Preactive and interactive teaching

In 1967, a yellow paperback book titled, Handbook for Physical Therapy Teachers, was printed and distributed by the American Physical Therapy Association (APTA).⁶ This small book was developed by a publication committee composed of Ruth Dickinson at Columbia University, Hyman L. Dervitz at Temple University, and Helen Meida at Western Reserve University. This book was the only source of information regarding physical therapy education at the time and included information on how to develop, organize, and teach a physical therapy curriculum across academic and clinical settings. The teaching focus of that pioneering book and this chapter is preactive teaching.

The terms preactive and interactive teaching were coined by psychologist Phillip Jackson.⁷ Preactive teaching refers to those elements one considers when preparing to teach a course. Such activities include reading background information, preparing course syllabi, developing media, and even arranging the furniture in the classroom. These activities are highly rational—that is, the teacher reads, weighs evidence, reflects, organizes, relates the current class content to past and future classes the students are involved in, and creates an optimal environment for learning. Like the first-year teacher who was grappling with how to organize a 2-hour lecture, most of these activities occur when the teacher is alone and in an environment that allows for quiet, deliberative thought. Preactive preparation allows the teacher time to think through the breadth and depth of information that is to be presented (subject matter knowledge) to a particular group of students (knowledge of learners) as well as the most coherent and understandable way to present the information (pedagogical knowledge).^1,²

By contrast, interactive teaching refers to what happens when the teacher is face to face with students. Interactive teaching activities are more or less spontaneous—that is, when working with large groups of students, the teacher tends to do what he or she feels or knows is right. In the chaotic milieu of a classroom, laboratory, or clinic, little time is available to reflect on what are appropriate and useful teaching strategies. Obviously, experienced teachers are considerably more skilled in interactive teaching and reflection-in-action than novice teachers.⁸ This is similar to experienced clinicians who seem to know the right thing to do with patients with an ease and confidence that amazes novice clinicians. However, thoughtful preactive teaching preparation can allow even the novice teacher the freedom to focus on student understanding and learning rather than remain tightly tied to one’s lecture notes. Preactive teaching elements are covered in this chapter. Chapter 3 focuses on interactive teaching elements.

Preactive teaching grid

This handbook assumes that the teacher is extraordinarily competent regarding the subject matter to be taught (subject matter knowledge) and is a physical therapist or physical therapist assistant who has a good knowledge of the students to be taught and what information they need for competent clinical practice. However, to organize and present material in a manner that is responsive to the program mission and desired student outcomes, the teacher is urged to think through the components identified in the preactive teaching grid (Figure 2-1). This grid is useful whether designing a whole course or a single class. When all components of the grid have been identified and are related to each other in a coherent fashion, the delivery of the course content also tends to be coherent to student and teacher. Note that the grid encourages the teacher to think through how much percentage in time and effort each of the elements contributes to the presentation of a particular content area.

Figure 2-1 The preactive teaching grid.

Philosophical orientation

Eliot Eisner conceived of five philosophical orientations that can be used to guide curriculum design: development of cognitive processes, academic rationalism, technology, societal interests (social adaptation and social reconstruction), and personal relevance.^9,¹⁰ These orientations are based on what teachers think the aims of a curriculum, course, or class should be—that is, why they are teaching what they are teaching.

Cognitive Processing-Reasoning

The philosophical orientation of cognitive processing-reasoning focuses on teaching students to develop and refine their intellectual processes (e.g., how to gather and analyze data, how to pose and solve problems, how to infer, how to hypothesize, and how to make judgments based on limited information). The concern of the educator is on the how rather than the what. Little emphasis is placed on acquiring facts because the development of cognitive processing-reasoning orientation proposes that by teaching students how to think, reason, and use resources, they will be able to identify, locate, evaluate, and apply whatever information they might need.

Problem-based learning (PBL) is the centerpiece of problem-based curricula. PBL scenarios that are based on key cognitive processes needed by physical therapists are developed by faculty and form the basis of the core curriculum. Students then use “triggers” from the problem case scenario to define their own learning processes and then engage in independent, self-directed study before returning to the group to discuss and build their knowledge base. The building of a knowledge structure or scaffold is an essential component of all learning. Students must build that structure for themselves, and the PBL approach is one that emphasizes a knowledge-building process that is centered on clinical reality. See Table 2-1 for an overview of the steps in a PBL tutorial process.^11,¹²

