Differentiated Instruction as a Viable Framework for Meeting the Needs of Diverse Adult Learners in Health Professions Education

Abstract

Health professions education (HPE) instructors are often challenged with simultaneously teaching adult learners of varying educational levels, needs, and backgrounds. With an increased focus on interprofessional education, instructors may be tasked with teaching extremely diverse audiences during a single educational session. While some aspects of differentiated instruction (DI) have been implemented within HPE contexts, the DI framework appears to be relatively unknown in many fields. Evidence from a range of educational fields outside of HPE supports the use of DI as a framework to enhance fairness, diversity and inclusion while meeting core instructional needs. In this Monograph, we explore DI and offer strategies for implementation amenable to many HPE settings.

Introduction

Health professions education (HPE) instructors are often challenged with simultaneously teaching adult learners of varying educational levels, needs, and backgrounds. For instance, with an increased focus on interprofessional education (IPE) across HPE programs, instructors are expected to teach extremely diverse audiences (e.g., learners or instructors from medicine, pharmacy, nursing, physical and occupational therapy, law, business, etc.) during a single educational session. In an effort to be inclusive, those designing IPE curricula typically focus on commonalities across HPE programs, and not necessarily on the needs of individual interprofessional learners. In the U.S. and other countries, clinical educators may also teach multiple levels of learners from the same field at the same time (e.g., medical students and trainees at the graduate medical education (GME)/post-graduate medical education (PGME) training level often accompany faculty for teaching rounds) [1]. Learners with physical disabilities or mental health challenges may also need supports to equitably access the curriculum. Last, the proportion of non-traditional adult learners pursuing higher education in many countries has increased due to societal changes, including economic and cultural [2], with increasing demands for access [3].

In this Monograph, we explore differentiated instruction (DI) as a framework for enhancing fairness, diversity and inclusion in instructional practices [4, 5] and offer specific strategies for implementation across HPE settings. Though our context is HPE programs in the U.S., we believe these strategies will be relevant to instructors in other countries who are interested in implementing DI practices within their own educational programs [4, 6].

Background

What is Differentiated Instruction?

DI, a recognized instructional framework outside HPE [1, 7–9], allows instructors to meet diverse learners’ needs within a common curriculum [7, 10, 11] thereby enhancing inclusion [5, 12]. DI is not synonymous with individualized instruction [13]. Tomlinson (2006) noted that DI provides a “framework for addressing learner variance as a critical component of instructional planning” [7]. The overarching goal of DI is to address the varied learning needs of individuals of different backgrounds and abilities by adapting instruction [9] to meet them where they are [14]. Puzio et al. defined DI as not “one strategy or practice – it is a diverse collection of educational practices and programs that provide students with multiple ways to learn and construct meaning” [15]. While U.S. academic institutions contributed the largest number of articles on DI in a 2020 bibliometric analysis [9], DI is implemented by instructors around the world.

Focus of Differentiation Practices

The overall goal of DI is to enhance inclusion [5, 13, 14]. Differentiation typically focuses on four areas: process, content, product, and the learning environment [10, 13, 15, 16]. Process differentiation entails using different teaching strategies and modalities to meet the needs, differing abilities, or interests of learners [13]. Content differentiation can refer to text (e.g., journal articles, textbooks, films, YouTube videos) or topic (e.g., learners tackle topics differentiated by educational level) [15], and often occurs via tiered assignments, adapted to match ability, interest, or training level. Product differentiation ensures learners have choices in how they ‘show what they know’ [13]. Learners may be required to meet the same goals and objectives and/or standards, but products can be as varied as a short paper, video, interview, or learner-created game when learners are asked to demonstrate knowledge on a topic (Table 1). Learning environment differentiation is about adapting the context or ‘environmental preferences’ within a physical setting (e.g., options for learners to work together and alone, areas with fewer visual or auditory distractions) [17]. It is important to note that differentiation can be used to address individuality, inclusivity, and the variability of skill, readiness, or interest likely to be present in any educational setting. Differentiation is thus a framework for eliminating inequities and focusing on individual strengths [5, 14, 16].

Table 1.

