Facilitating Learning in Clinical Practice BSC Nursing - Case Study Example

Abstract This paper is a reflective account of my experiential learning as a co-mentor and teacher to the nursing students in the clinical area of Forensic Nursing as applied to Mental Health Nursing. This paper presents the development of formative elements in assessment in a teaching module developed to facilitate learning in BSC (Hons) Nursing programme. This paper highlights the cycles of planning, implementing, and evaluating teaching, learning, and assessment strategies with the final goal of facilitation of learning. This paper has been written in the first person to accentuate the connection between the author and the course of events in the clinical setting. As a result, this elaborates mainly my experiences and thoughts as applicable to my reflections while teaching and assessing students in an attempt to show how mentorship, supervision, and assessment can enhance the learning experiences of the participants and the teacher, both. The evaluation of this action research is through my own reflections, performance of the students, dialogue with the colleagues in the team, and feedback from the students. This paper will also show how a well-planned, well-executed, and supervised assessment process incorporated within learning activities can influence facilitation of quality learning in a clinical environment with a goal to achieve standard of proficiency in the practice of Mental Health nursing. This reflective account also demonstrates, how as a co-mentor, I facilitated learning and supervised and assessed students in the practice setting and how as a teacher in my teaching assignment, I worked towards contributing to a student’s practice experiences and facilitating them to develop competence. Introduction: My job as a Forensic Mental Health nurse in a secure unit has taught me the implications, importance, and above all, the significance of my clinical practice. Many a times, my habitual reflections on my day’s work has thrown light on the intricate complexities of my profession, the demanding ethical implications of my job, and the rigorous requirement of my fitness for standards (NMC, Standards 02.04). This reflective process and a written account of it, I have seen, have invoked a critical appraisal of my own actions, and that has always opened vistas for self-analysis and experiential self- learning. Thus enriched, I believe, it had always fortified my art of clinical nursing practice by development of knowledge, its transmission, and its use in practice setting (NMC 2004b). As a nurse specializing in Mental Health, my work also includes Prison In-Reach work, where a group of experienced nurses go in to the prisons to evaluate and treat people suspected to have mental illness. This in-reach work is important, since once diagnosed to be suffering from mental illness, a patient would be transferred to our regional secure unit from the prison environment. In our unit, these patients get individualized care. The group of patients I work with is mentally disabled. They may suffer from schizophrenia where the perceptive abilities (Bentall, 2003) of these patients are distorted and are far from reality. They have grave disturbances of thought and thought processes (Green, 2001) along with languages. These patients prefer to be withdrawn in a social isolation, even to the extent of making themselves and the environment untidy. The other group of patients that I handle is that of personality disorder with “long-lasting rigid patterns of thought and action” (Wikipedia) that interferes with “long-term functioning of an individual” (Stedman’s Medical Dictionary), often leading to deviations in behavior and disorganized life style. Some patients carry the diagnosis of autistic spectrum disorder, which is a developmental and behavioural syndrome with social, language, and imaginative impairments manifested as repetitive adherence to routine (Wikipedia). The scenario is even worse in patients with drug- or chemical-induced psychosis. This is a major mental disorder, often unnoticed, induced by chemicals like alcohol or other recreational drugs causing derangement of personality and loss of contact with reality and manifested by incoherent speech and disorganized or agitated behaviour (The American Heritage Dictionary). Many of our patients may be suffering from learning disabilities (Kirk, S.A., 1976). According to NJCLD, learning disabilities are known to be associated with other handicaps, namely, sensory impairment, mental retardation, and social and emotional disturbances (NJCLD, 2005). These patients have problems in basic psychological process of understanding or comprehension. Mental disorder means, any disorder or disability of the mind. The degree or nature of the disorder may be such that these patients may warrant detention in a “hospital for assessment (or for assessment followed by medical treatment) for at least a limited period.” The patient “ought to be so detained in the interests of his own health/safety or with a view to the protection of other persons” (Mental Health Act, 1983). As a mental health nurse, I work in a ward of 16 patients, all of whom had been detained under this act. They have committed crime and are considered danger to self and others. The very description of the conditions they are suffering from makes things difficult to handle, and my role is not only to render care to them in the practice setting, also to help them rehabilitate. This is very crucial, extremely challenging, and oftentimes futile due to the nature of their illnesses, which relapse. My job and experience in this practice setting of Forensic