Table 2-1 Steps in the Problem-based Learning Tutorial Process

Step	Process
Step 1	Identify and clarify terms in the case scenario that are unfamiliar
Step 2	Define the problem or problems to be discussed (all views should be considered)
Step 3	Discuss the problem(s) at brainstorming sessions Suggest possible explanations based on prior knowledge Students draw on each other’s knowledge; identify areas of incomplete knowledge
Step 4	Review steps 2 and 3; move explanations to tentative solutions; record explanations and restructure if needed
Step 5	Formulate learning objectives; group works toward consensus of learning objectives; tutor makes sure learning objectives are focused, achievable, comprehensive, and appropriate
Step 6	Private study (all students gather information related to each learning objective)
Step 7	Group shares results of private study (students identify their learning resources and share their results); tutor checks learning and assesses group (scribe records key findings during each step of the process)

Adapted from Cantillon P, Wood D. ABC of Learning and Teaching in Medicine, 2nd ed. West Sussex, UK: Wiley-Blackwell, 2010.

In a problem-based curriculum, the entire curriculum is composed of clinical problems. For example, rather than a class of students sitting in traditional physical therapy courses, such as anatomy, pathology, therapeutic exercise, and health care policy, students in small groups guided by a mentor discuss patient problems. With any given patient problem, students learn to seek out, analyze, and act on the information they need. That is, students gather information from a variety of sources, including anatomy, pathology, therapeutic exercise, and health care economics because these sources relate to the patient problem under consideration. For an excellent overview of the advantages and disadvantages of problem-based learning, read The Challenge of Problem-Based Learning by Boud and Feletti.¹¹

Of course, in any class or any course in any curriculum one could be working toward the development of cognitive processes and reasoning. For example, you might ask students to use their “hunch” regarding the outcome of a patient care problem. Students could then identify and analyze what data their hunch was based on and what additional data they would need to confirm their hunch. By this process, the student is introduced to the cognitive processes of inductive and deductive thinking and how both processes are used in health care decision making. As another example, students could be presented with a clinical problem that represents a moral dilemma. Analyzing such a problem involves the cognitive processes of identifying the student’s own values, comparing and contrasting these values with the principles contained in a professional code of ethics, and working out a rational, empathetic decision. Because time to evaluate and treat patients has declined in all health care settings, teaching students to think rationally, humanely, creatively, and quickly is time well spent in every course.

This orientation is challenging to entry-level physical therapist and physical therapist assistant educators who have little enough time to teach groups of students the basic tenets and tasks of their profession without responding to the individual personal relevance requirements of each student. Although one sees a version of this approach in discussions about addressing generational differences. How are generation X or millennial students different from faculty who are mostly baby boomers, and does this matter in how faculty teach?¹⁵ The personal relevance orientation is very much in evidence in continuing education programs as well as post-professional graduate degree programs that must consider adult learners. The most successful continuing education programs appear to be those that offer clinicians knowledge and advanced skills (e.g., in manual therapy), which can be immediately applied in an individual clinician’s health care setting. The most successful post-professional graduate programs appear to be those that offer the student a great deal of latitude in what she or he chooses to pursue and where the faculty is dedicated to encouraging and supporting students in their individual pursuits.

Using the Five Curriculum Orientations to Guide Curriculum Design and Course Development

There are two useful ways to use these five curriculum orientations in developing a whole curriculum or a single course. In working with an entire curriculum design, the five philosophical orientations can be used to review the multiple courses that make up the curriculum and to identify what philosophical orientation the curriculum emphasis is built on. Faculty might realize that they are spending too much time on technology or academic rationalism and not enough time on developing cognitive processes and reasoning. You might find that the social reconstruction orientation is a nice thread throughout the curriculum, or it may be left out altogether. This is an enjoyable and often revealing activity for individual faculty as well as the collective faculty. It will clarify the faculty’s own values and beliefs about the mission, structure, and outcomes of physical therapist or physical therapist assistant education as well as how any group of faculty envisions the present and future practice of physical therapy.

In using the five philosophical orientations to develop a course, the teacher would first specify the goals of the course and then identify how much of each philosophical orientation will be used to help student reach those goals. For example, for a course in basic skills, the teacher probably wants a high percentage of class time devoted to technology (e.g., 60%). He or she might also want to teach students how to think about applying basic skills in a wide variety of clinical situations, so the teacher may plan to devote 20% of class time to stimulating cognitive processing-reasoning. Finally, the teacher might focus on some skills students will need to use immediately in clinical practice, such as taking blood pressure or performing bed-to-wheelchair transfers. Thus, the remaining 20% of the time might be used for laboratory sessions organized around common clinical problems in which students can learn basic skills that are immediately applicable in their next internship. Going through the process of thinking about philosophical orientations related to the goals for each class can be an eye-opening experience, which can guide teachers in reapportioning classroom and laboratory time appropriately. Such a process can also ensure that all class time is not devoted inadvertently to a single philosophical orientation or an orientation that does not have a coherent fit with the overall curriculum design.

