성인학습이론: 의학교육의 교수 학습에 대한 함의 (AMEE Guide No.83)

성인학습이론: 의학교육의 교수 학습에 대한 함의 (AMEE Guide No.83)

Adult learning theories: Implications for learning and teaching in medical education: AMEE Guide No. 83

DAVID C. M. TAYLOR1 & HOSSAM HAMDY2

1University of Liverpool, UK, 2University of Sharjah, United Arab Emirates

Introduction

Vygotsky와 같은 구성주의자

The more we read, the more we realise that there are many different ways of explaining how adults learn (Merriam et al. 2007). None of the individual theories fully explain what is happening when an aspiring health professional is engaged in learning. In this Guide, it will become clear that the authors hold a broadly constructivist view. Constructivists, like Vygotsky (1997), consider that learning is the process of constructing new knowledge on the foundations of what you already know. We will explain a constructivist schema, which we feel has an evidence base and forms a theoretical basis to help curriculum development, learning and teaching strategies, student assessment and programme evaluation.

Malcom Knowles의 Andragogy

Malcolm Knowles (1988) considered that adults learn in different ways from children. He introduced the term “andragogy” to differentiate adult learning from pedagogy; this differentiation now seems to be artificial. Many of the principles of andragogy can be applied equally to children's learning. It is probably more appropriate to think in terms of a learning continuum, which stretches throughout life, with different emphases, problems and strategies at different times.

Categories of adult learning theories

아래와 같이 구분지어질 수 있다.

Our task is complicated by the observation that the theories of learning flow partly from psychological theories of learning and partly from pragmatic observation. It is also important to remember that “learning” includes the acquisition of three domains: knowledge, skills and attitudes; any theories should ideally account for learning in each of these three domains.

In broad terms, theories of adult learning can be grouped into, or related to, several categories. There is quite a lot of overlap between the theories and the categories of theories, and here we give a simplified overview:

• 도구적 학습이론 Instrumental learning theories: 개인의 경험에 초점을 두며, 행동주의와 인지학습이론이 있다.
  These focus on individual experience, and include the behaviourist and cognitive learning theories.
• 행동주의 이론 Behavioural theories are the basis of many competency based curricula and training programmes (Thorndike 1911; Skinner 1954). A stimulus in the environment leads to a change in behaviour. Applying these theories usually results in learning that promotes standardisation of the outcome. This leads to the main issue with behavioural theories – namely who determines the outcomes and how they are measured?
• 인지학습 이론 Cognitive learning theories focus learning in the mental and psychological processes of the mind, not on behaviour. They are concerned with perception and the processing of information (Piaget 1952; Bruner 1966; Ausubel 1968; Gagne et al. 1992).
• 경험학습 Experiential learning has influenced adult education by making educators responsible for creating, facilitating access to and organising experiences in order to facilitate learning; both Bruner's (1966) discovery learning and Piaget's (1952) theory of cognitive development support this approach. Experiential learning has been criticised for focusing essentially on developing individual knowledge and limiting the social context (Hart 1992). Its application in medical education is relevant because it focuses on developing competences and practising skills in specific context (behaviour in practice: Yardley et al. 2012).

• 인본주의적 이론 Humanistic theories: 개개인의 발달을 촉진하고자 하며, 보다 학습자 중심적이다. 자기실현을 위한, 자기주도적이고 내적으로 동기화된 개인을 만드는 것이 목표이다. These theories promote individual development and are more learner-centred. The goal is to produce individuals who have the potential for self-actualisation, and who are self-directed and internally motivated.
• Knowles (1988) supported this theory by popularising the concept of “andragogy”. Although it explains the motivation to learn, its main limitation is the exclusion of context and the social mechanism of constructing meaning and knowledge. We now know that context and social factors are crucial in professional education (Durning & Artino 2011). 의미와 지식을 구성하는데 있어서 맥락적, 사회적 기전을 배제했다는 지적을 받음
• Self-directed learning suggests that adults can plan, conduct, and evaluate their own learning. It has often been described as the goal of adult education emphasising autonomy and individual freedom in learning. Although it is axiomatic to adult learning, there are doubts about the extent to which self-directed learning, rather than directed self-learning is truly achievable (Norman 1999;Hoban et al. 2005). A limitation of the concept is failure to take into consideration the social context of learning. It has also implicitly underestimated the value of other forms of learning such as collaborative learning. ((타인에 의해)지시된 자기학습이 아닌 진정한 자기주도 학습이 어느 정도나 가능하겠느냐에 대한 의구심이 있음, 학습의 사회적 맥락을 고려하지 않은 점, 협동적 학습과 같은 다른 형태의 학습의 가치를 낮게 평가하는 점 등이 지적받고 있음)

• 전환학습이론 Transformative learning theory: 학습자의 신념과 가정에 대한 도전으로서 비판적 성찰을 활용하는 방법. 아래와 같은 절차를 거친다. Transformative learning theory explores the way in which critical reflection can be used to challenge the learner's beliefs and assumptions (Mezirow 1978, 1990, 1995) The process of perspective transformation includes 
• A disorienting dilemma which is the catalyst/trigger to review own views/perspectives – “knowing that you don’t know” '무엇을 모르는지 안다'
• The context, which includes personal, professional and social factors
• Critical reflection. Mezirow (1990) identifies different forms of reflection in transformation of meanings, structures, context, process and premise. Premise reflection involves the critical re-examination of long held presuppositions (Brookfield 2000). 의미/구조/맥락/절차/전제에 대한 전환이 일어난다.

• 학습의 사회적 이론 Social theories of learning: The two elements that are crucial to social theories of learning are context and community (Choi & Hannafin 1995; Durning & Artino 2011). These concepts have been developed by Etienne Wenger (Lave & Wenger 1991; Wenger 1998), who emphasises the importance of “communities of practice” in guiding and encouraging the learner. Land and colleagues consider the way that learners enter the community of practice (Land et al. 2008). 학습자의 경험은 맥락과 공동체에 의해서 구성된다. The way in which a learner's experience is shaped by their context and community is developed by situativity theory and is discussed by Durning & Artino (2011). 상황인지이론의 주요 가정 세 가지 Situated cognition theories are based on three main assumptions:
• 학습과 사고는 사회적 활동이다. Learning and thinking are social activities
• 사고와 학습은 특정 상황에서 가능한 도구가 무엇인지에 의해서 구성된다. Thinking and learning are structured by the tools available in specific situations
• 사고는 학습이 일어나는 상황에 따라 영향을 받는다. Thinking is influenced by the setting in which learning takes place (Wilson 1993).

