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Five Principles for Using Educational Theory: Strategies for Advancing Health Professions Education Research

Samuel, Anita PhD; Konopasky, Abigail PhD; Schuwirth, Lambert W.T. MD, PhD; King, Svetlana M. PhD; Durning, Steven J. MD, PhD

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doi: 10.1097/ACM.0000000000003066
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The health professions education (HPE) literature is relatively new and is growing and diversifying.1 Educators and researchers in HPE value the input of scholars from diverse backgrounds who inform the work of HPE. Indeed, this diversity, coupled with the ability to empirically study how theory “works” in practice, is a strength of HPE that sets it apart from other fields2 of enquiry. An additional point of distinction is that HPE scholars face complex challenges that have an impact on the education of learners and the health care of nations, for example, rapid innovations in technology in health care and education with fundamental societal impacts. In HPE, we use theory to better understand the mechanics of the phenomena underlying these complex challenges and to guide us as we navigate the practical implications of these challenges. However, HPE researchers and educators, particularly those who do not have a background in education or social sciences, may lack a strong grasp of theory.2

Using theory in HPE is a balancing act, as Ostrom notes:

Without theory, one can never understand the general underlying mechanisms that operate in many guises in different situations. If not harnessed to solving empirical puzzles, theoretical work can spin off under its own momentum, reflecting little of the empirical world.3

Overreliance upon theory runs the risk of jeopardizing the work’s connection with educational practice. Conversely, if HPE research remains atheoretical (purely practical), there is a risk of pursuing inefficient and ineffective educational innovations. Understanding theory is also important in preventing a reinvention of the wheel. For example, with the advent of new technology, innovation is sometimes implemented without a deeper theoretical understanding of why previous educational innovations were ineffective. Consider the use of new technologies to assess the “skill” of clinical reasoning, for example. Moving from clever, paper-based solutions to virtual reality solutions ignores the fact that the issues are not a matter of fidelity but, rather, are more fundamental to the nature of clinical reasoning (i.e., superior performance is not solely based on some sort of generic problem-solving ability).4

To incorporate theory effectively, we must understand its scope and limitations. In this article, we have outlined 5 key principles for using theory. We have also suggested strategies for those who wish to integrate theory into their work to improve the scholarship and practice of HPE.

Principle 1: All Theories Are Not Created Equal

Theories are a way to decontextualize or recontextualize complex educational problems to enhance our understanding and to guide potential courses of action. They provide lenses for viewing a situation or problem, and not all lenses are equal. Some theories provide a general structure or scaffold to view a problem. Situated cognition is an example of such a theory. It argues that learning is strongly influenced by the situation in which it occurs and directs the researcher to examine the components of that situation and how they interact.5 In so doing, aspects of the situation and connections among those aspects may emerge that would otherwise have remained unexamined had this theory not been applied. The result is a better understanding of what makes learning effective (or ineffective). Another example of a theory that provides a more general scaffolding is ecological psychology. It views a situation6 (e.g., an educational activity) as a series of affordances (i.e., what the properties of the educational method allow or disallow the teacher and/or learners to do) and effectivities (i.e., those affordances that teachers and learners perceive to be in the educational method). Such “grand” theories7,8 can be considered as macro-level theories because they attempt to theorize all aspects of a learning situation. This type of theory can be applied to many situations to help identify and understand the features that contribute to the educational processes and outcomes of interest. By their nature, however, they often lack utility in terms of predicting what will happen in a given situation or of determining the best next steps. Consequently, these theories often cannot be tested in a single study but rather require a program of research (i.e., multiple studies pursuing a coherent or connected line of enquiry).9

Other theories are micro level8 and can only be applied to specific circumstances and/or components of the learning environment. They offer a more microscopic view, often providing more explanatory and, at times, predictive power than the grand theories. Generalizability theory10 is one example. This theory does not aim to explain multiple phenomena in complex situations but is a highly practical approach to separate components of variance in an assessment results matrix. In other words, once a design for a study has been determined, generalizability theory allows researchers to gauge potential error sources. While macro theories, such as situated cognition, help researchers to scaffold and enhance understanding of broader phenomena, micro theories, such as generalizability theory, enable researchers to work with data to create specific, functioning, defensible claims and inferences.

While combining micro and macro theories may seem counterintuitive, this approach is not dissimilar to practices in medicine. For instance, we use macro screening tests that are typically quite sensitive and then perform follow-up confirmatory (micro) tests that are more specific to the condition being considered. When we select an appropriate theory (i.e., macro, micro, or a combination of both), we are better able to align our theoretical perspective(s) with the problem under investigation. Although we have chosen micro and macro theories as illustrative examples, these perspectives do not exist as a dichotomy but, rather, along a continuum. Theories that provide macro perspectives are particularly useful for obtaining large-scale views of what is occurring, while micro theories are helpful to incorporate into subsequent experiments. We will provide an example of how we combine theories later in the paper.

