How health professionals maintain and update their professional knowledge in a self-directed learning context

doi:10.21203/rs.3.rs-3127576/v1

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Research Article

How health professionals maintain and update their professional knowledge in a self-directed learning context

https://doi.org/10.21203/rs.3.rs-3127576/v1

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Background. Given the changes in the current learning environment health professionals are facing major challenges to keep abreast of current and updated information with the rapidly growing clinical and scientific knowledge base. Being able to identify relevant, high-quality articles, adapt or adopt to new learning strategies with an already intense workload are just a few of the main challenges. Self-directed learning is skill central to competent health professionals and describes a process in which individuals evaluate their learning needs, goals and the resources needed for learning, however the emerging problems for professionals practicing SDL are manifold.

Design. A qualitative, exploratory approach based on four research questions was used to gain an understanding of how skilled health professionals maintain and update their professional knowledge. Twenty-six neurosurgeons completed a semi structed interview within the University Hospital of Bern.

Results. One of the main findings is the differences between health professionals in what strategies they employ to conduct SDL, which is ultimately compounded by their level of experience. All participants recognised that new or alternative learning strategies are necessary to manage this new learning landscape, and for many in particular the use of learning digital tools. However, many were unsure how to change their current behaviour.

Conclusion. The results highlight that positive factors influencing SDL in the workplace include learning leadership and support in identifying new or alternative strategies, an internal culture committed to learning as well as digital learning tools and networks and are all vital in managing the ever-changing learning environment.

Self-directed learning

health professionals

learning strategies

digital tools

Medical professionals are facing major challenges to keep abreast of current and updated information with the rapidly growing clinical and scientific knowledge (Prasad & Kumar, 2013). The expectation to update and maintain knowledge as a health professional is implicit in the medical field and is paramount to provide the best care for the patient (Corish, 2018). Medical knowledge has been expanding exponentially (Corish, 2018) over the last 10 years with an explosion of health care knowledge worldwide. Based on the advancement in technology and medical knowledge this situation will even advance. Research found that in the biomedical field alone, more than 1 million papers are added to PubMed database each year which qualifies as two papers per minute (Landhuis, 2016). This situation not only affects professionals in the healthcare system, such as practitioners, patients and systematic reviewers, but is also a barrier to the spread of evidence-based medicine (Klerings et al., 2015). Despite the exponential growth in academic papers (Bornmann et al., 2021), health professionals are required to stay up to date in their respective fields and maintain their existing knowledge base. To manage the information load and provide the most up to date patient care, health professionals must commit to lifelong learning after formal education (Qalehsari et al., 2017).

Recent research has identified Self Directed Learning (SDL) as the most appropriate methodology for the individual achieving and maintaining levels of expertise (Torres Kompen et al., 2019). Knowles, 1975, p.18 describes SDL as “a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes” (Knowles, 1975). The emerging problems and challenges for professionals practicing SDL are manifold, in which the traditional means of managing information (e.g., individually storing data in electronic filing systems) are ill suited to the realities of the digital age (Bryan, 2015). Changes in workload and the structures in the organisation of health care make it ever more necessary for health professionals to use their time productively and learn more efficiently (Teunissen & Dornan, 2008).

The current situation highlights that we have both more relevant health care information as well as misinformation readily available than that of any generation in history (World Health Organization. Regional Office for the Eastern, 2020), therefore it is necessary to be able to select relevant, high-quality articles from many sources when conducting SDL. This suggests that health professionals need to adopt new strategies or approaches to meet the demands of the current ever-growing learning environment. Habit theory highlights that when people encounter familiar situations are triggered automatically to repeat the same behaviour applied in the past (Gardner, 2015). This suggests professionals, especially experienced professionals may find it difficult to break the habits previously employed to select information, as they been successful up until this point (Klöckner & Prugsamatz, 2012).

Within the literature, these changes have led to an increased workload from two perspectives. Firstly, many health professionals need to invest a lot of time to find a more efficient individualised approach to conduct SDL, which is often unmanageable and time consuming. Secondly, as it is often unknown what the most relevant articles are, many professionals often attempt to read as many as possible as to not miss important papers in an already hectic schedule (Teunissen & Dornan, 2008) which often leads to a gap between intention and behaviour. Therefore, it may be necessary not just to break habits but also to retrain in new strategies/ technologies to manage information overload and support personal learning. Also, in the work environment more support is needed. This may include providing a communal website to share information and opinions as the relevance of research shows the importance of feedback from experts (Henderson et al., 2021) or granting time for personal learning.

