efforts to combine outcome data with education and to correlate outcome data with practice improvement. Evidence-guided education focuses on patient outcomes rather than best practices, and Glick posits that there is benefit to the systematic integration of such information to augment all aspects of medical education, although it may be most easily integrated into continuing medical education initiatives or postadverse event remediation activities [19]. Sources of outcome information may be based on a single adverse event or a system-wide practice analysis, the key being to identify those topics or scenarios that are most generalizable. Evidence-guided education recognizes that a continuum exists in which education, clinical care, patient outcomes, and performance improvement are inextricably linked.