• 동기 모델 Motivational models: 성인학습을 교육이론과 연결시켜서 설명하고자 하는 모든 이론적 모델이든 반드시 두 가지 중요한 요소를 포함하고 있어야 한다. '동기'와 '성찰'이다. Any theoretical model that attempts to explain and relates adult learning to an educational theory must have two critical elements – motivation and reflection. 그러한 이론 중 하나가 자기결정이론이며, 여기서는 내적 동기를 중요시하는데, 이를 유지하기 위해서는 세 가지 기본적 욕구가 충족되어야 한다. 자율성/역량/소속감(관계성)이다.  One such theory is self-determination theory (Ryan & Deci 2000; ten Cate et al. 2011; Kusurkar & ten Cate 2013). The theory recognises the importance of intrinsic motivation, and considers that three basic needs must be fulfilled to sustain it: Autonomy, Competence, and a feeling of belonging – or “Relatedness”.
• 학습에 대한 한 가지 이슈는, 성공에 대한 기대치가 높지 않으면 학습동기가 낮아질 것이라는 점이다. One of the issues about learning is that a low expectation of success will result in poor motivation to learn, unless the perceived value of success is overwhelming. This is partly explained by Maslow's theory of needs (Maslow 1954; Peters 1966), but it probably does not capture the balance between the different competing drives of hopes and expectation of learning as opposed to the time and effort needed to engage with the process. 기대가이론은 성공에 얼만큼의 '가치'를 두는가와 성공을 얼마나 기대하고 있느냐를 포함시켰다. The expectancy valence theory (Weiner 1992) incorporates the “value” of success and expectancy of success.
• The Chain of Response model 반응체인모델은 학습프로젝트에 대한 참여를 중요하게 본다. 세 가지 내적동기요인이 서로 연관되는데, 이는 자기평가/교육에 대한 학습자의 태도/목표와 기대치의 중요도이다. concerns participation by adults in learning projects (Cross 1981). In this model three internal motivating factors are inter-related: self-evaluation, attitude of the learner about education and the importance of goals and expectations. The main external barriers to motivation are life events and transitions, opportunities, and barriers to learning or obtaining information.

• 성찰모델 Reflective models: 성찰변화모델은 성찰이 행동을 하게 하고, 그리고 이를 변화시킨다는 것이다. The reflection-change models consider that reflection leads to action and then change. Reflective learning (Schön 1983, 1987) has important relevance to medical education, and more widely in society (Archer 2012). The role of deliberate practice (Duvivier et al. 2011), using reflection and feedback as tools to develop both knowledge and skills is starting to provide very valuable insights for educators helping students develop autonomous learning.

Even this brief consideration of types of theory applicable to adult learning will lead one to realise that they each have their strengths, and are each incomplete without the others. Before addressing a model that attempts to draw the theories together, we need to consider how we arrived at where we are.

성인학습이론의 역사적 맥락

Historical aspects of adult learning theories

In the late seventeenth century, the pervading view was that all knowledge derives from experience. Although he personally did not use the term, John Locke (Locke 1690)(비어있는 칠판) considered that the mind was a tabula rasa or “blank slate” at birth and that all acquired knowledge was derived from experience of the senses. These ideas were reworked and developed until the early twentieth century when Edward Thorndike (효과의 법칙, 연습의 법칙)derived his laws (Thorndike 1911), principally the law of effect – which stated that learning occurred if it had a positive effect on the individual, and the law of exercise – which meant that repetition strengthened the learning.

This was further developed by behaviourists, such as Skinner (1954) 빈도/인접성/우연성이 중요함. who demonstrated that some forms of learning could be demonstrated by a simple stimulus-response paradigm, so that a reward could be used to ensure an appropriate response to a stimulus. Skinner showed that there were three elements that strengthened learning, namely frequency (the number of times a stimulus was presented), contiguity (the time delay between the response and the reward) and contingency (the continued link between the stimulus and the reward). 

Chomsky (1975) 언어와 같은 고차원적 기술에는 행동주의적 관점이 적용되지 않는다. considers that the type of experiments favoured by behaviourists do not explain the acquisition of higher order skills, such as the learning of language. Chomsky argued that our brains are programmed to acquire higher order skills, which we develop and modify by experience. While some were looking at the potential neural mechanisms that underlie the acquisition of learning, others were considering the factors that can make it more effective.

Piaget, a cognitive constructivist, 인지적 구성주의자, 서로 다른 종류의 지식이 서로 다른 단계에서 습득된다. considered the different types of knowledge that could be acquired at different stages in a young person's life (Piaget, 1952). This stream of thought continues to the present day in the work of people like William Perry (1999) 대학생들이 이원론에서 다원론으로 발달해간다. who studied the way in which college students change from dualism (ideas are either true or false; teacher is always right) to multiplicity (truth depends on context; teacher is not necessarily the arbiter).

Social constructivists, like Vygotsky (1978), 사회적 구성주의자, 학습공동체가 학습을 만든다.  focus on the way that the learning community supports learning. A key idea in social constructivism is that of the Zone of Proximal Development, whereby a learner can only acquire new knowledge if they can link it in with existing knowledge. Conversations between learners/teachers articulating what is already known can extend the zone of proximal development by putting new ideas in the context of current understanding. This strand of thought has been taken forward in social learning theories by Bandura (1977),사회학습이론 and in a remarkable way by Wenger 학습공동체, in the concept of learning communities or “Communities of Practice” (Wenger 1998).

성인학습자와 교육학 

Andragogy and pedagogy: Knowles views and related learning models

Towards the end of the twentieth century, there was a body of research that suggested that adults learn differently from children and that “andragogy” was a better term for this process than “pedagogy”. The key difference between adults and children is said to be that adults are differently motivated to learn. Although the arguments no longer seem quite so clear, the line described by Knowles (Knowles et al. 2005) was that adult learners differ from child learners in six respects: 아동과 어른의 핵심적 차이는 어른은 학습에 대한 동기가 다르다는 것이다. 다음의 여섯 가지 차이가 있다.