Nursing naturally needs special knowledge and innovative care plan for these patients because, in my opinion, my job encompasses the interface between Psychiatry and Law. I have been practicing in this position for four years now, and as a part of my job, I have often been a co-mentor for many student nurses. In my work, I need to team up with some very experienced health care support workers. These people are very efficient in practice, but learning, a very important attribute of their job which ensures fitness to practice in the ever-changing world of Clinical Psychiatry, is not always an easy access for them. My position as a co-mentor could, I recognized while giving it a thought, be utilized to train and teach them very efficiently. I created a presentation after much deliberation on the subject of association of mental health and poor physical health, which mainly focused on the side effects of antipsychotic medications. In practice, antipsychotic medications are mainstay of therapy in psychiatric practice, and they themselves may cause serious health problems in patients identified as having some mental disabilities (Lambert, T. J.R. et. al, 2003). While delivering medications as a part of practice in such a clinical setting, it is important to recognize them in any given patient. Failure to do so is deficiency on the part of the students. It is a well-known fact that many psychiatric patients have other baseline health problems. With the aim of helping my students in practice and with the purpose of linking theory to practice in both academic and practice learning environments with focus on the skill element, I prepared, planned, and implemented this program. The goal was to utilize social learning theory and its application in the context of nursing education. The format I followed aimed at intelligent utilization of cognitive theories, to enable problem solving and the ability to understand and apply principles learned in a variety of clinical situations that they may encounter in practice. I would be satisfied with a lot of critical thinking if my students would apply those principles in the context of nursing work they do, if they are able to critically analyze the information that they receive, if they synthesize a work plan for themselves by demonstrating attention, retention, reproduction of knowledge in the clinical setting, and above all, by showing zeal and motivation to do a good work (Bahn, D, 2001). The basic reason for which I decided to have this course program is the professional belief that “mentors and teachers are vital to the preparation of next generation of practice nurses. It is essential that health care students are taught by those with practical and recent experiences of their profession” (NMC, 2005a ). I can now recollect how I was able to redefine my role as a contributor to their education in the practice setting, and how I coordinated the student experience and assessed my students’ learning. In other words, my program served as an instrument for competence assessment (Calman, L. et al., 2002). Looking back, I can see that I was having a goal to achieve three things by this exercise. I was facilitating learning in BSC nursing, I was exploring learning potentials of my students within assessment, and I was undertaking a plan to implement assessment strategies and their changes with evaluation of change in assessment strategy as applicable to co-mentoring. Did I respond to this goal adequately? Yes, I created a training material with the intent of enhancing learning of the student nurses and health care support workers who work and get practice in Forensic Mental Health nursing. Was there any fitness issue from my perspective? No, I am convinced that as a co-mentor, I have skills and expertise to prepare students which I am required to do for the new world of health care, and I need to ensure that student learning experiences or needs are fully supported and evaluated. For this purpose I had to assume two roles; one, the co- mentor and the other, the teacher or lecturer. In my vision, mentoring is not just the mechanical prescribed roles that are listed. I totally agree with the fact “Mentoring concerns the building of a dynamic relationship in which the personal characteristics, philosophies, and priorities of the individual members interact to influence, in turn, the nature, direction and duration of the resulting, eventual partnership" (Morton-Cooper and Palmer 2000). The exact implications of these terms became apparent when I took formal and informal teaching sessions and when I did an assessment of practice of my students. As defined by NMC, the term mentor is used to denote the role of a nurse, midwife, or a health visitor who facilitates learning and supervises and assesses students in the practice setting. An assessor has a similar role. The term lecturer, on the other hand, denotes the role of a teacher of nursing, midwifery, or Health Visiting employed in the educational institution responsible for delivery of educational courses (NMC 2005a). This translates into the responsibilities of application of theory; assessing, evaluating, and giving feedbacks; and facilitating learning in practice, performance, and experience (RCN tookit, 2005) . All of these are true, but to my reflections, this has another angle of viewing it. A mentor is a faithful guardian, advisor, and teacher (Homer, 800 BC) who is able to inspire self-assurance, enhance self-esteem, and increase self-confidence in the student learners (Northcott, N., 2000) and also challenges and changes own practice; it had always been a two-way process for me, the students learned from me, but I have learned more