Thoughts on Learning and Evidence Based Practices

"Knowledge is power"
Sir Francis Bacon

"Skill to do comes of doing"
Ralph Waldo Emerson

Formal Learning:

Learning is the act, process, or experience of gaining knowledge or skill. Learning can be divided into formal and informal areas. We're well acquainted with formal learning, since we invested years in the educational process and countless hours in the classroom and clinic to earn our degrees. Formal learning has given us the knowledge and credentials to practice our profession. I have nothing against traditional formal learning, since my entire academic career in audiology centered on teaching students in the classroom or clinic. However, traditional formal learning does have its' disadvantages, too! Once you're in the workplace, how much time can you take off to attend classes or workshops? Another big issue is how much energy (time, money, brain power) can you devote to educational pursuits while maintaining your career, family and hobbies? Generally, sacrifices will need to be made and priorities will be revealed!

Informal Learning:

We don't often recognize informal learning, or harness its enormous potential in the workplace. Informal learning is a "lifelong process whereby individuals acquire attitudes, values, skills, and knowledge from daily experiences and the educative influences in his or her environment, from family and neighbors, from work and play, from the market place, the library, and mass media." ⁽¹⁾ However, we tacitly acknowledge the value of informal learning when we learn more about our profession at our practicum sites than in our formal classroom lectures.

Informal learning takes place even when you're not aware it's happening. It can occur any place, any time and surprisingly, informal learning is responsible for 80% or more of what we learn in the workplace! Cross ⁽²⁾ explained "...at work we learn more in the break-room, than in the classroom. We discover how to do our jobs through informal learning - observing others, asking the person in the next cubicle, calling the help desk, working with people in the know. Formal learning - classes and workshops and online events - is the source of only 10 percent to 20 percent of what we learn at work."

Informal learning can become self-directed and focused and more meaningful, as it's often directly relevant to your job and can be done in bits and pieces as your schedule allows. We can't always take time to attend a two-day workshop, but we can usually spend a few moments interacting with others, or online to query, research and resolve issues of interest.

Pareto's Principle:

Pareto, an Italian economist, formulated the 80/20 principle in l906 by observing that 80% of the country's wealth was controlled by 20% of its citizens. The principle has been generalized to state that 80% of effects or consequences are due to 20% of causes ⁽³⁾. This same concept is referred to as the "80/20 rule" and it has a multitude of applications in our day-to-day life, and has been referred to in recent management books and articles.

In practical terms, if you have a daily "to-do" list of 10 items, you might choose the two items of highest priority to accomplish first. Those two items likely represent 80% of the total value of your list, and you'll still have plenty of time to work on the numerous and less important items - after accomplishing the first two.

Just for fun, I have applied Pareto's Principle to the process of formal learning. When applied to formal learning, Pareto's principle cautions us that 80% of the useful information contained in an hour's lecture will be located within 20% of the time allotted, or just 12 minutes! The principle might also remind us that 80% of the information we hear in a lecture is forgotten by the time we get 20 feet away from the classroom door. Well, maybe that's stretching Pareto's Principle a bit too far, but you get the idea.

My "Ah-Ha" Moment:

My "Ah-ha" moment regarding informal learning came while teaching an online course for AuD students a few years ago. Students had enrolled from across the nation and internationally, so it was the perfect opportunity for collaborative learning. Two of the interactive activities available within the course were the threaded discussions, where students could post answers at any time to a weekly question, and a once-a-week chat where students could meet and respond immediately to one another.

The threaded discussions and class chats were essentially the informal aspects of the course, while the readings, assignments and tests were more formal. I quickly noticed students were learning much from each other through informal channels than through their formal coursework. By brainstorming and building upon the information presented, by having a personal stake and responsibility to be part of the educational experience, by not being a passive participant, but rather, an active learner, the class became a self-motivated learning community, going far beyond the prescribed learning objectives.

Therefore, perhaps it can be argued that the most powerful and clinically pragmatic educational process incorporates evidenced based practices and informal learning, rather than the traditional formal learning venues? I am not arguing that informal learning should replace formal learning, not at all. I am suggesting that informal learning is indeed a powerful process, which if recognized and harnessed, could provide a powerful resource in tandem with more traditionally recognized educational models.

