EDUCATION BY DESIGN PROJECT PROPOSAL

Reflection as a Learning Practice for Adults Engaging in Technology-Based Learning: Quality Improvement in Health Care Environments

Prepared by Group 3: Katherine Becker - 23543101 Catherine Ranson - 72866015 Jennifer Stieda - 93566925

For ETEC510 Professor Diane Janes

June 12, 2011

EDUCATION BY DESIGN PROJECT PROPOSAL

Key Frameworks Health care providers are always concerned about providing the best patient care possible. Many are becoming aware that their clinical practices unintentionally interfere with this goal and therefore need to change in order to bring about improved patient care. Learning how to implement a quality improvement (QI) model is one step health care providers can take to reach their goal of best practices in patient care. The focus in designing our learning environment is to introduce a QI model to health care providers by using the often overlapping concepts of adult learning principles, constructivism, reflective practice, communities of practice and Collaboratives. Our design is informed by the views on adult education held by Malcolm Knowles and Jack Mezirow (Fidishun, 2000; Mezirow, 1991). Many of these concepts are paralleled in constructivism as described by David Jonassen (1999). Our learning environment will consist of an online course that will enable learners to choose topics that are applicable and relevant to their ongoing work or personal goals, allowing learners to immediately apply their learning in real life, situation specific environments. Learners will also have opportunities to share and build upon their prior personal and professional experiences with QI and change management via synchronous and asynchronous reflection activities. Richard Jordi (2011) suggests that reflection can enhance the kind of experiential learning we are proposing in our course design. Space is offered for personal reflection and a discussion forum is also provided for sharing experiences related to successes, road blocks, and solutions among the course community members. Such reflection is guided

EDUCATION BY DESIGN PROJECT PROPOSAL by thought provoking questions from the instructor as is consistent with constructivist learning theory (Jonassen, 1999). Learners move through the course together in an effort to develop a cohesive community of practice. Communities of practice are based on the idea that learning is a social activity that can enhance learning through networking, sharing knowledge, and helping each other solve problems (Wenger, 2006, 1996). It is our hope that the connections made during this course will endure beyond the time frame of the course and the learners will continue to share their QI experiences after the course is completed. We are using Collaboratives developed by the Institute of Healthcare Improvement to engage learners in developing a community of practice and actively putting into practice what is learned (Kilo, 1998). This approach involves bringing people together regularly, with support, to learn about and implement improvement methods, usually associated with specific topics. The group supports one another in their endeavor to integrate QI techniques into their daily work. The concept is intended to adapt and apply existing knowledge to multiple, similar sites to accomplish common aims (Kilo, 1998, p. 1). This learning environment is very constructivist in nature with learning taking place collaboratively, reflectively, and situationally (Jonassen, 1999). The problems tackled by learners are completely authentic since they are directly related to real life or personal issues. The improvement model being introduced through the course content provides opportunities for learners to test and adapt their knowledge in a meaningful situation. The collaborative nature of the course provides excellent opportunities for

EDUCATION BY DESIGN PROJECT PROPOSAL dialogue and reflective practice all of which should result in deeper and more significant individual and collective learning. Intentions and Positions Our intention in developing this learning environment is to provide health care

professionals with an effective means for implementing the Plan Do Study Act (PDSA) cycle within the collaborative process to realize QI in their health care facilities. The PDSA cycle was developed by Walter A. Shewhart as a tool to bring about QI in manufacturing environments (Best & Neuhauser, 2006). It is a continuous system of preparing, applying, evaluating, and adjusting operating procedures. Rona Levin outlined the PDSA model as follows:

FigurFigure 1. Plan Do Study Act cycle. Levin, 2009. p 86

EDUCATION BY DESIGN PROJECT PROPOSAL

In 2006, the World Health Organization released a document outlining a QI process that includes a cyclical approach (shown below) that bears similarity to Shewharts PDSA cycle.

Figure 2. A process for building strategy for quality. World Health Organization, 2006.

