The adult learner and second career students bring an abundance of life experiences to the learning environment that may include multiple past occupations, children, military service and geographical moves. 1 The instructors must be sensitive to the changes these learners are facing as the students take on their new role as learners rather than wage earners, supervisors, experts, etc. Although this change is often positive, it can also produce stress, anxiety, and confusion that the learner may bring to the classroom. 2 The career change may have been catalyzed by sudden unemployment or long standing dissatisfaction or disappointment with their previous work. 3 These students are more self-directed and voluntary in their learning, because they believe the decision to return to school is an important one. 1 They have the discipline necessary to excel. Life experience allows the older learner to better appreciate the significance of a comprehensive and well-rounded education. The instructor must find a combination of teaching styles that will address this added diversity within the classroom. The class environment becomes increasingly complicated if there are multiple adult learners participating in the same program with young undergraduate college students or recent graduates.
Although adult learners may have a large diversity of backgrounds in schooling, abilities, culture, and personal goals, they have all decided to return to school. The intuitive instructor has a chance to tap into accumulated life experiences of the adult learner and use these experiences as learning resources. Adult learners have a profound expectation that all of their class time be well spent and applicable to their newly chosen career. This has likely been a costly financial and personal decision for them. They expect that the time spent will reap dividends, and they believe the decision to return to school is an important one. They may take school more seriously and have a much clearer view of how the goal will be affected by their willingness to contribute to the class and participate in its activity. They are practical learners, so lab time and clinical affiliations are often very motivating activities if clear goals and objectives are presented early in the experience.
The adult learner’s sense of self-effectiveness will also have a significant impact on his or her educational experience. Some students’ careers may have plateaued, and they feel embarrassed about returning to school, participating in a class with younger students, or finding themselves pressured into leadership roles simply because of age, even though they may not be capable of holding these roles. 4 Those students in the over 50 age group may have the most difficult time adapting to student life. 5 The instructors who find themselves teaching adult learners must pay special attention to identify their learning style, connect on a level that is important to the student, ensure they know their life experience is valued, and identify their motivation factor for learning.
APPLICATION AND ENROLLMENT TRENDS
The early 1990s saw record numbers of applications in health related fields. We are now seeing the downside of that trend as applicants to medical, dental, nursing, and many allied health schools decline. 6,7 The 37,092 medical school applicants for the class entering in 2000 represented a 3.7 percent decrease from the number of applicants in 1999, with a nearly 26 percent drop over the last five years. 8,9 Nursing programs report a 2.1 percent drop, which continues a 6 year trend. 10 Such nationwide trends hit small and little known professions, prosthetics and orthotics among them, particularly hard. Some prosthetic and orthotic programs are barely able to fill their classes. This move away from the health professions is in direct conflict with this country’s increasing need for health services. Possible factors for these changes vary. An abundance of lucrative career opportunities in e-business related to a healthy economy draws talented young people away from the health professions. Some may reason that declining federal reimbursement coupled with increasing federal regulations may not be worth the years and expense of a medical education. For those intending to own their own business, maintaining compliance with federal regulations is more costly to the small business than it once was.
Women continue to represent about ten percent of the profession. 11 Female prevalence in the work place has dispelled the notion about gender specific professions. As the perception of the field of prosthetics and orthotics moves away from technical and toward clinical, gender hardly seems to be an issue anymore. There is no appreciable difference noted in how students perform based on gender.
Whether the lowest point of this declining trend has been reached is not yet clear. Initiatives to attract individuals into the field must be taken, profession wide, to deal with this alarming trend; the focus should be on student recruitment as early as high school and even junior high. Continued grass-roots marketing to young people will most certainly aid in increasing the prosthetic and orthotic workforce.
INSTRUCTIONAL DESIGN CHANGES
An area of continuing development is media delivered instruction. Today’s computer literate student body is less willing to endure lectures supported by certain media such as overhead transparencies. Minimally, LCD projected lectures prepared by presentation software with accompanying handouts are expected. Live lectures with web links to manufacturer homepages or medical links are useful to stimulate interest and keep content current. Quizzes accessed via the Internet offer a new twist on the old “take home” quiz. These types of activities appeal to students and make for more efficient use of both their time and the instructors’ time. Web based resources are phenomenal, and, when integrated into the classroom, they can significantly enhance the learning experience. Conversely, many students utilize electronic media technology in their class presentations.