Differentiated instruction adaptation examples

Audience	Type of Differentiation (e.g., process, content, product)	Strategy	Example
Same field, same training levels, same learning goals	Process	Flexible Grouping [13, 54]	Learners self-select into groups by ability or affinity. This approach can be integrated into a number of activities. Literature Circles or Journal Clubs are effective activities that promote understanding through dialogue and critical reflection.
	Product	Project-Based Learning [55]	All groups have the same assignment, yet each group can select the specific focus and depth (e.g., creating a presentation about a disease from a physiological perspective vs. a presentation of the same disease from a societal perspective). Group projects depend on collaboration. Expectations can use an honor system or require groups to rate individual team member contributions.
Same field, different training levels, same learning goals	Process	Peer Instruction (or Learner as Teacher) [56]	Learners take the role of teacher in a one-on-one or group setting. For large groups, using the Jigsaw technique may be most practical. Here, learners are placed in groups and tasked with becoming ‘experts’ in a topic. Group members are then redistributed and each member is responsible for teaching what they learned in their prior group to peers in the new group.
	Product	Tiered Assignments	Within a common curriculum, learners demonstrate specific skills/knowledge by producing products aligned with their skill/knowledge level and programmatic outcomes. All learners work on the same curricular topic, but outcomes will differ. Use curricular requirements (e.g., learning objectives, outcomes) for each group of learners. See Table 2 for examples.
Different fields, different training levels, same curricular goals	Process	Debates	Groups of learners debate on common issues from different professional perspectives. Debates are competitive by nature. Teams should be mixed ability.
		Games and Gamification [57]	Use traditional games such as Family Feud/Jeopardy or game apps such as Quizlet to insert a level of competition to the learning activities. These can range from reading reviews to assessments. An alternative to using games is to gamify activities by adding elements of gaming, such as creating a challenge for learners to solve and designating tracking scores or progress (e.g., leader boards, prices, etc.).
		Expert Panels	Create teams from different specialties and different training levels to act as expert panels on a topic they research together.
	Product	Choice Boards	Learners select the type of projects and topics they will complete, from a list of pre-determined options that are equally engaging and have varying levels of complexity.
Different fields, similar training levels, same curricular goals	Process	Broadening [1]	Learners are prompted to think of a case, then an additional component is added to highlight a particular perspective or misconception, after some discussion around the added component, another one is introduced, and the process is repeated in a snowball fashion until all professional views have been discussed.
Different fields, different training levels, different learning goals	Content, Process, and Product	Independent Study	Learners demonstrate learning and growth through completion of clearly defined projects designed to meet the targeted learning goals.

Implementation Across Educational Fields

The majority of studies on DI have focused on kindergarten through 12^th grade education (K-12) [7, 13, 15, 18], including gifted and special education. DI is also being studied at the post-secondary level, but to a lesser degree [14]. Due to the paucity of articles related to DI in the HPE literature, we believe that highlighting findings from a variety of settings – including K-12 – can help novice and seasoned HPE instructors avoid common mistakes and leverage best practices.

K-12 Education

The DI framework has allowed teachers in K-12 settings to accommodate learners’ differing needs, while still meeting the same overall curricular goals [13]. Puzio et al., in a systematic review of DI implemented within K-12 literacy instruction programs, noted that 13/18 studies reported statistically significant differences in reading comprehension achievement in cohorts utilizing DI when compared with controls, with DI cohorts scoring higher in comprehension [15]. Baseline testing was found to be critical for content differentiation, and student choice led to product differentiation [15]. For students with disabilities, DI has been critical to ensuring they can effectively participate in the curriculum, based upon their abilities and without the barriers posed by conventional, ‘one-size-fits-all’ instruction [5, 16, 18]. Baglieri and Knopf see DI as an approach to “disrupt discriminatory discourses” by normalizing differences of all types within a classroom [5].

DI has received a great deal of interest – both from a practice and research perspective – within gifted education [19, 20], as gifted learners face challenges in many educational settings and are considered at risk of failure [21] for a variety of reasons (e.g., academic underachievement, stress, social/emotional needs) [22]. Puzio et al. noted that some educational organizations have considered differentiation skills to be a core teaching competency for all teachers [15].

