|Year : 2014 | Volume
| Issue : 4 | Page : 219-223
Advancing reforms agenda for health professionals' education through transformative learning
Sanjay Zodpey1, Anjali Sharma2
1 Director, Public Health Education, Public Health Foundation of India, New Delhi, India
2 Program Officer- Academic Programs, Public Health Foundation of India, New Delhi, India
|Date of Web Publication||5-Dec-2014|
Director, Public Health Education, Public Health Foundation of India, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Zodpey S, Sharma A. Advancing reforms agenda for health professionals' education through transformative learning
. Indian J Public Health 2014;58:219-23
|How to cite this URL:|
Zodpey S, Sharma A. Advancing reforms agenda for health professionals' education through transformative learning
. Indian J Public Health [serial online] 2014 [cited 2019 Sep 20];58:219-23. Available from: http://www.ijph.in/text.asp?2014/58/4/219/146274
Health systems globally are facing enormous challenges for which the health professionals need to be prepared in order to respond effectively. However, as of today, the health professional education has not been able to conform well to address these challenges. In almost all countries, the education of health professionals has failed to overcome dysfunctional and inequitable health systems because of curricula rigidities, professional silos, static pedagogy (i.e., the science of teaching), insufficient adaptation to local contexts, and commercialism in the professions. [] Largely owing to these reasons, graduates who are being produced lack the necessary skills to understand determinants of ill health and become more responsive to the changing health needs of the population. There is also increasing global consensus that the education of health professionals is failing to keep pace with the scientific, social, and economic changes transforming the healthcare environment.  In view of this, it is certainly a high time, we revisit the quality and relevance of the health professionals' education and devise new strategies to revitalize it.
Recently, several initiatives from various parts of the world have played a key role in fostering and deepening the reforms agenda for health professionals' education. The report of the Joint Learning Initiative on Human Resources for Health (HRH) in 2004 was one of the pioneering work for the global call for reforms. It was followed by the establishment of the Global Health Workforce Alliance and the Asia Pacific Alliance on Human Resources of Health (AAAH), the publication of World Health Report 2006, the United States Agency for International Development (USAID) CapacityPlus Project (2009), the President's Emergency Plan for acquired immune deficiency syndrome (AIDS) Relief (PEPFAR)'s Medical Education Partnership Initiative-Nursing Education Partnership Initiative (MEPI-NEPI), launch of Asian Network on Health Professional Education Reform (ANHER), the development of the World Health Organization (WHO) Global Code of Practice on International Recruitment of Health Personnel, the WHO Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention Guidelines (2010), the Lancet report on Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World (2010), and the publication of WHO Transforming and Scaling up Health Professionals' Education Guidelines (2013). Several regional and country-level initiatives also contributed toward these efforts. The movement finally achieved the crescendo at the Sixty-Sixth World Health Assembly where Resolution on Transforming Health Workforce Education in support of Universal Health Coverage (2013) was passed (World Health Assembly Resolution 66.23). ,,,,,,,,, Organization of Prince Mahidol Award Conference (PMAC) on Transformative Learning for Health Equity in 2014 pushed this agenda further.  These global efforts focussing on the transformative education have beckoned for ushering a new dawn of health professional education. All these initiatives are noteworthy in advocating transformative learning as the highest form of learning, the proposed outcome of instructional reforms, and have been acknowledged as the most important fundamental driver of health professional education reforms for 21 st century.
