MODULE 1: Evidence supporting factors for effective CPD

Objectives

After reading this module and completing the exercises, you will be able to determine:

• The most frequent criticisms of CPD
• The factors required for creating effective CPD programs

Does CPD Make a Difference?

This question seems simple, but answering it is not. A great deal of time, money and effort goes into providing CPD for health professionals. .It is legitimate to question whether the outcomes are worth the expense. Some say “yes”, some say “no”.

This debate about the value of CPD is longstanding and ongoing. The ultimate goal of CPD can be stated as ensuring highest standards of patient care and safety possible. In considering the education or training required to achieve this goal, it is also important to consider:

• Is practice change always the goal of CPD?
• If so, can you legitimately state your specific intervention or program was responsible for that change?
• What if no change was needed because the practitioners in question were already operating at the gold standard?

We emphasize, the end goal of CPD is to ensure the highest standards of patient care possible and to positively affect healthcare outcomes. Sometimes professional practices are already at a very high standard. Sometimes health outcomes aren’t due to poor attitudes or a lack of knowledge or skills that require further education but are due to poor communication or lack of organizational support for change. These issues are not ones that can be addressed through educational events. We also need to recognize that health care professionals often attend CPD events to affirm their practices, not necessarily to change.

It is a too narrow vision to say that a program was unsuccessful because practice behaviour did not change. A program that contributes to positive health care standards by confirming already existing good practice and current level of knowledge is also successful! Sometimes the gap between current and ideal practice is very small and therefore will not demonstrate any significant changes when measured.

Moreover, there are several stages involved in changing a practice behaviour including:

1. No awareness of the need to change
2. Contemplating of the need to change
3. Committing to learning new information and skills
4. Implementing and maintaining a change.

Through participating in an educational event, a person unaware of the need for new practices may shift to contemplating the possibility of change. This is also a measurement of a successful educational event. (See Prochaska “Model of Behaviour Change”; in Module 10)

To summarize: Learning is complex. Instead of asking the simple question, “Does CPD make a difference?” educational research now acknowledges more of the complexity involved and focuses on components of education needed in order to maximize positive results. Thus, the question has now become “What are the factors that make CPD effective?”

For many years, however, people have expressed concerns about the effectiveness of CME. As a result, confidence in the ability of CME to address identified gaps in healthcare delivery was not high. But significant work over the past 20 years has demonstrated the effectiveness of CME, if [italics in original] it is planned and implemented according to approaches that have been shown to work.” (Moore. Macey report 2008)

Theory

Research has demonstrated that several factors and many different stimuli must be involved in an educational activity for behaviour change to occur. To believe that an evening lecture will make a significant difference in practice behaviour is more than a little optimistic. It is possible, but not likely. The following quote (dated but still true!) illustrates the process most professional learners follow before making a change in practice:

“Physicians (health care professionals) do not change their practice solely on the basis of information from one source. Recent studies have shown that the adoption of a new practice is perceived as the end result of a complex process during which the physician (individual), seeing the need for change, seeks information from several sources over a period of time. While a variety of information sources may facilitate the initial stages of the process, the ability to critique the medical literature and seek local professional opinions is crucial to the decision to implement a change.” (Parboosingh et al, 1984)

In an article examining the results of 99 randomized control trials of CPD, Davis et al (2010), found:

• Lectures predisposed learners to change but did not have a major role in affecting change in performance or practice
• Case discussions, hands-on practice, simulations and other methods that encouraged learners to apply theory in practical ways were effective in changing practice behaviour
• When two or more strategies were used in an educational intervention, the likelihood of change in practice behaviour increased
• When strategies that reinforced new practice behaviours were introduced into an educational intervention, effectiveness increased
• When educational interventions were spaced over time and included two or more meeting times, retention of new information increased. For example, a program that consists of a series of 6 seminars vs. a one-day event
• Pre and post course activities increased practice effectiveness
• Programs that included active engagement of the learner and problem-solving or decision-making activities achieved better results than those that kept the learner in a passive mode of learning

Marianopolis et al (2007) determined educational literature supports the conclusion that CPD is effective at least to some degree in achieving and maintaining the objectives studied including knowledge, attitudes, skills and practice behaviour and clinical outcomes.

This study reinforces that of Davis et al and demonstrates:

• Multiple techniques demonstrated improvements in knowledge
• The inclusion of case-based learning increased the likelihood of improvement in both knowledge and attitudes
• Longitudinal programs (a series of events or sessions conducted over a period of time for instance meeting once a month for 6 months) report a higher level of practice change.