Principle 2: Multiple Theories Can Be Used in a Given Research Study

There are times when a single theory may be insufficient to address the research question posed. In these situations, multiple theories can (and should) be used to explore the phenomenon under investigation from different perspectives. When researchers are trying to understand a complex phenomenon such as clinical reasoning, for instance, cognitivist theories11 may help to frame how reasoning incorporates learning experiences into long-term memory. In parallel, clinical reasoning can also be examined by using social constructivist theories.5,6 This approach can aid in understanding how the quality of reasoning—judged by, for example, the clarity, coherence, and plausibility of the claims and evidence—promotes interaction between learner and teacher or peers and thus affects the quality of the learning process. Just as researchers might bring together qualitative interview data and quantitative assessment data to more fully understand both the processes and outcomes of a given educational intervention, they can use multiple theories to understand different aspects and perspectives of an HPE context.

Again, this approach is similar to the practice of interdisciplinary health care. Understanding the complex phenomenon of chronic, benign low back pain requires more than a single theoretical approach. Gaining a full understanding of all the facets of this medical problem may require consideration of neurological, psychological, orthopedic, physiotherapeutic, occupational, social, and pharmaceutical perspectives. Similarly, in HPE, we encourage scholars to consider how multiple theories can assist them with their work. This form of triangulation, at the theory level, can deepen our understanding of the educational problem. This triangulation is particularly relevant because of the nature of HPE as a field that often deals with complex phenomena.

There is, however, one caveat to this principle: The different theories should belong to the same domain8 or paradigm of education.12 If there is misalignment with the epistemological assumptions between theories (e.g., a view of knowledge as concrete and fixed versus a view of knowledge as malleable and shifting), it may prove very difficult to integrate study findings and generate comprehensible claims without an appropriate mixed methods framework.13

Principle 3: You Can Deviate From a Theory’s Propositions

As discussed earlier, HPE is an interdisciplinary field of enquiry. Because of this and because HPE is relatively young (when compared with fields like psychology or sociology), existing theories are not always exclusively designed for our community. This requires researchers to remain agile in their application and use of theories. Consequently, we encourage HPE scholars not only to use existing theoretical propositions in their work but also to be open to revising theory as needed for better application to HPE settings. Good doctoral dissertations in HPE often require revising theories to facilitate better alignment to the topic and/or proposing an alternative theoretical model that uses more than one theory to explain the phenomenon under investigation. One example is using the element of transfer (from cognitivist theories)14 to understand the development of assessment expertise, such as in the domain of rater decision-making processes.15,16

Challenging the prevailing treatment approaches is not uncommon in clinical practice either. Our approach to CPR, for instance, has changed dramatically over the course of a decade, with harder and faster compressions, a different ordering of steps (circulation first), and a new ratio of compressions to breaths. As HPE researchers use theories from other fields, they may need to adapt and modify them to better align with the learners, instructors, and environments found in the health professions.

Principle 4: Terminology Can Be Reconciled Across Theories

A challenge we face as HPE scholars is understanding the range of theories that can be applied to our growing field. We can facilitate interdisciplinary collaboration and enhance theoretical agility in the HPE community by clarifying terminology and simultaneously reducing jargon. One way to do so is by examining the similarities and differences in terms from different theories and to use the results of this comparison to revise the terminology for the problem under investigation. For example, there has been some confusion regarding the terms self-regulation, self-direction, and self-determination.17 One approach would be to avoid the conundrum and to choose a single theory, say self-regulated learning, and to adhere to its terminology. In so doing, however, the researcher loses potential insights on adult learning that are specific to self-directed learning theory and on intrinsic motivation that are specific to self-determination theory. Instead, explicitly and carefully comparing and revising these terms can help make the associated theoretical contexts more transparent and better support the specific work (e.g., nursing students studying for exams, interprofessional teams working on communication strategies, practitioners improving their ongoing practice). By enhancing our understanding of terminology—and identifying the similarities and differences across theories—we can develop an agile tool kit to help HPE scholars move the field forward.

Revision of terminology is also inherent in clinical practice. There is a movement in nursing, for instance, to shift and standardize terminology to improve communication, patient care, and data collection.18 For instance, “small,” “moderate,” or “large” amounts of bleeding have been redefined to be consistent across practice contexts. Similarly, in HPE, scholars can carefully examine terminology and find innovative ways to adapt this terminology for use across a variety of practical and theoretical contexts.18

Principle 5: Theories Can Be Challenged

It is often thought that theories cannot be challenged because they are based on a significant body of empirical research. We argue that theory can and should be challenged, but in HPE, “theory testing” can differ from the standard, causal comparative design or experiment. The testing of a theory may involve repeated applications in various contexts to demonstrate transferability of a theoretical concept. In quantitative research, theory testing occurs through numerical outcomes with inferential statistics to demonstrate the generalizability of the conclusion. In qualitative research, the clarity and plausibility of the findings—the extent to which they create new insights and the extent to which these insights are adopted by the scientific community—are also forms of generalization. In both cases, the research outcomes constitute the “truth” only until a “better truth” is identified.

