Teaching and Learning in Practice

Introduction

In the context of life long learning within nursing there are many different study methods available to us. Half the battle is won when the individual has chosen the method which is most effective to them. Study can involve working alone or with others, and to achieve goals effectively the correct method is vital. Unfortunately there is no way of determining the best method; it is a case of trial and error.

The key to learning is to define and comprehend what lifelong learning is. Once an individual has established this, to be an effective learner one has to apply it. Life long learning is a continuation of learning after one has finished a particular course. In the case of a nursing degree it means staying up to date with policies and procedures and developing new branch specialities, but it can be applied to anything from business to driving.

In this paper we will try to answer the key points of contemporary teaching and learning issues within nursing. To cope with this task we will perform extensive research in field of learning teaching methodologies. Then, by examining main theories and methods learning, we will try to research different approaches in learning and teaching, mentioning by the way psychological issues in this field. After that we will examine end evaluate implementation of teaching and learning in practice.

Teaching and Learning

What does the term learning mean? It is a common task we practice every day often without realising, this is known as passive learning. This is the result of frequent exposure and nurses can learn important things this way such as the signs and symptoms of illnesses that are frequently encountered on the ward. The problem with this is that the nurse does not understand why they occur. Likewise if a nurse copies the skills performed by a more experienced nurse she is less likely to be able to modify the skill when a new and slightly different situation occurs.

Passive learning is an inevitable part of life, but to simply just copy the behaviour of our colleagues is not enough to demonstrate professional practice. Active learning however is when a nurse sets out to understand the concepts behind the principles behind the concepts and skills they are required to know. It may help if learning is viewed as a progression from the acquisition of knowledge through to higher level mental activities. (Walsh et al, 2001) A diagram explaining the progression of knowledge to active learning can be found in Appendix 1. This means that learning is not the mere acquisition of facts; it involves a range of intellectual activities.

As a nurse it is vital that a firm and extensive array of knowledge is gained. Nursing is an ever changing profession and more and more is learnt about the human body and its functions on a daily basis. This is hardly surprising as diseases mutate and it is necessary for new drugs to be developed. Life long learning is therefore essential.

It is easy for a person nurse to develop the key principles during training. The Code of Professional Conduct, (CPC), states that: “As a registered nurse, midwife or health visitor, you must maintain your professional knowledge and competence.” This means that once initial training is completed it is necessary for nurses to participate in regular training and develop competence and performance. As a nurse there is the responsibility of practicing and delivering care based on current evidence and what is thought to be best practice according to current guidelines.

As a person it is good practice to set some goals including long term that extend beyond time at university. This should give some motivation to carry on developing skills and knowledge enabling the best possible care to be given to the patients being treated.  In order to achieve goals an action plan needs to be made specifying what needs to be achieved and how it would best be achieved. There are three types of goals to be decided: short term, medium term, and long term. They should act as stepping stones until the individual reaches there ultimate goal.

Nursing is a practical job but it is still important to spend time reflecting. Abstract conceptualisation follows on from reflection. The concept is the idea; abstract conceptualisation is the understanding of the idea. As a nurse the ability to reflect is crucial to develop in-depth knowledge and skills and achieve life long goals effectively. Reflective practice is like any other skill, it can be learned, and become second nature once learnt.

Goodman (1984) said that there are three different levels of reflection. 1st- To reach given objectives: Descriptive;  2nd – Relationships between principles and practice;  3rd- Incorporates ethical and political concerns.  These different levels are can only be obtained through practice.

There are many theories relating to reflection and it depends on the individual which one is followed. Some are very simple such as Maslin – Prothero (2001):

WHAT?

SO WHAT?

NOW WHAT?