Post-Secondary Education

While DI is best known at the K-12 level, it is increasingly used in post-secondary education to meet the needs of learners pursuing varied professional goals and pathways [23, 24]. Here, DI has been introduced for the same reasons as outlined above. In a study of the effects of DI on undergraduate (university) math students, DI was found to enhance comprehension of mathematical concepts [24]. Hall et al. noted that at the college level, DI can provide opportunities to enhance motivation and student engagement [23], critical to learning [25]. They describe the use of DI in undergraduate public health courses where students were allowed to choose books aligned with their own professional interests for a book report assignment, a ‘choice’ strategy which is also applicable to HPE settings [23].

Health Professions Education

While examples of DI are common within the education literature (e.g., K-12, special education, and gifted) [14], very few articles related to DI could be found within the HPE literature. Leung, who called for DI more than 20 years ago, noted that instructors of medical students often treat learners in a homogenous fashion, believing learners’ needs are identical due to initial screening criteria for medical school programs [26]. In a descriptive paper, Whitney emphasized the applicability of DI to the field of radiologic technology, given the need to adapt instruction for adult learners who are more culturally/ethnically, economically, and generationally diverse than in the past [10]. Kantar et al., in a qualitative nursing study, found that preceptors recognized that all adult learners have different needs and used DI strategies to better meet those needs [27]. Preceptors used ongoing assessment to determine whether learners had met goals and aligned learning activities with learner needs [27]. Hirsch, in a qualitative dissertation study of the impact of DI in a baccalaureate nursing completion course, found that DI strategies were associated with enhanced student engagement [28]. Certain et al. noted that several multilevel teaching strategies used during inpatient rounds (e.g., targeting questions to specific learners based upon their training level or interests) [1] were actually examples of DI. This highlights the fact that some HPE instructors may already be implementing DI process strategies without knowing it.

Meeting the Needs of HPE Learners

Who are Our HPE Learners?

Considering the breadth of the adult learner population across HPE programs, many HPE learners fit the definition of ‘non-traditional' learners (e.g., learners with dependents, learners who are single parents, learners with demanding full-time jobs), as they experience competing demands from work, family, and other personal obligations [29]. And for adult learners who previously practiced as independent health care providers in other countries, the transition to GME/PGME training, a return to novice roles, and adaptation to new learning and teaching cultures [30] may represent additional challenges and stressors.

In the U.S. and other countries, HPE learners are considered to be part of a diverse learner population for a variety of reasons, including differences in culture/ethnicity, language, age, economic backgrounds, disabilities, and relevant work experiences. There has been heightened recognition of the need to focus on diversity, equity and inclusion in HPE in order to prepare a diverse workforce to serve an increasingly diverse patient population [31–33]. Research has shown that while health profession fields have become more diverse, providers are still not representative of the diverse patient populations they serve [32, 33]. Recruitment efforts in the U.S. have thus focused on groups which have historically been underrepresented in medicine, such as African American students [34]. As more learners from under-represented communities are recruited to HPE fields, questions of equity and inclusion have become paramount concerns. DI approaches, which have been shown to be effective in schools for increasing equity and inclusion and improving learning outcomes [8, 35, 36], should be considered for HPE settings, as well.

In the U.S., accessibility for learners of varying abilities in HPE settings has also been an area of renewed focus since updates were made to the Americans with Disabilities Act in 2008 [37]. HPE learners with disabilities may require accommodations based on a variety of physical or mental health challenges [37]. For learners with physical differences which require accommodations, meeting a long list of technical standards without regard to their desired specialties or interests can create unnecessary barriers to completing a program and being prepared to enter practice [38]. The Association of American Medical Colleges (AAMC) has proposed a more functional set of standards, which allows learners to focus on outcomes, providing additional flexibility for accommodations and assistive technology [39]. We argue that based upon experiences of instructors outside of HPE, the DI framework can be used to ensure that learners with disabilities can access the curriculum and meet functional outcomes required in their professions.

