Experiencing a Crisis: the nurse’s role

This assessment will demonstrate an understanding of learning and teaching processes and theories in relation to a teaching session given on the subject of oral health. This topic was chosen as the writer feels that, in her experience, effective oral care is provided by nurses on an infrequent basis. Maintaining appropriate and successful oral care can have an enormous impact on an individual’s well-being and also can enhance their self-image (Xavier 2000, Shepherd 2002). The nurse’s role is to provide mouth care or to supervise self-care or care by relatives as necessary (Turner 1996).

Yet many nurses seem to have little awareness of their responsibility to provide oral care, and those that do are often neglectful in their care (Fitzpatrick 2000). This view is supported by Adams (1996), whose research indicates that both pre- and post-registration nurses had a definite lack of knowledge from which to assess their patients’ oral status. Kenworthy and Nicklin (1989) expand the definition of teaching from how it has been traditionally thought of: as a planned or structured activity which is designed to increase or improve the student’s knowledge of a subject.

They believe that the days of the passive teaching-learning relationship are gone and that a teaching definition should include words like enable, facilitate, motivate and promote. The writer has encountered both styles of teaching in her native country and in the UK. Consequently, the writer undertook extensive research into teaching methods and constructed a written teaching plan (reproduced in Appendix One) before the beginning of the session to build upon this. At the outset, it was important to consider the age and background of the student group: ten adult, third-year, receptive student 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, cited by McKenna 1995c, Howard 1999a), the design of positive learning environments and effective learning opportunities (Kenworthy and Nicklin 1989) – which enables the adult student to contribute his or her previous knowledge into the process of learning. By using an andragogical approach, students can be self-directed but supported. The teacher and students are able to treat each other as equals.

The students can take responsibility for their learning and can demonstrate their own knowledge and expectations. The writer considered all of these factors and settled upon such an approach in this case. It was appropriate to start the teaching session by identifying the learning outcomes to the students 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 students 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 student learning as an individual. This 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 student-centred and skills-based, and each student 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 students 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 students about their own experiences, to encourage them to show their feelings and to contribute and discuss their ideas and suggestions. The students participated and contributed fully throughout the session. Humanistic psychology, which is concerned with students’ 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 teachers and role-models are copied by students; and where peer admiration or patient satisfaction is achieved (McKenna 1995a). 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 student (Howard 1999b). 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 students? 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, students were able to identify and label them. Skills of non-verbal communication were also important: face-to-face posture, eye contact and paralanguage.

The writer finished the session with an important recapitulation of the information “headlines” given, along with the learning outcomes (Quinn 2000). In conclusion, the writer has identified and studied the three major theories of the principles of learning and employed a teaching style based on aspects of all three. As the group of students was small, the writer could adopt a student-centred and skills-based approach (humanism). Operant conditioning enabled the writer to reinforce important points in the session (behaviourism). The information was presented by linking specifics to general concepts (cognitivism).

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