• 내가 이것을 왜 알아야 하지? The need to know (Why do I need to know this?)
• 나는 나의 선택에 대한 책임이 있다. The learners’ self-concept (I am responsible for my own decisions)
• 내가 중요하게 생각하는 것에 대한 경험을 가지고 있고, 당신은 그것을 존중해야 한다. The role of the learners’ experiences (I have experiences which I value, and you should respect)
• 나를 둘러싼 환경이 바뀌고 있으므로 나는 배워야 할 필요가 있다. Readiness to learn (I need to learn because my circumstances are changing)
• 내가 맞닥뜨릴 상황을 대처하는데 도움이 되는 학습을 한다. Orientation to learning (Learning will help me deal with the situation in which I find myself)
• 나는 내가 학습하고 싶기에 학습한다. Motivation (I learn because I want to)

These observations, in association with David Kolb's experiential learning model ((Kolb 1984), see Figure 1) have allowed the consideration of learning and teaching strategies appropriate for adult learners.

In Kolb's scheme, 

• the learner has a concrete experience, 
• upon which they reflect. Through their reflection 
• they are able to formulate abstract concepts, 
• and make appropriate generalisations. 
• They then consolidate their understanding by testing the implications of their knowledge in new situations. 
• This then provides them with a concrete experience, and the cycle continues. 

Learners with different learning preferences will have strengths in different quadrants of the (Kolb) cycle. In Kolb's terminology

•  “Activists” feel and do,
•  “Reflectors” feel and watch,
•  “Theorists” watch and think and
•  “Pragmatists” think and do. 

흔하게 인용되고 있고, 쉽게 이해가 되는 개념이긴 하나, Kolb cycle로부터 개발된 학습유형 인벤토리는 신뢰도와 타당도가 좋지 않은 것으로 알려져 있다.

From the educator's point of view it is important to design learning activities that allow the cycle to be followed, engaging each of the quadrants. Although it is often quoted, and easily understood, the learning style inventory developed from the Kolb cycle has poor reliability and validity (Coffield et al. 2004).

큰 틀에서 구성주의적 관점을 따르자면 중요한 것은 이전의 경험, 그리고 이 이전의 경험과 새로운 경험 사이의 불협화음이다. 이러한 차이에 대해서 성찰해 보는 것이 RIA이며, 추상적 개념을 형성하게 해주고, 새로운 자료를 이해하게 해준다. 또한 직접 실험을 하거나 토론/토의를 통해서 기존 지식에 대한 검증을 하게 만든다. 그러나 여기에 빠진 것은 ROA이다. 학습자가 그들이 사용한 절차에 대해서 생각해보고, 그것이 어느 정도로 적절하고 좋은 방법이었는가를 생각해보는 것이며, 이는 학습에 필수적이다. 

Of particular importance to those who follow a broadly constructivist line (but lacking in the original model), will be the prior experience/knowledge of the individual, and the dissonance between this and the concrete experience that is provided as the learning opportunity. When we see something new, attend a lecture, or talk with a patient, we compare what we are seeing with what we already know, and reflect upon the difference (reflection in action, (Schön 1983)). This enables us to formulate abstract concepts that make sense of the new data. In turn this will lead us to propose tests of our knowledge, through direct experimentation or through debate and discussion. This is a familiar process to all acquainted with the scientific/clinical method; however at least one key element is missing, and this is reflection on action. It is crucial that the learner thinks about the processes they have used, and the extent to which they were rigorous or appropriate in the use of the material; this is fundamental to learning.

기존의 정보와 새로운 정보 사이에 연결이 만들어지는 과정: elaboration, refinement, restructuring

The next issue is the way in which new knowledge becomes integrated into the existing knowledge base. Proponents of the transformative learning approach consider that meaningful learning occurs when connections are made between new and existing information (Regan-Smith et al. 1994). Norman & Schmidt (1992) suggest that there are three main elements to this process: elaboration, refinement and finally restructuring. 

• Elaboration is linking in new knowledge with what we already know. It is important, however, that the linkages are precise rather than general (Stein et al. 1984). 
• Refinement is the act of sifting and sorting through the information to retain those elements that make sense. 
• Finally, restructuring is the development of new knowledge maps (schemata) which arguably allow one to become an expert or demonstrate expertise (Norman et al. 2006).

Bloom's taxonomy와 Miller's pyramid에서 학습성과와 스캐폴드 만들기

Learning outcomes and scaffolding from Bloom's taxonomy to Miller's pyramid

교육자는 advance organiser를 제공함으로서 학습자를 도울 수 있다. 두 종류가 있는데 model과 metaphor 그리고 scaffolding이다.

The processes of acquiring new knowledge, relating it to what is already known and developing new understanding is complicated and difficult but educators can help the learners by providing advance organisers (Ausubel 1968). There are two types of advance organisers: models and metaphors, which we will consider later, and scaffolding.

Scaffolding이란 교수자가 교수학습자료를 이용해서 학습자를 인도하는 것이다. 복잡하고 방대한 양의 자료만 넘겨주게 되면 학습자는 한계점에 도달하게 되며, 이 상태를 state of liminality(경계선상태) 라고 한다.

Scaffolding refers to the structural things that teachers do to guide learners through the teaching and learning material. They are necessary because the sheer volume and complexity of knowledge to be acquired often leaves the learner standing on the threshold (in a state of liminality), rather than stepping into the world of learning.

경계선상태(liminality)의 문제는 과소평가하기 쉽다. 우리는 한계점 너머로 우리를 넘겨줄 누군가가 필요하다. 우리가 지식과 이해를 막 쌓기 시작한 단계에서 우리는 이것들이 어디에 해당하는 것이고, 서로 어떻게 연결되며, 개별 파트가 전체의 어디에 해당하는 것인지에 대한 아이디어가 필요하다. "Scaffolding"은 이러한 역할을 하는 것이다. programme level organiser가 주로 Scaffolding이 되는데, 여기에는 Syllabus, lecture, planned experiential learning, reading list 등이 포함된다. 흔하게는 요즘에는 학습성과의 목록을 제공해주기도 한다. 

It is easy to underestimate the problem of liminality. It is described well by Ray Land (Land et al. 2008; Meyer et al. 2010), but it refers to the sense of discomfort we feel when we do not quite understand the rules or the context of a new situation. We need someone to lead us over the threshold, introduce us to the new ideas, and probably explain some of the language (Bernstein 2000). As we start to build our knowledge and understanding, we need to have some idea of where things fit, how they fit together, and some idea of how the individual pieces are part of a greater whole. “Scaffolding” provides that perspective. Scaffolding includes programme level organisers, which are dependent on both the content and the context in which it is being learned. Programme organisers include the syllabus, lectures, planned experiential learning and reading lists. Most commonly, these days scaffolding includes providing learners with a list of intended learning outcomes. It is important to remember that it also includes the induction that students receive when they enter the programme or a new clinical environment.