The Value in Differentiating Instruction for HPE Learners

Even in training programs which are competency based, fairness (i.e., equity and equality in instructional practices) remains a continuing concern for program/course directors and curriculum developers [6]. Expectations for performance can differ across faculty, and learners in the same GME/PGME program (at the same training level) may undergo educational experiences and/or assessment practices which are actually not equitable (comparable) [6]. Learners may also be disadvantaged by instructors’ expectations, which are often based upon instructors’ personal experiences with learning environments and different teaching approaches and learning cultures [30] (e.g., participatory learning vs. teacher-directed learning).

Thus, given the vastly different life experiences, skills and knowledge that adult learners bring to learning encounters, it is important to design and implement curriculum in ways which enhance fairness and inclusion. This requires intentionality and mindfulness of fairness issues [6] when curriculum developers engage in the instructional design process. Critical steps when implementing DI include: creating specific learning objectives, designing educational activities which ensure learners meet targeted outcomes, identifying a range of assessment evidence which will allow all learners to demonstrate what they have learned [40], and ensuring that tasks are developmentally appropriate, yet challenging [24]. A mainstay of DI is flexible grouping, which offers learners the opportunity to bring their own individual strengths to a group assignment [13], rather than being grouped by ability or training level.

What follows are examples of the types of differentiation which are particularly relevant to HPE audiences, with the caveat that all types of DI (i.e., content, process, and product) can be implemented with any group of learners. Examples are listed by audience (e.g., field and training level).

Same Field, Same Training Level

Adult learners may be in the same professional field and at the same training level (e.g., nursing students), yet they may come from vastly different backgrounds (e.g., socio-cultural, educational, economic, work) [13, 27]. Learners may be at different readiness levels due to prior experiences or differing professional interests. For example, one learner may have acted as a caregiver for a family member with chronic medical conditions and may be very familiar with addressing basic health care needs, while another learner has no history of working with patients and seldom interacts with the healthcare system as a patient. For learners working toward the same educational outcomes, differentiation of process (how they learn) and/or product (how they demonstrate what they have learned) will enable faculty to address variance in learners’ needs while meeting the educational goals of the entire group [13]. See Table 1.

Same Field, Different Training Levels

When learners come from the same professional field, but are at different training levels (e.g., medical students and GME/PGME trainees), variability in knowledge and skill performance should be expected. In the U.S., an example of this in medicine is ‘teaching on rounds.’ This involves multi-level teaching during clinical rounds with learners ranging from medical students to GME/PGME trainees. In such settings, teaching is often directed to a specific training level, the middle [26]. Unfortunately, this approach can leave lower-level learners feeling neglected, while higher-level learners (e.g., residents or fellows) are often bored [1]. With this group of learners, process adaptations can be effective [1]. Adaptations can take the form of teaching to the highest-level, while carefully scaffolding (e.g., building in guiding questions) for lower-level learners. Other teaching strategies are listed in Table 1.

As learners at different training levels are typically required to meet different outcomes within competency frameworks, content differentiation may also be needed. This can be accomplished by first determining common curricular goals for all learners, and then differentiating when it comes to specific learning objectives and outcomes. See Table 2.

Table 2.

Examples of content differentiation – same field, different training levels

Common Competency	Common goals	Medical student objective	Resident objective	Fellow objective
Systems-based practice	Ensure safe transfer of patients	By the end of the educational experience, medical students will be able to list 3 elements involved in the safe transfer of patients from one clinical setting to another.	By the end of the educational experience, residents will be able to demonstrate skills in discharge planning, as assessed by faculty and nurse case manager observation.	By the end of the educational experience, fellows will be able to analyze gaps in hospital transfer protocols, as assessed by a quality improvement team leader.
Practice-based learning and improvement	Use self-reflection and self-assessment to improve practice	By the end of the educational experience, medical students will be able to reflect on the observation of a hospital transfer and articulate potential improvements.	By the end of the educational experience, residents will be able to analyze a transfer and assess their own performance via reflection.	By the end of the educational experience, fellows will be able to analyze a transfer, assessing their own leadership skills, via self reflection.

