Theory of Learning in Nursing - Article Example

Theory of learning in nursing Critically apply one theory of learning to the role of the preceptor in facilitating nurse learning in practice Critically apply one theory of learning to the role of the preceptor in facilitating student nurse learning in practice Learning theories Learning has been defined as “a relatively permanent change in behaviour with behaviour including both observable activity and internal process like thinking, attitudes and emotions” (Burns, 1995 cited in Dunn, 2002). The traditional sensory stimulation theory says that effective learning occurs when the senses are stimulated.(Laird, 1985 cited in Dunn, 2002). 75% of learning is through seeing, 13 % by hearing and all other senses account for 12 %. When multisenses are stimulated, greater learning is possible. The reinforcement theory, a behavioural theory of B.F. Skinner says that repeating a desired behaviour by the learner will occur if positive reinforcement is done. (Dunn, 2002) Negative reinforcement also causes a negative behaviour to stop. Punishment weakens behaviour and creates situations which help to eliminate behaviour. Competency-based training uses this theory of reinforcement. The cognitive gestalt approach is based on “experience, meaning, problem solving and insight development” (Dunn, 2002). This theory can be used when individuals have different elements; intellect, emotions, the body impulse, intuition and imagination. All the elements require activation for effective learning. The facilitation theory or the humanistic approach was developed by Carl Rogers. (Dunn, 2002) Here learning will occur in an atmosphere where learners feel comfortable. This approach provides scope for the eagerness of learners, allowing for change from old ideas, and changing one’s concept. Facilitative teachers are more accommodative of students’ ideas, bothered about fostering a good relationship with the students and accepting feedback from them, positive or negative. Learners take responsibility for their learning and provide input for it and self evaluate themselves. Kolb’s experiential learning theory is a continuous cycle of learning. People learn in four ways: concrete experience, reflective observation, abstract conceptualization and active experimentation which form the cycle of learning. (Dunn, 2002). Action learning theory allows learning from reflections. It is advantageous for finding solutions for issues which do not have a set correct answer and these answers are to be found from action of experimentation or experience. Adult learning or andragogy is a theory which is practical for education. (Dunn, 2002) It includes experience and active participation of the learners in their own learning and self-evaluation. Emotions govern these human responses. Teaching activities and learning can be planned activities by incorporating principles of learning and using theories or models to ensure a good outcome. Nursing education has used many of the theories for bringing out good and highly qualified graduate nurses. Thinking like a nurse is the first and foremost advice that a faculty tells the students with due respect to Florence Nightingale. (Vito-Thomas, 2005). Professional competence and student performance both decide the critical thinking. Critical thinking which includes “creative thinking, smart thinking, high quality, and in-depth thinking” are the representations of the concept. The vision of nursing comprises of the critical thinking, the ability to improve clinical systems and reducing the errors in clinical judgement all of which the nurse achieves through learning strategies. To mould a student to become an expert novice, the teaching is imparted in many processes. The traditional method is the clinical approach where students are exposed to the patients and they learn by observation and participation with guidance from their seniors. This method does not allow much chance for the student to use her skills of critical thinking or clinical judgement. The system of preceptorship changed the situation. Critical thinking Critical thinking has affective components and cognitive skills; perseverance, open-mindedness, flexibility, confidence, creativity, inquisitiveness, reflection, intellectual integrity, intuition, contextual and perspective are the affective components and information seeking, discriminating, analysing, transforming knowledge, predicting, applying standards and logical reasoning belonging to the cognitive skills group. (Scheffer and Rubenfield, 2000 cited in Vito-Thomas, 2005). Nurses being adult learners have the ability to become participants in the learning process. (Knowles, 1980 cited in Vito-Thomas, 2005). Facilitation for the process activities, cooperative collaboration and evaluation is done by the teacher in a fairly relaxed