Research article
Open Access

Transformative Learning and Medical Students Global Health Essays – A Qualitative Study

Ann Wylie[1], John Wong[2], Eleanor Bowen-Jones[3]

Institution: 1. King's College London, 2. Guy’s and St Thomas’ NHS Foundation Trust, 3. King’s Centre for Global Health & Health Partnerships, School of Population Health and Environmental Sciences, Weston Education Centre, King’s College London
Corresponding Author: Dr Ann Wylie ([email protected])
Categories: Educational Theory, Learning Outcomes/Competency, Teaching and Learning, Undergraduate/Graduate
Published Date: 14/07/2020

Abstract

Purpose

Transformative learning (TL) concepts are gaining prominence in medical education, specifically for global health components. Pre-elective essays are mandatory for final year medical students at a large UK medical school. This study considered what TL concepts were demonstrated in these essays.

 

Method

A 10% sample of essays were anonymised and analysed for components of transformative learning. The components include disorienting expereince, emotional response, critical reflection, perspective change and commitment to further action.

 

Results

 A sample was selected (N=40). The essays were coherent, 10% (4 out of 40) demonstrated 3 or more components of transformative learning with 1 essay demonstrating all components. There was evidence that students had transformative experiences.

Critical reflection is the most demonstrated component (30%), followed by commitment to future action (8 of 40 essays – 20%), disorienting experience (7 of 40 essays – 17.5%), and emotional response and perspective change (both 3 of 40 essays – 7.5%).

 

Conclusion

Some students demonstrated that transformative learning had taken place, linked their elective placements and global health learning outcomes. Introducing transformative learning skills and attitudes prior to the elective, may facilitate deeper transformative learning during the elective itself, but future research is required to explore this.

 

Keywords: Global Health; transformative learning; medical electives

Introduction

With an increasingly globalised and interdependent world it is only appropriate that we prepare medical students for them to address the health needs of the 21st century (Frenk et al., 2010). This includes new infections; behavioural and environmental risks; moving from curative to preventative care; achieving health equity within and in-between countries; and multidisciplinary and interdisciplinary efforts to find solutions to global problems such as climate change and urbanisation (Koplan et al., 2009), (Frenk et al., 2010). It is the scope of the problems (and not their location) that sets apart global health from public health (Frenk et al., 2010).

 

In a paper by Johnson et al. the authors discussed global health learning outcomes for medical students within the United Kingdom (Johnson et al., 2012). There are 6 key proposed learning outcomes such as global burden of disease, socioeconomic and environmental determinants of health, and health systems. The paper is one of the teaching resources given to students during their global health module.

 

At King’s College London Medical School, final year medical students undertake a global health module and as part of their assessment, write a 2000 words essay prior to their elective placement. The global health teaching comprises of 2 components: a virtual component and face-to-face symposia. During their virtual element, students are provided with 9 webinars on global health as well as links to key sites and email support. For the symposia element, there is a focus on the rationale for including global health in core curriculum and guides for students completing the global health essay. There is also a focus on their up and coming elective.

 

Transformative learning is a learning theory proposed by Jack Mezirow (Mezirow, 1997). Since its inception, transformative learning has been researched and discussed as a theory within adult education, including medical education (Taylor, 2007). Transformative learning is about challenging established assumptions through critical reflections, this transformation of perspectives occurs from a disorienting dilemma through to critical reflection. Currently the identified components of transformative learning include: ‘disorienting experience’, ‘emotional response’, ‘critical reflection’, ‘perspective change’ and ‘commitment to future action’ (Sawatsky et al., 2018).

 

Although transformative learning is a work in progress, it has the potential to be a pedagogy that can be used to help address the challenges to health professionals in the 21st Century (Van Schalkwyk et al., 2019).

 

More work is needed to study how transformative learning can be used in health professional education and how to assess its impact. It is also important to bear in mind the underlying philosophical position during any assessment when evaluating whether transformative learning took place (Tavares et al., 2019). This is important so that we are able to understand the underlying assumptions and examine justifications related to the philosophical positions (Tavares et al., 2019). Transformative learning is rooted in a constructivist epistemological position that emphasises critical engagement in learning and knowledge creation (Van Schalkwyk et al., 2019).