from the students (Atkins, S. & Williams, S. 1995). What were my plans of work and methods of its implementation? As I have already said, I created a power-point presentation on association between mental illness and poor physical health, mainly due to antipsychotic medications that we provide the patients as a part of the care in the practice setting. My focus was to make my students aware that existence of other associated physical ailments and poor physical health related to treatment of their basic psychiatric disorder, and this knowledge would change the whole perspective of their job to them, and this would lead to a modified care plan that my students would employ toward the patients. What was the fact that led to basis of such a plan? I have observed in practice and I have read that psychiatric patients have a very high rate of physical health problems, much of which go undetected (Lawrence D, Holman C, Jablensky A., 2001). To provide an appropriate care to these patients, it is important that healthcare providers are not ignorant of the physical aberrations, so this knowledge could empower and guide their transition from a state of dependence to a state of self-directed initiatives in patient care (Morton-Cooper, A. and Palmer, A., 2000). The teaching materials that I used are appended to this paper at the end, but to have a very brief idea about what I was planning to teach, I can recollect, I used a power-point presentation titled, The Association Between Mental Health and Poor Physical Health. The term poor physical health was discussed in light of the side effects of antipsychotic medications, and I explained what can be the side effects of antipsychotic medications. The necessity of care in the hospital setting was substantiated by fact that the National Service Framework of Mental Health states the patients with “severe mental illness” (D.O.H 2000) should have their physical needs assessed on admission to the hospital, and this calls for a better and thorough physical assessment in the hospital even if the patients are admitted to a psychiatric facility. I also gave them a brief overview of the commonly used antipsychotic medications that are used in an in-patient setting, discussed with them how far they know about this, how much is there yet to know, how this knowledge can help all of them in their practice settings, and what are the side-effects they would look out for. Last but not the least, I stressed on the importance of interacting with the patients and the need to inform the patients about the risks that they are subjected to while taking these medications, and how it becomes a part of our duty. I still vividly remember the class room allocated to us in our ward away from the ward environment , the presence of the students, excited, thrilled, and keenly interested, my mentor, the LCD projector, and the teaching aids like the handouts I created for this session. During this formal teaching session, of course, there was no patient present. While the formal teaching session was over, however, we moved on to utilize this knowledge in the practice setting in the informal teaching session. In this session, the patients were present in the clinical area; I demonstrated the art of taking a verbal and written informed consent from the patient by explaining what we were exactly up to, and we would administer medications to them. I explained the ethical issues behind it to the students, and all the patients co-operated. I showed them how a shift handover occurs in the hospital setting, and that happened in a specific room allocated for this purpose. I can see in my teaching diary, how I explained our drug delivery on the background of the knowledge of the formal classroom session to my students, and I could sense the appreciative and knowing look in the faces of my students. The feedback session was the most interesting part. Along with the teaching lesson plan, I drew up short questionnaires to collect feedback about these sessions, and I asked the Health Care Support Assistants to fill this form at the end of the sessions. In other words, I encouraged criticism and discussions on their impressions on the topic. The teaching plan that I prepared was methodical, it contained information about the date and venue, the number and list of health care support workers attending, an introduction that contained a brief overview of the planned session, and the expected behaviour of the learners in terms of application of the outcomes, the question of whether any development is necessary for this program to be more effective in delivering what it is supposed to do, a lively discussion related to the theoretical topic and its practical application in work, and over all, a summary and conclusion. To aid this process, I created photocopy handouts of my presentation, and I enumerated resources for further reading on the topic on the handout. The discussion was by far the most important part of the session. Although I sensed a total participation, honestly during the discussion, I came to understand that different members of the group customize their own methods for learning, and no single method works out for all. The teaching strategy that is appropriate for one person may turn out to be useless for other. This session of post teaching feedback and discussion taught myself a lot about the art of teaching. I can see in my diary that I have taken notes about my observations in the classroom that some students learn better in a group while interacting with the teacher and peers, some prefer to learn individually and on their own, and the other group learns only with the application of knowledge gained. While analyzing the