Understanding others’ learning styles could enable facilitators to improve and adapt their teaching styles and strategies to meet person’s needs. When poor results and/or non-attentiveness are evident this may be a catalyst for the educator to review the teaching methods used. It is not as important to figure out what style a person is, as it is to recognize how and why a person is learning in such a way and how to encourage their progression. (Adey, 1999)

Research on this topic of learning styles can sometimes seem confusing presenting explanations that are similar, yet quite distinct. A thorough understanding of these terms is essential in order to properly apply them in nursing and training. One of the clearest pieces of research presented by Curry (1990) defines these terms as:

• learning preference – favouring one method of teaching over another
• learning strategy – adopting a plan action in the acquisition of knowledge, skills or attitudes
• learning style – adopting a habitual and distinct mode of acquiring knowledge
• cognitive strategy – adopting a plan of action in the process of organising and processing information
• cognitive style – a systematic and habitual mode of organising and processing information.

The most prominent feature that differentiates Curry’s terminology from others is the degree to which they can be observed and understood. For example, learning preferences are often expressed, in phases like “I really like working in groups”, “I just can’t come to terms with new concepts unless I discuss them with others”(Curry, 1990). Similarly, learning and cognitive strategies may be noticed by observing persons or by allowing them to think aloud as they study.

Different Approaches

First style of learning is a pillar of humanism, one of three distinct schools into which practitioners have split the process of education: the others being cognitivism and behaviourism. The humanistic approach to learning is person-centred and skills-based, and each person is considered as an individual. It is concerned with wholeness of experience and the search for personal meaning. Key to this humanist approach were the writings of the influential psychologist Carl Rogers (1983), who encouraged the active involvement of persons in learning by exploring the theory of “self”: the understanding of self-actualisation, human growth and the fulfilment of the individual.

There are three basic principles of this person-centred approach: genuineness, empathy and unconditional positive regard. As this was a small group, the writer was able to ask the persons about their own experiences, to encourage them to show their feelings and to contribute and discuss their ideas and suggestions. The persons participated and contributed fully throughout the session.

Humanistic psychology, which is concerned with persons’ thoughts, feelings and experiences, contrasts directly with behaviourism. This is the change in observable behaviour brought about by the manipulation of the link between stimulus, response and reinforcement, disregarding feelings and experiences. The behavioural school argues that environment controls behaviour and learning therefore comes from conditioning (Thomson 1999). Examples of conditioning in nurse education are the way in which the attitude, behaviour and values of facilitators and role-models are copied by persons; and where peer admiration or patient satisfaction is achieved (McKenna 1995). The writer feels, however, that within this framework it is difficult to establish which practices are beneficial, and which are not advantageous.

From the three key tenets of behavioural psychology identified by Myles (1993) it is operant conditioning that the writer believes is the most beneficial within the nursing education context. This is an active process which disregards the role of the stimulus and encourages behaviour to be spontaneously emitted by the subject. The writer was able to positively reinforce important points within the teaching session as reactions and behaviours reached her desired response, with phrases like “nearly there”. However, the writer concurs that the application of behaviourism into the teaching process can mean that learning is dangerously dependent on the output of others and not on the active input of the person (Howard 1999).

The last of these three schools, cognitivism, is the process of knowing (Adams and Bromley 1998) and of thought processes (Payne and Walker 2000). Cognitivism emphasises internal purposive, mental processes (Quinn 2000) and covers various modes of knowing. It includes the acts of problem-solving, reasoning, imagining and remembering (McKenna 1995b, Adams and Bromley 1998).

Cognitive psychology is concerned with the interrelation of constituent parts to a whole system, and this expansionistic approach has become more popular since the development of the digital computer in the 1950s (Hayes 1984, Quinn 2000). It is in the validity of learning by discovery as an important tenet of cognitivism that two of the leading exponents of the school differ. David Ausubel (1978) believed that most classroom learning is receptive, and that a discovery style of learning is not feasible as it requires greater time and resources – so the understanding of specifics is only possible by the comprehension of general concepts. Jerome Bruner (1960) believed that specifics could be used to identify universal concepts, an inductive style of learning. After new information was acquired, he felt, it had to be analysed, processed and then evaluated (Quinn 2000). Learning for Bruner, then, was by isolation and categorisation of objects. The implication for this teaching session based on Bruner’s theory was that the principles of oral care in preventing infection must be fully explained at the outset – however this was too complex a task, in terms of time and depth.