According to the Intention- behaviour gap theory, in this case, it is impossible to read all the relevant articles despite good intentions (Faries, 2016). Studies have shown that this increase in workload or cognitive exhaustion has led to a decrease in performance, not only beyond processing but for some beyond coping (Khosrow-Pour, 2004). Moreover, the realisation that learning all relevant material is impossible can completely demotivate learners (Roetzel, 2019) and can lead to a sense of learned helplessness. Learned helplessness is a motivational problem that can arise when someone feels as though they cannot control their learning environment and can subsequently impair their ability to learn (Ramírez, 1992).

An important aspect of SDL is employing strategies that most motivate us to learn (Loyens et al., 2008). It is important for health professionals to identify their own learning needs highlighting the relationship between individual workload, motivation, habits and learning strategies in the context of SDL (Klerings et al., 2015). In addition to traditional learning strategies such as a good organizational system, prioritizing tasks and seeking feedback from peers (Crans et al., 2022; Qalehsari et al., 2017) more recent research highlights the use of electronic mediums such as digital libraries and recommended reading lists based on previous searches (Pluye et al., 2020). Recent research has found that professionals are utilizing specialised research tools designed specifically to support learning (M, 2018), such as Mendeley, Evernote and the more recently Notion (Murphy, 2020). These tools offer a variety of functions to help motivate, increase productivity, reduce workload and support learning (Murphy, 2020).

Although it appears the digitalization of learning is more and more commonplace, it can be a struggle to identify which digital research tools are most the suitable, including what functions they offer or how to use them appropriately (Freeman et al., 2019). Additionally, users seem to be uncertain about how digital technologies will continue to influence research in the future and which research tools will be sustainable (Tsatsou, 2014). From this perspective, medical experts just continually improve and evolve with technology to benefit from the range of tools to support in their learning (Manganello et al., 2013). Research suggests that many professionals avoid new technologies as they learn through their many interactions that experimentation often leads to unfortunate consequences including confusion, time-wasting and learned helplessness (Evans-Greenwood et al., 2021). Despite the increased current use of tools, a vast majority of health professionals feel insufficiently trained to deal with the digital revolution (2016, 2016). As a result, many tend to remain with their trusted traditional methods (Evans-Greenwood et al., 2021) and believe themselves incapable of navigating the complexities of a new digital tool, therefore potentially missing supportive features.

Research questions

When using the term SDL, this paper will refer to the definition by Knowles (1975). Derived from the background described above we formulated the following research questions for this qualitative study.

RQ 1: How do health professionals maintain and update their professional knowledge in an SDL context?

RQ2: How do the demands of the current learning environment combined with an intense workload, impact the motivation of health professionals in their SDL?

RQ 3: What strategies and/ or digital tools are health professionals using to navigate the current learning environment and support their SDL?

RQ 4: What are the challenges health professionals face in relation to the use digital health tools to support their SDL?

The research questions were addressed from a qualitative, exploratory approach, utilising semi-structured interviews to gain an understanding of how skilled health professionals maintain and update their professional knowledge.

Sample

We investigated surgeons for this research, which were identified as a population of health professionals, with an existing hectic schedule who are required to maintain and keep on top of the latest research. A sample of twenty-six neurosurgeons agreed to be interviewed and a theoretical saturation (Hennink & Kaiser, 2022) was reached while interviewing the last six surgeons. Ten of the sample were female (M = 35.5, SD = 6.11), sixteen were male (M = 34.9, SD = 8.13), aged between 27–54 years old. Participants were based within the University Hospital of Bern and spanned across a wide breadth of experience in practice. Less experienced surgeons, in this sample, were classified as 9 years or less as a certified doctor (Mehrotra et al., 2012). More experienced surgeons, as ten years or more. There were fourteen experienced surgeons (53.8%) and twelve less experienced surgeons (46.2%) included in the study.

