Writing the content of an activity

The text of a continuing education activity has to meet its learners' needs, expand their knowledge and build their skills, and what is known about how adults learn shapes how that text is drafted. Accreditors also expect cultural competence in the content, and its patient cases are a primary place to build it. A document that transmits a clinical practice guideline faces a further choice: whether to quote the guideline's recommendations or to restate them.

What the content is for

Continuing medical education (CME) for physicians and continuing education (CE) for nurses, pharmacists and other health professionals has to meet learners' needs, expand their knowledge and build their skills, so medical writers in the field should know adult learning principles and the newer insights of the learning sciences. ¹ Incorporating adult learning principles into the content is likely to make an activity more effective and to increase its effect on clinicians' behaviour and on patients' health outcomes. ¹ The Alliance for Continuing Education in the Health Professions, which promotes best practices in CME and CE, identifies these principles as a core knowledge domain for professionals who develop content. ¹

Health professionals are extremely busy, and their capacity to learn in the moment depends on many factors, including their specialty, proficiency level and workplace setting. ^{2, 3} The writer's goal is to help them process, synthesise and apply new information in the relevant context, using adult learning strategies to move learners from what they know and can already do toward what they need to know and apply in practice. ³

Adult learning principles

Adult learning principles draw on assumptions from twentieth-century educators and psychologists, including Malcolm Knowles and John Dewey, who argued that teaching adults (andragogy) differs from teaching children (pedagogy), so that adult learning needs its own educational approach. ⁴ Adults learn best when they direct their own learning and are intrinsically motivated. ⁴ Intrinsic motivation is the interest, pleasure and satisfaction of learning itself, and extrinsic motivation is the outcomes associated with learning, such as clinical practice demands or improved patient care. ⁴ Adults actively seek learning when they have specific problems to solve, and they want to apply what they learn to real-life situations at once. ⁴ They bring a rich store of life experience, which gives learning its context and a foundation for reflection. ⁴ They also learn best when they control the timing, nature and direction of their learning. ⁴

In summary form, the principles are:

1. Adult learners are self-directed.
2. Learning should be relevant to professional needs or social roles.
3. Learning should be problem-oriented and support the immediate application of knowledge.
4. Adult learners appreciate opportunities for feedback and reflection.
5. Adult learners prefer control over the timing and direction of learning.

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Content written to these principles should be learner-centred, problem-oriented, relevant to practice, based on educational need and aligned with the anticipated outcomes, and four steps help the writer get there: ⁶

1. Consult the needs assessment. Learn the knowledge and skill needs and the clinical practice and performance gaps it presents. A comprehensive needs assessment shows the clinical gaps and the anticipated outcomes that the education targets.
2. Identify the audiences. Ask who the learners are, what they need, and what experience or background they bring to the activity.
3. Review the anticipated outcomes. Identify the problem the content needs to address, and what learners need to know or be able to do once they have read the material.
4. Apply SMARTER goals to the content. Keep it specific, measurable, action-oriented, relevant to the learner, the learning objectives and the anticipated outcomes, time-specific, evaluable and realistic.

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The learning sciences

Early twentieth-century adult learning theory was concerned mainly with how adult learning differs from learning in childhood. ⁷ A century later, adult learning scholarship also covers cognition, memory, and the structure and function of the brain, and how sociocultural, professional and organisational contexts and social and emotional factors, such as demographics, technology and stress, shape adult learning. ⁷ The learning sciences are multidisciplinary, and draw on cognitive psychology, sociology, neuroscience, anthropology, behavioural economics and other disciplines. ⁷

Cognitive load and memory

Cognitive learning theories describe how people process, structure and retrieve information. ⁸ Information is absorbed through the senses, in sensory memory, then processed in working, or short-term, memory and organised into schemas of increasing complexity. ⁸ This processing builds on prior knowledge and is affected by cognitive load, which has two parts: intrinsic load, the volume of information to be processed, and extrinsic load, the work required to process it. ⁸ Short-term and long-term memory work together with cues and context, so that new information can be integrated with prior knowledge and consolidated more deeply into memory. ⁸ Forgetting and unlearning are also important in learning new information. ⁹

The learning sciences offer many empirically tested strategies that yield deep, durable learning. ⁹ One principle, argued by Brown and colleagues in Make It Stick: The Science of Successful Learning, is that interactivity correlates with higher learning impact: the more actively learners engage with educational content, the more likely they are to retrieve and apply information in the appropriate context. ⁹ To that end, instructional designers boost interactivity in e-learning by building effortful and repeated recall, recognition and retrieval into learning activities. ⁹ Microlearning, which delivers short, media-rich bursts of content spaced out over time, is thought to boost interactivity and retention by reactivating memory, avoiding cognitive fatigue and moving new information more efficiently from short- to long-term memory. ⁹

Writers can manage cognitive load, ease processing, bolster retention and increase interactivity with these tactics: ^{8, 9}

• Stay on track. Make sure the written content addresses the learning objectives.
• Edit ruthlessly. Reduce distractions and eliminate extraneous information.
• Be bold. Highlight the essential points for the learner.
• Build iteratively. Present ideas in sequence, from simple to more complex.
• Parse it out. Break complex ideas into bite-sized portions of text.
• Pair image with text. Embed images, graphics, audio or video clips where appropriate.
• Offer opportunities for retrieval practice. Include questions that encourage retrieval from long-term memory and help the learner connect new information with prior knowledge.
• Promote active discovery. Include exercises or activities, such as matching, polling or multiple-choice questions, that help learners find the gaps between what they thought they knew and what they ought to know.