 

Within medical education, recently, there have been published papers on transformative learning and professional identity formation during international health electives (Sawatsky et al., 2018), as well as a scoping review looking at transformative learning as a pedagogy for the health professions (Van Schalkwyk et al., 2019). These papers contribute to the growing literature in this emerging area.

 

Relating to global health, Frenk et al. described the purpose of transformative learning is to ‘produce enlightened change agents’ (Frenk et al., 2010). It is with these works in mind that we approach our data analysis and discussion of our findings in this paper.

Methods

Consent was through opt in and 90% of 420 students consented. All students’ essays analysed obtained a pass mark. A random sample of essays (N=40) were anonymised and thematically analysed without regard to the grade. A lead researcher was overseeing the data collection process.

 

Nvivo 12 (QSR International) was used by two independent researchers to thematically analyse the essays to look for components of transformative learning. The data were analysed in 2019.

 

We followed the analytic framework used by Sawatsky et al. to look at the components of transformative learning: ‘disorienting experience’, ‘emotional response’, ‘critical reflection’, ‘perspective change’, and ‘commitment to future action’ (Sawatsky et al., 2018). In addition, we assessed whether the essays are coherent.

 

Ethical approval was obtained for this study (King’s Ethical approval - Ref 5719).

Results/Analysis

In the academic year 2018-2019, there were 420 final year medical students who completed a global health module and a 2000 word essay at King’s College London. We analysed 40 of these essays. The topics of these essays were chosen by the students and ranged from infectious disease to maternal obesity, sustainable development goals and social determinants of health. All the essays analysed were coherent to read.

The top 50 most mentioned words in the 40 sampled essays were put into a "word cloud", and as expected "global" and "health" featured strongest.

 

A total of 16 of the 40 essays (40%) demonstrated at least one component of transformative learning. A total of 9 of the 40 essays (22.5%) demonstrated at least 2 components of transformative learning. 4 of the essays (10%) demonstrated at least 3 components of transformative learning. 2 of the essays (5%) demonstrated at least 4 components of transformative learning with 1 essay (2.5%) demonstrated all of the 5 components of transformative learning.

 

Table 1 lists the number of essays and the number of references for each of the 5 components of transformative learning. We will go through each of the transformative learning components in turn, outlining the general themes noted, along with quotations for each of the components.

 

Table 1: Number of essays and Number of references for each of the component of transformative learning

Component of transformative learning

Number of essays

Number of references

  1. Disorienting experience

7

12

  1. Emotional response

3

3

  1. Critical reflection

12

26

  1. Perspective change

3

4

  1. Commitment to future action

8

9

 

1. Disorienting experience

For one of the students, an exposure to patients with a condition that the student did not associate with that geographical area was a disorienting experience. This emphasised the universal importance of global health concepts for the student. 7 of the essays (17.5%) had demonstrated a disorienting experience.

‘From my first clinical placement, the need for an understanding of global health was clear when I attended a tuberculosis clinic. I had thought of the disease as something that happened very far away.'

Other students reflected on patient cases they have encountered and reported something unexpected/disorienting/surprising.

‘It really struck me that based on observation alone, I would have considered her to only be slightly overweight. This was the first time I realise my perception of obesity had been shifted by the high exposure to obese healthcare users over the last 3 years. It also made me re-consider how many pregnant women I’d already encountered who would actually be classified as obese.’

For these examples, the disorienting experience involved noticing something that differed from their expectations. The disorienting experiences could be categorised into different types of experiences as follows: practice-based, literature-based, identity-based and teacher-led.

2. Emotional response

Only a small minority of students demonstrated an emotional response to what they are writing - three essays (7.5%). Writing about the results of a report regarding inequities in access to surgery, one student revealed that:

‘The immense disparity in surgical care to me was overwhelming’

This student also referred to the results of the report as “surprising” and “alarming”, indicating that the emotional response co-occurred with a disorienting experience.

One student expressed “pride” at the global effort in tackling global health issues, and another found it “extremely concerning” that someone who has been diagnosed with a manageable condition such as diabetes suffer from long term debilitating changes to their health. Other emotional descriptors used by students included “shockingly” and “sadly”.