Evidence-Based Practice:

To determine whether information is valid, reliable, important, and useful, we as scientists and professionals, realize the importance of evidence-based practices (EBPs). EBP is the "use of current best evidence in making decisions about the care of individual patients." ⁽⁴⁾ According to Drake (2001) "Evidence-based practices are interventions for which there is consistent scientific evidence showing they improve client outcomes." ⁽⁵⁾

The process of creating EBP includes;

1. Identify the particular issue or problem at hand
   
2. Search the literature for relevant research
   
3. Evaluate the research evidence
   
4. Choose an intervention and justify its selection with the most valid evidence

Identify:

Identifying a particular issue or problem begins with asking a good question, which you can easily construct using the PICO system of analysis ⁽⁶⁾. The system consists of Problem, Intervention, Comparison, and Outcome. For example, if one were evaluating the value of gingko biloba as a treatment for tinnitus.... the "Problem" is that tinnitus affects millions of people in the U.S. The "Intervention" is gingko biloba. The "Comparsion" treatment is a placebo or no treatment. The hoped-for patient "Outcome" is a significant reduction in tinnitus.

Search:

There are many places and methods offering search assistance. The traditional paper-based libraries are always an alternative, but quicker and more efficient searches are usually accomplished online, and it is easier and more efficient than ever.

For peer-reviewed evidence on gingko biloba as a treatment for tinnitus, the Cochrane Database of Systematic Reviews at www.nelh.nhs.uk/cochrane.asp is considered a "gold standard." By typing "tinnitus" and "gingko biloba" into the search engine, I came up immediately with a review published in 2004 by Hilton and Stuart ⁽⁷⁾ of 12 clinical trials which indicated no significant effects of gingko biloba on tinnitus. Already, I had pretty convincing evidence to advise against the use of gingko biloba for tinnitus relief.

The National Library of Medicine also has a Clinical Queries section which searches for clinically relevant abstracts of peer-reviewed research www.ncbi.nlm.nih.gov/entrez. I typed in "tinnitus and gingko biloba" into their search engine and couldn't believe my eyes. The first study ⁽⁸⁾ in a list of 5 had the title: "Gingko biloba does not benefit patients with tinnitus: a randomized placebo-controlled double-blind trial and meta-analysis of randomized trials."

Other search engines to be considered for information related to communication disorders include; www.askjeeves.com, www.google.com, www.yahoo.com, the AAA and ASHA websites, as well as www.audiologyonline.com and www.speechpathology.com, sumsearch.uthscsa.edu(9). and others are worthy of additional exploration and consideration, too.

Evaluate:

If you can't find systematic reviews or meta-analysis evidence in the appropriate online databases, you may need to evaluate for yourself the available journal articles and the peer-reviewed and non-peer-reviewed resources. Evaluating research is the process of determining whether the evidence presented is valid, reliable, and useful. Some questions to ask in the evaluation process include the following;

1. Is the literature review relevant and complete?
   
2. Are the research questions/hypotheses stated in a measurable way?
   
3. Are the materials and methods used in the study suitable to answer the questions/hypotheses?
   
4. Is the sample size adequate?
   
5. Are the statistics appropriate?
   
6. Are the conclusions and recommendations justified?

Intervention Selection:

Using your scientific and analytic skills to answer the above questions will help you to "verify and validate before you incorporate." Of course, a working knowledge of statistics is extremely useful, and many pragmatic online sources are available. ⁽¹⁰⁾

Summary:

You might consider your clinical practice a rich, everyday source of informal learning, from which you can take advantage of on-the-job and work-related resources. You don't have to wait for a formal lecture to learn valuable, useful, and specific information. You can learn from patients, as their questions or comments spark your curiosity and inspire you to investigate and learn more about a particular subject in more detail.

Applying the principles of evidence based practices to informal learning events may provide a wealth of important clinical observations and outcomes.

References:

1. Informal Learning, online at agelesslearner.com/intros/informal.html.

2. Informal Learning -The Other 80%, online at www.internettime.com/Learning/The Other 80%.htm

3. Pareto's Principle or How to Manage Your Tasks with Limited Time, online at https://caribvoice.org/Consumer's Corner/pareto.html

4. Primary Care Clinical Practice Guidelines, online at medicine.ucsf.edu/resources/guidelines/intro.html.

5. Drake RE, Goldman HH, Leff HS, Lehman AF, Dixon L, Mueser KT, Torrey WC.
Implementing evidence-based practices in routine mental health service settings. Psychiatr Serv. 2001 Jan;52(1):45-50.

6. Evidence Based Practice: Asking the Clinical Question, online at info.med.yale.edu/library/nursing/education/clinquest.html.

7. Hilton, M., Stuart, E. (2004). Gingko biloba for tinnitus. Cochrane Database of Systematic Reviews, Issue 2, April 19.

8. Rejali, D., Sivakumar, A., Balaji, N. (2004). Gingko biloba does not benefit patients with tinnitus: a randomized placebo-controlled double-blind trial and meta-analysis of randomized trials. Clin Otolaryngol Allied Sci, 29(3), 226-31.

9. SUMSearch, online at sumsearch.uthscsa.edu.

10. Will G. Hopkins, 2001.. A New View of Statistics. www.sportsci.org/resource/stats/summarize.html