The CTC approach is a theoretical framework and a practical approach for enabling and measuring behavioral change resulting from attending an educational event that involves requesting CTC statements from learners and, in cases where a follow-up is used, following-up with them at later time to ask about compliance with their statements and reasons for non-compliance (Mazmanian & Mazmanian, 1999
; Purkis, 1982
; Wakefield, 2004
). There is a solid theoretical foundation to explain how and why the CTC approach may facilitate learning and change including Locke's goal-setting theory (Locke et al., 1981
), Rogers' diffusion of innovations and communication networks (Rogers, 1995
; Rogers and Kincaid, 1981
), reflective learning (Schön, 1983
), and the transtheoretical model of change (Prochaska, Reddling & Evers, 2002
) that were discussed in Jones (1990)
, Mazmanian and Mazmanian (1999)
, Mazmanian, Waugh and Mazmanian (1997)
, Overton and MacVicar (2008)
, and Wakefield et al. (2003)
. There is also some empirical evidence of this effect of the CTC approach (Pereles et al., 1997
), although the extent of the influence of the CTC approach on educational outcomes remains largely unknown (Mazmanian & Mazmanian, 1999
; Wakefield, 2004
As an evaluation tool, the CTC approach can be used for several purposes. One common purpose is documenting the impact of education on clinical practice in quantitative terms, such as the number of intended practice changes, number of learners who made CTC statements, mean number of commitments per learner, and percentage of compliance with stated commitments (e.g., Mazmanian & Mazmanian, 1999
). In addition, findings related to the reasons for non-implementation of a CTC statement may advance understanding of how change occurs in a given clinical area and, thus, what could be done to better address specific barriers to practice improvement with future educational and/or organizational interventions. Also, the collected CTC statements can be compared to activity objectives (Dolcourt & Zuckerman, 2003
; Lockyer et al., 2005
), activity content (Curry & Purkis, 1986
; Pereles, Lockyer, Hogan, Gondocz, & Parboosingh, 1997
), evidence-based messages incorporated into the content (Wakefield et al., 2003
), and amount of time allocated to a content area relevant to the CTC statements (Lockyer et al., 2001
). Such analyses are helpful to verify the program planners' assumptions; identify “major points of impact”, that is, instructional points that stimulated practice change (Purkis, 1982
); and document anticipated and unanticipated learning outcomes (Dolcourt & Zuckerman, 2003
There is considerable variation in how the CTC approach has been implemented in the CME field (Wakefield, 2004
). In order to characterize variations in how CTC is defined and implemented as an evaluation method, we conducted a MEDLINE search using “commitment to change” and “continuing medical education” as search terms and, additionally, reviewed references in the identified articles, yielding 18 published studies that employed the CTC approach as a means of assessing the outcomes of an educational activity. We then examined the CTC approach used in each case for similarities and differences. A major difference we found is whether the approach is used in a post-only design (in which information is gathered from participants only in the period immediately following an activity) or post/follow-up (participants are asked to write CTC statements after the educational activity and then are queried at a later time regarding their progress in making changes). Many published CTC studies have used the post-only design (e.g., Neill, Bowman, & Wilson, 2001
); indeed, it is considered likely that the majority of evaluations of continuing education programs for healthcare professionals using CTC have been limited to collecting CTC statements (Mazmanian & Mazmanian, 1999
). However, some authors, notably Mazmanian and Mazmanian (1999)
and Wakefield (2004)
, consider a follow-up to be an integral part of the approach.
We found other differences as well (). Procedures for collecting commitment to change statements varied in the wording of the question eliciting CTC statements, use of the strength of commitment question, and inclusion of a signature line. Approaches for conducting the follow-up also varied. We observed differences in wording of questions about implementation, the scales used to assess implementation, inclusion of additional questions (e.g., about barriers to change and intention to continue with the initiated changes), and data collection procedure (e.g., written questionnaire versus verbal communication). The timing of the follow-up also varied.
Procedures of the Post/Follow-up Commitment to Change (CTC) Approach
To date, little empirical evidence has been made available to provide guidance choosing from among these various options in designing a CTC evaluation. One important example is the study conducted by Mazmanian and colleagues, which found that a learner's signature on a CTC form does not appear to influence self-reported compliance with CTC statements (Mazmanian, Johnson, Zhang, Boothby, & Yeatts, 2001
), but questions such as how to decide on the optimal timing for a follow-up (Wakefield, 2004
) have not been systematically examined.
In the absence of empirical evidence, several authors have theorized about the impact of various choices or offered rationales in support of different options. For example, on the issue of how to word the CTC question, Overton and MacVicar (2008)
hypothesized that if the initial CTC request includes an explicit reference to “commitment”, it is likely to evoke an attitudinal commitment. However, if learners are asked to indicate intended practice changes, the request is likely to produce a behavioral commitment to action. Wakefield (2004)
suggested that asking what participants “plan to do” rather than “plan to change” may result in CTC statements more predictive of actual changes in practice behavior.
We came to a conclusion that variations in how the CTC approach has been used suggest it can be tailored to a particular educational program and program/evaluation purposes. At the same time, some uncertainty remains as far as how different components and procedures of the CTC approach influence the results obtained through its application.