3. Critical reflection

This component of transformative learning was by far the most common with 12 of the 40 essays (30%) demonstrating critical reflection. Students reflected on various aspects of global health including global burden of disease, socioeconomic and environmental factors of health, cultural competency and healthcare services.

‘Developing awareness of the global burden of disease, understanding the social determinants of health (especially the impact of migration and the health challenges facing new arrivals in the UK) and fostering cultural competency are key elements of the global health approach in order to ensure quality healthcare for London’s diverse population.’

Despite not having been on their elective, some students were able to reflect on how their ‘home’ (UK) healthcare situation compared with their intended elective placement and their linked preparation research.

‘...there is an uncomfortable implicit realisation that the systems in place in some countries are so far from what we are used to in our privileged positions in the UK.’

4. Perspective change

Three of the 40 essays (7.5%) demonstrated perspective change. By reading around the topics, students’ perspectives were shifted. Examples include changing an “entrenched idea” held about the best way of teaching and talking about disease around the globe, and factors leading to health in addition to healthcare provision:

‘But provision of healthcare is not enough; careful consideration of the factors leading to health determinants go beyond geographical location and access to medical care.’

5. Commitment to future action

This was the second most common category after critical reflection. Eight of the 40 essays (20%) demonstrated a commitment to future action. Most of this is through the student’s up and coming elective placement. Points that were raised in this component of transformative learning include further exploration of the socioeconomic and environmental factors on a healthcare system; drawing comparisons between ‘home’ and ‘host’ institutions; tackling inequalities in health; talking to local people regarding a policy implementation and offering a training session for the department on their upcoming elective.

‘As I plan my elective in Obstetrics, I hope I will be able to use what I have learnt here and see each interaction with an obese woman as a chance to discuss lifestyle change and exercise...’

Students’ intentions may change again when they find themselves in the new situation of the elective and under the guidance of their supervisors. This raises an interesting question about how intentions and commitments to action unfold and change shape across multiple learning interventions.

Discussion

This study used global health essays, written by final year medical students to identify if there is evidence that transformative learning took place. To our knowledge, this is the first study of its kind looking at essays written before elective placements/ international health electives.

 

The findings suggest that students were able to articulate and demonstrate global health concepts in their written essays. This maybe a reflection of the learning during their global health module prior to the writing of the essays.

 

In addition to raising global health topics, the essays provided a platform for students to link global health learning outcomes as previously published (Johnson et al., 2012) to the students’ upcoming elective placements. Topics such as global burden of disease, socioeconomic and environmental determinants of health and health systems were raised by students. How much students understood about these topics is beyond the scope of this study, but the fact that these are in their scholarly essays suggests that students appreciated their importance within the theme of global health.

 

The essays acted as an assessment modality, and it was also an opportunity for students to enhance their learning and for transformative learning to take place, in some of the students. With a total of 40% of the essays demonstrating at least one component of transformative learning, this is an interesting finding. How many components of transformative learning are needed before one can say transformative learning has taken place? A similar question has been raised by Van Schalkwyk et al. in their recent paper – is movement through the components of transformative learning required in order for transformative learning to have taken place (Van Schalkwyk et al., 2019)?  It could be argued that if there is evidence from the students of a disorienting experience, perspective change and critical reflection, then transformative learning has taken place.

 

Perhaps the most important finding is that the essays in this study elicited critical reflection in 30% of the students. Reflection is known to deepen professional values, have a positive effect on empathy and enhance engagement in the learning process (Winkel et al., 2017). For these students, enhanced empathy and engagement in learning may be good preparation for transformative learning to occur during the elective processes, but further research would be needed to evaluate this. Indeed, as part of their global health module, students are taught skills for reflection, underlying the importance of reflection in medical education per se and part of being a life-long learner as a practicing clinician.

 

In the literature, critical reflection has been linked to the quality improvement competencies (Wittich et al., 2010). In this regard, we can make a similar connection to say that critical reflection allows medical students to link to the global health learning outcomes as published by Johnson et al. (Johnson et al., 2012).