Development of instrument

The interview schedule was developed in seven steps and followed the structure from Gideon (2020) (Gideon, 2012). First, after reviewing the current literature on SDL as presented in the introduction, our research group consisting of three psychologists and two medical educators (N = 5) set out to develop a “road map”. This focused on how, where why and with what support do professionals conduct SDL. Second, the main actors were identified that have been documented to influence the SDL of health professionals: tasks and activities, type of learning support and feedback, as well as personal knowledge, beliefs and emotions shaped through their history and experiences of learning (Brydges & Butler, 2012). Third, from this initial “road map and factorswhich also reflected the four research questions, to ensure the most important aspects, we broke these issues down into ten sub- themes, two for each of the five themes identified above (Table 1.). Fourth, with this basic concept in mind, we used these ten sub themes as deductive themes to guide the development of the interview schedule. Then, three members of the research team devised two possible questions for each of these ten deductive themes. Fifth, the 60 raw questions were reviewed for relevance and clarity resulting in some eliminations and/or amalgamations, 40 initial questions were identified as relevant. Sixed, the first set of 40 questions were pilot tested on three independent professionals from different backgrounds, who were asked to provide feedback on clarity and relevance on the interview schedule. Seventh, based on their feedback the question route was finalised: 7 questions were further eliminated due to relevance or duplication. In addition, some prompts were added to ensure no information was missed (see Appendix 1). Finally, based on the feedback from the pilot-interviewees the order of the original interview questions was reorganised to ensure a natural flow of questioning. A recapitulation of the question structure is shown in table 1:

Table 1

The five initial concepts and how these supported the questions development.
Search & Retrieve	Motivation	Barriers and impact of workload	Strategies	Digital Tools
Sub-theme 1–2	Sub-theme 3–4	Sub-theme 5–6	Sub-theme 7–8	Sub-theme 9–10
1 – n specific questions and prompts	1 – n specific questions and prompts	1 – n specific questions and prompts	1 – n specific questions and prompts	1 – n specific questions and prompts

This process resulted in a final set of 33 questions to be addressed in the interviews. The ten deductive sub questions were based on aspects of SDL which differed in complexity and amount of information. Therefore, also the amount of interview questions relating to each of them differed. For example, how experts conduct their SDL required a number of prompt questions to ensure important information was not missed in comparison to attitudes towards SDL, which only required one interview question.

Procedure

An invitation email was sent out to surgeons in the Neurosurgery department in Bern (Appendix 3). The interviews lasted between 21–86 minutes. All interviews were audio recorded. Ethical approval was given from the cantonal Ethics commission, and participants provided verbal consent (audio recorded). The participants were assured anonymity and confidentiality to encourage an honest, open discussion on their learning practices. Data was collected between September 2019 and December 2019.

Analysis

All the interviews were transcribed according to the intelligent verbatim transcription method (McLellan et al., 2003). Interviews were analysed using thematic analysis according to Braun and Clarke (2006), guided by NVivo (Bazeley and Jackson, 2019). In the initial coding phase, ten theme nodes were identified which corresponding to the 10 deductive themes addressed above. These theme nodes were further refined in subsequent rounds of data analysis. Several rounds of coding were performed, each time focusing on identification of new themes and amalgamation of subsidiary nodes.

The subsequent iterative analysis of the material resulted in the identification of five themes including, strategies for SDL and selection of sources, attitude and motivation towards SDL, factors supporting and preventing SDL, strategies to support SDL and digital tools to support SDL were identified.

Findings

The deductive codes shown in Fig. 1 were in some instances amalgamated, recoded and/or renamed based on the subsidiary nodes. In this instance, subsidiary nodes highlighted the emerging patterns between the topics on SDL. The subsidiary nodes with the most codes and important statements on the same topics eventually became five main themes (see Fig. 2.). The first two themes (from Fig. 1) were amalgamated into the theme, strategies for SDL and selection issues, the second two coded themes into attitude and motivation to SDL, the third two coded themes into factors supporting and preventing SDL, the fourth into strategies to support SDL and finally the last two coded themes into digital tools to support SDL.

Each of these five inductive themes were identified in the analysis and were guided by the four overall research questions. The strategies employed by health professionals affect and/or influence each of the four additional inductive themes (see Fig. 2.). These themes are addressed below.

Strategies to support SDL, and selection of sources.