In Chapter 5, the Teaching Goals Inventory is presented and discussed. At that point, you will be able to see how the curriculum philosophy you are using is tied directly to your specific teaching goals.

Learning theories

The next column in the upper part of the preactive teaching grid contains learning theories (see Figure 2-1). Theories about how people learn have been discussed at least since the time of the Greek philosopher Plato (428-347 BC). Plato postulated that knowledge was innate—that is, in place at the time of birth. The function of a teacher was to help the learner “recall” what one’s soul had already experienced and learned. Nearly 2000 years after Plato, the British philosopher John Locke (1632-1704) proposed an opposite view of the learner. Locke postulated that infants were born with the mind a blank slate, a tabula rasa. The teacher’s role was to provide experiences that would fill this blank slate with knowledge.¹⁶

There are many ways to classify learning theories. We use four broad categories (Table 2-2)¹⁶^–¹⁹:

• Behavioral learning theories

• Cognitive learning theories

• Experiential/problem-solving learning theories

• Social-cultural learning theories

Table 2-2 Common Categories of Learning Theories

Learning Theory	Key Concepts	Examples of Application
Behavioral learning theory	Based on the concept that behavior could be influenced by the consequences (that reinforcement could help shape the desired behavior) Useful for teaching skills with measurable actions Foundation for performance-based education Some behavioral checklists may be inadequate for some professional competencies	Mastery learning, where you have the opportunity to practice the behavior and receive feedback on performance until mastery is achieved Often used for teaching technical patient care skills Can be used for assessing clinical competencies (particularly skills)
Cognitive learning theory	Emerged when limitations of behavioral theory were discovered Learning is an active process of meaning making whereby the organization or structure of knowledge is a critical element Addresses the use, such as information processing and retrieval and transfer of knowledge into practice settings	Foundation for building knowledge in the learner’s memory Knowledge that is connected to a clinical context bolsters retention Building a strong knowledge structure is necessary for developing reasoning and clinical judgment skills
Experiential/problem-solving learning theory	Experience and reflection on that experience are central to learning Students must learn not only what but also how to apply what they know Reflection-in-action is necessary for building practice-based knowledge	Designing learning opportunities whereby learners are engaged in active learning Creating learning experiences in which there is a structure that facilitates learner reflection on the learning Experiential learning is well suited to clinical or community settings
Social-cultural learning theory	Learning occurs in the social or practice setting The learning is situated in the community of practice as the learner engages in participation with others Meanings are socially constructed in these communities of practice	Clinical practice settings are powerful examples of social-cultural learning The social learning community needs to build self-efficacy in learners to allow them to have incremental success and enhanced participation Role models and mentors can have a powerful effect on the learners

Learning theories provide the teacher with ideas about how to present students with different types of knowledge and skill in a way that reinforces the underlying philosophical orientations the teacher is focusing on.

Behavioral Learning Theories

The behaviorism theory was developed in the first half of the 20th century as a result of numerous experiments, primarily on animals and birds, by the experimental psychologists E. L. Thorndike ²⁰ and B. F. Skinner.²¹ The basic theory of behaviorism rests on their observations that behaviors that were rewarded (positively reinforced) would reoccur. For behaviorists, the process of learning involves rewarding correct behavior until the behavioral change is consistently demonstrated.^16,¹⁷

Physical therapists and physical therapist assistants use behavioristic principles continually in patient care to teach psychomotor skills. For example, patients are reinforced with enthusiastic praise for attempting and subsequently achieving self-care activities or gait training. In classrooms, acquiring accurate knowledge (i.e., knowing the right answer) is rewarded by receiving high grades and praise from faculty. Lack of responsiveness to acquiring the knowledge presented is quelled by poor grades and perhaps even failure to proceed in the program. Computer-assisted instruction is based almost exclusively on this learning theory. Students receive immediate feedback contingent on the accuracy of their responses. Clearly, many psychomotor skills and specific facts that need to be memorized are successfully taught using behavioristic principles. For a teacher whose main philosophical orientation to a course is technology, the predominant learning theory of choice would be behaviorism. The behavioral approach works well when teaching a skill with a measurable action.^17,¹⁸

Cognitive Learning Theories

Cognitive learning theory focuses on the development of knowledge structures, abstract problem presentation, and problem solving that are critical elements of clinical reasoning. Cognitive learning theory development stemmed from the perceived inadequacy of stimulus-response behavioral theories of learning that did not account for advanced knowledge and skill development that is so critical in professional education.^17,¹⁸ Jean Piaget’s well-known research demonstrating the influence of the environment on the cognitive development of children and the stages of the learner as he or she is developing cognitive schema.^22,²³ Building on the work of early theorists, Ausubel²⁴ asserted that learners construct meaningful knowledge by being able to connect new concepts or knowledge to what they already know.²⁴ Learners need to build that structure, not just have information poured in.