But then, what is transformative learning, what is its basic premise, and why is transformative learning so necessary? Jack Mezirow, a stellar intellectual in adult education introduced and developed his delineation and theory of transformative learning in the late 1970s and early 1980s. Mezirow described the transformative learning as being "constructivist, an orientation which holds that the way learners interpret and reinterpret their sense experience is, central to making meaning and hence learning."  The theory has two basic kinds of learning: Instrumental and communicative learning. Instrumental learning focuses on learning through task-oriented problem-solving and determination of cause and effect relationships. Communicative learning involves how individuals communicate their feelings, needs, and desires.  Dr. Patricia Cranton, another leading writer on transformative learning, says that the "elegantly simple" definition of transformative learning includes the idea of people changing the way they interpret their experiences and their interactions with the world.  Transformative learners are more reflective, develop inclusive thinking, are more open to differences of opinion, and become less judgemental about other issues they may encounter. Armed with these new ways of thinking, learners are able to use new thoughts to guide action.  John Dirkx, another theorist, views transformational learning as a meaning-making process within adult education, aimed at promoting a democratic vision of society and self-actualization of individuals. He has summarized what may be called as four different strands of thoughts within the research and theory of transformative learning.  He shed light on the perspectives of Paulo Friere (1970) who referred to transformative learning as conscientization or consciousness-raising. By critical consciousness, he referred to a process where the learners are able to analyze, pose questions, and take actions on the social, political, cultural, and economic contexts that influence and shape their lives and liberates their thinking at both personal and social levels. Transformation as "Critical Reflection" was popularized by Mezirow who developed a theory of adult learning grounded in cognitive and developmental psychology. Drawing from the day-to-day experiences and making meaning out of them through reflection, critical reflection, and critical self-reflection was the centrality of this theory. Reflection and dialogue remain the cornerstone of the learning process. Transformation as "development" was propagated by Daloz who like Mezirow and Freire relied in constructivist views of knowledge and learning. However, unlike the previous two, Daloz's opinions of transformative learning depends less on rational, reflective acts but more on holistic and intuitive processes. He expresses the psycho-social and developmental context where most of the adult learning takes place. He also emphasized that formal educational experiences can play a critical role in helping adults recognize this process of meaning making and construction. He frames this role of fostering transformative learning within the metaphor of the mentor. The fourth strand of transformative learning theory is represented by Robert Boyd. For Boyd, transformation is a "fundamental change in one's personality involving (together) the resolution of a personal dilemma and the expansion of consciousness resulting in greater personality integration." 
The Lancet Commission Report titled "Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World" that developed a common strategy for post-secondary education in medicine, nursing, and public health at the global level regarded "transformative learning" as the highest of three levels in which informative learning is about acquiring knowledge and skills; its purpose is to produce experts. Formative learning is about socializing students around values; its purpose is to produce professionals. Transformative learning is about developing leadership attributes: its purpose is to produce enlightened change agents who work effectively as teams in a health system and can use global resources to address local priorities. Transformative education excogitate how adult education should be conceptualized and perceived.  Transformative educators do not necessarily teach content that is remarkably different from more instrumentally oriented educators. They may be found in the workplace, running a continuing education program, or teaching an adult education class. However, they teach the content with a different end in view, often using instructional strategies.  As a valued outcome, transformative learning involves three fundamental shifts: From fact memorization to searching, analysis, and synthesis of information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities.  Transformative learning aims to awaken students to issues of injustice, and to promote their critical analysis of assumptions, beliefs and values that lead to and sustain social inequities, so that they may become agents of social change. 
In order to foster transformative learning, the educator's role is to assist learners in becoming aware and critical of assumptions. This includes their own assumptions that lead to their interpretations, beliefs, habits of mind, or points of view, as well as the assumptions of others. Educators must provide learners practice in recognizing frames of reference. By doing so, educators encourage practice in redefining problems from different perspectives. The goal is to create a community of learners who are "united in a shared experience of trying to make meaning of their life experience".  Opportunities to effectively participate in discourses at the same also encouraging equal participation among learners can be employed by educators. They can also encourage dialogue from different perspectives through controversial statements or readings from opposing points of view without shaping the discussion. They can push the learners to dwell and critically reflect and experience with discourse through the implementation of methods like metaphor analysis, concept mapping, consciousness raising, life histories and participation in social action. Transformative learning theory would be about learners undergoing a major change in their understanding of a topic, world view, comfort zone, through a particular learning experience/activities. i.e., it is not just learning by rote, but involves a "eureka!" moment that may be uncomfortable for the learner at first as it takes people out of their current comfort zone. 