Ausubel’s receptive style of learning was the most beneficial, but how could information about mouth care be put across and retained by the persons? The cognitive theorist Robert Gagne (1975) had found that the short-term memory is only capable of seven-item storage. He examined a way in which information could be organised and presented so it could be passed into the long-term memory and easily retrieved when required. The writer examined Gagne’s theories and made an effort to bundle information in the session in a variety of different ways. The main points of the teaching session were displayed on an overhead projector – the images were enhanced, and the text was easy to distinguish and not overcrowded. A number of handouts were distributed, and a quiz was also used as an educational game method. Pictures of the anatomy of the oral cavity were distributed, and, after a period of two-way interaction, persons were able to identify and label them. Skills of non-verbal communication were also important: face-to-face posture, eye contact and paralanguage. (Quinn 2000).

The teaching process can be defined in many ways. A learning approach/theory has been developed to cover each aspect, all of which are outlined below. The behaviourist approach is more commonly known as classical and operant conditioning and is based on a stimulus-response. Pavlov first introduced classical conditioning. He observed the behaviour of dogs and their salivation at the sight of food. Pavlov deemed this an unconditional response. He developed this further and sounded a bell with a meal and discovered the dog would salivate upon hearing the bell only. Pavlov called this a conditioned response.

However, Skinner (1968) introduced operant conditioning. Skinner experimented with rats. He designed boxes for the rats, which housed a mechanism that delivered food pellets each time the lever was pressed. In the rats’ natural behaviour, it makes accidental contact with the lever three or four times and food is delivered. After this the rat demonstrates an intentional behaviour. This indicates learning has occurred.

Carl Rogers and Abraham Maslow developed the Humanistic approach in America in the 1960’s in a reaction against the two other prominent psychology approaches. The emphasis is placed upon the individual and the stimuli, which motivates individuals to perform certain behaviours. Maslow’s hierarchy of needs demonstrates this. (Culan 2000).

Bruner developed the Cognitive approach, in the late 50’s and early 60’s. Bruner compared the mind to a computer, stating that we too are information processors. He studied the internal mental processes between the stimuli we receive and the responses we make. Cognition means to know and the cognitive processes refer to the ways in which knowledge is gained, used and retained. Cognitive psychology is the most dominant approach to psychology today.  Constructivist learning approach is a follow on to the cognitive approach. However the emphasis is placed upon the individuals self awareness and view on their own learning. (Reece 1997)

A domain of learning approach was developed by Bloom (1972). He identified the three stages in which learning occurs as the:

• Cognitive – knowledge gain
• Psychomotor – skill development
• Affective – attitude formation.

Research and evidence has proven that no single theory can cover all aspects of learning (Hartley 1984). Classical and operant conditioning stress the importance of immediate feedback in learning to maintain a positive attitude to learning. However, Cognitive and the domains of learning, enable clients to develop problem solving skills and the underpinning knowledge of theory and skills. Each theory has pros and cons, determining which theory relates to your personal situation, will assist in effective learning.

Learning Styles

Consequently, there are many ways to interpret learning styles.  David Kolb (1986) has written extensively on the subject and his model is frequently used.  Kolb identified two separate learning activities:

• Perception

Each of these distinct learning activities has inherently opposite stances to each other. For example some people perceive information using physical experiences such as, feeling, touching, seeing, and hearing, while others perceive information abstractly, by mental or visual conceptualisation.

Once information is perceived it must be processed. Some people process information effectively by active experimentation (doing something with the information) while others perceive best by reflective observation (thinking about it).

Kolb describes four learning dimensions in his model (see Appendix 2):

• Concrete experience – learning from specific experiences, relating to people, and sensitivity to feelings and people
• Reflective observation – careful observation before making a judgement, viewing things from different perspectives, and looking for the meaning of things
• Abstract conceptualisation – Logical analysis of ideas, systematic planning, acting on intellectual understanding of a situation
• Active experimentation – ability to get things done, risk taking, influence people and events through action

Active experimentation coupled with concrete experience produces, primarily a “hands-on” learner, a learner that relies on intuition rather than logic. One that relies on other people’s analysis rather than their own, and enjoys applying their learning in real life situations. Learners that can combine concrete experience with reflective observations progress better by looking at points of view, and watching others rather than taking action. They gather information and create many categories for things. Imagination plays a large part in their problem solving techniques and develops sensitivity to their learning. Reflective observation coupled with abstract conceptualisation styles of learning produce learners that like solving problems, finding practical solutions to their learning. Technical skills are dominant and social and interpersonal are shied away from.