We must teach students to embrace these new technologies, because the practitioner of the future will do much of his or her daily business on a computer. Reviewing components and placing orders on a manufacturer’s homepage, using electronic billing, and communicating within the practitioner’s own company via e-mail and CAD technology are just a few examples. Wireless access and Personal Digital Assistants have already become routine in some areas of practice. Technology cannot replace good clinical judgment, but it can serve to make practice more efficient.
The rapid emergence of distance education over the World Wide Web will undoubtedly have an impact on prosthetic and orthotic education. The ubiquitous nature of internet access makes this form of delivery convenient. It can bring to the field an audience who previously could not seriously consider a career in prosthetics and orthotics. The scarcity of programs, for many students, means relocating and incurring a sizable debt, which is something to which few individuals can realistically commit.
An electronic means of delivery, whether provided to the distance or local student, puts new demands on faculty. Educational/instructional technology is a body of knowledge of considerable depth. Graduate degrees in educational technology are on the increase as educators in all fields begin to recognize that technology will have a significant impact in the classroom, live or virtual. Caution must be exercised when designing curriculum for the web. From an instructional design perspective, written lectures cannot simply be put onto a web page. Systematic development should be utilized and begins with needs assessment, goal and task analysis, identifying prerequisite skills, analyzing the learner and contexts, writing performance objectives, and developing assessment instruments. 12 All of this done before instructional materials are developed. Formative and summative evaluations continue to be relevant and insure quality curriculum. One might argue that the prosthetics and orthotics profession, as a hands-on profession, doesn’t lend itself to this type of delivery. Certainly, the didactic portion of any curriculum can be served up in this fashion. Virtual reality technology simulations can provide additional experiences. Similarly, telemedicine is used to deliver patient care and education to regions with limited access to healthcare. However, hands-on patient management must still be part of the curriculum either under the mentorship of a local clinician or through scheduled visits to the home campus. The effectiveness of cross-country curriculum delivery will be established as web-based education in prosthetics and orthotics emerges over the next several years.
TEACHING STYLES DESIGNED TO PRODUCE AN INCREASINGLY WELL-ROUNDED STUDENT
There is little argument that providing prosthetic and orthotic services is a complex skill that is not easily mastered. Successful clinicians have developed sub skills in many areas that are collectively used to lead them to successful outcomes in patient treatment. The traditional view of learning suggests that these complex treatment skills can be broken down into simple skills that can be independently mastered even if they are not taught completely in context. This view may be seen in educational programs that have a large variety of basic courses providing a broad overview of topics that the students are expected to integrate themselves. The expectation may be that the student will not be able to perform complex thinking skills until each simple skill has been mastered. This view also places the instructor as the primary active participant in the classroom who will impart wisdom to the passive student who seemingly has come to class as an empty container waiting to be filled with knowledge.
The constructivism view of learning suggests that an instructor lecturing to a class may not always provide for the most effective way to learn. 13 This view bases its theory on the notion that learners must be active participants in their own education. Students learn by actively applying themselves to complex meaningful problems rather then just practicing isolated sub skills. They must be free to make mistakes, learn from them, and try again. The challenge for today’s instructor is to identify and integrate the knowledge and experience that each given student has brought to the program. No student is an empty vessel as suggested by the traditional view of learning. Over the course of a program, the instructor needs to verify what knowledge is present, examine its merit, modify it for accuracy, substitute correct for incorrect, and, finally, identify the gaps in knowledge. As this process takes place, the instructor’s goal should ultimately be to add to what the students brought with them. This is especially true when teaching students who have significant clinical patient management experience. Given that most states do not have regulations preventing an informally trained or untrained person from treating patients, it has become increasingly common for program applicants to have experience assisting or even independently providing patient care. 11 Rather than immediately setting out to delete experience a student has, the instructor should consider analyzing this experience based on the previously mentioned progression. Skills and knowledge a student has gained prior to entering the program may actually be validated by the education, or, conversely, the education process may demonstrate the need to undo poor habits or correct erroneous thought processes.