How to translate the transformative education from philosophy to practice is crucial for advancing reforms in health professional education. The implementation of transformative changes in the education of health professionals is justified by clear objectives: To ensure the availability of a workforce that is sufficient in number and skills mix, and has the competencies and professional outlook that correspond to the needs of the population it will serve. WHO suggests that there is robust evidence from systematic reviews done in developed countries on the effectiveness of simulation methods with different groups of health professionals. Several studies were done with medical, nursing and midwifery personnel but also with dentists, chiropracters, and veterinarians. Simulation methods are useful in helping students to acquire skills and to accelerate learning. They allow for a variety of situations and are specially designed for the development of manual skills that can only be learned through repetition.  Simulation methods seem to improve competencies and performance, as well as learner satisfaction. Various teaching strategies can be utilized for this viz. recalling life crisis through narrating stories, turning points; critical reflection can come through writing journals and research articles, engaging empathetic conversation, engaging in rational dialogues through small group discussions, collaborative writing, brainstorming, and employing problem based learning. 
The competencies of graduates should include leadership and communication skills. Moral and ethics also need to be emphasized. Transformative teaching can transform learners from mere knowledgeable professionals to competent professionals capable to do the tasks required to meet the healthcare needs of the individual or population groups; be able to work effectively in teams to deliver healthcare; learning together to work together for better health service delivery; be able to provide leadership and become change agents. Online learning environment can also be a good platform for applying transformative learning theory as it provides a flexible, more open and relaxed learning space than face to face context. Asynchronous discussions allow students time and mental space to read and reply. The documentary nature of communication allows students to reflect and discourse structurally and allow for iteration and reiteration of concepts in various formats. 
To bring the reforms in health professional education, transformative pedagogy is a necessitated entity that needs to be channelled in the teaching and training institutions. The transformative education is not only transforming education, but it also involves social transformation. The focus should be beyond hospitals and colleges but also reach out to community settings. Health professional associations and education institutions can play an active role in supporting transformative education that will facilitate the social accountability. However, ownership and commitment of faculty is needed in order to move forward. 
WHO has endorsed the transformative learning theory time and again and has put forth eleven recommendations to transform and scale up health professionals' education and training.  These recommendations are related to faculty development, curriculum development, simulations methods, direct entry of graduates, admission procedures, streamlined educational pathways and ladder programs, inter-professional education, accreditation, continuous professional development for health professionals, and governance and planning. For faculty development, health professionals' education and training institutions should consider designing and implementing continuous development programs for faculty and teaching staff, Governments, funders, and accrediting bodies should consider supporting the implementation of higher education policies for mandatory faculty development programs that are relevant to the evolving healthcare needs of their communities and health professionals' education and training institutions should consider innovative expansion of faculty, through the recruitment of community-based clinicians and health workers as educators. It also urges for curriculum development and suggests that health professionals' education and training institutions should consider adapting curricula to the evolving healthcare needs of their communities. The importance of simulation methods (high fidelity methods in settings with appropriate resources and lower fidelity methods in resource limited settings) of contextually appropriate fidelity levels in the education of health professionals has also been stressed. Health professionals' education and training institutions should consider direct entry of graduates from relevant undergraduate, post-graduate, or other educational programmes into different or other levels of professional studies. For admission procedures, health professionals' education and training institutions should consider using targeted admissions policies to increase the socio-economic, ethnic, and geographical diversity of students. Health professionals' education and training institutions should consider using streamlined educational pathways and ladder programs for the advancement of practising health professionals and consider implementing inter-professional education in both under-graduate and post-graduate programs. National governments should introduce accreditation of health professionals' education where it does not exist and strengthen it where it does exist. Continuous professional development and in service training for health professionals is required to be relevant to the evolving healthcare needs of their communities.
However, there are several challenges to engage in transformative education. In order to take forward the above-mentioned 11 recommendations of WHO, lot of advocacy would be required at the governance and institutional level. Reforms will have to be undertaken in instructional framework to facilitate incorporation and integration of transformative learning into the curricula. The existing traditional educational system also poses challenges toward implementation of transformative education such as having faculty trained in transformative learning and attitude of faculty with aversion to not change. Moreover, evidence that transformative education will change the paradigm also needs to be documented and reflected. But, having said this, it is important to remember that "True success is not in the learning, but in its application to the benefit of mankind".  Hence, transformative education should be seen as driver to create motivated and competent health professionals who would apply knowledge and skills to strengthen the health systems, support universal health coverage, improve health outcomes and contribute to achieve sustainable development goals in post 2015 agenda.
| References|| |
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al
. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58.
