Enhancing Transformative Learning in Physician Assistant Education

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1 paeav21n1.qxp 4/8/2010 9:48 AM Page 18 SPECIAL ARTICLE Enhancing Transformative Learning in Physician Assistant Education Claire Babcock O Connell, MPH, PA-C Much of what educators try to impart to PA students involves learning that is not objective or easily measured. An important part of PA training involves personal growth and experiencing new ideas, beliefs, cultures, and ways of life that are, at times, antithetical to a student s frame of reference. Transformative learning is a theory that helps structure this part of education. Utilizing the framework and parameters of transformative learning can help the PA educator meet the goals of personal growth in the students. J Physician Assist Educ 2010;21(1):18-22 Claire Babcock O Connell, MPH, PA-C, is a faculty member at the University of Medicine and Dentistry of New Jersey, School of Health Related Professions, Physician Assistant Program, Piscataway, New Jersey. Correspondence should be addressed to: Claire Babcock O Connell, MPH, PA-C University of Medicine and Dentistry of New Jersey Physician Assistant Program Robert Wood Johnson Medical School 675 Hoes Lane Piscataway, NJ Phone: (732) oconnecb@umdnj.edu INTRODUCTION Learning is the process by which an individual acquires or adjusts knowledge, skills, or attitudes. Several learning theories have been widely disseminated and discussed, including behavioral, cognitive, and humanistic theories. In 1978, Jack Mezirow introduced another learning theory, which he named perspective transformation. 1 This differed from existing theories of learning in that it framed learning as more than just a transmission of facts, ideas, behaviors, and attitudes. Mezirow postulated that learning is a process of recognizing the limitations of one s current knowledge and perspectives and being challenged to think and grow beyond these limitations. The basic tenet of the transformative theory is that learning is a change process: "Perspective transformation is the process of becoming critically aware of how and why our assumptions have come to constrain the way we perceive, understand, and feel about our world; changing these structures of habitual expectation to make possible a more inclusive, discriminating, and integrating perspective; and, finally, making choices or otherwise acting upon these new understandings." 2 Transformative learning fits well within the model of adult learning. According to andragogical methods, adults take responsibility for their learning; they bring their experience to learning and are ready to learn whenever the need and opportunity arise. Learning is not confined to structured settings within a prescribed curriculum and scheduled tasks. On the contrary, learning is a process of change that takes place in any setting and at any time. Mezirow structures his transformative theory into frames of reference or meaning schemes that are the structures or assumptions through which we understand experiences. 3 There are cognitive components (perceptions, knowledge, memory, judgment, and reasoning), conative components (drive, impulse, and action) and emotional components (expression, feelings, beliefs, and attitude). These frames of reference set and shape expectations, perceptions, cognition, and feelings. An individual s frames of reference are based on the totality of his or her experiences over a lifetime cultur- 18

2 paeav21n1.qxp 4/8/2010 9:48 AM Page 19 al, familial, economic, and political and the individual moves from one frame of reference to another depending on the context of the moment. An individual tends to reject ideas that fail to fit within his or her frames of reference. Frames of reference come in two dimensions: habits of mind and points of view. 3 Habits of mind are durable: they are broad, abstract, and orienting; habitual ways of thinking, feeling, and acting. Habits of mind are influenced by assumptions and form a set of codes: cultural, social, educational, economic, political, and psychological. They act as filters for interpreting experience. Points of view are supple. 3 They represent sets of immediate, specific beliefs, feeling, attitude, and value judgments. They offer a degree of malleability to the meaning schemes. Through experience, points of view are transformed and, in turn, may affect frames of reference if given enough credence by the learner. According to Mezirow, 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. 3 THE STRUCTURE OF TRANSFORMA- TIVE LEARNING Physician assistant (PA) educators are in a distinctive position to promote transformative learning. The typical PA student encounters many new and challenging experiences throughout his or her training time. Students encount-er settings, cultures, beliefs, and actions that are outside of their past experience and comfort zone. These experiences often cause discord as they do not fit within the student s predetermined frames of reference. It is through structuring and guiding the student s response to these experiences that we, as educators, can facilitate the transformative process and encourage growth. It is our goal to produce professionals who are not only capable clinically but are compassionate and empathic, able to help others no matter their background or how they differ from the student s own understanding of life. Any act of transformation must begin with an activating or initiating event. 