Whether students have past clinical experience or not, all aspects of education must be taught in the context of their future practice as independent clinicians. Context is critical to provide meaning to learning. If today’s students are unclear how a particular course or even individual lecture will benefit their clinical practice, it may be very difficult to hold their attention. The students need to know that what they are being asked to spend their time studying is relevant and not only needed just to pass the exam. It is the instructor’s responsibility to bridge this gap of communication. According to John Keller, if you use information from the learner and context analyses, you can help your students understand the relevance of the instruction and sustain their attention. 14
With these polarized teaching styles in mind, the issue of motivation must be addressed. The instructor is charged with discovering what motivates both the individual and the class as a group. It is a moving target where assumptions based on factors such as age, gender, and socioeconomic status must be avoided. John Keller developed the ARCS model, which addresses attention, relevance, confidence, and satisfaction. 14 Keeping a class interested throughout an entire course, much less even one class session, can be a daunting task. Designing class sessions with active participation, variety in delivery format, and problem solving activities all help to keep the class interested. Relevance can be addressed by creating links between the instruction and learner experiences. Although the Commission on Accreditation of Allied Health Education Programs does not require a specific amount of patient contact, this is a critical bridge to learning. Each student is required to participate in 250 hours of clinical experience for each discipline of practice. 15 This requirement is meant to aid the students in transferring their learning from school to real life. Clinical affiliations are a reasonable format to expect the students to participate in complex problem solving activities without the weight of responsibility for the outcome. Student confidence should be built by providing clear learning objectives up front so it is understood what will be learned. Incorporating possibilities for success throughout a course will also allow them to see the correlation between their efforts and the skill/knowledge they have obtained. Today’s students need to feel satisfaction about their educational experience. They should see consistent standards and expectations held by their instructors. Instructors who teach by example in their actions will provide the students with a frame of reference for professional behavior while in the program. This is key to helping the students feel satisfied about their education throughout the entire program; satisfaction that is built by providing relevant educational experiences will last well beyond the diploma or certificate of completion.
1. Nebraska Institute for the Study of Adult Literacy. December 15, 2001; http://literacy.kent.edu/|P5nebraska/curric/ttim1/m1-cont.html
2. Jeska S, Rounds R. Addressing the human side of change: Career development and renewal. Nurs Econ. 1996; 14: 339.
3. Hurtri M. When careers reach a dead end: Identifying occupational states. J Psychol. 1996; 130: 383.
4. Bailey LL, Hansson RO. Psychological obstacles to job or career change in late life. J Gerontol B Psychol Sci Soc Sci. 1995; 50: 280.
5. Sanders GR, Nassar R. A study of MSW women students who have had previous careers. J Women Aging. 1993; 5: 97.
6. American Society for Healthcare Human Resources Administration of the American Hospital Association. December 15, 2001; http://www.ashhra.org/
7. Weaver RG, Haden NK, Valachovic RW. U.S. dental school applicants and enrollees: A ten year perspective. J Dent Educ. 2000; 64: 867–874.
8. American Medical Association. American medical news. December 15, 2001; http://www.ama-assn.org/sci-pubs/amnews/pick_01/prca1224.htm
9. Barzansky B, Etzel S. Educational Programs in US Medical Schools, 2000–2001. JAMA. 2001; 286: 1049–1055.
10. American Association of Colleges of Nursing. Nursing school enrollments continue to post decline, though at slower rate. December 15, 2001; http://www.aacn.nche.edu/Media/NewsReleases/enrll00.htm
11. American Board for Certification in Orthotics and Prosthetics, Inc. Practice Analysis of the Disciplines of Orthotics and Prosthetics
, 2000; 3.
12. Dick W, Carey L, Carey J. The Systematic Design of Instruction, 5th Ed. New York: Addison-Wesley Educational Publishers Inc., 2001; 2–12.
13. Anglin GJ. Instructional Technology, 2nd Ed. Englewood: Libraries Unlimited. Inc., 1995; 41.
14. Keller JM. Development and use of the ARCS model of instructional design. Journal of Instructional Development. 1987; 10: 2–10.
15. Commission on Accreditation of Allied Health Education Programs. Standards and Guidelines for an Accredited Educational Program for the Orthotist and Prosthetist. January 6, 2002; http://www.caahep.org/standards/op.htm