Abstract conceptualisation when focussed together with active experiments tends to ensure learners are very concise and logical. People issues do not seem important where as abstract ideas are. Logical explanations are used more often than practical ones. Kolb’s model is only one of many. Anthony Gregorc modified Kolb’s dimensions by focusing on random and sequential processing of information. This is similar to top-down and bottom up processing. Top-down learners look at the whole task (random) while bottom-up learners proceed one-step-at-a-time (sequentially). (Gregorc, 1984)

Kolb’s (1986) Learning Cycle and Gibbs Reflective Cycle (see Appendix 2) are both very similar but go into more detail than Maslin – Prothero.  The benefits of reflection are high in nursing. It helps the development of nurses’ autonomous practice, and it develops knowledge. Reflection however is only valuable when it is reflective practice and not just thoughtful practice. There is a difference between just thinking about an experience and in – depth exploration of it. To successfully reflect the individual should be open minded, responsible, objective, willing to explore emotions and, adaptable to change.

Another approach to preferred learning style is David Hunt’s notion of cycling through all four of Kolb’s dimensions (Entwhistle, 1981). That is, first experience the problem then reflect on it, then analyse it, then act on it. In this approach the learner will recognize that some modes in the cycle come more naturally to them than others and will be able to identify the modes of learning that require further work.  Later research conducted by Honey & Mumford (1992) modified Kolb’s cycle and suggested four learning styles corresponding to each of the stages.  They identified four main learning styles: the activist, the theorist, the pragmatist, and the reflector. The Activist enjoys new experiences and challenges, an environment of changing activities and appreciates the chance to develop ideas through discussion and interaction with others. The Reflector appreciates the opportunity to reflect before making a decision, prefers to listen and observe others debating and discussing issues, and prefers to work alone. The Pragmatist likes linking theory with practice, enjoys problem – solving, and appreciates the opportunity to develop practical skills. The Theorist enjoys theories and models, and thrives on problem – solving when it involves understanding and making sense of complex issues.

Honey and Mumford’s theory on the four main learning styles is very successful but, may not the best way for nurses to achieve their goals effectively. Learning as a nurse would involve integrating and mixing these learning styles as they do not really cater for a nurses needs. In terms of long term goals The Pragmatist is the most ideal learning style for a nurse as it involves learning practically with some element of theory. This is necessary as when dealing with patients, nurses need to know the correct method of doing something and needs to understand why they do it, but practice means that a nurse feels confident to put the theory into practice, therefore feeling confident about their abilities and more able to reassure the patient.

According to educationalists, this model offers an excellent framework for designing, developing and delivering diverse learning experiences for all (Rowntree, 1992) No one has a “pure” style. Each of us has a unique combination of natural strengths and abilities. By learning some of the common characteristics of each of the four combinations used by Gregorc, Kolb and Honey and Mumford, (Dunn et al, 1999) facilitators can recognize and value how persons learn best. Facilitators can then help them to improve in facets of the learning styles that they least use and understand.

Implementation

Although nurses constantly learn through practice it is a good idea to develop good study methods as a back up to the practice. Achieving this means gaining firm knowledge, and ability to learn new and specialist skills. Information can be sought by reading relevant materials. Journals are a good way of receiving information on new and revised policies. There are an abundance of journals available. The information may come from a general nursing magazine or from a journal that focus’ on a specific branch of such as paediatric nursing. It is also good practice to start reading newspapers and listening to news reports.

As well as reading and researching into the techniques that are required, it is also important to practice. As a nurse it is important to become familiar with the routine and ensure that the task will be carried out with confidence. It is important that a nurse feels confident carrying out the different tasks that may be asked. It makes the patient feel more relaxed in a very stressful situation.