4 This event does not have to be life-changing any new experience that forces one to reflect on one s assumptions can be an opportunity to undergo a transformative process. Educators can serve as the catalyst by exposing students to the limitations of their current knowledge, beliefs, or approach to life and encouraging them to examine these critically. The trigger can be a single event, such as participation in a community service project. For example, students often are surprised to learn that most clients at the local soup kitchen are not, in fact, homeless. While helping out during dinner shifts and interacting with the clients recently, students learned that the majority of the patrons were employed but at such low salaries that they cannot afford to both pay rent and buy groceries. The trigger could also be a slow process of acquiring new experiences, understanding, or awareness such as through completing a clinical rotation with a population other than one s own. The process of transformation, however, requires more than just the experience. It is not enough to simply experience something new the learner must also undergo critical reflection. It is important that the learner examines the internal discord brought about by the new experience and then takes action, which may result in an alteration of previously settled points of view, habits of mind, or frames of reference. The process of transformation/ transformative learning includes several steps. 5 The learner must: Experience a disorienting dilemma (discord) Undergo self-examination Perform a critical assessment of his or her assumptions Recognize that others have gone through a similar process Explore options for reconciling discord (roles, relationships, actions) Formulate a new plan of action Acquire knowledge and skills to implement the new plan Try out new roles, relationships, or actions Build competence and self-confidence Reintegrate and re-evaluate the new point of view The steps are fluid and not necessarily linear. When faced with the discourse that may arise from a new experience and subsequent critical self-assessment, the learner is given the chance to explore the myriad choices for resolving the dilemma. The learner then has the opportunity to develop a plan of action to test one or more options; each examination will likely necessitate acquisition of new knowledge, beliefs, or skills. The Journal of Physician Assistant Education 2010 Vol 21 No 1 19

3 paeav21n1.qxp 4/8/2010 9:48 AM Page 20 New roles, relationships, or actions are tested, allowing the learner to build competence and self-confidence within the evolving point of view. If successful, the learner can continue to reintegrate and re-evaluate the new point of view and adjust his or her frame of reference to reflect personal growth. This process is repeated each time the learner is confronted with another transformative experience. Reframing can be objective (task oriented, problem solving) or subjective (self-reflective assessment of beliefs, ideas, meaning). The outcome may be an elaboration on existing points of view, the establishment of new points of view, a small transformation of an established point of view, or an epochal change in meaning scheme. 3,5 One student spent 4 weeks working with an outreach unit in inner-city Camden, New Jersey, which included a needle-exchange program. Upon completion of the experience, the student described how her perspective on individuals with drug abuse problems had changed, from believing that the individual was weak and deserving of jail time to wanting to advocate for change in drug laws and increasing rehabilitation programs. ENHANCING TRANSFORMATIVE LEARNING IN PA EDUCATION The Role of the Instructor Transformative learning requires risk taking by both student and instructor and often promotes tension, discomfort, and distress. Examining their belief systems and frames of reference may trigger long-hidden emotions for learners. As a faculty member, it is important to consider the content and context when setting up opportunities for transformation, as they can help or hinder the process. 5,6 Before introducing a Box. Ground Rules for a Safe Learning Environment These should ideally should be established together at the beginning of the process. Suggestions include: Respect for each member of the group No preconceptions No names provided when discussing written entries with a group Listen when others are speaking No personal attacks One person speaks at a time Do not interrupt others Do not raise voices All discussion and input is kept within the group learner to a situation that will likely cause discord, the instructor should take the time to evaluate the experiences and previous risk-taking of the student(s); any cultural beliefs that may be challenged by the experience; recent events at home, school, or work that may influence the experience; and the attitudes, relationships, and power hierarchy of the group. This may seem like a daunting task, but it can be done through online/ anonymous pre-session questions to judge the group s stand on an issue and the current level of emotional stress in the group, or to direct inquiry into specific topics. Instructors must be ready to calm emotional outbursts or help with conflict among members of the group, while continuing to facilitate the learning process. The instructor must set up a trusting environment. 