Key: This is an illustration of how content can be differented for learners from the same field who need to meet the same competency, but will need learning objectives to be differentiated by training level

Different Fields, Different Training Levels

In educational sessions where interprofessional learners (e.g., nurses, respiratory therapists, social workers, medicine fellows) are taught simultaneously, developing differentiated content (Table 3) and allowing for differentiation of products would be most relevant, though process differentiation may be helpful in providing additional support/guidance for all learners. It is important to note that content differentiation is relevant if targeted outcomes are different for each profession. In the event that there is a shared outcome, then process or product differentiation may be most appropriate.

Table 3.

Example of content differentiation – different HPE fields, common goals

Common Competency	Common goals	Medicine Trainee Objective	Pharmacy trainee objective	Nursing trainee objective
Systems-based practice/systems-based care	Improve quality of care for patients at the Free Clinic.	By the end of the Free Clinic Rotation, medical students will be able to describe roles of key stakeholders within the Free Clinic microsystem.	By the end of the Free Clinic rotation, pharmacy residents will be able to advocate for patients experiencing difficulties acquiring prescribed medications.	By the end of the Free Clinic rotation, nursing students will be able to identify social system resources for patients seen at the clinic.

Key: This is an illustration of how content can be differented for interprofessional learners who need to meet a similar competency across all fields (i.e., systems-based practice/systems-based care)

Different Fields, Similar Training Levels

In educational sessions where interprofessional learners are in different fields, but have similar training levels (e.g., medical students, nursing students, social work students, etc.), both process and content differentiation can be effective approaches. Similar to the different field/different training level, the learning outcome plays a key role in differentiation decisions.

Considerations in Implementation

Supporting Instructors

As DI strategies can be challenging for novice instructors to incorporate within their own teaching settings [41] without institutional support (e.g., professional development, mentoring/coaching, planning time) [8, 14, 18], we offer some recommendations for supporting instructors during their DI journeys.

1. Encourage instructors to start small. If the prospect of overhauling curriculum and embracing a DI framework seems daunting, encourage instructors to consider small steps they can take today. Examples include any of the following: provide choices to learners (e.g., products demonstrating what they have learned); reframe questions with different learners in mind; create a set of cases with varying degrees of complexity that learners can choose from; and/or offer a variety of resources for a range of professions/interests [13, 15, 23].

2. Train teachers. In order to successfully implement DI within HPE programs, teachers (i.e., HPE faculty/instructors) need to be trained. Goodnough noted that in some teacher preparation programs, the topic of differentiating instruction specifically for diverse learners is not always a formal aspect of the curriculum [42]. Several authors emphasized the ongoing need for professional development [18, 41], especially for junior instructors who may not understand the instructional design and teaching skills needed when utilizing a DI framework [41]. Instructors in HPE fields may have little to no education on best practices for teaching adult learners [43], let alone how to differentiate instruction for different groups of learners. The importance of leadership’s support in providing professional development related to DI practices has been noted in the literature [14]. When offering professional development related to DI, we recommend emphasizing the purpose of differentiation and its applicability to all learners across HPE settings, as well as the importance of using learners’ baseline data as a starting point for differentiation [15]. See resources such as van Geel et al. [41] for a discussion of high quality differentiation.

3. Enhance teacher self-efficacy. Researchers have found that teachers’ self-efficacy concerning DI was strongly associated with their implementation of DI practices in the classroom [11, 44]. Providing opportunities to practice key skills and receive feedback can enhance instructor self-efficacy. Trying out proven strategies such as giving learners choices [15, 45] and recognizing their accomplishments will enhance the learning experience and bolster teacher confidence [46]. In addition to providing feedback to instructors on their DI practices [18], encouraging instructors to seek learner feedback and build on small wins will also help improve self-efficacy in DI practices.

4. Provide resources outside of HPE. Shareefa and Moosa, reporting on their bibliometric analysis of 100 articles, noted that 283 authors had contributed to the DI literature [9]. Given the paucity of descriptive and research articles on DI in HPE, instructors who are interested in DI are encouraged to access the multitude of resources within other educational fields (e.g., K-12 instruction, gifted, secondary, post-secondary education). Tomlinson’s work [7, 13] is a good starting point.