 

In terms of limitations and challenges, although the essays were good to excellent, only 10% had 3 transformative learning indicators. 10% in 40 essays is a small sample but increasing the sample size for analysis could provide more reliable findings.

 

In addition, post-elective essays may be more valuable to demonstrate transformative learning, but some pragmatic issues arise with this as shown in a previous study (Sawatsky et al., 2018). Emotional responses are perhaps more likely to occur after the students’ elective experiences. Furthermore, research to explore whether engaging in transforming learning activities prior to elective strengthens transformative learning during the elective experience would be of interest.

 

It would be interesting to look at whether teaching students specifically about Transformative Learning itself can influence their ability to experience and demonstrate transformative learning in their essays. These could be areas of further work.

 

It will also be interesting to see if these findings could be replicated by other medical schools.

Conclusion

Some students showed evidence that transformative learning took place during the research and writing of global health essays. Global health essays provide an opportunity and have the potential for transformative learning to take place, as well as acting as an assessment modality and research opportunity for students prior to and in some cases without an elective placement experience.

COVID19 could potentially disrupt elective placements globally in the short to mid-term, so it is imperative that global health remains in curricula, even if it cannot be directly linked to electives. 

Take Home Messages

  • Medical electives and global health activities are opportunities for students to experience transformative learning
  • Demonstrating evidence of transformative learning is challenging
  • Global health essays offer students and educational researchers a way of exploring these concepts
  • Critical reflection provides most students with opportunity to demonstrate transformative learning which medical educators could build on

Notes On Contributors

Dr Ann Wylie Is a lecturer in Medical Education in Department of Primary Care as well as deputy director of King’s Undergraduate Medical Education in the Community team (KUMEC). Her specialist areas include are Health Promotion, Public Health, Global Health and Primary Care. She is the Elective and Global Health module lead for the MBBS programme, the module lead for Nutrition and Health Promotion for the MPH programme and the Chair of the sub-assessment board for MPH. ORCID: https://orcid.org/0000-0001-6626-0751  

Dr John Wong is a Data and Research Manager at Guy’s and St Thomas’ NHS Foundation Trust in London. He read Medicine at King’s College London School of Medicine. His research interest includes medical education and health research. He has published peer-reviewed paper in medical education, with a focus on community-based medical education.Dr Wong has presented at national and international conferences on community-based medical education. 

Ms Eleanor Bowen-Jones is a PhD Candidate in Global Health Research at King’s College London, funded by the Royal Society of Medicine. Her research interests include undergraduate medical electives, Global Health ethics, and multi-disciplinary approaches to medical and health professions’ education and research. She has presented at national and international medical education conferences.

Acknowledgements

We would like to thank all the final year MBBS students who have consented for their essays to be analysed.

Bibliography/References

Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., et al. (2010) ‘Health professionals for a new century: transforming education to strengthen health systems in an interdependent world’, The Lancet, 376(9756):1923-1958. https://doi.org/10.1016/S0140-6736(10)61854-5

Johnson, O., Bailey, S. L., Willott, C., Crocker-Buque, T., et al. (2012) 'Global health learning outcomes for medical students in the UK’, The Lancet, 379(9831):2033-2035. https://doi.org/10.1016/S0140-6736(11)61582-1

Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., et al. (2009) ‘Towards a common definition of global health’, The Lancet, 373(9679):1993-1995. https://doi.org/10.1016/S0140-6736(09)60332-9

Mezirow, J. (1997) ‘Transformative Learning: Theory to Practice’, New Directions for Adult and Continuing Education, (74):5-12. https://doi.org/10.1002/ace.7401

Sawatsky, A. P., Nordhues, H. C., Merry, S. P., Bashir, M. U. et al. (2018) ‘Transformative Learning and Professional Identity Formation During International Health Electives: A Qualitative Study Using Grounded Theory’, Acad Med, 93(9):1381-1390. https://doi.org/10.1097/ACM.0000000000002230

Tavares, W., Kuper, A., Kulasegaram, K., and Whitehead, C. (2019) ‘The compatibility principle: on philosophies in the assessment of clinical competence’, Adv Health Sci Educ Theory Pract, Nov 1. https://doi.org/10.1007/s10459-019-09939-9