4,6 Ground rules should be established before the event so that all participants feel safe exploring ideas and beliefs that may be sensitive (see Box). Participants should agree to keep confidences, show respect, accept alternative points of view, agree to disagree on issues, and keep an open mind through each event or discussion. It may be helpful to have ground rules displayed and reiterated before beginning a sensitive discussion such as exploring bias and prejudices. A case study exhibiting blatant bias on the part of a provider (such as a refusing to care for a patient of a different race) is one way to begin discussion about stereotypes and prejudice. If tensions begin to mount during the discussion, the instructor may refer back to the ground rules and ask the group to reaffirm their agreement with one or more ground rules. This will bring emotions back to a level at which further discussion can ensue. The instructor should seek to provide a safe environment in which learners can explore options and also facilitate the learners quest to discover and explore new roles, relationships, or actions. As Taylor put it, it is important to create a community of knowers who are united in a shared experience of trying to make meaning of their life experience. 7 All parties must be ready to accept the challenges and risks inherent to transformative change. The goal of transformative processes is positive growth; however, the critical assessment and discord may uncover highly charged emotions and potentially 20

4 paeav21n1.qxp 4/8/2010 9:48 AM Page 21 harmful interactions. The instructor should set the stage and act as a role model, demonstrating a willingness to learn and change as well as admit faults, explore biases, and take risk. But the instructor must not be emphasized over the learner. The instructor and the learners share the responsibility of creating a safe environment and promoting growth. The learners help create the conditions under which transformative learning can occur in a safe, accepting environment where it is okay to take risks with one s feelings, beliefs, emotions, and relationships. 3,4,5 There are many areas within the PA curriculum where transformative learning can take place, including discussion of ethical questions, exploring cultural belief systems, working with underserved populations, participating in community advocacy programs, exploring health policy or social justice issues, fostering leadership and professionalism, and exploring the medical humanities and medical narrative concept. McGonigal encourages educators to purposely set up activating or initiating events. 8 For example, a discussion of health beliefs and cultural viewpoints can be facilitated by a field trip to a neighborhood bodega or by inviting a local shaman to speak to the class about health beliefs or practices. The applied experience, together with academic inquiry, fosters intellectual openness and allows the transformative process to occur. Educators can foster transformative learning by understanding and accepting students backgrounds and belief systems and then providing conflicting viewpoints and creating a disorienting dilemma. The experience should challenge the knowledge, beliefs, or assumptions the student brings to the learning environment. Opportunities for transformation can be constructed both in the classroom setting, such as watching a controversial movie (Crash, Philadelphia), and outside the classroom, such as volunteering at a homeless shelter or a crisis center. Readings, case studies, poems, prose, quotes, media, stories, and demonstrations can be integrated into classroom time. External opportunities for transformative growth may include clinical encounters, community service activities, social gatherings, and a myriad of other situations. Each opportunity brings with it a chance to challenge the students assumptions and encourage deeper experience. Educators should not be afraid to challenge the students and assist them as they confront their assumptions and fears. The Importance of Reflection With each new experience, students can be encouraged to examine their reactions and responses and explore the possible reasons behind them. The instructor s role includes offering counter-examples or alternative perspectives, thus encouraging further exploration and risk-taking. Instructors can facilitate the process as students work through their thought processes individually, in small groups, or via an online method. It is also often helpful to combine different methods of reflection such as a solitary reflection (eg, journaling) and public reflection (eg, group discussion). Reflection can be very specific and directed or left open-ended. With each reflective process, students should be encouraged to tie the reflection back to the actual experience as well as contemplate a similar experience they may encounter in the future. Instructors need to understand individual differences. Some students will embrace opportunities to undergo the transformative process; others will resist. The risk of exposing one s past experiences, beliefs, or feelings may be too much for some students. A transformative learning environment requires educators to be willing to re-evaluate their role as educators and to empower learners to foster critical self-reflection and selfknowledge. This approach to education is vastly different than traditional lecture/learner style and may produce distress in the instructor. It is also more difficult to measure success as an educator through this approach, as the learning is not easily measured. The goal of transformative learning is to fundamentally challenge or alter assumptions, to enable instructors and learners to make new connections on their own, and to foster an understanding that both learners and teachers are together trying to make meaning of life experiences. 