To update and maintain knowledge all surgeons utilised the internet using specific medical or academic search engines such as, Pub med, OVID, Medbase etc. Despite using key terms and filters, search queries often resulted in an insurmountable number of articles. To identify relevant articles, surgeons must scroll through many sometimes hundreds of search results. In many cases, the number of “relevant and irrelevant articles” is unmanageable.

Sometimes it will take me half an hour just to read through the list of abstracts of all the articles from just one search query. They hardly come back in any order of priority (0172018)

Less experienced surgeons reported more issues with selection than experienced surgeons, stating that their main strategies were using filters and key words. However, as the amount of available research increases and for a lack of a better approach, they were open to new strategies such as information pooling.

It’s not always easy to know what to read, I often just use the sources that are recommended in the clinics (006312014)

It would be great if we could find and share relevant articles with each other, it would definitely cut the workload down (018312016)

Less experienced surgeons said they benefitted from the advice and recommendations of more experienced colleagues but that it would be more useful to share the most up to date relevant findings with each other as they often need to research the same topics. It was suggested that a specialised platform or website with articles only relating and available to neurosurgery would be more efficient.

It would be great if we had a place, like a platform where only neurosurgeons recommended articles where only relevant findings were available (019392014)

More experienced surgeons acknowledged that their knowledge and experience make this easier, as it’s a habit formed over time to select quickly required articles. They conclude that the ability to draw on a previous knowledge base to select relevant articles reduced the amount of time to complete tasks.

I often know what I’m looking for and I have my own personal markers – otherwise, how do you differentiate between an author who’s not very relevant but is screaming very loud, with many citations and one who’s not. There are so many factors to consider I guess you just learn to spot them with experience (014402020)

I can identify pretty quickly if it’s worth reading, I have some kind of flow chart, a check list in my mind. (002402004)

However, it was also noted that some relied very much on “old habits” and that this is not always effective for identifying the most up to date relevant research.

I think I mostly find what I’m looking for, either in my conference folder or my congress folders. I’m not sure (026492004)

Attitude and Motivation, and selection of sources

Findings show that how a surgeon selects their documents alongside the learning strategies they employ has an impact on their motivation to conduct SDL. Unlike ten years ago, when a time could be set every month to read all relevant papers now many experienced surgeons accept that it is impossible to read them all and therefore stick their current strategy.

I don’t even open the emails anymore, I just read the titles of the journals of the month. It’s far too many to be expected to read. They should summarise all the most important journals that month into a paragraph (026492004)

I have 20 notifications with apparent new and relevant findings, I don’t even have time to read the notification (016542000)

However, they do seem to be more confident that the articles they have time to read are the most important or relevant. This relates to their selection strategy; in that they rely on certain markers based on habit and experience.

I just seem to know what I’m looking for, its second nature (026492004)

On the contrary, some less experienced surgeons who are overwhelmed by the sheer number of articles admit that their strategy was often to read as many possible and were initially more motivated to read as much as they can, in case they missed something. Stating they often use many hours of free time to catch up on necessary research.

Well, I’m still new, so I’m not really maintaining, just updating. I try to read everything I can, so it means I read a lot after work. I usually spend my days off catching up on research journals that I haven’t got time to read in the week. Not enough time to sleep sometimes. Haha. (012262018)

Some less experienced surgeons suggested that despite planning to learn at certain times of the day or week, the amount was often so overwhelming that it was impossible to know where to start. Instead of scaling the down the task to make it more manageable it caused them to be completely demotivated and reduced any attempts at trying to read them. Leading to a complete lack of motivation and often a sense of guilt and failure.

I had all these plans last weekend to catch up on all the reading I’ve missed. I had so many articles in my unread folder I didn’t even know what topics I wanted to start with. In the end I didn’t read any. (013312016)

I haven’t had a chance at all this week to look at any of the stuff I saved and now I’m already on another topic so I’m not sure I’ll even have the chance again (006312014)

Factors supporting and preventing SDL, and selection of sources.

The workload for all surgeons is undoubtedly high, however, the findings highlight that the impact of selection issues and the increasing number of articles affected less experienced surgeons much more. All less experienced surgeons reported that conducting SDL is done outside of their working hours. Most of them reported as much as 95% was conducted outside of work.

