보건의료인교육에서의 SDL (Ann Acad Med Singapore, 2008)

보건의료인교육에서의 SDL (Ann Acad Med Singapore, 2008)

Self-directed Learning in Health Professions Education

M Hassan Murad,1MD, MPH, Prathibha Varkey,1MBBS, MPH

지식이 얼마나 빠르게 증가하고 있는가

• More than 600,000 new citations were published in MEDLINE in 2005; this raised the total number of indexed citations to more than 14 million citations.1 
• In a study be Williamson et al,2 2 out of 3 primary care physicians described the volume of literature as unmanageable, and 1 out of 5 reported that they were not using or were unaware of the 6 selected recent clinical advances in medicine. 

의사의 지식의 쇠퇴

• In addition, physicians’ knowledge declines with time, which may result in lower quality of care.3 
• Ramsey et al4 showed that the knowledge of internists inversely correlated with the number of years elapsed since their board certification, with a sharp decline noted after 15 years.

교과서와 리뷰 문헌마저 충분히 최신 근거를 반영하지 못함.

Textbooks and review articles lag chronologically behind the current evidence.

CME프로그램 대부분이 의사의 행동을 바꿔놓지 못함.

Furthermore, systematic reviews of continued medical education programmes (CME) demonstrate that most of these programmes are not effective in changing physicians’ behaviour, do not affect patients’ outcomes, and are generally not based on learners needs.6-8

SDL은 평생학습을 위한 촉망받는 방법이었다.

Self-directed learning (SDL) has been suggested as apromising methodology for lifelong learning in medicine.

• The Liaison Committee on Medical Education (LCME) endorsed accreditation standards in 2004 that promote flexibility and innovation in learning and provide medical students with skills necessary for self-directed learning.9
• The Accreditation Council for Graduate Medical Education(ACGME) recommended that residents should become self-directed learners, evaluate their learning with innovative tools such as computerised diaries and portfolios, and facilitate the learning of others.10 
• The American Board ofInternal Medicine (ABIM) recommends that a basic component of the maintenance of certification programme is that physicians become lifelong learners and be involved in a periodic self-assessment process to guide continuing learning.11 

그러나 SDL의 개념은 여전히 모호하다. 학생과 교육자 모두 그것을 정의하고 그것의 가치에 동의하는데 어려워한다.

However, the concept of self-directed learning continues to be elusive, with students and educators finding difficulty in defining it and agreeing on its worth.12,13

SDL은 다양한 개념과 용어로 사용되어 왔다.

The term SDL has been used widely in the literature to describe various concepts in learning such as 

self-planned learning, 

learning projects, 

self-education, 

self-teaching, 

autonomous learning, 

autodidaxy, 

independent study, and 

open learning.15

우리는 SDL을 Malcolm Knowles의 일곱 가지 요소로 구성된다고 보았다.

We considered SDL to consist of 7 key components as described by Malcolm Knowles (Table 1). Knowles22 defined SDL as a process, in which individuals 

• take the initiative, with or without the help of others, 
• in diagnosing their learning needs, 
• formulating goals, 
• identifying human and material resources for learning, 
• choosing and implementing appropriate learning strategies, and 
• evaluating learning outcomes. 

We evaluated the included articles to determine how often educators applied these SDL components in their programmes and whether these components were effective compared with traditional didactics.

Table 1. Key Components of Self-Directed Learning 

1. The educator as a facilitator 

2. Identification of learning needs 

3. Development of learning objectives 

4. Identification of appropriate resources 

5. Implementation of process 

6. Commitment to a learning contract 

7. Evaluation of learning process

촉진자로서의 교수자 The educator as a facilitator: 

교수자는 skill의 source이며 content의 source가 아니다.

Although self-directed learning may imply the lack of the need for an educator,learners often need an expert to introduce them to the basicsof SDL including the appraisal of educational needs,adoption of a theoretical construct and development oflearning goals.43 Therefore, teachers in SDL programmesare seen as a source for skills rather than a source of content,and they assume the role of facilitators or consultants to thelearner.44 

학습 요구의 파악 Identification of learning needs: 

교육요구는 현재의 역량과 기대되는 역량 사이의 간극이다. 학습요구를 파악하는 것은 SDL의 핵심적 요소이다. Beckert 등은 학생의 요구와 self-drive에 기반한 학습활동이 외부 자원에 의해서 정해지는 활동보다 더 효과적임을 보여줬다. Knowles도 학습자가 학습요구를 더 명확히 알아낼수록, 그 요구와 사회, 기관, 학업적 열망이 조화를 더 잘 이룰 수 있으며, 더 효과적인 학습이 일어날 것이라 했다.

Educational needs arethe discrepancy between the present level of competencyand the required level of competency (or the differencebetween aspiration and reality).45 Identification of learning needs is an integral component of SDL. Beckert et al46demonstrated that learning activities based on student’sneeds and self-drive are more likely to be successful thanactivities dictated by extrinsic sources. Knowles45 alsosuggested that the more explicitly learners identify learningneeds and the more harmonious their needs are withsocietal, organisational or academic aspirations, the morelikely effective learning will take place.

