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Effective In-Service Training Techniques, Timing, Setting and Media:

Synthesis of an Integrative Review of the Literature

In the context of continuing health professional education What evidence is there to support educational techniques, timing (single vs. repetitive), setting, and media used to deliver instruction? What evidence exists about the outcomes (knowledge, skills, attitudes, provider behaviors, patient outcomes) of continued health professional education?

In the context of continuing health professional education

Julia Bluestone, MS Peter Johnson, PhD Judith Fullerton, PhD Catherine Carr, DrPH Jessica Alderman, MPH James BonTempo, MS

Inclusion/Exclusion Process
Titles and Abstract Review
Journal Database


First Quality Review: 81 excluded


Second Quality Review: 100 excluded

Grade One

Grade Two

First Tier

Additional Time and Setting Hand Search: 8 added

First Tier

Systematic Reviews

Randomized Control Trials

What do you know?

Educational Techniques Media used to deliver instruction



10 20 30 40

10 20

10 20 30

10 20 30 40

Techniques for 10 Points

In a systematic review, didactic instruction was found to result in which level of learning outcomes? a) no-to-low b) low-to-moderate or c) moderate

Techniques for 10 Points techniques and providing printed materials alone clustered in the range of no-to-low effects, whereas all interactive programs exhibited mostly moderate-tohigh beneficial effects. The most commonly used techniques, thus, generally were found to have the least benefit (Bloom)

Techniques for 20 Points

Of the following, which has the strongest evidence to support it as an effective educational technique? a) Self-directed learning b) Clinical simulations c) Team-based learning

Strong evidence base

Techniques for 30 Points Which of the following has the strongest evidence for skill development outcomes? a) Demonstration b) Using a checklist c) Practice and feedback Dose-response, or providing sufficient practice and feedback was identified as important for skill-related outcomes (McGaghie, Moores, ONeil)

Techniques for 40 Points

The use of SMS messages, without additional training, has been shown to improve clinical practice behaviors by which percent? a) 3-10% b) 9-18% c) 24-26%


Techniques for 40 Points


Timing for 10 points

Which of the following has stronger evidence to support it? a) A 5-day training on training skills b) A series of 30 minute practice sessions spread over a week c) Weekly practice sessions of 15 minutes, over two months, each session repeated several times


Timing for 10 points And the winner is. Repetitive RCTs: Better knowledge acquisition, better retention and some evidence of improved practice behaviors (Kerfoot articles) Systematic reviews: better learning outcomes (Marinopoulos, et al)


Timing for 20 Points Repetitive, short learning interventions have been shown to increase retention by how much? a) 2-fold b) 4-fold c) 8-fold


Timing for 20 Points


Setting for 10 Points In one randomized clinical controlled trial focused on emergency obstetrical skills, a classroom setting, simulation center and workplace all resulted in similar knowledge outcomes, true or false?


Setting for 10 Points

Simulation Center

Workplace Learning

However, setting matters for skills


Setting for 20 Points

Clinically integrated teaching has some evidence to suggest it can improve: a) Knowledge b) Skills c) Attitudes d) All of the above


Setting for 20 Points

Several RCTs focused on clinical decision making skills comparing interactive lecture vs. clinical integrated teaching found clinically integrated teaching more effective. Clinical integration may be an effective method for clinical practice behaviors, attitudes and critical thinking and communication skills.


Setting 30 Points
Educational psychology literature reinforces that situated learning Faculty for 10 Pts results in easier transfer into practice, true or false? TRUE


Media for 10 Points

Evidence has shown that computer-based instruction knowledge outcomes can be: a) Slightly less effective b) Similar to face-to-face c) Equal or better than face-to-face


Media for 10 Points

Computer-based equally or slightly better One RCT found: Greater efficiency Three months post-test results found no difference in retention (Harrington and Walker). Two RCTs found: computer-simulated patients equal and less expensive than live, standardized patients

Media for 20 Points

Multiple systematic reviews caution against: a) Use of print only media b) Self-directed learning via mobile c) Computer-delivered without face-to-face


Media for 20 Points

Multiple systematic reviews caution against the use of print-only media (Berkhof, Bloom, Moores), concluding that that live instruction is preferable to print-only (Marinopoulos, Rampatige). Targeted use of multimedia improves learning outcomes


Media for 30 Points

We do NOT have enough evidence to support the use of mobile as a medium to deliver continued professional education, true or false? FALSE


Media for 30 Points

e-IMCI: 84.7% performance compared to 61%

Promising for point-of-care decision support


CHWs: Rich media job aids: 33% reduction in

errors; 30% increase in compliance (Arango)

Extremely promising for reminders/reinforcement


Media for 40 Points

Which of the following is the best answer? Media to deliver instruction should be selected based on its ability to: a) Be innovative b) Deliver effective techniques c) Undergo rigorous evaluation Technique, Technique, Technique, and Technique

Research Agenda

Evaluate promising practices in LMICs Test with lower-level cadres Ethiopia: Post-BeMONC SMS MCHIP MNH Champions



Recommendations: Techniques
Select techniques that help the learner process and integrate information More case-based, problem-based and simulation, less didactic instruction Prioritize simulation for emergency skills Increased feedback and interaction = positive learning outcomes Avoid passive techniques, choose case-based approaches & simulations

Recommendations: Timing
Leverage technology to provide short, repeated exposures Aggressively explore the use of spacing and testing Shorter, repeated workplace based trainings for skills practice

Recommendations: Setting
Select setting based on if it will support effective techniques, and
Reduce absenteeism Address workplace quality assurance Reduce costs and increase productivity

Increase use of mentored, facility-based approach for skills-practice and feedback portion of training

Recommendations: Media
Select media based on if it will support effective techniques, and more effective learning Use appropriate technology to deliver instruction efficiently