Learning outcomes can be further refined using Bloom's taxonomy (Bloom et al. 1956), which has been revised by several authors, including Anderson (Anderson & Kratwohl 2001). In Figure 2, Bloom's taxonomy is shown in the pyramid itself, and Anderson's development of it in the side panels.

Anderson은 Creating을 Evaluating보다 높이 두었는데, 둘 다 학습자가 지식을 활용해서 무언가 하게 한다는 점을 공통적으로 강조하고 있다. 학습성과는 따라서 '동사'와 관련되어야 하며 학습해야 하는 '목록'이 되어서는 안된다.

Anderson's modifications indicate a belief that “creating” is a higher attribute than “evaluating”, but they are also important in emphasising that the learner does things with knowledge. Learning outcomes, therefore, should be associated with verbs, rather than lists of things to learn. The difficulty with the model is highlighted by the differences between Bloom and Anderson's model. In reality, the elements of the pyramid are arranged in a cycle. Evaluation leads to developing a new idea which is then applied, analysed, evaluated and so on.

Bloom's taxonomy는 다양한 변형이 있다. Miller의 피라미드는 그 하나다. 그러나 지식은 피라미드의 기초일뿐 피라미드 그 자체는 아니다.

Bloom's original work led to several variants. In medical education, the most frequently encountered is Miller's pyramid (Miller, 1990; Figure 3), which can be used as a guide for planning and assessing within a curriculum. The pyramid is important, because in training students for the healthcare professions it is essential to remember that the outcome of training is intended to be a graduate who can take their place in the workforce (Action). Knowledge is the foundation of the pyramid – but not the pyramid itself.

안내적 발견학습과 학생의 학습전략 

Guided discovery learning and students’ learning strategies

조하리의 창 In a structured learning environment new knowledge is sufficiently similar to the existing knowledge to allow its relevance to be perceived. A more challenging condition applies in real life, when the relevance of information is often far from apparent. The variants of this situation are described by the Johari Window (Figure 4), named after its originators Joseph Luft and Harry Ingram in the 1950s (Luft & Ingham 1955).

여기서 두 가지가 명백해지는데 개개인간 토론이 실용적 지식을 늘려준다는 점과, 일부는 여전히 잘 모르는 상태로 남아있을 것이다라는 것이다. 

Two things are immediately apparent from this construction – namely that (1) discussion between individuals will increase the amount of practical knowledge, and that (2) some things remain a mystery until we talk to someone else with a different range of knowledge or understanding. It follows that the more diverse a learning group's membership is, the more likely the individuals within the group are to learn. There will always be “unknown unknowns”, but teachers can help students move into those areas through a careful choice of task, resources and, of course, patients. Before we look at the ways in which we can assist learning, there are two other considerations; both of which relate to the way that the learner thinks about knowledge.

다양한 학습스타일이 있을 수 있다.

Newble, Entwistle and their colleagues, in a number of studies (Newble & Clarke 1986; Newble & Entwistle 1986), have shown that there are several different learning styles, and that learners have different learning preferences. There is a real and active debate about whether learning styles are fixed or flexible, and the extent to which they are determined by the context (Coffield et al. 2004). It does seem clear that some learners prefer to work towards a deep understanding of what they are learning; others prefer to acquire the facts, a term known as surface learning. A moment's reflection will show that each can be an appropriate strategy. Sometimes deep understanding is needed, and sometimes it is enough to know “the facts” – the surface. It is important to know normal blood gas values or electrolyte levels and this surface learning triggers appropriate clinical action. However, to sort out a patient with acidosis requires a deeper understanding of how the various physiological systems interact. The ability to be strategic about the sort of learning we engage in is important. But it can be affected by the assessment system. So, if an assessment system tests for recall of facts, then the successful learner will employ surface learning. If the system rewards deep thought, understanding and reasoning, then the successful learner will aim for that. Strategic learning이 세 번째 스타일인지 아닌지에 대한 논란이 있다. There is a difference of opinion about whether “strategic” is a third learning style or not (Newble & Entwistle 1986; Biggs et al. 2001). 

서로 다른 스타일에 대해서 아는 것은 중요한데, 왜냐하면 강의는 대체로 surface learner에, 확장된 프로젝트는 deep learner에 어필할 것이기 때문이다.

Recognising the different styles is important, as (most) lectures will appeal more to surface learners and extended project work will appeal more to deep learners. Some subject material actually needs to be known and rapidly recalled (blood gas values, electrolyte levels), while other material needs to be deeply understood to allow appropriate interventions (coping with acid base disturbances, or circulatory shock).

이원주의에서 다원주의로의 발전해나간다.

In a series of studies on American students in their college years, Perry (1999) noted that students change in their approach to learning as they progress through their college years. Typically students develop from an approach based on “duality”, with a clear view that the teacher will tell them the difference between right and wrong, towards “multiplicity”, where they recognise that context is important, and that they, their colleagues and the environment are valuable sources of knowledge and experience. Together with this change in focus comes a greater confidence with coping with uncertainty. This work was based on a relatively able, affluent and homogenous population of undergraduates and was subsequently extended by Perry's colleagues to a wider cross section of society. They (Belenky et al., 1997) uncovered a group of “silent” learners, who did not recognise their own rights to question or construct knowledge. Belenky and colleagues also extended the scale beyond receiving and understanding knowledge, to being co-constructors of knowledge (Belenky et al. 1997).

그러나 일부 연구에서는 꼭 이러한 방향으로 발전해나가는 것은 아니라고 하기도 한다.

Some recent work by Maudsley (2005) shows that medical students develop in the way they learn, but that the progression is not always from duality to multiplicity. There are two explanations for this paradox, one is that the learners tend towards more strategic learning styles in order to cope with the demands of the assessment system; the alternative explanation is rather more complex and relates to the business of becoming a new member of the profession.

학습이란 단순히 지식을 얻는 것 만이 아니라, 그것을 이해해서 활용하는 것 까지를 일컫는다.