Prince Mahidol Award Conference. Transformative Learning for Health Equity Available from: http://www.pmaconference.mahidol.ac.th/index.php?option=com_content&view=article&id=608&Itemid=207 [Last accessed on 2014 Nov 23].
Joint Learning Initiative. Human Resources For Health: Overcoming The Crisis. The Joint Learning Initiative. Cambridge: Harvard University Press; 2004. Available from: http://www.who.int/hrh/documents/JLi_hrh_report.pdf [Last accessed on 2014 Nov 22].
World Health Organization. The World Health Report 2006 - working together for health. 2006. Available from: http://www.who.int/whr/2006/en/ [Last accessed on 2014 Nov 22].
Global Health Workforce Alliance. Scaling up, saving lives. Geneva: World Health Organization; 2008.
Planning, developing and supporting the health workforce. Results and lessons learned from the Capacity Project, 2004-2009. Washington, DC, USAID, 2009. Available from: http://www.capacityproject.org/images/stories/capacity_project_final_report.pdf [Last accessed on 2014 Nov 23].
WHO consultation on the transformative scale-up of medical, nursing and midwifery education. Second technical reference group meeting: Nursing and midwifery education experts; 2010 July. Available from: http://www.who.int/hrh/documents/education/en/ [Last accessed on 2014 Nov 22].
The U.S. President's Emergency Plan for AIDS Relief. PEPFAR's Medical & Nursing Education Partnership Initiatives. Available from: http://www.pepfar.gov/partnerships/initiatives/index.htm [Last accessed on 2014 Nov 22].
Asia-Pacific Network on Health Professional Education Reform (ANHER) Available from: http://www.healthprofessionals21.org/index.php/news-views/asia [Last accessed on 2014 Nov 22].
Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://www.who.int/hrh/retention/guidelines/en/index.html [Last accessed on 2014 Nov 22].
World Health Organization. WHO Global Code of Practice on the International Recruitment of Health Personnel. Available from: http://www.who.int/hrh/migration/code/WHO_global_code_of_practice_EN.pdf [Last accessed on 2014 Nov 22].
World Health Organization. Transforming and scaling up health professionals' education and training. Geneva: World Health Organization Guidelines 2013; 2013.
Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, CA: Jossey-Bass; 1991.
Mezirow J. Transformative learning. Available from: http://www.instructionaldesign.org/theories/transformative-learning.html [Last accessed on 2014 Nov 26].
Cranton P. Getting to know transformative learning theory. (n. d.). Available from: http://www.transformativelearning.org/index_files/Getting%20to%20know%20Transformative%20Learning%20Theory.pdf [Last accessed on 2014 Nov 23].
Taylor E. Fostering transformative learning. In: Mezirow J and Associates, editors. Transformative Learning in Practice. San Francisco, CA: Jossey Bass; 2009. p. 3-17.
Dirkx JM. Transformative learning theory in the practice of adult education: An overview. PAACE J Lifelong Learn 1998;7:1-14. Available from: https://www.iup.edu/WorkArea/DownloadAsset.aspx?id=18335 [Last accessed on 2014 Nov 23].
Transformative learning. Available from: http://www.en.wikipedia.org/wiki/Transformative_learning [Last accessed on 2014 Nov 23].
McAllister M, Oprescu F, Downer T, Lyons M, Pelly F, Barr N. Evaluating STAR - a transformative learning framework: Interdisciplinary action research in health training. Educ Action Res 2013;21:90-106.
Definition of Transformative Learning. Available from: https://sites.google.com/site/transformativelearning/definition [Last accessed on 2014 Nov 24].
Technology in practice for TL. Available from: http://www.slideshare.net/susanlulee/introduction-to-transformative-learning [Last accessed on 2014 Nov 24].
Can TL be applied to online distance learning? Available from: https://sites.google.com/site/transformativelearning/can-tl-be-applied-to-online-distance-learning [Last accessed on 2014 Nov 24].
Gaps and Recommendations on 'Transformative Health Professional Education'. Technical Working Group (Twg) #2. The role of transformative education. Results from the Public Consultation on the HRH Working Papers at the 8th AAAH Conference. Weihai; 2014
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