CHAPTER 1
Education and Training as a Behaviour Change Intervention

Jo Hart1, Lucie Byrne-Davis2, Wendy Maltinsky3, Eleanor Bull4,5,6, Nicola McCleary7 and Chris Armitage8

1 Professor of Health Professional Education, University of Manchester, UK
2 Professor of Health Psychology, University of Manchester, UK
3 Health Psychology Senior Lecturer, University of Stirling, UK
4 Senior Health Psychologist, Manchester University NHS Foundation Trust, UK
5 Highly Specialised Health Psychologist, Derbyshire County Council, UK
6 Honorary Senior Lecturer, University of Manchester, UK
7 Senior Implementation Research Fellow, Ottawa Hospital Research Institute, Canada
8 Professor of Health Psychology, University of Manchester, UK

Learning Points

• Education and training can be an intervention to change healthcare practice
• Clinical practice is composed of multiple behaviours, such as diagnosis, treatment and management, monitoring and supporting self-management
• Practice behaviours are influenced by capability, opportunity and motivation
• There are theory- and evidence-based methods to increase the likelihood of clinical practice change

WHAT IS CONTINUING PROFESSIONAL DEVELOPMENT?

Continuing professional development (CPD) is an umbrella term, covering all kinds of activities that help health professionals learn and develop throughout their careers (e.g., Peck et al. 2000). Among the most widespread CPD activities are the structured education opportunities that we will describe in this book as CPD training courses, although they are also called educational meetings or workshops (Forsetlund et al. 2021). As long ago as 2002, the UK NHS was estimated to directly spend approximately £1 billion annually on workforce CPD (Brown et al. 2002). CPD is seen as crucial to developing the more flexible, multidisciplinary health workforce envisioned in the recent NHS Long Term Plan (Karas et al. 2020). Given how much is invested in CPD, it is even more important that CPD is designed to maximise practice improvement, so the benefits of investment can be fully realised in terms of improving care delivery and ultimately health outcomes.

THE PURPOSE(S) OF CPD

In healthcare (and social care) settings, the main aim of CPD is to maintain and improve standards of safe and effective care. For instance, the Health and Care Professions Council, one of the nine regulators of the UK health professional workforce, define CPD to ensure practitioners 'keep their skills and knowledge up to date and are able to practise safely and effectively' (HCPC 2022). CPD may also aim to increase staff motivation, well-being and retention (Brown et al. 2002) through supporting staff to form new networks, feel valued, meet their personal development needs and benefit from reflective time away from their usual roles. This all sounds fantastic in theory, but as educators ourselves working to organise a wide range of CPD in the UK and internationally, we have found that developing training that changes hearts and minds, and most importantly, practice, is not all that easy. Research agrees: a recent Cochrane review combining 215 studies of educational meetings for healthcare professionals found these to only slightly improve professional practice compared to no intervention, with even fewer effects on patient outcomes (Forsetlund et al. 2021). Indeed, despite the aim of CPD being to improve and maintain safe and effective care, a review of accredited CPD activities offered to health professionals in Canada showed that 96% of the learning objectives targeted changes in cognition, i.e. were not designed to promote practice change (Légaré et al. 2015).

THE CHALLENGES OF CHANGING PRACTICE THROUGH CPD

If you have ever led a CPD training, you may have some examples of challenges you have come across. We describe some examples below from our own experience. Through talking to others, we think these types of challenges are quite common. Imagine that you have just wrapped up a one-day training course, teaching hospital staff to use structured assessment approaches to handle medical emergencies. You're packing away the handouts, feeling pretty happy with all the positive feedback forms. Staff members come up to you and tell you that 'It was amazing! We loved it! Thank you and please come back again for more!' but that 'of course, we can't do any of those things in our clinic.'. What about training a group of community health improvement workers to use a new communication tool with families? They're nodding and smiling in all the right places; it seems to be going well, but then you mention the fateful words 'role play', their arms fold and they frowningly say 'oh no, in our team, we don't do role play.'. What if a colleague tells you they don't think CPD should aim to change practice, that this is 'paternalistic' and practitioners should not be 'manipulated into changing what they do'?

Maybe you've worked hard for the last few months doing hand hygiene training across your hospital and you're thrilled that you've trained so many people. Then the audit figures come in and frustration of frustrations. staff hand hygiene compliance is the same as it was before! You can feel like all your efforts have been like stirring water in a bucket - you can see the water swirling and rippling at the time, but as soon as you stop, the water settles and it's like your hand was never there.

As psychologists working in multidisciplinary teams (MDT) with colleagues from different professional backgrounds, we and our MDT colleagues believe that behavioural science might hold some of the answers to challenging training situations. In this book, we offer a guide to developing engaging training which is grounded in a deep understanding of learners' practice and its drivers, uses behavioural science theory and evidence-based tailored training techniques and takes a behavioural approach to evaluation.

In this chapter, we will introduce you to some of the robust theory and methods underpinning this approach, particularly the Behaviour Change Wheel method (Michie, van Stralen and West 2011) developed in the past decade. Following this, in Chapter 2, we will focus on how to identify and specify the multiple behaviours that your training aims to change. Chapter 3 will introduce methods to help you understand what helps and gets in the way of helping health professionals to carry out these behaviours. These behavioural influences will be targets for your training. We will explore, in Chapter 4, a step-by-step approach to using the information about behaviours and their influences to develop targeted, engaging training approaches. Finally, in Chapter 5, we will explore how to assess learners' progress and evaluate training meaningfully using behavioural science methods. We hope that this book, built on a good foundation of educational principles and folding in some behavioural science, will help you to create CPD that is ready to fly, just like our cover image.

Many of these ideas are as old as the behavioural theories underpinning them (up to 150 years). We hope that educators will recognise much good practice that they already do, as well as offering a space to reflect on times like those examples above where things didn't go so well. The book aims to offer opportunities to mindfully experiment with change in your CPD, from small tweaks to creating behaviourally informed CPD from the outset. We welcome readers to get in touch with thoughts and experiences as they try out ideas. Working closely with our MDT colleagues and at the research-practice boundary is how we all will keep building the science on how to develop training which offers learners a positive experience, builds confidence, motivation, knowledge and skills, and most importantly enables learners to translate this into improvements in their practice back in their real-life work setting.

IMPORTANT CONCEPTS AND THEORIES

Miller's Pyramid

Miller's Pyramid is famous in medical education (Miller 1990). Figure 1 neatly shows the building blocks of performance from 'knowing', 'knowing how', through 'showing how' and all the way to 'does'. Miller's model has been hugely influential, shaping educational curricula and approaches to assessment of professional competencies in spheres far beyond medicine (Cruess et al. 2016).

FIGURE 1 The interaction of capability, opportunity, motivation and Miller's Pyramid. The first diagram (top left) shows Miller's Pyramid, the second (top right) that most of Miller's (knows, knows how, shows how) is capability, the third (bottom) that opportunity and motivation can move us between 'shows how' and 'does'.

Undoubtedly, in order to do something, someone must almost always know how to do it (the exception being things that we do of which we are not aware). Does it follow, though, that if someone knows how to do something and can actually do it (show how) that they will do it in practice? Behavioural science tells us that just because someone can do something does not mean that they will . So, how does behavioural science fit with Miller's...