Healthcare professionals have adopted the PDSA cycle and implemented it within a QI method that can be referred to as a Collaborative. The use of Collaboratives in health care QI fosters the identification and sharing of best practices in healthcare operations toward improvement in healthcare outcomes (Health Council of Canada, 2007). This is accomplished through the following key components as identified by the United States Agency for International Development, 2007: Clear objectives Regular support to QI groups Opportunities to share experiences and results As the model of collaborative process relies on a foundation of support, ample opportunity for group collaboration and learner-to-learner interaction will be included in our learning

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environment, allowing participants to support one another in the learning process. Interactivities fostering reflection will play a key role and, because the PDSA cycle is itself a model for learning, it will serve as a guiding principle for our learning environment. Literature on reflection as a learning tool has been varied, and a survey of related literature reveals that reflective practices in adult education have both proponents (Hoyrup, 2004; Jordi, 2011) and opponents (Burnard, 2005; Ixer, 1999). While Hoyrup identifies two distinct forms and two distinct levels of reflection that must be identified and addressed to result in effective learning, (2004, p.443), Ixer questions the motivation of those endeavoring to impose reflection on learners (1999, p.523). However, synchronous and asynchronous reflection interactivities provide an effective vehicle for the support that underlies the collaborative process and the study component of the PDSA cycle. As such, reflective interactivities will play a significant role in our learning environment. Collaboratives as a QI approach have been adopted across Canada with positive results (Health Council of Canada, 2007). Despite their promising implementation, some may argue that the specificity of the problem and context result in a lack of transferability to other environments; however, a review of related literature supports the use of Collaboratives in health care QI (Best & Neuhauser, 2006; Health Council of Canada, 2007; Kilo, 1998; Wenger, 1996, 2006). The use of reflective and collaborative interactivities fit logically with the content of our learning environment, as they are recognized and supported in adult learning theory and as QI techniques within the culture of the target learners. Key Concepts and Contexts Through our design project, we will create a flexible learning environment to train healthcare providers to effectively implement the PDSA Cycle for QI by means of

EDUCATION BY DESIGN PROJECT PROPOSAL an online course. E-learning has become very appealing to the adult learner as they can learn anywhere, anytime and at a lesser cost than face-to-face learning (Waight & Stewart, 2005). The course will be delivered using the open source e-learning software platform known as Moodle. The platform allows a focus on collaborative construction of content and interaction which is continually progressing. Our learning environment will include a combination of reflective and collaborative activities including synchronous voice chats, discussion board forums, wiki space for sharing of outcomes in specific situations, blog space for reflections, as well as messaging and email, hyperlinks to useful online resources, course readings, and a final report assignment outlining the results of their QI implementation and the next steps for their site. We have identified with the conceptual model introduced by Waight and Stewart (2005) that there are four championing factors that support adult learners through elearning design, those being leadership, learning culture, technology infra-structure and finances. In addition, we recognize that e-learning instructional design, integration of learning theories and technology are all important mechanisms to ensure that learners will achieve competency. Additional guiding principles of e-learning presented by Johnson & Aragon (2003) will shape the culture of our learning environment, including addressing individual learner differences, delivering content through interactivities that will motivate learners, providing hands-on activities, creating real-life context and social interaction, promoting learner reflection, and avoiding information overload. All of these aspects will be considered in our course design.

EDUCATION BY DESIGN PROJECT PROPOSAL

Figure 3. Valuing the adult learner in e-learning within corporate settings (Waight and Stewart, 2005, P.338)

As previously mentioned, the PDSA Cycle is the foundation to how our learners will implement QI within their individual workplace. The health care learner will understand that the primary purpose of PDSA QI is to examine the functional relationship between processes and outcomes in health care practices. Reducing variation as a method to improve quality is the focus and contribution to quality management. The PDSA cycle is used to implement changes that lead to improvement and is an on-going process. The cycle is intended to identify what needs to be improved, implement the design change, measure and analyze the outcomes and act upon unmet outcomes (Best & Neuhauser, 2006). The framework of the learning interactivities will be presented through a collaborative, learn-by-doing approach to QI. The learner will have opportunities to engage with other practitioners from various disciplines and facilities to learn how to