environment. The learner becomes adept in putting together the learning experiences with her life experiences and evolves a meaning making her more informed. The interaction between the two kinds of experiences, the precise definition of the concept and integration of many concepts are evident in Ausubel’s Assimilation Learning theory (Tomey, 2000 cited in Vito-Thomas, 2005). Prioritising or organizing the various concepts by way of importance or hierarchy enables the student to sharpen her inductive and deductive thinking. The teaching of nursing has shifted from an information-driven process to one promoting “higher level thinking and clinical judgement”. (Vito-Thomas, 2005) It is no more a process of loading facts. Research has begun to discover innovative strategies for teaching and learning so that critical thinking and judgement are stimulated in their clinical studies. The new strategies include activities which are self directed, role-playing, problem-based learning, mastery learning, case studies and clinical rounds. To these are added the reflective logs or journaling and reflective practice group sessions which enable the teacher to gauge how much the student has learnt. She will be honing her skill of metacognition in the process of reflection. The student gets the opportunity to express her experiences in her own words. The teacher who goes through the student’s logs finds areas for personal dialogue with her. (Vito-Thomas, 2005) Clinical rounds also allow open discussion. Collaboration of ideas helps the creation of plans for the patients. Different perspectives are brought out for critical thinking. A study was conducted to find out the responses about the teaching/learning processes. 134 junior and senior nursing students participated. Several believed that the methods they learnt would help them use critical thinking in their future practice. Education without experience may not produce results as expected in their student life. The process is complete only when they use the learnt strategies in their practice. Encountering problems in real-life occurrences would help them demonstrate their critical thinking and expert clinical judgement. Following role models who exhibit critical thinking is the best way of how to think like a nurse. (Vito-Thomas, 2005) Preceptorship This is an alternate teaching/learning method in nursing apart from the clinical method. The preceptorship is an extra obligation and responsibility of the staff nurse (Younge, 2008). It is usually not part of the job description. Preceptors are to be prepared to provide a high quality preceptorship. They need systematic support and acknowledgement of their work. As yet professional standards have not been established for preceptorship. (Younge, 2008). A proactive approach may have to be adopted to select preceptors. Job satisfaction increases with increased preparation for it. (Speers, Strzyzewski and Ziolkowski, 2004) The needs of the preceptors during the development of teaching skills and during the day-to-day demands must be addressed and given sufficient support (Speers et al, 2004). A formal reward system in a cost effective manner is being suggested for preceptors (Younge, 2008). All the students do not show a similar progress in learning after the preceptorship is completed. Some may even indulge in unsafe practices. The high quality of the student and the positive student-preceptor relationship both influence the quality of precepting experience (Younge, 2008). A study was conducted by Luhanga and her team mates: it concluded that “early identification and intervention of unsafe practice are critical and consist of red flags regarding knowledge, attitudes, skills and professionalism”. (Luhanga, 2008) Allowing an unsafe student (who is incompetent, has a questionable clinical practice, and who has a poor knowledge and psychomotor skills) into the nursing profession can cause a dilemma (Duffy, 2004). The unsafe student has the potential to be harmful to herself, her client or the other staff. The extra time required to evaluate and document a student’s progress causes a great amount of stress on the part of the preceptor who can experience burn outs. Intergenerational conflict among the students can cause attitude problems.