5. Encourage instructors to recognize differences in all learners. Almost three decades ago, inclusion was called a “moral imperative” [5]. The calls for equity and inclusion have only strengthened, as we examine educational practices across fields and settings. Rather than stigmatizing learners with different abilities, instructors can be encouraged to recognize that all learners are unique and have differing interests, abilities, cultural backgrounds, language abilities and are at different stages in terms of self-regulation [5, 8]. Leung encouraged instructors to get to know their learners and their learning needs, which will aid DI efforts [26].

Supporting Learners

Learners who are new to a differentiated curriculum will also need training and supports. What follows are strategies instructors can use to support diverse learners within a differentiated curriculum.

1. Create a psychologically safe learning environment. One of the first steps in implementing DI approaches is to ensure the learning environment is psychologically safe for learners (i.e., they feel safe to ask questions and display vulnerability) [47–49]. Instructors can start by being open to feedback and questions, and encourage their learners to challenge assumptions, ask questions, and use failure as a learning opportunity [49].

2. Orient learners to DI. Just as faculty will need to understand DI, so too will learners. It is always important to orient new learners to the curriculum, including goals/objectives, competencies (if applicable), any expected outcomes, and performance expectations. Orienting learners to the overall DI framework and what this means for instruction and assessment is also important.

3. Provide choices. To enhance motivation and learner engagement, instructors can provide learners with choices whenever possible. Allowing learners to choose assignments which better match their professional interests (e.g., creation of a slide set or escape room to teach HPE concepts) is one possibility for longer courses. All learners must demonstrate they have mastered the same key concepts, but they can have a say in how they do it [23]. Flexible grouping, mentioned earlier, is another example of providing choices to learners [13].

4. Enhance access. Introduce universal design elements to enhance access to educational settings for all learners [16]. For example, classroom design and layout and the use of technologies, including assistive technologies, provide flexibility and equity for learners of all abilities, disabilities, body sizes and strengths [50]. In addition, there are many specific accommodations that can be provided to individuals with disabilities to enable them to more fully participate in instruction [16]. In the U.S., resources such as the Job Accommodation Network [51], and the Coalition for Disability Access in Health Sciences Education [52], as well as an institution’s own office of disability services may provide creative solutions in particular circumstances. UNESCO’s guide for ensuring equity and inclusion offers an international perspective on inclusion and provides valuable resources and examples to enhance equity in educational settings [4].

5. Consider tiered assignments. Offering tiered assignments to learners is a common curricular strategy in DI [11, 53]. ‘Tiering’ refers to variation in tasks based upon learner readiness, while still meeting common curricular goals [53]. Heacox notes that tiering “can be based on challenge level, complexity, resources, outcome, or product” [53]. To implement, instructors typically start with whole group/whole class prompts, which are then followed by tiered assignments/tasks. See Table 1.

Conclusions

Evidence from a range of educational fields supports the use of DI as a framework to enhance fairness, diversity and inclusion while meeting core instructional needs. While some HPE instructors may be familiar with teaching strategies which fall under the DI framework (see Table 1), they may be unaware that these strategies are part of a larger framework known as DI. For instructors who are new to DI, this Monograph offers examples of process, product and content differentiation, and a variety of methods for supporting instructors and learners as DI is incorporated into curricula. While instituting DI can mean additional upfront planning time, instructors may wish to implement this flexible framework in their own educational settings in order to better meet the unique needs of their diverse HPE learners.

Abbreviations

HPE

Health professions education

DI

Differentiated instruction

IPE

Interprofessional education

GME

Graduate medical education

PGME

Post-graduate medical education

K-12

Kindergarten through 12^th grade

Authors' Contributions

CYC – initial conceptualization of the project, synthesized the literature, and contributed to writing and editing; CMF – synthesized the literature and contributed to writing and editing (co- first author); APL – contributed to writing and editing; MS – conducted a search of the literature and contributed to editing; RK – contributed to writing and editing. All authors reviewed and approved the final version of the manuscript.

Availability of Data and Material

Not applicable.

Declarations

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

All authors have approved the manuscript.

Competing Interests

Authors have no competing interests to declare, financial or otherwise.