discussion and keenly following my students talking, I noted also that there were individual differences between the health care support workers attending my class. They differed in their verbal skills, vocabulary, and fluency or skills of communication. The retention of some was remarkable in that they can remember what they see, some were better to retain what they see and hear. Theories that I described in this session were explained and detailed in the handout. All the relevant references were also briefed in the handout. I also gave a brief outline of different theories that could be used in teaching, and I highlighted the fact, despite arguments against the humanistic approach among the three, that is, behaviouristic, cognitive, and humanistic, I am utilizing the humanistic approach, only to make my students passionately participating in the session. I did not try to define or get into the nuances of theories of learning, rather I stressed on the attributes of humanistic approach so that they can participate in problem solving, they can apply their reasoning in understanding the subject, they can have a free will and entry into the subject matter, and they can, as a result, self-develop themselves and cooperate with the whole process. I mentioned the two pioneers in this theory, where Maslow is known for his theory of motivation, where learning is spontaneous process once the needs are satisfied (Maslow, A, 1987) , whereas Rogers felt the need to place the student at the centre of the learning process through active self discovery rather that instigation by a stimulus (Rogers C. R., 1980). Things here begin to get complex, since no theory of learning or teaching seems to offer a generalized solution to this problem. I was given to understand that teaching is a complex activity varying from one situation to one other, and the innate intelligence of the teacher, her experience, and her choice of strategy can have effect upon the level of motivation and intensity of interest of the group concerned. My group consisted of Health Care Support Workers, and I discovered that even though my students are good at their Work, many of them lack confidence as new learners and many are just at a loss about how to employ self-learning without being dependant on the teacher. I could also point out people with prior learning experience who could have a different and exciting receptive approach and attitude to further learning activity. Naturally, this was in essence a mixed group in terms of their problem solving abilities, decision making capabilities, in terms of individualistic learning style and curve, and with respect to their techniques of study. The most important thing I learnt was about their levels of motivation. I discovered that the best learner is the one who is best motivated. As a teacher, I too immediately learned to plan my action while teaching, to boost their grasping abilities and to accept a teaching strategy that would effect a very high level of motivation for most of my students, to arrange for some inspiration and stimulation during the session. It would be wise if I make the background of my co-mentorship explicit now. In the world of present day nursing care and training, the necessity of “mentoring work-based learning”, where mentors would facilitate and guide the learners through “work-based learning experience” , which would help the new inexperienced colleagues in developing a programme of learning that would enhance the career potential. This mentor would support learning and assess “learning outcomes” in practice, develop the qualities of fitness in practice, judge the performance status to recommend entry into the register (Ramage, C., 2003). Mentorship concerns the supervision of students in practice setting, but recently following the changes in post-registration education policy, attention has shifted to the qualified nurses (Andrews M. and Wallis M., 1999). The aim of this policy is to consolidate pre-registration learning, and after a period of preceptorship, the new registrant is ready to take on the role of associate mentor under the guidance of an experienced and senior mentor (NMC 2002b). I planned and implemented these sessions at the beginning of the course in January 2007 as an undergraduate. I am already a nurse, and I took this module as a part of my degree. I can co-mentor now under the guidance of my mentor. Once I complete my degree, I look forward to become a mentor myself where I can assess anyone formally, and the University has set out the terms and aims that I have discussed to enable me to be qualified in this area. Due to the work requirements in my work place as a co-mentor, I have been allocated students during a span of time, and they are supernumerary while on placement. While working with them in an attempt to ensure an effective learning experience for them, I soon discovered that there is a marked difference between the younger students and matured older students. I later discovered while researching that many researchers in this field have propounded the fact that baseline education of the trainees modify their behaviour in the training setting (Richardson, D.R., 2000) . I also could recollect similar findings in my experience as a co-mentor. This is important since my strategies are based upon these findings and facts, and my main goal in this project is to influence the students, to acknowledge their practice achievements by a sound system of exchange of constructive feedbacks, and ultimately facilitation of learning, where I should be able to identify their current learning needs as applied to the clinical setting and as related to their individual progress, where