(Wieck and Landrum, 2006). The present generation of nursing students belong to the “Y” group. Their characteristics are self-reliance, questioning behaviour, being well-informed on latest technologies, good multi-taskers, optimistic in nature, with high self expectations and centred on getting high grades. They also have a low threshold for boredom, need clear guidelines and have no hesitation to challenge authority. Their preceptors belong to the boomer generation. Their characteristics would include dedication, sacrifice, hard work conforming to rules, respect for authority and considering duty before pleasure. (Hart, 2006). Reluctance of teachers to fail an unsafe student with poor performance arose because of the lack of experience, poor confidence levels, inability to recognize the student’s problems early, fear of appeals (Dudek, Marks and Regehr, 2005), hope that they may pick up the skills later, unwillingness to jeopardise their future and feelings of personal failure. Their decisions are seriously wrong as unsafe students find their way into practice and continue their poor professionalism. The study findings of Luhanga (2008) were that the unsafe practices must be detected early and intervention provided to correct the practice. Some skills like drug administration may not be provided in the university program. The students need to be adequately prepared for their experience of preceptorship. Client safety, student achievement of their course objectives and reducing the level of load on the preceptor can all be achieved by the selection of suitable students. Unsafe students must be identified early to give them ample time for improvement (Luhanga, 2008). Workshops for staff development for preceptorship also need to be frequently executed. The stress of single preceptorship has now given way to multiple preceptorship or team preceptorship for each student. Team preceptorship The registered nurses’ residency programs have become a tough proposition for nurse preceptors. The orientation periods for new graduates have become lengthy to ensure that a student nurse is thoroughly prepared for confident care of patients. Preceptors who guide many students singly are at a risk of burnout. This has led to the suggestion of a team of preceptors for them. A study was conducted by Beecroft and her colleagues in the Childrens’ Hospital in Los Angeles (2008). They found many faults of the single preceptorship. Inconsistent and haphazard assignments were being handled by one person. When the primary and alternate preceptors were not around, the students came under the guidance of any available Registered Nurse. The skill level and competency of the available nurse and the student would be at a discord; the nurse would not know the prior performance of the student. Another problem seen was that the same people would be the primary and alternate preceptors for the students. (Beecroft, 2008) The risk of burnout was definitely high in the 6 month residency period. The nurses who were posted as preceptors were inadequate in number. At the same time there were some nurses who desired to become preceptors but were not given the chance while novices who were competent were given the job. The opinion that the less experienced ones should not precept existed among the expert older nurses. Following on this, the younger preceptors were fearful of being criticized by the older ones should their students become less successful. The expert nurses also resented the “encroaching” of their territory.(Beecroft, 2008). Moreover they felt threatened by the go-getting attitude and the enthusiasm of the students who had great aspirations. Suggestions from the study about preceptors provided the means of attaining a solution: a good preceptor would be one whose experience is close to those of the student, whose personalities match with ongoing communication and daily evaluations, the preceptor offering support and empathy for the preceptee and maintaining realistic expectations. (Beecroft, 2008). Modic and Schloesser (2006) suggested that newly competent nurses with eighteen months of nursing experience could be good preceptors. These preceptors can introduce or orient the student nurses to the routines .of the unit. When the students are ready to handle patients, the expert nurses can take over. The team approach is believed to facilitate the career development of a new preceptor. Preparation for the role of preceptor can be worked out at a workshop where orientation is provided. The subjects of adult learning styles and principles, critical thinking, problem solving, conflict resolution, developing reflective habits, conducting feedback, and methods to enhance performance are discussed at the workshop. The team preceptorship is now instituted into the student’s residency. (Beecroft, 2008). The Modified Collegial Clinical model and the Lev Vygotsky’s theory Adopting a slight change in the collegial clinical model of Salera-Vieira where one preceptor helps to bring out good qualified and enthusiastic novice nurses, the team preceptorship could be used with the Lev Vygotsky’s theory. The development of an appropriate model for nursing preceptors is necessary to make practice changes so that the staff nurse is well equipped with sufficient knowledge to be skilled and efficient preceptors to their students.