If I’m lucky I can get some time between rounds, but you always have to be available so it’s not the right environment to sit down and read long articles (018312016)

In addition, if the lack of motivation has led in a decrease in learning, then the pressure and workload to catch up is increased for the next planned session of SDL.

I didn’t do anything last weekend; I was just too tired. I will have to make up for it on my next day off (017272018)

In contrast, more experienced surgeons stated that most of their updating and maintaining knowledge took place during working hours except with bigger research demands.

I just needed to find some evidence to support the review I’m writing, I can usually find some time (021402006)

Some experienced surgeons reported that to create time in the working day, they often had to delegate everyday tasks.

It’s really frustrating because you need to keep updated in your career, it’s expected however it’s not possible to manage it within the framework so, if you’re in the position you can delegate the work but even if you’re in a position to delegate the work, there’s always this dissatisfaction because it’s not always a good solution (014402010)

Strategies to support SDL, and selection of sources.

Within these findings, participants mainly referred to how and where they stored their articles. Findings show that twenty-one out of twenty-six surgeons used their computer hard drive as their main library to store documents. Most stated they used their hard drive library as they were habituated to use it and it is a simple system to use. However, many reported that as the amount of information increased, it is difficult to retrieve information in a timely fashion. Despite being organized, users could not always find articles using key words. Many reported that this system results in many unorganised folders and subfolders which become over flooded.

I guess it was after my exam that I realized I couldn’t just keep storing papers into different folders. I had so many in my unread box that I could never find anything again. (012262018)

Many experienced surgeons stated that they have used the same search, storage, and retrieval strategies for a long time, however some admitted this could often be a time-consuming process when trying to retrieve dated articles.

I can usually find what I need in my congress or conference folders but sometimes there are so many papers, or I can’t remember what I saved it as (016542010)

Of the five surgeons who reported using a Document Management (DM) system outside of their hard drive, three reported using the more advanced document management systems such Evernote and Mendeley. Two less experienced surgeons stated they used Notion, a digital tool that provides a range of functions alongside document management.

The findings highlighted that there were differences between the attitudes of more experienced and less surgeons in the possibility of a using an alternative DM system. All reported concerns about the time and effort needed to invest to use a new strategy/tool without knowing if it’s suitable.

I use my computer; I mean I basically only used my hard drive but I’m struggling to find things and we have so many new articles to save. I downloaded Mendeley, as someone recommended it, but it’s a bit of a project, I’m not sure how it works yet. I hope it’s worth it. (003282016)

However more experienced surgeons had more concerns over usability, complexity and how much technical prowess is needed to navigate such tools. In addition, many stated that even though admitting sometimes it’s timelier to retrieve articles, this system still works and so there is no need to change it for an alternative which may not even be suitable.

I think it would take me longer to learn how to use it than it does to use my computer. I’m not saying I wouldn’t try it, but I don’t know much about what’s available (023372007)

Two less experienced surgeons reported using a relatively new research tool which also store documents called Notion. Both stated that they had evolved with the advancement of technology and tend to try the newest tools.

I use Notion. It gives you the possibility to define a topic and then save all types of media and documents and everything in between in the same place. It’s just like freehand and it’s awesome because you can save everything on that topic (020332014)

Digital tools to support SDL, and selection of sources.

This section focuses on the digital tools health professional use to support them in their SDL. These range from the “usual ones” which include windows office, cloud, google, etc. Some of the less experienced surgeons reported using digital tools specifically designed to support research activities such as Notion.

The findings highlight that more experienced, and some less experienced surgeons still prefer to use traditional methods of learning, stating that these strategies are just electronic versions of the traditional way to research.

I much prefer to go through articles and highlight them with a pen, I find that I remember the information more anyway. I have a colour system which I’ve used since university so it’s the same thing really (022272017)

Many surgeons stated that they hadn’t heard of most of the digital tools available to support learning and therefore had not thought about using them.

I’m not even sure what tools there are to help me research, and I don’t have time to find out

In some cases, it was the fear that they would be too complicated and waste time. Despite not being entirely happy with their learning strategies, more experienced surgeons seem less motivated to try digital research tools as they would not be instinctive to use, preferring to “keep things simple”.

