United for Future: Learning from experience in Nursing

 

Dr. Pramilaa R

Professor Cum Principal, Chirayu College of Nursing, Bhopal

 

ABSTRACT:

Learning takes place in an every individual during their lifetime irrespective of the volume learnt. Nursing is a skill based profession. Student nurses are provided with adequate learning experiences to master the skills to practice nursing. That is acquired profoundly with experience based on sound knowledge. Reflective thinking is a strategy which all nurse teachers are expected to teach all students and render opportunities to acquire experience through it. Reflective thinking results in self awareness, self improvement and empowerment. This article is headed by elaborating on experience based learning, their components and significance in learning. And Kolb’s experiential learning theory is explained. It is further highlighted with the support of research studies on the consequences of providing desirable and undesirable learning experiences. The challenge for nurse educators in choosing learning experiences has been emphasized as it is believed that both positive and negative behaviors can be easily adopted by the students. Therefore, meticulous planning is essential to obtain strengthened student learning, professionalization and socialization into the professional role. The goal of nursing cannot be accomplished alone; therefore, it is vital and integral for the nursing community to remain united always.

 

 

 

INTRODUCTION:

Life is an incessant chain of experiences. These experiences amplify the individuals to live a more educated and fertile life. Experience is the key constituent to success for all human beings. Education and experience enable individuals to invigorate respect for each other. One of the ultimate meanings of life is to learn. Every individual learns something during their lifetime. Effortful learning amalgamated with real life builds strength toward attaining success very frequently. The incorporation of knowledge and practical experience is a precious asset to professional life. When practical experience is deprived, knowledge and concepts cannot be nourished.

 

It must be understood that having knowledge is representative of having information, but in order to evolve the expertise in a particular field, one has to go for doing things practically that invariably results in the progression of effective skills. Thus, experience is the knowledge or mastery of an event or subject gained through involvement in or exposure to it. And learning is the process whereby knowledge is created through the transformation of experience. Learning in simple term means that permanent change in behavior through education, training, practice and experience.

 

General principles of Learning¹:

·      Readiness: implies a degree of concentration and eagerness. Individuals learn well when they are physically, mentally and emotionally ready to learn and do not learn well if there is no reason

·      Reinforcement: continuous and repetitive practice ensures the retention of knowledge and skills

·        Effect: is based on the emotional reaction of the student. It has a direct relationship to motivation.

·        Primacy: things learned first are usually learned easily and remain, without effort, in the mind of learners.

·        Recency: states that things most recently learnt are best stored in the memory

·        Intensity: implies that a learner learns much more from real thing than from a substitute

·        Freedom: states that when learners freely learn, learning occurs better

·        Requirement: states that one must have something to obtain or do something

·        Behavior modeling: set model for students to follow

·        Feedback: timely and adequate feedback motivates the learners

·        Learning transfer: those that can be transferred to work are most likely to be retained

 

Reflective thinking:

It is the learning we gain by reflecting on the experiences we encounter. It is through the reflective process that meaning is created and new insight gained. Example: Have you ever missed the bus and then thought next time I will leave the house 5 minutes earlier?

 

Reflection as described by Schon is the process in which professionals utilize to highlight concealed or tacit knowledge². Bengtsson states that reflection remains as a prominent instrument in the accumulation of practical knowledge and skills in the field of education³. Reflection is a significant human activity in which people recall their experience, ponder about it, examine and evaluate it⁴. The outcome of learning becomes successful only when working with experience occurs.

 

The significance of reflection in nursing cannot be underrated. It can be employed on many paradigms, to reflect on an event, a fraction of time even, and the actions, thoughts and feelings corresponding with that happening, or can be utilized to help develop an understanding of a more general time duration, by fragmenting, considering, analyzing and critiquing the who, what, why, when and how of the happenings of that time⁵. It can be manipulated to reflect on events as they occur- reflection in action-and on situations from the past- reflection on action². Additionally, it can be utilized to acknowledge new skills and communicate organized new perspectives.

 

Reflection guides to better understanding of our strengths and weakness; acknowledgement of our fears; and recognition of possible inadequacies or areas of improvement. Fig 1 described what reflection is⁶.

 

Reflection is
Self awareness Thinking of yourself, your experiences and your view of world	Self improvement: Learning from experiences and wanting to improve some area of your life	Empowerment: Putting you in control of making changes and behaving in a different way

Fig. 1: What is reflection?

 

 

 

 

 

Fig. 2: Kolb’s experiential learning theory

Learning from experience:

The concept of learning from experience has been promoted by John Dewey in 1939. His approach implanted on the proposition that a person’s response in any circumstance is chosen from the exiting stock of memorized responses that have functioned well for them in past ⁷. David Kolb (1984) defines experiential learning as ‘the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience’⁸.  

 

Kolb’s experiential learning theory (Fig.2) presents a cycle of four elements

1.    Concrete experience

2.    Reflective observation

3.    Abstract conceptualization

Active experimentation

 

Kolb’s theory works on two levels. First level: A four stage cycle

1. Concrete Experience (CE):

Is being involved in a new experience. They like to learn by experiencing. They learn from and with other people and value discussion and feedback.