The process of learning new things is not just about acquiring knowledge (surface learning), it includes being able to make sense of it, and hopefully making use of it. But being able to do these things means that you have to acquire an understanding of where things fit. A novice stands at the threshold, not quite knowing what to expect, and sometimes not even knowing what they are supposed to be looking at. This is a state of liminality, and the learner needs to have some threshold concepts so that they can move further (Land et al. 2008; Meyer et al. 2010). Frequently the difficulty is in the vocabulary or the way that language is used (Bernstein 2000), but it can also be troublesome concepts (Meyer & Land 2006), or just becoming part of the “team” and assuming a new identity (Wenger 1998). The role of the teacher is to help the learner over the threshold, and, as discussed above, help them until it starts to make sense. If we follow Wenger's arguments (Wenger 1998) then we will see that the whole community has a role in leading the novice over the threshold, and helping them to take their place in the community of practice, that is, in this case, the healthcare profession

성인은 어떻게 학습하는가?

How adults learn: a multi-theories model

다섯 단계를 제안하고자 한다.

It will be clear by now that there are several different theories about, and approaches to, learning. In the section that follows we introduce a model that encapsulates them and can be used to structure, plan and deliver successful learning experiences. We propose that there are five stages in the learning experience, which the learner needs to go through. The learner and the teacher will have particular responsibilities at each stage. We shall outline the model first, describe the responsibilities and then discuss each element in greater detail.

Outline

All learning starts with the learner's existing knowledge, which will be more or less sophisticated in any given domain (Figure 5).

• 학습자의 지식이 도전받고, 그것이 완전하지 않음을 알게 되는 과정
  The dissonance phase exists when the learner's existing knowledge is challenged and found to be incomplete. The challenge can be internal, when a learner is thinking things through, or it can be external, provided by a teacher or patient. There are several things that influence whether the learner will engage with the dissonance phase. These include the nature of the task, the available resources, the motivation of the learner, and the learner's stage of development and their preferred learning style. It ends with the learner reflecting and determining their personal learning outcomes.
• 학습자는 dissonance에 대한 가능한 설명과 해답을 찾아보게 되고, 과제수행/연구/성찰/토론 등을 통해서 새로운 정보를 정제(refine)하게 된다.
  During the refinement phase, the learner seeks out a number of possible explanations or solutions to a problem (elaboration), and through completing tasks, research, reflection and discussion refines the new information into a series of concepts which are, for the learner, new.
• 학습자가 새롭게 얻어 증가한 지식을 처리하기 위해서 자신의 생각을 더욱 발전시키거나 재구조화하는 단계이다.
  The organisation phase is where the learner develops or restructures their ideas to account for the increased information they have acquired. There are at least two elements to this: reflection in action, where the learner tests and re-tests hypotheses to makes sense of the information and the organisation of the information into schemata which (for the learner, at least) make sense.
• 이 단계는 가장 중요한 단계라 할 수 있는데, 왜냐하면 여기서 학습자들은 새롭게 얻은 지식을 분명하게 표현하고, 동료나 선생님의 신념에 맞서게 되기 때문이다. 피드백은 기존의 스키마를 강화시킬 수도 있고, 또는 새로운 정보를 다시 고려하게 함으로써 학습자를 굴복시킬 수도 있다.
  The feedback phase is arguably the most crucial, as it is where the learner articulates their newly acquired knowledge and tests it against what their peers and teachers believe. The feedback will either reinforce their schema, or oblige the learner to reconsider it in the light of new information.
• 이 단계에서 학습자는 그들이 수행한 단계를 다시 생각해보면서 지나간 학습 사이클을 되돌아보고 거기서 무엇을 배웠는지(지식 측면의 향상)와 더불어 학습절차(RoA)까지 성찰해보게 된다.
  During the consolidation phase the learner reflects upon the process they have undergone, looking back over the learning cycle and identifying what they have learned from it, both in terms of increasing their knowledge base, but also in terms of the learning process itself (reflection on action).

Adult learning model in action

각각의 다섯 시기에 학습자와 교수자가 해야 할 구체적 역할들이 있다.

During each of these phases, we propose that there are specific roles for teachers and learners.

The model that we have given here shows that there are a number of ways in which applying the model can help in the design of learning activities, whether in one-to-one discussions, small group work, seminars or large lectures. The same principles apply to planning curricula, at short course, module or programme level. Whether working with an individual learner, or planning a major programme, the educator needs to recognise that the learner needs to move through a cycle, in order to truly understand and learn. We also need to be explicit that educator and learner have specific responsibilities at each stage of the learning process.

확장형 성인학습모형 

Adult learning model “expanded”:

The dissonance phase

The key to success as an educator is probably providing the advance organisers. We need to know what we want the learner to learn, and how it fits into the greater scheme. That means that we must have clearly defined outcomes, at the appropriate levels of one of the modifications of Bloom's taxonomy (Figure 2). We may need a student to gain new knowledge, apply their knowledge or create a new hypothesis, for instance. Once we know our intended outcome we are in a position to start thinking about the best way of helping the learner to acquire, and demonstrate that they have acquired, the learning outcomes.

학생이 무엇을 하게 만들까를 먼저 고민하지만, 그보다 가장 적절한 과제를 위해 고려해야 할 다음의 다섯 가지를 먼저 생각해야 한다.

When we plan an educational intervention, we usually start with an idea of the task we want the students to be involved in (attend a lecture, take a history from a patient, write an essay, or whatever). There are, however, five considerations that define the most appropriate task, and they should come first.

(1) 어떻게 학습자를 격려하고, 사전 지식을 활용하게 할 수 있을지 고민하라
Consider how the learner can be encouraged to articulate their prior knowledge

The entire learning process starts with what a learner already knows. In any intervention, we need to make sure that the learner has the possibility to articulate what they already know about something. There are many possible techniques, for instance “buzz groups” in lectures (Jaques 2003), the early phases of the PBL process where learners discuss what they already know (Taylor & Miflin 2008), or discussing something on the ward before performing an examination or obtaining a history from the patient. This stage helps the learner anchor the new knowledge in what they already understand, and places them on the first stage of the learning cycle. It also highlights to the learner where the gaps or uncertainties are in their knowledge.

(2) 학습스타일과 그것이 갖는 함의를 생각하라.
Consider learning styles and their implications

If the aim of the educational intervention is simply to present the learner with new knowledge, then surface learning is the most appropriate learning style. It is not the most appropriate learning style, though, if the learner is required to understand, or later elaborate on the knowledge (Newble & Entwistle 1986; Biggs et al. 2001). Elaboration, and the later stages of Bloom's taxonomy require an increasing depth of understanding. There are complicating factors, since many learners are strategic in choosing surface learning styles before they enter University courses, so they may appear to show a preference for surface learning. Even at graduate level, if students know that they will be tested on their acquisition of facts, rather than their understanding, they will naturally choose a surface learning style. If the educator is aiming for a deeper level of understanding, then it will be necessary to make sure that the assessment process does not derail it.