Cervero 2014 in conducting several systematic reviews determined that CME (CPD):
“has a positive impact on physician performance and patient health outcomes…reviews also conclude that CME has a more reliably positive impact on physician performance than on patient health outcomes.”

The reviews support previous research showing that CME leads to improvement in performance and patient health outcomes if it is more interactive, uses more methods, involves multiple exposures, is longer, and is focused on outcomes that are considered important by physicians.

The articles referenced above emphasize best results are achieved in educational events that incorporate predisposing, enabling and reinforcing factors.

1. Predisposing strategies such as: Generating interest or getting participants’ attention (examples: assessment of learning needs, pre-test of knowledge, interviews)
2. Enabling strategies such as: Selecting methods that promote learning and retention. (examples: memory aids, algorithms, patient data (examples; providing tools that aid application,) practice guidelines)
3. Reinforcing strategies such as: Planning for application to practice. (examples: Reflective exercises, “commitment to change” documents, follow-up interviews, post-test of knowledge, reminders and feedback)

You will learn more about these strategies through completing the remaining modules and referring to the materials provided in the additional resources.

Recap:

What we know for sure:

• The goal of CPD is multifaceted and includes affirming good practice and changing practice behaviour where necessary and appropriate
  ○ A one-off lecture will not make a big impact on practice change
  ○ If practice change is required, longitudinal interventions with multiple approaches are the most effective
  ○ No single intervention or course will change practice behaviour
  ○ Providing relevant practice cases significantly improves effectiveness
  ○ Active learning is key to increasing likelihood of change in practice behaviour
  ○ Educational interventions that use more than one factor (predisposing, enabling and reinforcing) are more likely to result in change in behaviour.

Test Your Knowledge:

1. Look at a current CPD program that you are involved in. What factors are currently designed into the program to ensure participants will maintain effective practices or if necessary, change practice behaviour?
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2. Assuming practice change is desired, what one activity could be added to:

a) Predispose learners?
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b) Enable learning?
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c) Reinforce behaviour change
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You will find the answers to these questions in the preceding text.

Would You Like to Learn More?

• Cervero RN, Gaines JK. (2015) The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews. Journal of Continuing Education in the Health Professions, 35(2):131–138
• Cervero Effectiveness of Continuing Medical Education (2014): Updated Syntheses of Systematic Reviews, Ronald M. Cervero and Julie K. Gaines, July 2014 ACCME Page 17 of 19 652_20141104
• Davis DA, Thompson MA, Oxman AD, Haynes RB. (1992) Evidence of the Effectiveness of CME. JAMA September 2, Vol 268, No 9
• Forsetlund, L., Bjorndal, A., Rashidian, A., Jamtvedt, G., Obrien, M.A., Wolf, F., Davis, D., Odgaard-Jensen, J., & Oxman, A.D. (2009). Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews (2): CD003030
• Green L, Kreuter M. (2005). Health program planning: An educational and ecological approach. 4th edition. New York, NY: McGraw Hill.
• Marinopoulos SS et al. Effectiveness of Continuing Medical Education. (2007) Evidence Report/Technology Assessment No. 149 (Prepared by the Johns Hopkins Evidence-based Practice Center, under Contract No. 290-02-0018.) AHRQ Publication No. 07-E006. Rockville, MD: Agency for Healthcare Research and Quality.
• Olson, C.A., & Tooman, T.R. (2012). Didactic CME and practice change: Don’t throw that baby out quite yet. Advances in Health Sciences Education: Theory and Practice, 17(3), 441-451.
• Parboosingh J et al. (1984) How Physicians make changes in their clinical practices. Annals RCPSC Vol 17 No 5
• Thomas, M.D. Gregory P. Prokopowicz, M.D. Rehan Qayyum, M.D. Eric B. Bass, M.D. (2007), M.P.H. Effectiveness of Continuing Medical Education AHRQ Publication No. 07-E006
• Davis, D.A., & Galbraith, R. (2009). Continuing medical education effect on practice performance: Effectiveness of continuing medical education: American College of Chest Physicians evidence-based educational guidelines. Chest, 135 (Suppl 3): 42S – 48S.

Internet search terms:

• Precede/Proceed planning model
• Effectiveness of continuing health education
• Does CE make a difference?
• Predisposing, enabling and reinforcing factors in adult learning.

End of Module 1

This module has provided you with some sound evidence as to the value of CPD activities and what factors can increase effectiveness.

Module 2 will introduce you to the basics of adult learning theory which serve as a foundation for program planning.