I would be able to create and develop opportunities for the students to identify and undertake experiences to meet their learning needs as a step- ahead to their careers, and through these I would be able to demonstrate custom-made and exclusive strategies that will assist with integration of learning from both educational and practice settings (Price B, 2004). I found that the younger students appear to be more anxious, self-conscious, and fearful of failure and indeed appeared more careful and cautious, whereas the older and experienced ones were more demanding of effective learning and often more critical about the mentor. As a mentor, one of my important roles were to assess their learning to ensure effective learning experiences of my students, to provide opportunity to achieve learning outcomes for the students by contributing to the development and maintenance of a learning environment (Stuart C.C., 2002). I had also a very important role to learn as a co-mentor, to devise strategies for quality assurance and quality audit as far as the fitness to serve as a health care nurse is concerned and also to create a free dual-mode constructive but critical feedback exchange system where I could contribute to creation of an environment in which change can be initiated and supported (QAA, 2001). I had the responsibility to identify and apply and disseminate research findings within the area of practice, as I did in case of antipsychotic medications and related physical problems, and thereby contribute to development and review of courses (UKCC, 1999). Thus far was the account of my co-mentorship, but how well I did my job? Looking at the notebook, I can find my mentor’s comments on my formal teaching session. My mentor was very keen on criticizing me as required by the norms, but I must agree that did not dishearten me. It was a very constructive input. Almost in unison with my own reflections, my mentor decided and evaluated my teaching session and also suggested about how it could be improved. One suggestion was particularly lucrative to me, and I decided to follow it in the next opportunity, was the method of collecting data and feedbacks through audio records that could be used to provide answers to questions, and those can be utilized in future sessions as well as in any teaching session. My mentor also drew my attention to other minor aspects of my teaching as well as my content, and we had thorough discussions about that. It was nice exchange and quite enriching one for me. Since it was my first ever teaching experience, I was quite nervous about it and anxious too about how it would go. This was caught right by my mentor. My mentor talked about my body language and how important it is to earn confidence of the students in the classroom setting. I explained that since the students of my class were the Health Care Support Workers whom I taught on a daily basis in the ward or clinical setting, any lack of knowledge displayed in front of them in the classroom would hamper my image and would make me appear foolish in front of them, which I did not want to happen. Teaching is something that I do not do on a daily basis. Anyway, I made a resolve that next time onwards this would change. However, my mentor raised a few questions, I guess, in order to fix my orientation to the actual goal of this formal teaching process. My mentor drove the discussion regarding a critical appraisal of my teaching methods looking at whether my objectives were specific and realistic, were the structure and method appropriate to the material and situation, whether the students’ needs and area of knowledge were identified, whether I interacted with my students and if so, what was the level of interaction, whether the material was logically structured and presented at the right level or not, whether active participation was encouraged and the question technique appropriate. The final feedback that nailed my strategy was that, it was not appropriate to hand over the handouts before the powerpoint presentation. It could have distracted, hence better be given at the end of the session. My mentor also commented that though my presentation was very informative, the discussion time was less, and I could have allowed more time for discussions by encouraging them more in participating in discussions (Jones, L et. al, 2001). The informal teaching session comprised of demonstration of administration of medication to the patients in the clinical area with a student nurse, and I carried out shift handover by myself in presence of my fellow nurses and demonstrating these to the Health Care Support Workers who also attended the formal teaching sessions. All these three sessions were observed by my assessor. My assessor asked me the most prudent question, while the informal teaching was happening to the student nurse, whether I gave any constructive feedback to the student. In this regard, my mentor had few documentations to fill, these are appended at the end of this paper. One encouraging thing is my mentor felt that I had done well and was pretty confident while doing the informal teaching in the clinical setting, and I looked absolutely authoritative while doing the shift hand over, mainly because I do these jobs on a daily basis. Mentorship is an important tool for supervised experiential learning. In teaching, I discovered students who lack confidence as learners and difficult independent students. Prior learning has a profound effect on approach and attitude to further learning. These learners can be supported by providing a range of support services. I feel that some students may require intervention of specialists where mentors are not equipped