It is possible, but challenging, to use lectures to provide more than surface knowledge. Deep learning comes through discussion, research and weighing up the evidence. Curricula that use PBL (Taylor & Miflin 2008), Team based learning (TBL: Michaelsen et al. 2002) and Case-based learning (Ferguson & Kreiter 2007) are designed with this in mind, but more traditional programmes can introduce elements of the more discursive styles, or require learners to complete particular tasks, such as research, small group work or preparing papers.

(3) 학습자의 발달단계를 생각하라
Consider the stage of development of the learner

In the same way that surface learning has attractions for many learners, Perry's stage of duality has attractions for both the learner and the educator (Perry 1999). Lectures can reinforce a state of duality in which the learner accepts what the lecturer says. But learners need to be comfortable with uncertainty, dealing with a partial picture and recognising when they need to know more. It is not enough for a doctor just to know the right answers in a perfect situation; we rightly expect them to understand why they are the right answers, and how they are determined by circumstances. A senior clinician will have sufficient experience to recognise this, and it should come across in traditional bedside teaching. Learners can also develop their understanding of systems through well-facilitated PBL or case-based learning, where the facilitator encourages learners to think about the value they attribute to “facts”, and the way in which they think about them. Helping the learner shift from duality to early multiplicity, and look beyond the obvious first impressions, is crucial to bedside teaching, for instance, where test results or images have to be related to the patient's account of their problem.

(4) 학습자의 동기를 생각하라
Consider the learner's motivation

Sobral's (2004) work has shown that student's motivation can be strongly influenced by the educational environment and their frame of mind towards learning. This is also central to the self-determination theory (ten Cate et al. 2011; Kusurkar & ten Cate 2013). If that is the case, then early clinical contact that is both stimulating and relevant to the desired learning outcomes will be beneficial.

Although adult learners are expected to be self-motivated, they will also have a host of competing concerns. Balancing two or more imperatives is a normal state of affairs for both learner and educator. It is the responsibility of the educator to ensure that the task will engage the learner for long enough to allow the learner's enthusiasm to be captured. It is equally important not to squander the learner's energy and enthusiasm with poorly thought out tasks, or issues that are either trivial or too difficult.

There is more to consider here, particularly the dimensions of self-directed learning (Garrison 1997), which include motivation and self-regulation (Zimmerman 2002). There is some evidence that problem-based learning students are better at self-regulation (Sungur & Tekkaya 2006), which includes the ability to construct meaning. The goal, however is self-directed learning which transcends self-regulated learning to include motivation and, crucially, the ability to determine what should be learned (Loyens et al. 2008). Again, this is fostered by problem-based learning, but is easily destroyed by publishing or giving the students detailed intended learning outcomes.

(5) 자원을 고려하라
Consider the resources

가장 중요한 자원은 뭐니뭐니해도 시간이다.

Naturally, we need to consider physical resources such as space, books, journals, and access to electronic resources. The most precious resource, for all of us, is time. Whenever an educational activity is planned there must be sufficient time devoted to preparation and planning, including planning the way in which the activity will be evaluated and assessed. Clearly there will need to be sufficient time made clear for the educator/s involved in the delivery, but also in the evaluation and assessment processes. It is also important that there is sufficient time for the learners to engage with the learning activity and complete any necessary additional work, such as reading, and of course reflecting upon the material and the way in which they have learned.

위의 다섯가지를 고민하고 나서 과제를 고민하라.

Finally consider the task

The task the learners are set has to take into account all of the preceding considerations.

It needs to have learning outcomes which are aligned with the curriculum as a whole and which are specific enough to be reasonably achievable within the allocated time. No one could learn the anatomy and physiology of the nervous system in a couple of days, but they might be able to master the anatomy and physiology that underlie the crossed extensor reflex.

Opinions are divided about whether every task should be assessed, but it is widely asserted that “assessment drives learning” (Miller 1990), so attention needs to be paid to the assessment opportunities, and the material covered should be included in the assessment blueprint (Hamdy 2006).

The elaborate and refine phase

Dissonance에서는 가능한 많은 대안을 찾는게 우선이다. 

The dissonance provided by the task has been sufficient to introduce new possibilities, facts and concepts to the learner. They must now start to make sense of them. The first stage in this process is to consider as many of the possible explanations for the new information as possible. This is equivalent to the brainstorming phase in problem-based learning and has two main advantages. 

• The first is that it helps ensure that connections are made between the new information and previous knowledge, ensuring that everything is learnt in the context of what is already known. 
• The second is that it reinforces our natural tendency to be appropriately inventive and to think widely. This skill will be crucial for the future healthcare professional, where the obvious explanation for a patient's symptoms may be wrong. Shortness of breath, for instance, may have a respiratory or a cardiovascular origin.

Refinement를 하지 않고 Elaboration만 하면 혼란만 가중된다. 따라서 가능한 설명이 모이면, 그것들을 '가장 가능성 있는' 답안으로 정교화해야한다.

Elaboration without refinement will just lead to confusion, so once a number of possible explanations for a scenario have been determined, it is necessary to refine them into the most plausible solutions. This will be after some research, reflection and discussion or in the clinical environment after reading the patients notes or seeing the results of appropriate tests. In this phase we are mirroring the scientific and clinical method, which is a valuable exercise in and of itself. The outcome of this phase is the generation of a working hypothesis.

Elaboration과 Refinement 시기에 일어나는 대부분의 일은 학습자 내부에서 진행되지만, 그 모험이 성공할지 여부는 어떤 과제를 주었는지, 그리고 적절한 자원을 제공하였는지에 달려있다.

Most of what happens in the elaboration and refinement phase is internal to the learner, but the success of the venture will stem from the nature of the task they were set, and the provision of appropriate resources. The task must be such that it requires some thought and engagement to complete it, and the resources need to be appropriate to the task and the understanding of the learner. This phase is the key part of problem-based learning, but can also arise out of clinical and bedside teaching when the educator is aware of the possibilities and careful to exploit them.