학습 목표의 개발 Development of learning objectives: 

pool of needs로부터 objective를 정한다. 높은 우선순위를 가진 것, 그리고 학습 평가를 촉진하기 위해 측정가능한 것으로 정하게 된다.

Learning objectives are the desired outcomes of learning and are derived from the pool of needs generated by learners. Learners translate needs into objectives and ideally, would choose the ones that are higher on their priority list and are measurable to facilitate learning evaluation.45

학습 계약에 대한 헌신 Commitment to a learning contract: 

학습계약이란 과목 전문가의 조언하에 '무엇을 어떻게 배우고, 어떻게 확인할 것인가'를 설명한 문서이다. 따라서 이 문서는 학습자의 자기주도성을 인정하며, 학습목표, 자원, 전략, 성취의 근거 등을 명확히 해준다.

A learning contract is a formal document prepared by learners in consultation with a subject expert to demonstrate “what is to be learned, how it is to be learned, and how learning will be verified”.40 Thus, learning contracts acknowledge learners’ self- directedness and specify learning objectives, resources, strategies and evidence of accomplishment.22

Pereles 등은 학습 계약을 작성한 의사가 더 변화가 많았고, 더 환자에게 영향을 주었음을 확인했다. 의과대학 교육에서도 1학년돠 2학년 학생 중 학습 계약을 활용한 학생이 더 많은 SDL task에 도달하였고, SDL에 더 긍정적인 모습을 보였고, SDLRS에서도 점수가 높았다.

Pereles et al42 reported geriatricians who made a written commitment to change their practice after an educational course made more changes and affected more patients when compared with counterparts in a control group. In undergraduate medical education, first- and second-year medical students who used learning contracts were able to accomplish more SDL tasks, demonstrated more positive attitudes regarding SDL, and scored higher on the self-directed learning readiness scale (SDLRS).40

학습자원 확인 Resource identification: 

Knowles는 학습자가 학습자원 배정에 참여해야 한다고 했다. 적절한 자원을 자신이 선호하는 학습방법에 따라, 목표에 따라 정한다. 

Knowles22 advocated direct involvement of learners in the allocation of learning resources. Learners in consultation with a subject expert, choose the appropriate resources based on their preferred method of learning and the type of learning objectives. He suggested that...

• cognitive objectives are best learned by lectures, written resources, interviews, colloquy and panel discussions; 
• behavioural objectives are best learned by experience-sharing, role-playing, sensitivity training and case-based learning and 
• psychomotor objectives are best learned by skill practice exercises, role-playing, simulation and drills. 
• procedural skills: SDL interventions designed for health professions education describe the use of written materials (e.g. articles, workbooks), computerised modules, web sites, audio-visual aids (e.g. videos) and mannequins for teaching procedural skills.28,30,33,43,47

학습과정 진행 Implementation process: 

SDL의 분위기를 조성하고 라뽀를 쌓으려면 촉진자들은 인트로덕션 미팅을 가져야 한다. 이 미팅에서는 학습자와 교수자의 파트너십을 강조한다. 또한 학습요구, 목표, 계획, 평가도구 등을 결정하기 위한 후속 미팅이 이어진다. 학습자들은 처음에는 부정적 느낌이나 혼란 불만이 있으 수 있지만 점차 SDL에 긍정적인 느김을 갖게 될 것이다.

To build rapport and set the climate for SDL, facilitators should conduct introductory meetings with learners. These meetings emphasise the partnership between learners and educators, rather than dependency of students on teachers. Subsequent meetings can be utilised to identify learning needs, goals, learning plan and evaluation means.22 Learners may experience initial negative feelings such as confusion and dissatisfaction; however, transformation to positive feelings as SDL progresses is expected.48

학습 평가 Learning evaluation: 

포트폴리오가 권장된다. 포트폴리오의 장점은 아래와 같다.

Learning portfolios that demonstrate the acquisition of knowledge, skills, attitudes and achievements have been recommended for health professionals undertaking SDL.52 Learning portfolios enable learners to control the educational process, maintain autonomy, promote reflective thinking, increase SDL skills and evaluate learning outcomes.52 Portfolio computerisation can further enhance their role by providing better accessibility, ease of use and security features for confidential information.38,39

MCQ나 OSCE, 질적/양적 자기보고 척도도 가능함.

In addition to portfolios, SDL can be evaluated by multiple choice questions, OSCE, and qualitative and quantitative self-reported measures of competency.22,34,35,49,53

SDL의 효과성

Effectiveness of SDL

일반적으로 SDL의 효과를 비교한 연구는 적다. 여기서 확인한 여러 연구도 학습자의 수용도나 만족을 측정했다.

In general, there is paucity of evidence to document the efficacy of SDL compared with traditional didactics. In this review, we found most studies to be mainly focused on evaluating learner’s acceptability and satisfaction with SDL as well as feasibility of SDL projects rather than studies providing information on the impact of SDL learning outcomes.

교육이론과 SDL 

Education Theory and SDL

SDL은 여러 교육이론, 교육개념과 일관된 측면이 있다.