 

2. Reflective Observation (RO):

Is watching others or developing observations about one’s own experiences. They learn by reflecting. They like to look at things carefully from a variety of perspective.

 

3. Abstract Conceptualization (AC):

Is creating theories to explain observations. They are logical and systematic. They appreciate deductive thinking based on careful understanding. They create ideas that are clear and well- structured.

 

4. Active Experimentation (AE):

Is using theories to solve problems and make decisions. They learn by doing. They like to practice and try new things. They are not afraid of taking risks and are known for getting things done. 

 

Table 1: Learning styles and characteristics of learners

Learning styles	Description	Characteristics of learners
Diverging	to move apart CE/RO	·       Recognize problems ·       Brain storm options ·       Gather information ·       Strong in arts ·       Work in groups ·       Receive personal feedback ·       Generate lot of ideas
Assimilating	to absorb- take up mentally AC/RO	·       Plan and Create models ·       Define problems and Develop theories ·       Be patient and take  logical approach ·       Provide good explanation rather practical opportunity
Converging	to come together AC/AE	·       Solve problems ·       Make decisions ·       Reason deductively ·       Find solution to practical issues ·       Experiment new ideas
Accommodating	adapt- make fit-change to suit new purpose CE/AE	·       Get things done ·       Lead and take risks ·       Initiate and be adaptable ·       Intuition rather than logic ·       New challenges and experience ·       Actively engaged with world

 

 

Second level: each representing a combination of two preferred styles

The learning styles and characteristics of learners are given in table 1.

The two continuums: East to West axis is called Processing Continuum (how we approach the task) and North to South axis is called Perception continuum (our emotional response). The continuum shows both cannot be done simultaneously. When we encounter in a new learning situation we make a choice a) To do or watch; and b) To think or feel.

 

Essential components of experience based learning

Andresen, Boud & Cohen (2000) provided a list of criteria for experience based learning (EBL)⁹:

·        The goal of EBL augments something personally important or meaningful to the students

·        Students should be personally involved

·        Reflective thought and opportunities for students to write or discuss their experiences should be ongoing throughout the process

·        The whole person is enveloped, it means, not just the intellect but also their senses, their feelings and their personalities

·        Students should be acknowledged for prior learning they bring into the process

·        Teachers are required to establish a sense of trust, respect, openness and concern for the well- being of the students

 

Significance of experience based learning (EBL)

·      EBL is a powerful teaching tool while classrooms lectures address cognitive domain, it implicates whole student: cognitive, affective and physical domains (Oxendine, Robinson & Wilson, 2004)¹⁰

·      EBL provide a change of pace from traditional classroom assignments and enhance learning for students with a diversity of learning styles (Millenbah et al., 2003)¹¹

^·          EBL has lasting impact. (Kirk & Thomas, 2003)¹²

·      EBL can aid the students and teacher gets closer. Because they exchange aspects of their own actions and decisions.

 

Evidences demonstrating desirable learning experiences for nursing students:

Nursing is a practice-based profession. Clinical education is an integral and fundamental part of the nursing curriculum. The quality of nurse education relies hugely on the quality of the clinical experience. Students need effective clinical experience to enable application of theory to practice. These experiences are cardinal to the students’ preparation for invading the workforce as an expert and independent practitioner. Vitale E had undertaken literature review on clinical teaching models for nursing practice from January 2010 to September 2012 at Italy. Four innovative clinical teaching models for nursing practice were considered: a) Problem based learning method, b) Self regulated learning strategy, c) Developing reflective skills of nursing students, and d) Computer based clinical simulation¹³. Yet, another study aimed at experience of problem-based learning for raising quality of nursing at Slovenia among 198 nursing students. Results projected that problem based learning encourages nursing students motivation, independence, and team work and helps to acquire knowledge and skills necessary to function in nursing¹⁴. The aforementioned studies have recognized the strategies to install among nursing students to create desirable learning experiences.

 

Clinical placement dispenses openings for students to observe role models, practice, enhance their skills and problem-solving abilities and reflect on what they see, hear and do. As they practice in the clinical environment, it is important that the nursing student integrates theoretical content rendered by the educational institutional with realities of nursing practice. The concept of preceptor- preceptee could accomplish largely in the transformation of a student to a clinical nurse. Relationship between the staff and nursing students is the single most crucial factor in creating a positive learning environment. Preceptorship is one to one clinical education model with an educational relationship provides preceptees with access to proficient role models within a particular time. Wilkinson JM at Ghana (2016) suggested for the implementation of Clinical teaching partnership (CTP) as training of preceptorship faced challenges. CTP is a collaborative model shared by service and academia. They enumerated use of CTP in teaching students clinically to enhance their ability to think critically, solve problem, make decisions and reflect on practice¹⁵. Nurse educators should choose wisely while adopting the strategy in their practice provided we are able to accomplish the goal in the preparation of sound nurses.