‘Confidence comes with practice.’ Practice may not always be thought of as a learning method. It is however one of the most valuable learning experience to anybody. An individual can be taught things and be the most skilled and competent person but, could that person put it into practice in a real situation.

Communication is a good learning method as well as helping the nurse look more confident and competent. Life long learning involves being able to communicate effectively. By talking to colleagues and having a good comprehension of them new skills can be learnt. Quite often nurses will learn from each other and good communication skills are imperative.

Does a nurse know everything there is to know about nursing? No

Does a nurse know when they know everything about nursing? No

So how can a nurse possibly know when learning ends?

Thus, many nurses will share the same goal, to become the best nurse that they can possibly be. This means that learning within nursing will never end. As previously stated it is one of the few ever changing professions and so to become a competent nurse it is necessary to stay up to date and continue learning throughout life.

David Boud et al (1993), present five propositions of experiential learning that they go on to discuss throughout the book. I shall briefly outline these propositions and explain the ways in which they relate to and have informed my own practice. Firstly in the ways they relate to my own practice as a ‘learner’ facilitator and secondly, in the way I integrate considerations relating to these propositions into my teaching practice and inform my development and standards of effective practice.

1. Experience is the foundation of and the stimulus for learning. “Learning always relates in one way or another, to what has gone before. There is never a clean slate on which to begin; unless new ideas and new experience link to previous experience, they exist as abstractions, isolated and without meaning,” (Boud et al, 1993) At all times I like to work on the principle of developing ideas a little further each session, employing constant revision and building on previous learning. “While experience may be the foundation of learning, it does not necessarily lead to it: Their needs to be active engagement with it.” (Boud et al, 1993) As Boud et al point out we link new experiences to those of the past and create new meanings and insights. This highlights the use of keeping autobiographical records of lessons and reflecting upon them in order to evaluate, improve and build upon an effective teaching practice. Through the journal we enter into a dialogue with our experience enabling us to: “Turn experiential knowledge… into propositional knowledge which can be shared and interrogated.” (Boud et al, 1993)
2. Learners actively construct their experience. “We attach our own meanings to events. While others mayattempt to impose their meanings on us, we ultimately define our own experience.” (Boud et al, 1993) This proposition highlights the importance of a learner’s personal and cultural history. Being aware of this has encouraged me to recognise the various different ways in which persons make meaning and to allow this process to flourish without attempting to impose my personal definitions and meanings on them.
3. Learning is a holistic process. “Much writing about learning has treated it as if it existed in separated domains which were separated from each other.” (Boud et al, 1993, p12) Common divisions are between the cognitive, affective and psychomotor. As Boud et al point out, it can be useful to consider these different aspects of the learning process, however we must maintain awareness that often these different areas are interconnected and that: “ No one aspect should be generally privileged over the rest. Within educational institutions the systematic bias towards the intellect and to the analytical is most pronounced and the influence of learning in these institutions has spread widely, leading to a lack of emphasis on people as whole persons and on problems that are taken out of context.” (Boud et al, 1993)
4. Learning is socially and culturally constructed. “While learners construct their own experience, they do so in the context of a particular social setting and range of cultural values; learners do not exist independently of their environment.” (Boud et al, 1993)
5. Learning is influenced by the socio emotional context in which it occurs. “…there is almost a taboo about them [feelings and emotions] entering into our educational institutions” Two key sources of influence suggested by Boud et al are: “Past experience and the role of others in the present as supportive or otherwise.”(Boud et al, 1993) Support, trust and confidence in the learner can help to overcome any negative experiences of past learning experiences. The past can create expectations, attitudes and dispositions that effect the present. Humanist theories of education take account of influences upon the learner such as self-image and intrinsic motivation.

At the outset, it was important to consider the age and background of the group: ten adult, third-year, receptive person nurses. An andragogical approach would be the most effective for this group. Andragogy as applied to teaching is the art and science of enabling adults to learn (Knowles 1984), the design of positive learning environments and effective learning opportunities – which enables the adult person to contribute his or her previous knowledge into the process of learning. By using an andragogical approach, persons can be self-directed but supported. The facilitator and persons are able to treat each other as equals. The persons can take responsibility for their learning and can demonstrate their own knowledge and expectations.