I tried Mendeley recently, but I never got into it, I’ve heard of some others, but I don’t have the time to learn how to use them and who even knows if they work. I guess if it was a guarantee that it was already a good system (017272018)

In contrast, some less experienced surgeons highlighted that they were open to try new technologies that support their research activities however often they haven’t heard of them or what functions each tool offers. Stating that there is no time to even conduct the initial research into exploring what digital tools are on offer to support learning.

I hadn’t even heard of notion until before today, I maybe would try it, what it does. I should stop printing out everything, so I need to do something, I just don’t have the time (019392014)

Less experienced surgeons reported using specialized tools to help them highlight, tag key words, and structure how to write an article. The tools are designed to make this more process efficient.

I’ve always had problems starting to write on a blank page, with the program I’m using now it sets out the structure and includes all the information you’ve highlighted into each section even before you’ve started. So, you don’t waste time trying to find things you’ve marked, and it already feels likes you’ve started your paper (011322013)

I love Notion, it helps me organize my notes and all my diagrams and well everything. (005332010)

Findings show, the surgeons who are native users of technology often utilize a combination of the tools to support them in their learning.

I use notion, I don't know if you have heard of it and used to work with Evernote, and I use endnote and a couple of medical apps. I changed to Notion, and I've been quite happy with it. (022272017)

These surgeons stated that it was learned skill overtime and therefore have developed their technology skills alongside advancements in technology and their self-managed learning.

I used Evernote at Uni, my supervisor recommended it. Then I just tried other ones that my friends were using. The latest one I tried was Notion (022272017)

Guided by the SDL literature and the four research questions, five inductive themes related to the SDL of health professionals emerged from the data. Interestingly, one of the main findings was the difference between more experienced or less experienced surgeons within and across each of these themes. In general, findings support the literature that to keep updated and conduct SDL health professionals try to identify sources that provide crucial data (Landhuis, 2016). However, given the increasing number of insurmountable articles the task of finding relevant articles is time consuming and leads to cognitive exhaustion (Roetzel, 2019).

The first research question addresses how healthcare professionals perform SDL. We found that there were differences in how SDL is conducted, between less and more experienced surgeons. In relation to strategies for SDL and selection of sources, surgeons with more experience stated that throughout their career they had developed their own strategies to quickly identify relevant information. This is based on their previous experience such as, knowledge of the author, the format of article and depth of the findings. Many highlighted that this skill becomes integral throughout years of research and practice. This is supported by (Gardner, 2015) which states that habitual behaviour becomes detached from conscious motivational processes. Therefore, more experienced surgeons’ conduct their SDL without being conscious of their strategies. In many respects, these strategies continue to be effective, however less and less over time. This is supported by the literature that “old” habits may override motivational tendencies to adopt new strategies (Gardner, 2015). This inability to change behaviour may be detrimental to their SDL as the amount of information in the digital age increases.

In contrast, findings found that less experienced surgeons who cannot rely on ingrained habits born out of years of experience reported how time consuming and inefficient selecting relevant articles could be on SDL, stating that they would be much more open to learning new strategies. Some less experienced surgeons highlighted the benefits of information pooling and more of a community approach noting how useful if would be if the workload or learning could be shared between colleagues. This is supported by recent academic medical blogs suggesting the way we conduct SDL needs to change, suggesting that instead teaming up and sharing relevant knowledge to stay on top of studies is a good way to avoid missing important papers (Henderson et al., 2021). However, sharing articles and information is more than changing a strategy in the scientific field, it is not enough to just share information, it would require a different way of thinking, a different way of learning (Henderson et al., 2021).

Furthermore, findings show that less experienced surgeons are much more open to adopting alternative digital tools to support SDL and increase selection efficiency. Stating that, a dedicated digital platform in Neurosurgery (respectively, also for other groups of professionals) which only verified surgeons were registered would be largely beneficial. Designed only for registered experts it would act as a global mentor-peer support site so that less experienced surgeons would not miss landmark research and more experienced surgeons could maintain their knowledge through sharing. This is supported by the research highlighting how much guidance and feedback from mentors particularly in the field of health is valued (Henderson et al., 2021). Successful strategies have a large impact on the motivation to conduct SDL.