Cognitive learning theories also address the most important aspect in learning, that of transfer of knowledge to actual practice settings that require problem solving and decision making. Experience with clinical cases is a very important element in building a knowledge structure (cognitive schema) that students will remember and be able to apply. Teachers need to remember to build from typical cases to more complex cases in building this structure.

Robert Gagne proposes a hierarchy of learning that begins with the simple and concrete and moves to the complex and abstract.²⁵ The ideas contained within stages of a hierarchy suggest that higher-order cognitive abilities build on lower-order cognitive abilities. That is, students must master lower-order abilities before they can master higher-level ones. Gagne suggests the following hierarchy: (1) facts, (2) concepts, (3) principles, and (4) problem solving. Thus, for example, students should be able to identify the muscles, nerves, and connective tissues involved in the shoulder rotator cuff (facts) before they can understand conceptually how these structures fit together. After they understand how the structures are related, they can understand the biomechanical principles involved in the rotator cuff mechanism. After understanding these principles, they can solve problems related to rotator cuff injuries. If a student missed any one of these steps, it would be difficult to proceed to the next step. For example, if the student did not understand conceptually how the various tissue structures are related, then it would be difficult to understand the biomechanics of movement. Thus, cognitive structure learning theories are very useful in thinking about ways to organize and present information. For a teacher whose main philosophical orientation to a course is academic rationalism, the predominant learning theory of choice would be cognitive learning theories.

Albert Bandura’s work in social learning theory and more recently social-cognitive learning theory has led to the development of several models and frameworks for understanding the underlying values and beliefs that are part of health behaviors and facilitating behavior change.²⁶ Much of this work is focused on applied behavioral theory and adherence (see Chapter 13).

Experiential/Problem-Solving Learning Theories

John Dewey (1859-1952), who has been called America’s greatest educational philosopher, expanded on the experiential learning theory or learning through context and experience.¹⁷ For Dewey, the issue of activity (i.e., students being actively involved in an authentic experience from which they could learn) was essential.²⁷

This principle of learning through experience clearly operates in clinical practice and academic settings. Physical therapists, who in the past prepared patients for functional activities by working on strength and endurance of specific muscle groups, now ascribe to modern motor learning theories in which teaching movement within meaningful functional patterns hastens the acquisition of motor skills (see Chapter 14). In academic settings, it is known that students need a framework for information so that the knowledge “makes sense.” For example, the tedious process of memorizing anatomic origins and insertions of muscle groups in an anatomy class has long been seen as an absolute necessity to the practice of physical therapy. However, students are quick to point out that learning this anatomic information is greatly enhanced by acquiring corresponding knowledge of the function of muscle groups in a kinesiology class and learning how to assist patients to improve the function of muscle groups in a therapeutic exercise class. In this manner, students learn and understand the origin and insertion of muscle groups in the context of muscle function and in the context of the use of this information in patient care. Thus, memorization of anatomic structures is easier because it has a useful experiential context and therefore “makes sense.”

Dewey described the process of human problem solving, reflective thinking, and learning in many slightly different ways because he knew that intelligent thinking and learning is not just following some standard recipe. He believed that intelligence is creative and flexible—we learn from engaging ourselves in a variety of experiences in the world. However, in all of his descriptions, the following elements always appeared in some form: Thinking always gets started when a person genuinely feels a problem arise. Then the mind actively jumps back and forth—struggling to find a clearer formulation of the problem, looking for suggestions for possible solutions, surveying elements in the problematic situation that might be relevant, drawing on prior knowledge in an attempt to better understand the situation. Then the mind begins forming a plan of action, a hypothesis about how best the problem might be solved. The hypothesis is then tested; if the problem is solved, then according to Dewey something has been learned.¹⁷^–¹⁹

Both in the classroom and in the clinic, when teachers present students with clinical problems to solve, they are following the traditions of John Dewey. Perhaps even more important, Dewey illuminates how we learn from our experience in clinical practice. His postulation that learning occurs from actively solving meaningful problems explains the accumulated wisdom of experienced practitioners that is far beyond the knowledge contained in current textbooks. The concepts of reflection-in-action and reflection-on-action described by Donald Schön and elaborated on in Chapter 3 of this book are the present-day versions of this experiential learning theory that was first articulated by Dewey.⁸ For a teacher whose main philosophical orientation to a course is development of cognitive processing-reasoning, the predominant learning theory of choice would be the experiential.

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