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Experiential, emotional and social learning

Competency-based education and interprofessional continuing education also benefit from insights into the experiential, emotional and social nature of learning. ¹⁰ In experiential learning, experience is an important baseline for reflection: a learner meets a problem, which is a concrete learning event, takes stock of the options for addressing it, which is reflection, and actively experiments in designing solutions, which is sometimes called knowing-in-action. ¹⁰ Experiential learning often includes activities in which learners appraise their own current practice, identify a problem in it and work through problem-based learning, alone or in a team. ¹⁰

Work as any kind of clinician is often stressful and can provoke powerful emotions, and emotions affect how and what people learn, through physiological responses to situations and the subjective experience of those responses, which is mood. ¹⁰ In a positive mood, people are more likely to absorb, retain and retrieve information, to see the bigger picture and to apply new information to practice. ¹⁰ Role play is one CME and CE activity that might be used to explore how emotional states affect both clinical practice and learning. ¹⁰

Emotional learning is grounded in social cognitive theory, which suggests that people learn more effectively when they observe and interact with others. ¹⁰ Social learning happens when a person belongs to a community of learners or a community of practice. ¹⁰ Communities of practice are often self-organised and treat participation and collaboration as the key drivers of learning, and journal clubs and discussions in social media groups are examples of CME and CE that make good use of them. ¹⁰

In competency-based education, learners also need to develop expertise and progress from novice to mastery, and that progress requires deliberate practice, which involves effort, repetition and feedback. ¹⁰ Deliberate practice is a common characteristic of virtual simulations and of case- and vignette-based activities, which are designed to mirror real-world challenges in health care and let learners practise reasoning, communication and procedural skills. ¹⁰ Online patient cases are often highly interactive and come with feedback that shows the consequences of the learner's choices, guides the learner toward an end goal and allows room for failure and course correction. ¹⁰ Written feedback can take the form of expert or virtual-patient commentary, or notes on the clinical outcomes that followed from the decisions the learner made in the activity. ¹⁰

Writers can build these insights into an activity with these tactics: ^{10, 3}

• Build reflection into the text. Use open-ended or polling questions that encourage learners to think actively about how to apply the information in clinical practice.
• Use metaphors. They can help learners integrate new information into clinical practice.
• Emphasise context. Where possible, describe the clinical, professional and organisational context in which learners are expected to apply new information or skills, which situates learning in relationships and communities of practice.
• Use storytelling to engage learners. A story-based approach through patient cases or vignettes promotes clinical problem-solving and deliberate practice, and it builds the learner's empathy with the patient's experience.
• Deliver concrete, constructive feedback. Feedback in small, digestible chunks defuses defensiveness, minimises negative emotional responses and reduces cognitive load.

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Cultural competence

Accreditation bodies such as the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education expect CME and CE providers to integrate cultural competence into education for the intended learners, whether physicians, pharmacists or nurse practitioners. ¹¹ The Commonwealth Fund, almost twenty years before 2023, defined cultural competence as "the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients." ¹¹ The California Medical Association, which accredits CME organisations in California, has developed standards to ensure that accredited CME includes cultural and linguistic competency statements, and content that addresses, implicitly or explicitly, topics such as communication skills, health care disparities, biases and stereotyping, cross-cultural pharmacological issues, and sociocultural factors that affect health beliefs and behaviours. ^{11, 12} In 2023 the ACCME was also working to incorporate diversity, equity and inclusion into all aspects of accredited education. ¹²

A primary way to integrate cultural competence standards into CME and CE is to broaden representation within the content, such as in patient cases. ¹² The social, cultural and linguistic characteristics of patient cases can be diversified by using diverse names, describing different marital statuses and relationships, and including images that represent people with disabilities, Black, Indigenous and other people of colour, and people in LGBTQIA+ communities. ¹² Writers should consider the characteristics they give patients in hypothetical case studies and patient journeys. ¹¹ They can also educate themselves on cultural norms related to communication, decision-making, family dynamics, spirituality and other factors affecting health and health care. ¹²

Quoting a guideline's recommendations

When a continuing education document transmits a clinical practice guideline, one argument holds that the guideline's recommendations should appear mostly verbatim, and rests this on the theory of lexical priming that Michael Hoey set out in 2005. ^{13, 14} Hoey's hypothesis is that a person's cumulative encounters with a word prime it for use in discourse, so that each word comes to occur with particular other words as collocations. ¹³ He defines a collocation as a psychological association between words up to four words apart that occur together more often than random expectation in corpora. ¹³ From January to March 2010, CE in-service materials for nurses were written that gave guideline recommendations in mostly verbatim text, as intentional encounters with the words into which deliberate collocations were built. ¹⁵ Their authors concluded that Hoey's theory supports giving guideline recommendations in mostly verbatim text. ¹⁶