The second research question focuses on how the learning environment combined with an intense workload affects the motivation to conduct SDL. Given the demands of the current learning environment combined with an intense workload the findings showed there were differences in both attitude and behaviour between more and less experienced surgeons in relation to their motivation to learn. More experienced surgeons accepted that it is impossible to read all articles and therefore did not even attempt to. Relying instead on their strategies to select relevant articles choosing to “read smart” not read everything. However, as medical knowledge is increasing exponentially (Corish, 2018) these current strategies may become more and more ineffective.

In contrast, many less experienced surgeons reported the need to read as many articles as possible in case they missed something important. The results found that without a knowledge base it was difficult to select articles by relevance therefore tried to read them all. Within the literature, this task is often reported to lead to feelings of failure and ultimately a lack of motivation to conduct SDL (Faries, 2016). This is called the intention behaviour gap, stating that although the intention might be high, the arduous nature of the task could negatively affect behaviour and affect productivity (Faries, 2016). Some of the surgeons in this study, reported these feelings of being overwhelmed with no idea where to start with the amount of literature to “catch up on”. This highlights the need for healthcare institutions to support their staff, e.g. to conduct SDL during working hours with protected time to learn. Some surgeons stated that these feelings of being overwhelmed led to a bigger drive to find alternative strategies or digital tools to support them in their SDL. Whether the amount of literature to learn is leading to feelings of helplessness or to increased motivation, most surgeons agree that this change in the learning environment is forcing health professionals to reflect on their current learning strategies to cope with the increasing amount of information.

The second research question also addresses the impact of an intense workload combined with the learning environment on the motivation to conduct SDL. Within our analysis, this related to factors that supported or prevented conducting SDL. For surgeons, there is an implicit expectation to dedicate their own time to meet the expectation of the workplace (Klerings et al., 2015). However due to the number of articles to read and insufficient selection strategies, less experienced surgeons reported an extremely high workload. Therefore, all less experienced surgeons reported that they conducted SDL outside working hours, as high as 95%. These surgeons were very motivated to find alternative strategies or tools to support this process before the workload got too much. This is supported by (Klerings et al., 2015) suggesting that information overload leads to cognitive exhaustion and impairs the work effectiveness of healthcare professionals. More experienced surgeons reported that to create time in the working day, they often had to delegate tasks. Although this may be a disputable solution, many see it as unavoidable due the pressure to manage everyday tasks and conduct SDL. However, this has consequences on the workload of other team members and again highlights a need for sustainable solutions. The literature is clear in stating that positive factors influencing SDL in the workplace include learning-committed leadership and management, an internal culture committed to learning, work tools as well as resources and learning networks (Crans et al., 2022). Hence, health professional leaders, have the power to influence how young professionals are conducting SDL, by e.g., supporting their protected time, or actively advise in which tools that provide support.

The third research question focusses on what strategies and/ or digital tools experts use to navigate their learning environment to support their SDL. Findings show that twenty-one out of twenty-six surgeons used their own library at their computer hard drive to store documents. Many stated this was out of habit with some highlighting the increasing number of issues when retrieving information in a timely manner. Findings highlighted a difference in the attitudes between more experienced and less experienced surgeons in the possibility of using an alternative Document Management (DM) system or other digital tools. Some less experienced surgeons reported using the latest digital tools to support their SDL and all of them expressed an interest in strategies including digital tools that would help them overcome some of the challenges faced in the current learning context. The surgeons utilising these specialised tools e.g., Notion, Mendeley and Evernote), would be classified as Native users and have employed various digital tools throughout their professional career. Interestingly, their experience of such tools suggests they are easy to use and offer community and collaboration features, which everyone could benefit from. Stating that once familiar with, these tools greatly supported research tasks. Recent research supports the potential positive features of new digital tools (Senbekov et al., 2020). However, this research does not report how or to what extent users are supported, or what level of digital literacy is necessary to benefit from such tools.