to deal with such problems (Jarvis, P and Gibson, 1997). We need to learn to meet the changing demands of various occupations. All the tasks we engage in call for new knowledge, new skills and new attitudes at various stages of learning. Through reflective action planning, I have become skilled in changes that influenced the staffs’ perception of me and becoming a mentor has improved my professional position within my work place. As a mentor, I will have an impact on the students’ learning. I realized that reflection allowed me to give my own opinions and criticize myself to develop a better teacher and a better mentor in nursing education of the future age (Butterworth, T. and Faugier, J., 1997). Reference List Adapted from http://www.learningandteaching.info/learning/humanist.htm Humanistic Approaches to Learning Andrews, M. and Wallis, M., Mentorship In Nursing: A Literature Review. Journal of Advanced Nursing, January 1, 1999; 29(1): 201-7. Andrews, M. and Wallis, M., Mentorship In Nursing: A Literature Review. Journal of Advanced Nursing, January 1, 1999; 29(1): 201-7. School of Health and Community Studies, The North East Wales Institute, Wrexham, Clwyd Bahn, D. Social Learning Theory: Its Application In The Context Of Nurse Education. Nurse Education Today, February 1, 2001; 21(2): 110-7. Bentall, R. (2003) Madness explained: Psychosis and Human Nature. London: Penguin Books Ltd. Butterworth, T. And Faugier, J., 1997. Clinical Supervision And Mentorship In Nursing. London: Chapman & Hall. Calman et, al (L Calman, R Watson, I Norman, S Redfern, and T Murrells) Assessing practice of student nurses: methods, preparation of assessors and student views. Journal of Advanced Nursing, June 1, 2002; 38(5): 516-23; Department of Nursing Studies, University of Edinburgh, Edinburgh, UK. lynn.calman@ed.ac.uk C.H.A.I.N. Work-Based Learning Event Key Issues On Mentoring Work-Based Learning Dr. Charlotte Ramage, principal lecturer, Work-Based Learning Coordinator, Institute of Nursing & Midwifery, Brighton University, Reading, December 8th and 9th 2003 http://chain.ulcc.ac.uk/chain/event/ramage(additional_info).pdf Elizabeth J Pask, Nursing Ethics, Vol. 10, No. 2, 165-174 (2003) DOI: 10.1191/0969733003ne591oa © 2003 SAGE Publications English National Board And Department Of Health., 2001b. Placements in Focus: Guidance for Education in Practice for Health Care Professions. London: ENB / DOH. Green, M.F. (2001) Schizophrenia Revealed: From Neurons to Social Interactions. New York: W.W. Norton. Reference List Homer C800bc In: Morton-Cooper, A. And Palmer, A., 2000 Mentoring, Preceptorship and Clinical Supervision: A guide to professional roles in clinical practice. 2nd ed. Oxford: Blackwell Science. Jarvis, P. & Gibson, S., 1997. The Teacher, Practitioner & Mentor. 2nded.Univ. of Surrey: Nelson Thornes. Jones, L, Walters, M. S. and Akehurst, R., 2001. The Implications Of Contact With The Mentor For Preregistration nursing And Midwifery Students. Journal Of Advanced Nursing,35 (2), 151-160. Jones, L, Walters, M. S. and Akehurst, R., 2001. The Implications Of Contact With The Mentor For Preregistration nursing And Midwifery Students. Journal Of Advanced Nursing,35 (2), 151-160. Kirk, S. A. (1976). Samuel A. Kirk. In J. M. Kauffman & D. P. Hallahan (Eds.), Teaching children with learning disabilities: Personal perspectives (pp. 239–269). Columbus, OH: Charles E. Merrill. Maslow, A. (1987) Motivation and Personality (3rd edition) New York: Harper and Row . Milnor, J (John Nash and “A Beautiful Mind” http://www.ams.org/notices/199810/milnor.pdf, page Moral Agency In Nursing: Seeing Value In The Work And Believing That I Make A Difference, Thames Valley University, Slough, UK, anonymous. Morton-Cooper, A. And Palmer, A., 2000. Mentoring, Preceptorshipand Clinical Supervision: A guide to professional roles in clinical practice. 2nd ed. Oxford: Blackwell Science. NMC, Protecting the public through professional standards, NMC, Portland Place London (pp 22, section 4). Nursing and Midwifery Council (2004b) Standards of proficiency for pre-registration nursing education, London: NMC.Available from www.nmc-uk.org (pp 24). Nursing and Midwifery Council (2005a) NMC, consultation on a standard to support learning and assessment in practice, final report, London: NMC. NMC 2000a, Guidance for mentors of student nurses and midwives An RCN toolkit, Royal College of Nursing. 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Section 9: Placement Learning, Gloucester: QAA.Available from www.qaa.ac.uk Responsiveness to Intervention and Learning Disabilities A report prepared by the National Joint Committee on Learning Disabilities representing eleven national and international organizations June 2005 http://www.ldaamerica.org/pdf/rti2005.pdf Richardson, D.R. Comparison Of Naive And Experienced Students Of Elementary Physiology On Performance In An Advanced Course. University of Kentucky, Lexington, KY 40536-0298, Advances in Physiology Education, 23:91-95, 2000 Rogers C R (1980) Freedom To Learn For The 80s New York: Free Press.  Stedman’s Medical Dictionary, Personality Disorder. The Americal Heritage Dictionary, Psychosis, http://www.montana.edu/wwwai/imsd/rezmeth/psychosis.htm Stuart C C (2002) Assessment, Supervision And Support In Clinical Practice: A Guide For Nurse, Midwives And Otherhealth Professionals, Edinburgh: Churchill Livingstone. United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1999) Fitness for practice, London:UKCC.Available from www.nmc-uk.org The UKCC is the former name for the Nursing and Midwifery Council (NMC). Wikipedia, Personality disorder, http://en.wikipedia.org/wiki/Personality_disorder Appendix Read More