Taylor, E. W. (2007) ‘An update of transformative learning theory: a critical review of the empirical research’, International Journal of Lifelong Education, 26(2):173-191. https://doi.org/10.1080/02601370701219475

Van Schalkwyk, S. C., Hafler, J., Brewer, T. F., Maley, M. A., et al. (2019) ‘Transformative learning as pedagogy for the health professions: a scoping review’, Med Educ, 53(6):547-558. https://doi.org/10.1111/medu.13804

Winkel, A. F., Yingling, S., Jones, A. A., and Nicholson, J. (2017) ‘Reflection as a Learning Tool in Graduate Medical Education: A Systematic Review’, J Grad Med Educ, 9(4):430-439. https://doi.org/10.4300/JGME-D-16-00500.1

Wittich, C. M., Reed, D. A., McDonald, F. S., Varkey, P., et al., (2010) 'Perspective: Transformative learning: a framework using critical reflection to link the improvement competencies in graduate medical education'. Acad Med, 85(11):1790-1793. https://doi.org/10.1097/ACM.0b013e3181f54eed

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethical approval was obtained for this study from the Bio, Dental and Medical Research Ethics Panel at King's College, London, Ref: LRS 17/18-5719.

External Funding

This article has not had any External Funding

Reviews

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Stijntje Dijk - (04/08/2020) Panel Member Icon
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I would like to thank the authors for submitting this interesting paper on transformative learning and students’ global health essays.

The aspects of transformative learning is indeed one that is very relevant and has gained a more visible presence over recent years (even if as the authors point out, the theory was developed much earlier). I am happy to read how the authors investigate the assessment of these components of learning.

Should the paper be further developed in the future, there are a several areas that I would believe could be given further elaboration to increase the impact and understandability for an outside reader:
- Methods: “a random sample” -> How did randomization take place?
- Methods: “we assessed whether essays were coherent” - based on what criteria was this assessed?
- Methods: I missed the background information on what the instructions for students were - this would influence my interpretation of the results. For example, if they had explicit instructions to reflect on each of the domains of TL as mentioned in the methods section, I would find the results of 40% showing one component very low. If having a critical reflection was part of the assessment method, and only 30% of students showed this, then that would influence how I as a reader interpret how all students received a satisfactory grade.
- Methods: Although essays were randomly selected regardless of grade, it could be worth adding a description of their average rank/grade amongst the sample are: Are we looking at an analysis of - randomly assigned - the best of the best essays? Or can they be considered a representative sample? - Which also relates to how randomization was done: randomized from the full stack of essays, or based on subcriteria.
- Methods: Could the authors elaborate on when the essays took place? In the introduction, it seems that these are pre-elective essays, however when reading the results section, the language segments indicate students having had specific experiences (“the need for an understanding of global health was clear when I attended a tuberculosis clinic”, “students reflected on patient cases they have encountered”. Were these experiences students then had from previous internships, not related to the global health elective?
- Results: “the top 50 most mentioned words featured global and health the strongest” - Observing frequency of wording is an interesting approach, although one can expect the words global and health to be most frequently used. I am wondering whether the authors investigated if any words specific to transformative learning were also investigated? Have the authors considered providing a frequency table for e.g. the 10 most frequently used words? Were there any words that surprised the authors?
- Discussion: It would be interesting to additionally see a critical reflection of the authors on their findings, especially also perhaps concerning statements from students that they may have come across. It would be interesting to see a reflection of the authors on how well the papers served as an assessment method. By providing further details throughout the paper on how the assignment was phrased and assessed, others may be able to take on lessens from this paper to a higher extent than they would now when organizing similar exercises at their institutions. I would also be interested to see how your findings are different or similar to other studies that have conducted similar methods (if existent)? Or how the group that wrote the essays and participated in the course compares to TL of students who haven’t undertaken this course, to review how their views and essays were impacted.

Thank you again for your interesting paper,
Stijntje Dijk
Jessica Servey - (16/07/2020)
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This has a unique look at essays early in a medical student's career for transformative learning. I am not certain the results recommending we teach these components are novel. I think this would be more intriguing linking to the reflection literature and how to teach and assess reflection.