It was appropriate to start the teaching session by identifying the learning outcomes to the persons and making clear to them what they should acquire from the session (Quinn 2000). Equally, it was important to take a degree of negotiation, flexibility and discussion into account, among other techniques of andragogical learning. By asking the persons to share their experiences at the outset and by enquiring as to their present comprehension of the importance of oral care, the writer was able to build a sense of informality and inclusiveness in the group and establish a peer-to-peer approach, with each person learning as an individual.

Planning and delivering teachings, is a complex procedure incorporating many factors. If these are covered in a logical order, then an effective teaching with positive outcomes should occur.  To ensure this occurs, a process known, as APIE should be followed. If you Assess, Plan, Implement and Evaluate, then your teachings effectiveness is measurable.  One of the most important factors is to decide what to base your teaching on and identify your target audience, learning environment, barriers to learning and relevant policies.

Considerations and Conclusions

My teaching was based upon rehabilitation with regards to exercise, targeting adults from a multi cultural society who were due to be discharged from hospital. In order to make my teaching suitable for the adult learner, I understood it had to be flexible, with regards to date and timing of the meeting. Use learning theories/ styles with the emphasis on discussion and negotiation and place them in control as this contributes to the fundamental system of life long learning. (Redman 2001). Recognising the individual is also extremely important, as understanding their individual needs is imperative. Research has been carried out by psychologists to highlight the different ways in which we approach and process information. However, due to the nature of the teaching, it was extremely important for myself to maintain a degree of control, in order to guide patients through an uneventful recovery.

The teaching followed an active format, with group participation and demonstrations and knowledge at the same time. The teaching session was based upon the Social learning theory and the cognitive approach. The social learning theory was most relevant due to its components of positive and negative reinforcement and imitation. When learning within the group situation, individuals often can feel intimidated by others, however if all patients worked together, then they copied each other, imitated and internalized with one another. This was a positive outcome from the participation perspective of the session, however the patient or patients who began to stray from the exercise regime for example, exercised more than was recommended, then their recovery had a possibility of being delayed and other patients sometimes imitated this behaviour or felt belittled and depressed as they couldn’t exercise as much or as often.

In order to reduce these factors, positive and negative reinforcement were used. Patients were praised on their achievements and progression and a more negative approach was used to those who were straying from the programme although praise was given for their commitment and enthusiasm. The cognitive approach was used as a guide for ensuring the patients had the underpinning knowledge about the exercises. This approach likens the human mind to a computer, using a stimulus-response mechanism, also similar to classical and operant conditioning. One hoped the patients would internalize the theory given to them, which included exercises and possible side effects if too much or too little was carried out and liken it to themselves with the response being any side effects they incurred.

The two theories were used accordingly as one thought the cognitive approach reduced the number of negative factors with the social learning theory. The pros and cons with each theory and found the social learning theory to be essential for group participation but didn’t account for individualization, which the cognitive process accounted for. When used together, they supported my teaching style appropriately. Not all theories work together, it is determining your personal teaching style, target audience and teaching subject which is most important and the theories are a reference.

If the teaching session were to be repeated in the future, one would hope to be able to capture a wider audience from within and outside of the healthcare profession, using current feedback to build upon and construct a more effective teaching. One believes the teaching, which has been delivered, was of a positive outcome as the focus was concentrated on demonstrating motivation and a high degree of interest, which was shown in the feedback.

The ideal teaching would incorporate every aspect required, however due to time restrictions and limited facilities it is virtually impossible to deliver a teaching which is suitable to every client. The one solution to this, would be to divide clients into groups, of similar age, ethnic groups and physical and mental ability, however due to equal opportunities, disability acts and race relations, this could never occur. One hopes this would never happen in the future as every client brings something unique and positive to them to each session. We all learn from one another and one believes if another teaching were to be, carried out it would be improved, due to experience.

Having carried out the research and undertaken the teaching, the importance of client education is extremely important. Government policies are beginning to highlight this loophole and health professionals are beginning to visualize society in the future if client education doesn’t occur.

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