Finally, the fourth research question addresses the challenges healthcare professionals face in relation to the use of digital tool to support their SDL. experienced surgeons reported either a lack of awareness of digital tools or the lack of motivation and time to find out what is available. This supports the research that many professionals avoid new technologies as they lack technological knowledge, time, or effort to learn it (Manganello et al., 2013). Many of the most experienced surgeons believed that it was too late to adopt these latest tools, as they had not been keeping up with evolving technology. There was already an expectation that the technology would be too complicated or time consuming and therefore a reluctance to try it. (Evans-Greenwood et al., 2021) suggests that many professionals tend to stick to known, habitual safe tools and methods of use, as they believe themselves incapable of navigating the complexities of a new digital tool without being explicitly taught how to do so. This is in line with the research on the importance of raising digital awareness from an early point, implementing a support system to support healthcare professionals adapt to evolving digital landscape (2016, 2016).

An interesting finding alongside a lack of motivation to explore alternative digital strategies, was the lack of awareness about what digital tools are available to support professionals in their SDL. It can be easy to dismiss a new or alternative method if there is a gap in the technological knowledge. This highlights the importance of promoting which digital tools are available within the workplace and what functions they offer in order to support SDL (Freeman et al., 2019).

LIMITATIONS

There are limitations that should be considered in interpreting the findings of this present study. Perhaps most importantly, in the process of data analysis there could be issues with bias and the robustness of the data interpretation. To reduce the risk of such biases and increase reliability, we correlated the stability of responses through a rigorous questionnaire development process and the main themes were coordinated with multiple coders. Reliability was enhanced by detailed field note and a transcription of all interviews. In addition, the five identified inductive themes are not definitive and may not be generalisable to all healthcare professionals. However, the literature supports our findings in relation to other healthcare professionals, therefore we feel that they are robust and are confident in their relevance. Lastly, due to the rapid increase of information and advancement in the use of digital technology, it should be considered that the findings of this study provide a snapshot of time and as the use of advanced technology becomes mainstream, therefore this study could present as an important reference point for comparison for further studies.

One of the main findings of this study is the differences between less and more experienced health professionals in what strategies they employ to conduct SDL and strategies to select relevant high-quality sources. The study found that the choice of strategy is compounded by their level of experience. However, and more importantly, despite difference in strategies both more and less experienced surgeons agree that in light of the increasing amount of information alternative strategies need to be considered such as, specialized platforms to share information, including a dedicated community site for registered health professionals. This would create a global community to ensure less experienced surgeons would not miss landmark papers and allow more experienced surgeons to share their wisdom and maintain their knowledge base.

In direct relation to the second research question, the findings highlight that in the current learning environment, the strategies experts employ to select sources and the factors supporting and preventing SDL has a huge impact on their motivation to learn. Less experienced surgeons are severely impacted by the unrealistic number of articles to read, conducting most of their SDL outside of working hours. Despite established strategies, more experienced surgeons admit they may need to break “old” habits to cope with the increasing amount of information. Alternative strategies or digital tools to support this are necessary to manage the new learning landscape. This could reduce cognitive exhaustion and prevent feelings of learned helplessness or burnout in relation to SDL. For all healthcare professionals, the increased workload forces health professionals to reflect on their current learning.

Interestingly, in relation to the use of digital tools, less experienced surgeons highlighted a range of benefits in relation to SDL, particularly searching, managing, storing, and retrieving relevant information. However, what is strikingly clear is the divide between less and more experienced surgeons in the use of digital tools. To prevent the widening digital divide, more needs to be done to raise awareness of what digital support is available for professionals and how it supports SDL. There is a need for more evidence-based research on what digital tools can help meet learning needs. To reduce the fear and misconceptions around the latest technology, tools and alternative strategies should be promoted as an integral part of health education, raising awareness in this era of rapidly advancing technology. Providing consistent reliable information about advanced digital tools may encourage learners to adopt new strategies without confusion, time wasting or the feeling of failure.

This research highlights that both more and less experienced surgeons will benefit from adopting alternative strategies to select relevant articles, increase motivation and reduce workload. Many of these strategies may lie on the one hand, in the use of specialized digital tools designed to support professionals in their SDL, and on the other hand, for the management to develop and support a strategy for SDL and making it more manageable during the working hours.

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No competing interests reported.

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How health professionals maintain and update their professional knowledge in a self-directed learning context

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Abstract

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Introduction

Research questions

Methods

Sample

Development of instrument

Procedure

Analysis

Findings

Attitude and Motivation, and selection of sources

I just seem to know what I’m looking for, its second nature (026492004)

Discussion

LIMITATIONS

Conclusion

References

Additional Declarations

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