SDL is consistent with several educational concepts and theories including the theory of adult education, humanism, constructivism, empowerment, the Schön model, and the Kolb learning cycle.44 

• The theory of adult education assumes that adult learners display attributes of maturity, independence, self-direction, responsibility and individuality; and that their learning is related to their social roles and previous experiences. Thus, it may be more appropriate for adult learners to use less paternalistic learning models that promote partnership between the learner and the teacher, such as SDL.44,45,56
• The humanist approach to learning is consistent with SDL in that the locus of learning relates to the needs of the learners and the motivation for learning is self-actualisation and self-fulfillment.44,57 
• SDL is also consistent with constructivism in that learning is not acquired by transplanting knowledge in an empty reservoir; it is rather built by learners based on their prior knowledge, experiences, cultural and psychosocial background.58 
• In addition, SDL empowers learners. Learners who have been personally, educationally, socially or politically oppressed, take control of their own learning and experience a liberating effect by using SDL.59,60
• The Schön and the Kolb learning models resonate well with the philosophy of SDL. After encountering a question that requires knowledge, skills or attitudes that learners do not possess in their “zone of mastery”, learners face a “surprise” that provokes learning. The problem that instigates learning can be a specific problem (a question that pertains to an individual situation) or a general problem (a gap in knowledge or skill that can be applied to in a variety of situations).

SDL의 한계

Limitations of SDL

SDL의 적용은 그 실제 도입에서의 다양성과 교육자들이 가진 SDL의 정의의 다양성에 의해서 제약을 받는다. 또한 SDL의 효과를 측정한 무작위 연구도 별로 없다.

The application of SDL in health professions education is limited by the heterogeneity in the implementation and definitions of SDL by educators. In addition, only a few randomised studies document the efficacy of SDL. There is also a lack of evidence on the content that is most appropriate for SDL.

또한 SDL에 대한 학습자의 준비도를 측정하는 표준화된 척도도 없다. SDLRS가 있지만 미래의 학습 행동을 예측하는 능력이 떨어진다. OCLI와 Rayn 설문지도 있긴 하다.

Furthermore, there is no standardised method to assess learners’ readiness for SDL. 

• The most widely used and studied scale is the SDLRS, developed by Guglielmino in 1977. Despite the good convergent, divergent and criterion validity, the SDLRS is criticised for reliance on self-report instead of objective data and for its inability to predict future learning behaviour.44,63 
• Other readiness scales, such as the Oddi continuing learning inventory (OCLI), which emphasises personality traits enabling for SDL, and the Ryan’s questionnaire, which emphasises students’ perceptions of SDL, have little evidence of validity.63-65 
• The accuracy of learners’ self-assessment of learning needs and learning outcomes has been doubted repeatedly in the literature.

SDL과 PBL은 서로 섞여가면 사용된다.

SDL and PBL have often been used interchangeably in the literature, often erroneously. Since SDL is often initiated after encountering an educational challenge or a “problem”,27 SDL has been linked with problem-based learning (PBL) in the literature.

그러나 PBL도 교수자가 목표를 정해줄 수 있고 강의 등을 방법을 사용하기도 한다.

However, this is not always the case, and PBL curricula can contain learning objectives dictated by teachers and course organisers and can also include didactics.73,74

또한 근거가 서로 상충된다.

In addition, the evidence regarding SDL activities in PBL curricula is conflicting.

또한 SDL이 가르칠 수 있는 것인지 내재적 인적 특성인지에 대한 의견도 엇갈린다.

Moreover, there is a debate regarding whether SDL can be taught or is it an inherent personal trait. We found ample evidence to show that SDL can be taught. In fact, in at least 4 of the studies included in this review, it was clearly demonstrated that the interventions used led to increase in learner’s knowledge about SDL, SDL skills, ability to identify learning goals, develop learning contracts, execute SDL, as well as improved perceptions and attitudes about SDL.24,29,39,40

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Ann Acad Med Singapore. 2008 Jul;37(7):580-90.

Self-directed learning in health professions education.

Murad MH1, Varkey P.

Author information

• 1Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA. Murad.Mohammad@mayo.edu

Abstract

INTRODUCTION:

Self-directed learning has been recommended as a promising methodology for lifelong learning in medicine. However, the concept of self-directed learning continues to be elusive, with students and educators finding difficulty in defining it and agreeing on its worth.

METHODS:

In this paper we review the literature of self-directed learning in health professions education and present a framework based on Malcolm Knowles' key components of self-directed learning.

RESULTS:

The key components of self-directed learning are: the educator as a facilitator, identification of learning needs, development of learningobjectives, identification of appropriate resources, implementation of the process, commitment to a learning contract and evaluation of learning. Several but not all of these components are often described in the published literature.

CONCLUSION:

Although the presented framework provides some consistency for educators interested in applying SDL methods, future studies are needed to standardise self-directed learning curricula and to determine the effectiveness of these components on educational outcomes.

PMID:

 

18695772

 

[PubMed - indexed for MEDLINE] 

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