7 How is this process or theory of learning evaluated? Unlike a basic science or clinical medical course, it cannot easily be assessed. Methods to evaluate the transformative process are, by nature, qualitative including small group discussions, focus groups, scales, surveys, content analysis, narrative designs, and written responses. 5,8,9 Whatever evaluation method is chosen, the essential element is reflection, which is a process to foster deeper understanding of an experience and how that experience changes the learner. Reflection can be scary. The process forces one to examine sensitive emotions. However, if it is encouraged in a safe, nonjudgmental way, it can be very valuable. It should not be weighted down with fear of failure or effect on the student s grades. This type of learning is best graded as a pass/fail; if the student participates in the experience and in critical reflection, credit should be given. The Journal of Physician Assistant Education 2010 Vol 21 No 1 21

5 paeav21n1.qxp 4/8/2010 9:48 AM Page 22 Reflection serves to identify the discord and connect the rational/cognitive and the affective/emotional components of learning. Reflection begins with a review or re-creation of the experience with a goal of further understanding the actions and relationships that occurred, what influenced the experience, what else may have been happening at the same time. Students are then encouraged to explore how the experience made them feel, especially how the experience may have made them uneasy or caused dissonance with their preconceived ideas, beliefs, or feelings. Students should be encouraged to reflect on their gut reactions while undergoing the experience as well as the responses they may have felt later, after the experience was completed. Students may reflect on how they felt about themselves, their emotions, their relationships, their hopes and fears. Students should be encouraged to share all their thoughts without any risk of judgment or consequence. The instructor can model reflection by engaging in the same tasks and sharing his or her thoughts and reactions, whether through discussion or written reflection. 4,5,8,10 SUMMARY A safe environment, enough time for critical reflection, support for all perspectives, and respect for all involved is essential to transformative learning. A culture of respect and safety will encourage dialogue and critical discourse and facilitate transformative growth. This environment will allow students to test new perspectives as they challenge their assumptions. It is important to strike a balance between support and challenge. Educators should actively challenge students, but do so with compassion. If pushed too hard, students will resist. If pushed too little, the opportunity will fade. The educator acts as both the catalyst and a foundation of support for transformation. Patient care will present our future PAs with numerous opportunities for self-examination and transformation of frames of reference. Transformative theory offers a model that can help them to engage in the discourse that may arise in everyday encounters. Encouraging self-reflection and exploration of beliefs, attitudes, and roles in a safe environment while in training builds the learner s capacity to continue to challenge his or her assumptions. Not all learning is transformational; learning should happen through many forms. The ideal curriculum will call on several theories or models of education in order to produce the most valuable output, the graduate. In PA education, there is typically an emphasis on behavioral and cognitive approaches to learning; however, it is also wise to include opportunities to explore transformative processes as well. To fully embrace the theory of transformative learning, educators must be willing to take the risks it entails and to challenge their students to reflect on and learn from their experiences. REFERENCES 1. Mezirow J. Perspective transformation. Adult Education. 1978;28; Mezirow, J. Transformative Dimensions of Adult Learning. San Francisco: Jossey- Bass; Mezirow J. Transformative learning: theory to practice. New Directions for Adult and Continuing Education, no. 74. San Francisco: Jossey-Bass; Summer Cranton P. Teaching for transformation. New Directions for Adult and Continuing Education, no. 93. San Francisco: Jossey-Bass; Spring Cranton P. Understanding and Promoting Transformative Learning. 2nd ed. San Francisco: Jossey-Bass; Sockman BR, Sharma PR. Struggling toward a transformative model of instruction: it s not so easy! Teaching and Teacher Education. 2008:24; Taylor, EW. Building upon the theoretical debate: a critical review of the empirical studies of Mezirow s transformative learning theory. Adult Education Quarterly. 1997;48(1): McGonigal K. Teaching for transformation: from learning theory to teaching strategies. Newsletter on Teaching. 2005;14(2). 9. Foster CR. Teaching and learning in the service of transformation. Change. Heldref Publications; Wright KA, Powers SL, Ali M. The role of reflective journaling in physician assistant education. J Physician Assist Educ. 2007;18(4): FURTHER READING Mezirow J et al. Learning as Tranformation: Critical Perspectives on a Theory in Progress. San Francisco: Jossey-Bass; O Sullivan EV, Morrell A, O Connor MA. Expanding the Boundaries of Transformative Learning. New York, NY: Palgrave, St. Martin s Press;