The organisation phase

이 시기에 학습자는 문제를 모든 관점에서 바라보면서 그들이 이미 아는 것에 대응하여 가설을 검증하고 재검증해본다. 이는 복잡한 과제이며, 이 때 학습자는 RiA를 통해 스스로를 비판적으로 성찰하게 된다.

During this phase the learner looks at a problem from all angles, testing and retesting the hypothesis against what they already know. Part of this phase is fitting the information into what the learner already knows, and part of it is in constructing the new information into a story that makes sense to the learner. This is a complex task and involves the learner reflecting in action, challenging him- or herself to reflect critically.

교육자는 두 가지 지지하는 역할을 하게 된다.

The educator has two roles in supporting the learner. 

• The first role is to provide them with scaffolding, a skeleton to support their ideas and give them coherence and structure. This may be the framework of the programme, with a series of themes, or it might be a lecture or lecture series, or it could even be a syllabus. The danger with scaffolding is that if it is too detailed it removes any freedom or responsibility from at the learner. It then becomes very difficult to determine whether true understanding (rather than simple recall) has been achieved. It also means that the learner will not know, until too late, whether they truly understand the subject.
• The second role for the educator is to encourage critical reflection. At its best the educator will model this in tutorials or the supervising clinician in bedside teaching, but it is perfectly possible to model one's way of thinking about a problem in a lecture or seminar. Given that so much of our knowledge base changes, critical thinking is probably the most important skill we can give our students.

학생들로하여금 그들의 성찰적 기술을 검증해볼 수 있는 기회를 제공하는 것이 중요하다. 상호토론, 비공식적인 방법, 소그룹, 교육자와 함께, 친구들과 함께 등 다양한 방법이 가능하다.

It is essential that we provide students with opportunities to test their reflective skills. There are many possible ways but they include discussion with each other, informally, or in small groups, with the educator, or with critical friends. Although the idea of critical friends (Baskerville & Goldblatt 2009) is usually associated with teachers/researchers, there is no reason why it would not work between students, although they would need training and support in the first instance.

피드백 Feedback

피드백의 두 가지 요소

There are two elements to feedback.

• 하나는 무엇을 배웠는지를 설명하는 것이다. The first is articulating what has been learned. All educators know that the real test of understanding something is explaining it to other learners. So the newly acquired material needs to be explained, or used in some way.
• 학습자와 교육자가 도출된 결과에 만족할 때까지 주장의 강점과 약점을 짚어주고, 추가 질문을 하는 것이다. The educator's role, together with other learners, is the second element of feedback, which is to point out the strengths and weaknesses of any argument, and to ask further questions, until learner and educator are satisfied that the outcome has been met. In any facilitated small group session or bedside teaching session, this is part of the role of the facilitator – it is perfectly possible and acceptable to challenge constructively without handing out the correct answer or humiliating the student. In a group that is working well (whether a formal, structured group or a self-formed study group) other group members will pose questions and seek clarification. This is a combination of feedback and discussion, and can lead to co-construction of knowledge (Belenky et al. 1997). It is also relatively simple to provide feedback in a lecture theatre – either through team-based learning activities, or through instant feedback devices such as “clickers”, or, dare one say, the raising of hands!

가장 적절한 시점이 있다. 가장 확실한 예는 '평가를 하는 바로 그 시점'이다.

Although feedback is best given in frequent, small, doses, there are clearly times when it is crucial. The most obvious example is when the learner is being assessed. This is when learners realise the extent to which they have acquired and can demonstrate new knowledge. Any effective assessment system will provide learners with an indication of where they are going wrong, and which areas they should focus on for clarification of their understanding.

종종 놓치는 두 가지 요소가 있다.

There are two further elements of the feedback phase that are often ignored. 

• 교육자가 스스로의 피드백에 대해서 생각해보는 것 
  The first is the duty of the educator to seek and reflect upon the feedback they obtain about their own performance. In this way we can develop and hone our skills to become better at what we do. 
• 학습자와 교육자가 그들이 학습한 방법에 대해서 생각해봐야 한다.
  The second relates to epistemology. Educator and learner also need to reflect upon the way that they have been learning, and the relative highs and lows of the experience. This is to ensure that we can work smarter (rather than harder) next time.

The consolidation phase

두 가지 도전에 맞닥뜨리게 된다.

The learner faces two challenges in this phase. 

• 하나는 지금까지 해온 것에 비추어봤을 때 이번에 배운 것이 무엇인지를 성찰해보는 것이다.

The first is to reflect on what has been learned in the light of what was known before.

Does it all make some sort of sense, or is there a logical inconsistency that needs to be thought through? 

How does the new knowledge help to explain the bigger picture and increase our understanding?

If the exercise has been subject to assessment, this is where the learner should ideally think about their assessment results, and their areas of relative strength and weakness, so as to ascribe confidence levels to what they think they know.

• 학습자는 이미 자신의 학습과정이 작동한 방식에 대해 느끼고 설명한 바가 있을 것이다. 이 시기에서는 학습에 대한 스스로의 책임이 어디까지인지에 대한 고려를 해봐야 한다.

The learner will already have articulated (in the previous phase) how they felt the learning process worked. In this consolidation phase they need to consider the extent to which they took personal responsibility for their learning. 

How far are they along the continuum towards co-constructing knowledge? 

To what extent were they personally responsible for any breakdown in the process? 

What should they do differently next time?

교육자의 역할

The role of the educator in this phase is to provide encouragement for reflection on action. This might be through the provision of written feedback about examinations, highlighting areas of relative strength and weakness, or it could be through an appraisal or portfolio process. The key is to move from a right/wrong type of feedback to one where the possibilities for future development are made explicit. The educator's role, after all, is to lead the learner towards a deeper understanding.

의학교육 기관 차원의 함의

Institutional implications and applications of adult learning theory in medical education

At an institutional level connecting adult learning theory with practice is challenging. Some theories or aspects of a theory will be more relevant and helpful than others in a particular context. In exactly the same way that clinicians are expected to adopt practices on the basis of the best available evidence, educators should make use of the best available evidence to guide their educational decisions. Medical education institutions should rationalise and be explicit about their mission, vision, programme and curricula development, learning strategies, students’ assessment and programme evaluation guided by adult education theories and their particular socio-cultural context.

