In the previous section, multiple areas of programme outputs, areas and impact were drawn from low-medium quality studies. Programme pedagogy and key didactic feature
were drawn from eight low quality studies out of nine. Drennan (2010) was the only researcher to use a validated assessment tool to evaluate differences in critical thinking of two nurse cohorts. While six studies (Chaboyer and Retsas, 1996, Green et al., 2008, Le et al., 2007, Nicolson et al., 2005, Tsimtsiou et al., 2010, Wildman et al., 1999) used combined qualitative and quantitative methods of data collection, the value of this design was not clear, nor did it appear to impact the overall study conclusion. It was not clear if qualitative data were used to interpret quantitative surveys; or if qualitative data facilitated the design of postal questionnaire (Teddlie and Tashakkori, 2009). Analysis of programme documents was not attempted in any of the studies, hence losing a rich source of data related to programme structure and delivery (Creswell and Plano-Clark, 2011). Moreover, while qualitative-based research identified programme outcomes and impact inductively, some themes lacked theoretical saturation because of underreporting of causes, conditions, context, contingencies, consequences, and covariances (Glaser, 1978) that would modulate changes. Nonetheless, while most studies drew on graduates’ accounts, five programme evaluations (Chaboyer and Retsas, 1996, Murray et al., 2001, Spence, 2004, Barnhill et al., 2012, Zahran, 2013) drew on stakeholder data i.e. educators, managers and colleagues, adding more credibility to findings.
The synthesis of the review findings into a completed programme theory Logic Model is illustrated in Figure 2.2. This synthesis of M-level programme theory across several healthcare professions offers a pathway that represents how programme philosophy, pedagogical activities and context led to its outputs, outcomes and impact. The inclusion of programme activities and context by some studies facilitated the collective synthesis of this model. However, because of the low to moderate quality of synthesised evidence, the model needs to be interpreted and used carefully and potentially needs further testing to seek its representation across various healthcare M-level programmes. Nonetheless,
the synthesised data can offer a comprehensive lens to evaluate M-level education. Yet, the isolation of the reported outcomes and impact to M-level education is difficult because of drawing on retrospective studies.
The synthesised evidence offers few details that link the outcomes and impact to programmes’ pedagogies, learners’ biographies and the wider context. A longitudinal study could have comprehensively captured programme’s pedagogy and the learning context that drove changes (Hodkinson et al., 2008). For example, it could have facilitated capturing the frequency, type and duration of programme activities as well as making informed judgments about whether the evaluated programmes delivered learning activities as planned or not. Also, utilising longitudinal studies could have offered comprehensive understanding of learners’ biography and learning dispositions (Hodkinson et al., 2008), particularly in terms of understanding about how learners’ biography, pre-programme clinical experience, in-service training and peer learning might contribute to outcomes and impact (Huber, 2011). Moreover, it could have provided an account for how spatial (place-related) and temporal (time-related) dimensions of M-level education can influence learners’ dispositions and identity development (Bloomer and Hodkinson, 2000, Hall, 2013).
There is an evidence, however, that learners’ reactions to programme activities determined the extent of transformation. For example, whilst engagement in critical reflection drove transformative changes in practice (e.g. Spence, 2004b), such scrutiny to one’s practice generated reactions that ranged from being defensive of their experience to being receptive to new knowledge. This gap between students’ learning dispositions and the intended outcomes of M-level education can be a source of conflict that potentially interrupts the learning process. The evidence suggests that acceptance of such
scrutiny of one’s practice is associated with a supportive learner-centred environment that offers constructive feedback (Petty et al., 2011a).
Figure 2.2: M-level education Logic Model synthesised from systematic review of literature. Whilst it is presented from left to right, the pathway does not imply causality
Whilst the value of this learner-centred approach was not further examined in reviewed studies, flexible pedagogy was found elsewhere to promote learners’ autonomy (Nissilä, 2005, Harrison, 2012, Trede and Smith, 2012, Hughes et al., 2015) as learners engage in a transactional relationship with their peers and educators. Also, the safe learner-centred environments have the potential to alleviate learners’ anxieties that impact learning engagement (Glover et al., 2008, Fisher-Yoshida et al., 2009) and therefore, achieving successful learning outcomes.
Learners’ motivation was identified as ‘catalyst for personal growth’ (Whyte et al., 2000, p.1078). However, the review offers little evidence on how the extrinsic motivation at the
motivators would better inform M-level educators in designing effective learning environments that can cultivate learning engagement and even augment motivation (Rao et al., 2014). For Ryan and Deci (2000), this involves understanding how the interaction between psychological and sociological aspects of motivation modify learners’ actions. In accordance with Hager and Hodkinson (2009), who emphasised the role of workplace structure in supporting practitioners’ learning, the review identified that learners’ motivation to maintain an advanced level of practice was dependent on workplace environment (Stathopoulos and Harrison, 2003, Nicolson et al., 2005, Green et al., 2008). Graduates from several programmes expressed a sense of frustration because M-level advanced skills were not welcome within the healthcare system (Stathopoulos and Harrison, 2003, Spencer, 2006, Green et al., 2008, Perry et al., 2011, Zahran, 2013). This potentially limits the full integration of knowledge and skills in practice and brings graduates into conflict with managers and colleagues.
For example, drawing on the experience of nursing, occupational therapy and physiotherapy clinical educators, Gerrish et al. (2000) likened graduates of nursing programmes to mavericks who did not fit comfortably into workplace cultures. They further suggested that learners’ empowerment and awakening led to conflict with managers and colleagues (Gerrish et al., 2000). On the other hand, physiotherapist working in the NHS are encouraged to work towards M-level qualification (National Health Service, 2005). In the context of musculoskeletal physiotherapy, Haywood et al. (2013) identified the positive role that physiotherapy professional bodies and employers play in supporting practitioners’ professional learning when compared with other healthcare practitioners who manage musculoskeletal conditions.
Finally, modelling learners’ transition was described in three medium quality studies. Perry’s et al.’s (2011) and Petty’s et al.’s (2011a) models drew on the physiotherapy
population and are consistent with Mezirow’s (1994) stages of adult learners’ ‘revolutionary’ transition where learner’s professional identity is transformed (Figure 2.3). In contrast, Cragg and Andrassy’s (2004) model drew on the nursing population and indicated an ‘evolutionary’ nature of transition, where learners develop their existing professional identity. This potentially explains why graduates from several nursing programmes highlighted the positive impact of their programme’s theoretical content (Chaboyer and Retsas, 1996, Nicolson et al., 2005). Therefore, it appears that learners’ transition is discipline-specific and probably influenced by workplace context. This interpretation remains debatable in the absence of comprehensive examination of learners’ biographies.
Figure 2.3: Stages of adult learners’ transformation. Adapted from Mezirow (1994, p. 224)