(Dearholt, 2008). The Collegial Clinical Model has been suggested as a model for orientation where one nursing instructor is posted for a group of students. (Salera-Vieira, 2009). A successful orientation strategy may be used to retain new graduate nurses from leaving and the responsibility falls on the shoulders of the nurse preceptors. These preceptors have to care for patients at the same time (Salera-Vieira (2009). The objectives behind this innovative model were manifold. The comfort level of the new graduate nurses in their new roles was to be enhanced. The preceptors were to be helped by the administration. The hospital money must be saved by preventing new graduate nurses from leaving. The transition of a student nurse to the professional role of nurse has been described as one of stress in most literature. The shock of the reality of the professional nurse is “overwhelming, frustrating and confusing’ to many new graduate nurses (Casey et al, 2004, Santucci, 2004). The orientation of the student nurse is a costly affair in time and energy. (Buss-Frank, 2005) Casey et al have also indicated role strain in the transition. Among the adult learning theories, Lev Vygotsky’s socio-cultural development theory appears to be suitable for the orientation model or collegial clinical model. (Salera-Vieira, 2009).The central concept is named as the zone of proximal development or ZPD (Sanders and Welk, 2005) Four stages have been described in the transition. The first stage of assisted performance shows the assistance of an experienced peer or preceptor. As the stage one progresses, the responsibility shifts from the preceptor to the student or learner. The student moves from “other-regulated ‘to self –regulated and no assistance is expected in stage two. In stage three, learning is internalized and there is no more assistance. The GNs would not be found in this stage (Sanders and Welk, 2005) Stage four occurs when the nurse is placed in a new situation where a stressor has occurred. The processes of other-assisted, self-assisted and internalization again are experienced. The Vygotsky’s theory incorporates the ability of the social environment to develop the learner cognitively. Increasing or decreasing the social environmental support as needed would help the learner accomplish higher in the ZPD (Sanders and Welk, 2005). The ZPD is at the highest level of success when ‘scaffolding’ occurs between the educator and student. The concept central to the Vygotsky’s theory is that scaffolding and the change in social support are a response to learner’s educational needs. The scaffolding and assisted performance incorporate strategies for education found in nursing education: modeling, feedback, questioning, instructing and cognitive structuring (Sanders and Welk, 2005). The nursing educator has both verbal and non verbal professional behaviour. References: Beecroft, P., Hernandez, A.M. and Reid, D. (2005). Team preceptorships: A new approach for precepting new nurses. Journal for Nurses in Staff Development, Vol. 24, No. 4, p. 143-148. 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Hallmarks of unsafe practice: what preceptors know. Journal for Nurses in Staff Development, Vol. 24, No. 6, p. 257-264, Wolters Kluwer Health / Lippincott, Williams and Wilkins Modic, M.B. & Schloesser, M. (2006). Preceptorship. Journal for Nurses in Staff Development. Vol. 22, No. 1, p. 34-40 Salera-Vieira, J. (2009). The Collegial Clinical model for orientation of new graduate nurses: A strategy to improve the transition from student nurse to professional nurse. Journal for Nurses in Staff Development, Vol. 25, No. 4, p. 174-181, Wolters Kluwer Health / Lippincott, Williams and Wilkins Sanders, D. & Welk, D.S. (2005). Startegies to scaffold student learning: Applying Vygotsky’s zone of proximal development. Nurse Educator, Vol. 30, No. 5, p. 203-207 Santucci, J. (2004). Facilitating the transition into nursing practice. Journal for Nurses in Staff Development, Vol. 20, No. 6, p. 274-284, Wolters Kluwer Health / Lippincott, Williams and Wilkins Speers, A., Strzyzewski, N. & Ziolkowski, L. (2004). Preceptor preparation: An investment in the future. Journal for Nurses in Staff Development, Vol. 20, No. 3, p. 127-133, Wolters Kluwer Health / Lippincott, Williams and Wilkins Vito-Thomas, P.D. (2005). Nursing student stories on learning how to think like a nurse. Nurse Educator, Vol. 30, No. 3, p. 133-136, Lippincott, Williams and Wilkins Wieck, K. & Landrum, P. (2006). Understanding the generational gaps: Preserving your mental health at school and work. National Student Nurses Association (NSNA). Retrieved October 29th, 2009. from the NSNA website www.nsna.org Younge, O. Hagler, P., Cox,.C. and Drefs, S. (2008). Time truly to acknowledge what nursing preceptors do for students. Journal for Nurses in Staff Development, Vol. 24, No. 3, p. 113-116, Wolters Kluwer Health / Lippincott, Williams and Wilkins Read More