Institutional mission, vision and curriculum outcome

Many health care education programmes will have mission or vision statements describing graduates who have knowledge, skills and attitudes that allow them to respond to the health needs of the population with a high degree of moral and social responsibility. In outcome-based education one can expect a variety of strategies, each relying on one or more different educational theories. Understanding how people learn is important, and both learners and educators need to remember that learning is a process through which they weigh their knowledge against a critical examination of alternative possibilities (Ahlquist 1992). This understanding is basic to problem-based learning and the majority of clinical practice.

Although knowledge is the easiest, and most public domain, more than half of the outcome domains of medical education are related to attitude e.g. lifelong learning, empathy, utilitarianism, communication with patient and colleagues, ethics and professionalism. Transformative and experiential learning theories constitute an important theoretical frame for learning strategies suitable for these outcomes. The institution should be ready to embark on educational and cultural environment changes in order to operationalise these concepts.

Learning and teaching

Applying adult learning principles in medical education will probably necessitate changing educators’ and learners’ perceptions of their roles. Adult educators may consider adopting a view of themselves as both learners and educators. The learner's role is not only to receive knowledge but also to search, challenge, construct knowledge and change their own perception, views and beliefs.

Applications of these strategies necessitate significant institutional culture changes, active faculty development and increased learner autonomy and self-direction. To develop these skills all learners (including faculty members) should be trained to ask questions, critically appraise new information, identify their learning needs and gaps in their knowledge and most importantly to reflect and express their views on their learning process and outcomes.

The clinical environment is challenging for the learner and the educator. Clinical educators, students and patients interact together within the context of a hospital, clinics and community at large not just in a classroom. Time is at a premium, and the stakes for the patient are often high. Because of this it is important to make the best use of learning theories when helping people to learn.

Self-directed and experiential learning are key strategies, but feedback is crucial to help the learner make the best use of their contact time. Clinical reasoning, hypothesis generation and testing are essential skills for good clinical practice. The model of adult learning we have illustrated (Figure 5) shows that perception, insight, meaning-making and mental networking are interlinked and essential for good reasoning abilities. The clinical teachers should explain how they come up with a diagnosis or take a management decision by exploring with the learner the mental processes in the teacher's and the learner's minds by which “the implicit becomes explicit”.

Self-directed learning and student goal-setting should always be encouraged and supported but they should also be discussed, monitored and recorded. Portfolios, logbooks and reflective journals are particularly important tools for this. The key for successful implementation is for them to be more than “tick box” exercises, and we have found that using them as a basis for discussion makes them more effective.

Ethics and professional behaviours can be, and often are, taught but understanding them is demonstrated and consolidated within the clinical environment. Asking students to observe, record and discuss incidents that have ethical and professional implications is crucial to this development (Maudsley & Taylor 2009). Perspective transformation theory (Mezirow 1978) is most appropriate for acquiring these competencies. It supports reflection, and examination of the learner and teachers’ assumptions and beliefs, hoping it may lead to individual and social change. An off-shoot of adult learning theories is situated cognition (Wilson 1993) developed by Wenger (1998) into the theories of communities of practice. Its application to the clinical environment is relevant. Learning and thinking are social activities structured and influenced by the setting and tools available in a specific situation (Lave & Wenger 1991). Learning and teaching approaches at the bedside are different from the operating room, emergency department or in the community (Durning & Artino 2011; Yardley et al. 2012). Each context has its educational power and value. Observing the performance and behaviour of a trainer as role model, reflection in and on action and feedback on performance are important education principles to be considered in teaching and learning in clinical settings.

Student assessment and programme evaluation

Awareness of adult learning theories is needed to develop and select evaluation systems and instruments that can measure the expected competencies and outcomes. What to measure, how, when, by whom are important key questions and their answers are not always easy. The assessment should be tied to specific learning outcomes, and the learner should be given whatever feedback will help them develop or consolidate their knowledge, skills or attitudes. Time constraints mean that some elements of the feedback will need to be the learner's self- and peer-evaluation, but this should not be seen as a problem. Encouraging discussion, debate and reflection will increase learning opportunities. It is important to allow time, and provide a structure, for these activities if they are to be properly integrated into the learning/assessment system.

As mentioned above, a well thought through portfolio/log book with elements of reflection will allow for the learner's progress to be documented for themselves, and, importantly, for the educator/assessor.

By applying adult learning theories consistently and carefully, the educator can be sure of helping learners become part of the healthcare profession, and lay the foundations for a career of life-long development.

Summary

성인학습이론은 다양한 교육적, 사회적, 철학적, 심리학적 이론과 연관되어 있다.

Adult learning theories are related to several educational, social, philosophical and psychological theories. Most accessibly these were clustered by Knowles and called “andragogy” clarifying how adults learn best and their attitude towards learning.

단순한 모델을 제시하였고, 학습자와 교수자의 역할에 대한 함의를 제시하였다. 싸이클이지만 어느 사이클의 포인트에서든지 들어갈 수 있다.

A simple model is proposed which has considered different aspects of adult learning theories and their implication to the learner's role and teacher's role. Although the model is presented as a cycle actually the learner and teacher can enter the cycle at any point.

성인학습이론은 거의 모든 측면에 영향을 준다.

Adult learning theories should influence all aspects of health profession education, from mission and vision statements, outcomes, implementation and evaluation.

임상교육과 학습환경은 성인학습이론을 적용하기에 매우 이상적인 환경이며, 그 유용성을 보여주고 있다. 

The clinical teaching and learning environment is an ideal field for using adult learning theories and demonstrating their utility. Reinforcing clear thinking in both teacher and learner and considering them should improve clinical learning, and even clinical outcomes.

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Med Teach. 2013 Nov;35(11):e1561-72. doi: 10.3109/0142159X.2013.828153. Epub 2013 Sep 4.

Adult learning theories: implications for learning and teaching in medical education: AMEE Guide No. 83.

Taylor DC1, Hamdy H.

Author information

• 1University of Liverpool , UK.

Abstract

There are many theories that explain how adults learn and each has its own merits. This Guide explains and explores the more commonly used ones and how they can be used to enhance student and faculty learning. The Guide presents a model that combines many of the theories into a flow diagram which can be followed by anyone planning learning. The schema can be used at curriculum planning level, or at the level of individuallearning. At each stage of the model, the Guide identifies the responsibilities of both learner and educator. The role of the institution is to ensure that the time and resources are available to allow effective learning to happen. The Guide is designed for those new to education, in the hope that it can unravel the difficulties in understanding and applying the common learning theories, whilst also creating opportunities for debate as to the best way they should be used.

PMID:

 

24004029

 

[PubMed - indexed for MEDLINE]