EDUCATION BY DESIGN PROJECT PROPOSAL improve best practices. The implementation of Collaboratives is based on the evidence of current research literature (Saskatchewan Health Quality Council). An additional focus within the course delivery will be reflective practice noted to be a key concept in adult education and experiential learning. The learner will be encouraged to recapture their own experiences, think about the experience, reflect and then self-evaluate. Reflective practice is widely used in formal, informal, individual and organizational learning activities to gain a deeper understanding of both what is learned and the learning process (Jordi, 2011). The learning environment will have a strong foundation in learning theories which will include constructivism through collaborative work, the creation of a community practice, elements of behavioral learning through using reinforcement, cognitive learning promoted through reflective practice, and social learning through synchronous and asynchronous group discussion.

EDUCATION BY DESIGN PROJECT PROPOSAL References

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Barab, S. & Duffy, T. (2000). From practice fields to communities of practice. In D. Jonassen and S. Lands (Eds.), Theoretical foundations of learning environments. Mahewh, NJ: Lawrence Erlbaum. Best, M., & Neuhauser, D. (2006). Walter A Shewhart, 1924, and the Hawthorn factory. Quality & Safety in Health Care. 12, 142-143. doi:10.1136/qshc.2006.018093 Burnard, P. (2005). Reflections on reflection. Nurse Education Today. 25, 85-85. Fidishun, D. (2000). Andragogy and technology: Integrating adult learning theory as we teach with technology. In Proceedings of Extending the Frontiers of Teaching and Learning. Retrieved from http://frank.mtsu.edu/~itconf/proceed00/fidishun.htm Health Council of Canada. (2007). Collaboratives improve health outcomes. Why Health Care Renewal Matters - Lessons from Diabetes. Retrieved from http://healthcouncilcanada.ca/docs/shiningalight/Collaboratives%20improve%20health% 20outcomes.pdf Hoyrup, S. (2004). Reflection as a core process in organisational learning. Journal of Workplace Learning. 16(7/8), 442-454. Ixer, G. (1999). Theres no such thing as reflection. British Journal of Social Work. 29, 513-527. Jonassen, D. (1999). Designing constructivist learning environments. In C. Reigeluth (Ed.), Instructional design theories and models: Volume II. Mahwah, NJ: Lawrence Erlbaum. Johnson, S.D. & Aragon, S.R. (2003). An instructional strategy framework for online learning environments. New Directions for Adult and Continuing Education. 10, 31-44.

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Jordi, R. (2011). Reframing the concept of reflection: Consciousness, experiential learning, and reflective learning practices. Adult Education Quarterly. 61(2), 181-197. doi:10.1177/0741713610380439 Kilo, C.M. (1998). A framework for collaborative improvement: Lessons from the Institute of Healthcare Improvements breakthrough series. Quality Management in Healthcare, 8(4), 1-13. Levin, R. (2009). Implementing practice changes: Walk before you run. Research and Theory for Nursing Practice: An International Journal. 23(2), 85-87. doi:10.1891/15416577.23.2.85 Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: Jossey Bass. Saskatchewan Health Quality Council. About the collaborative approach. Retrieved from http://www.hqc.sk.ca/download.jsp?bbuPrJg1Np7/HkCNJkGgZTBIzBf0QfLQkUwK4Q BZaJvIpoSjp0XKjg== United States Agency for International Development. (2007). Trainers guide: Collaboratives for quality improvement in healthcare. Retrieved from http://www.hciproject.org/node/1049 Waight, C., & Stewart, B. (2005). Valuing the adult learner in e-learning: Part one - a conceptual model for corporate settings. The Journal of Workplace Learning. 17(5), 337-345. doi:10.1108/13665620510606751 Wenger, E. (2006). Communities of practice: A brief introduction. Retrieved from http://www.ewenger.com/theory/

EDUCATION BY DESIGN PROJECT PROPOSAL Wenger, E. (1996). Communities of practice: The social fabric of a learning organization. Healthcare Forum Journal, 39(4), 20-26. Retrieved from http://www.ewenger.com/pub/index.htm

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World Health Organization. (2006). Quality of care: A process for making strategic choices in health systems. Retrieved from www.who.int/management/quality/assurance/QualityCare_B.Def.pdf