This challenge of theory testing in HPE should not deter us from conducting further research. After all, practice devoid of theory is not useful; neither is theory devoid of practice. Indeed, we suggest that HPE offers a unique opportunity to examine educational outcomes because we educate students to become professionals across well-defined health professional domains. Thus, it is easier to link performance in practice with performance during training. We argue that theories should be continually tested and revised according to the evidence in our field because what we do affects the health care of the communities that our health professionals serve.

In medicine and public health, for example, the theory that smoking has a causal relationship with lung cancer was not tested by a single causal comparative study but, rather, by a whole program of research eventually leading to consensus. In HPE, programmatic theory testing is often more useful than a single, definitive “big bang” study. Take, for example, the challenge of understanding context specificity—a vexing medical phenomenon whereby a physician sees 2 patients with identical symptoms and findings (and the same underlying diagnosis) but arrives at 2 different diagnostic decisions.19 We discuss this challenge next as a context in which to understand how the 5 principles of using educational theory can be applied to a complex research problem.

A Practical Example

The phenomenon of context specificity in clinical reasoning is a complex problem. Traditionally, clinical reasoning was conceived as an individual skill, affected only by the difficulty of the content of the medical case. However, something more than the medical content is driving the physician’s clinical reasoning when context specificity is observed. First, we sought to empirically investigate context specificity in the simulation environment where we could control the “stimulus” to explore this phenomenon. We carefully crafted both video and live simulation cases with identical content, which differed only by the presence or absence of contextual factors (information other than the content needed to arrive at a correct diagnosis, such as the patient being a non-native English speaker, electronic health record malfunctions, or a fatigued physician).

We struggled with what theory to apply to the phenomenon of context specificity because there were no readily apparent HPE theories that integrated the notion of reasoning as an individual ability and how it could be affected by the health professional’s environment (Principle 3: You can deviate from a theory’s propositions). Therefore, we started with a macro theory, situated cognition theory (SCT), to help us operationalize some of the important features and interactions in a clinical encounter and to obtain a basic understanding of what might be important in understanding context specificity (Principle 1: All theories are not created equal). We then realized that we had to adapt this theory to our specific research context, requiring multiple discussions and experiments.20,21 We identified examples of aspects that played a role in a physician’s clinical reasoning, other than merely the medical content, needed to arrive at the diagnosis (which we termed contextual factors). Using SCT, we grappled with these matters and grouped contextual factors related to the patient, the physician, and the encounter (see Figure 1).

Figure 1
Figure 1:
Contextual factors in clinical reasoning from a situated cognition perspective.

From this macro theory, we were able to see how such contextual factors can affect a physician’s clinical reasoning, leading us to identify 2 more micro theories to further guide the investigation: cognitive load theory (CLT) and self-regulated learning theory (SRLT) (Principle 1: All theories are not created equal; Principle 2: Multiple theories can be used in a given research study). Using CLT, we developed measures of the potential increased mental effort (i.e., cognitive load) that might be generated as a result of the contextual factors. Although CLT is a learning theory (as opposed to a theory of performance), we adapted CLT principles for learning to evaluate performance, thereby enhancing the theory to meet our needs as HPE scholars (Principle 3: You can deviate from a theory’s propositions). Then, alongside CLT, we used SRLT to explore the tools that physicians might be using to manage this increased cognitive load (e.g., strategic planning, setting goals) (see Figure 2).

Figure 2
Figure 2:
Contextual factors in clinical reasoning from a multitheoretical perspective.

The integration of these 3 different theories (SCT, CLT, and SRLT) forced us to grapple with—and reconcile—some terminology mismatches, such as the definition of clinical reasoning (Principle 4: Terminology can be reconciled across theories). We had to reconcile the meaning of the term clinical reasoning across multiple fields and establish a defensible meaning to help address the challenge of defining context specificity. Applying this integrated framework, we were able to do the following: investigate the phenomenon using a series of experiments, provide a new lens through which to understand context specificity, enhance our understanding of these theories in a clinical sitting, and test our theoretical predictions (Principle 5: Theories can be challenged).

In this article, we have identified 5 principles for using educational theory in HPE, offering illustrative examples, including a narrative of a theoretical challenge we faced in a recent program of research examining context specificity. The complex phenomena that are characteristic of HPE can pose multiple challenges for researchers. We maintain that existing theories can offer diverse perspectives to address these challenges and move the field of HPE forward.


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