 

Students identify that the skills and attributes of nurse teachers, their attitude towards them and access to relevant learning opportunities, is paramount in the achievement of positive learning outcomes. Williamson E (2010) at US aimed at multiethnic experiences among nursing students learning to expand students’ learning experiences with Hispanic and South Asian clients. In addition to classroom experience, the project encompassed home visits with individual families. Visits focused on health promotion, disease prevention and illness care. On completion of experience, students were able to relate more therapeutically to minority clients and to plan culturally acceptable nursing interventions and they showed increased cultural self efficacy¹⁶. This study finding showed the behavioral changes that had occurred among students. This result was obtained because right learning experiences were selected by nursing faculty.

 

Positive behaviors are those that are considered desirable for the professional development of the student. This is supported by a qualitative study done in Iran using hidden curriculum to teach professionalism in nursing students. Themes and subthemes emerged were: A) Development of understanding the professionalism elements – i) Learning from professional ethics  such as patience, humility, altruism, ii) Learning from patient centeredness  like empathy; B) Variety of influenceability strategies- i) Observational learning: Most of the participants considered it as important strategy in professionalism, ii) Learning from feedback: It was the next learning method of professionalism identified; C) Influenceability to various resources- Majority of the participants expressed that the following health professionals were of great resource to them pertaining to learning. They were i) Nurse educators, ii) Nurses and head nurses, iii) Physicians, iv) Peers, and v) Patients¹⁷.

 

Evidences demonstrating undesirable learning experiences for nursing students:

There is no two opinions globally as to the vital role of clinical experience can play in the development of the skills, attitude and knowledge of nursing students.  A literature review using articles from 2003 to 2012 regarding analysis of nursing students learning experiences in clinical practice at South Africa was performed.  Themes emerged were: a) Theory practice gap: Students reported disparity between what was learnt in the classroom and simulation laboratory and the actual practice in the clinical environment; b) Task involvement, participation and opportunities for learning: Responses from students that they were doing routine tasks and sometimes non-nursing duties. Lack of challenging opportunities for students to be able to learn critical and clinical judgment skills; c) Clinical supervision and support: Students felt that this role was not satisfactory as clinical nurse educators take more of a role of evaluation than supervision, d) Feedback: Students expressed concern that feedback was always negative with poor communication that lead them feel demotivated; e) Conducive clinical learning environment: Relationship problem were highlighted including staff being unfriendly, with bad attitude, hostile and denying opportunities to learn¹⁸. This study finding reveals that learning experiences were given to the students but it was not desirable. Many studies have demonstrated almost same findings. Another qualitative study has similar findings. It was conducted by Sharif F and Masoumi S with 90 randomly selected students nursing students’ experience of clinical practice at Iran. Four themes were emerged: a) Initial clinical anxiety: Almost all students had identified feeling anxious in their clinical placement. Worrying about giving wrong information to the patient was the main issue; b) Theory practice gap: Almost every student described in some way lack of integration of theory into clinical practice; c) Clinical supervision: Majority of the students’ had the perception that their instructor’s have a more evaluative role than a teaching role; and d) Professional role: Student nurses expressed that often they thought that their work was not really professional nursing¹⁹. These results imply that nurse educators are expected to design strategies for more effective clinical teaching. As role modeling relies heavily on imitation and observation, both positive and negative behaviors can be easily adopted by the students.

 

A vision of unity:

It is not the lack of unity that is killing us; it is the lack of vision. Nurses must seek professional unity and respect through education. Florence Nightingale valued education and stressed that nursing is calling, a profession that requires commitment, compassion and conviction. Without higher education, nurses will lack the vision and skills required in modern nursing practice. It is up to us to pursue a vision for future and doing this together is the best way. The benefits of unity are resource sharing, knowledge exchange, community presence and trust, opportunity for community cohesion, shared responsibility, collective bargaining and mitigates group thinking.

 

CONCLUSION:

Nurses should tighten their knots of relationship among the nursing community to maintain the standards of our profession and professionalism as well. Professional nurse autonomy can be magnified only when they are competent with skills fortified with sound knowledge base. The role of nurse educator is challenging in providing desirable learning experiences during the course of learning that is uniform to all students. Meticulous planning of learning experiences ultimately results in strengthened students learning, professionalization and socialization into the professional role.

 

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4.     Reid B. Be we’re doing it already! Exploring a response to the concept of reflective practice in order to improve its facilitation. Nurse education today. 1993; 13(4):305-309.

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15.   Atakro CA, Gross J. Preceptorship versus Clinical teaching partnership: literature review and recommendations for implementation in Ghana. Advances in Nursing. 2016. http://dx.doi.org/10.1155/2016/1919246.

16.   Williamson E, Stecchi JM, Allen BB, Coppens NM. Multiethnic experiences enhance nursing students learning. Journal of community health nursing. 1996; 13(2): 73-81. Published online 07 June 2010.

17.   Karimi Z, Ashkttorab T, Mohammadi E, Abedi HA. Using hidden curriculum to teach professionalism in nursing students. Iran Red Crescent Med J. 2014; 16(3): e15532.

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Received on 04.10.2018       Modified on 11.11.2018

Accepted on 03.12.2018       ©A&V Publications All right reserved