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Kathleen Ryan is the Acting Nurse Educator for the Cardiothoracic Nursing Course at St. Vincent's Hospital Sydney. |
Two different approaches to education and curriculum design are examined and applied to post graduate certificate courses and clinical education. The approaches are behaviourist where objectives are formulated and learning experiences are planned to meet them, and problem based learning where contextual problems are set as the basis for students' knowledge acquisition. The latter approach is preferred as it encourages the development of critical reasoning rather than arms the student with facts.
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Why won't nurses take responsibility for their own professional development and on-going education? Perhaps teaching strategies and curriculum designs of nursing education are not conducive to adult learning and the development of self-directed learning skills.
In an endeavour to answer this question, two different approaches to education and curriculum design have been examined and applied to both post-graduate certificate courses and clinical education. In reviewing current literature on nursing education and in particular, the curriculum revolution which de Tornyay (1990: 292) depicts, one may assume that the traditional behaviouralist model of curriculum has long been abandoned in all nursing education. However in reality, I have found this not to be true. In hospital-based, post-graduate certificate courses, there is a strong emphasis on behavioural objectives and students utilise these objectives to guide their theoretical study and clinical practice. As the behaviouralist approach to curriculum design is tangible for me, 1 feel it appropriate to examine this approach and compare and contrast it to the problem-based learning. Before examining individual curriculum designs or educational approaches, it may be advantageous to explore the expected goals of curricula.
Greaves (1987: 10) believes the intention and purpose of nursing curriculum should be educationally valuable and creditable. In addition to the educational preparation of nurses, the curriculum aims to prepare nurses on an occupational and professional basis.
There appears to be a consensus of opinion that nursing curriculum reflects a philosophy of nursing that meets the current and future need of society for health care (Orb & Reilly, 1991: 56). Presently in Australia there is an emphasis on preventative and community health medicine. Acute care hospitals are too expensive to maintain and in New South Wales some of the traditional, large teaching hospitals are under threat of closure or privatisation. Nurses educationally prepared to work in acute care or general hospitals are suddenly faced with seeking employment caring for the aged in a nursing home or in the community nursing setting. The question must be asked, have these nurses the appropriate skill to deliver safe, effective nursing care in these settings?
De Torynyay (1990: 293) cautions that despite the majority of health care being community-based in the future, there will be a continued need for hospitals to care for the acutely ill and that well prepared nurses will be required to function effectively in a variety of health care settings. To achieve this goal is it appropriate for all nursing education to embrace one "master curriculum" which will fulfil all societal health care needs?
Traditionally, and in some institutions currently, curriculum design utilising objectives has been employed to prepare nurses educationally and professionally.
Objectives provide broad statements for the expected outcome of an educational programme (Yura, 1985:5). The objectives should be achievable and reflect the philosophy of nursing if they are to be successful in preparing nurses to perform the activities of their professional role (Conley, 1973: 225). Conley (1973: 221) also emphasises the importance of identifying the behaviours which students should demonstrate on completion of an educational programme. These identified behaviours become the specified objectives of curriculum and are referred to as "terminal behaviours". These behaviours should flow from the objectives of the nursing programme and are measurable through fillment of the stated objectives. Sockett (1976: 38) states that, planning a curriculum using objectives implies specificity and what the students are to achieve is stated in advance. In this curriculum design the objectives are formulated and all learning experiences are then specifically planned to realise the stipulated objectives (Yura, 1986: 7). A curriculum approach which contrasts to the objectives design is problem-based learning.
Problem-based learning allows for structuring of a course with proposed problems as the focus for the students activities. With the assistance of teacher support and relevant learning material, the students progressively acquire knowledge and skills through dealing with a succession of contextual problems (Boud & Feletti 1991: 14). This contextual based learning allows the students to apply their new-found knowledge directly to a problem they will encounter in their professional lives. The significance of what has been, or is to be learnt is clearly demonstrated, hence providing enhanced motivation for learning. Facts are not committed to memory to be applied to practice at a later date (Barrows 1985: 2). Barrows emphasises the three major broad objectives problem-based learning when applied to a medical curriculum are:
These educational objectives could also be applied to nursing education as is the current practice in the faculty of nursing at the University of Newcastle (Brown, 1992).
The acquisition of self-directed learning skills is of paramount importance in the nursing profession to prepare nurses for the rapidly changing practices in health care services. Curriculum developers must look to, and to some extent, predict the future in an endeavour to adequately prepare nurse practitioners. To focus only on current issues, or the past, would indeed be short-sighted and self-limiting and may have serious repercussions for people requiring the services of health professionals (Yura 1986: 3). Rush et al. (1991: 121) believe that nurse educators have attempted to keep pace with societal trends by shuffling the substance of the curriculum but have failed to address the issue of curriculum design. Preparing for unidentified future requirements of nurses as health care givers, requires the student to learn effective problem-solving strategies throughout their professional life (de Tornyay 1990: 293). Curriculum developed utilising the problem-based learning approach, foster, the procurement of self-directed learning skills which will enable the nurse to keep abreast of societal trends and the changing demands on the health care system and hence the nursing profession. Barrow (1985: 3) reiterates that no school or teacher is capable of teaching a student all the necessary knowledge, facts and skill which they will require for their professional lives; therefore the skill of self-directed learning is essential.
In order to apply either of these curriculum/educational approaches to hospital-based, post-graduate nursing courses and clinical education, it is important to examine the design principles and the advantages and disadvantages of both. Although objectives are common to both curriculum approaches, the way in which the objectives are formulated and utilised contrasts the two systems. Behavioural objectives direct learning to a specific level of knowledge or acquisition of a specific skill to be demonstrated by the student at a particular point in time. by anticipating the results of learning, both the student and the teacher can be restricted, which may be a problem when setting behavioural objectives to prepare nurses for the future (Creaves, 1987: 19). Objectives in problem-based learning while allowing students to know what is expected of them, also specify the process, that is, problem-based learning. The impetus for learning also contrasts these two curriculum. The objectives approach concentrates on facts and concepts to be learned, whilst the problem-based learning approach proposes a problem and allows the student to identify their own learning needs. All these factors must be taken into consideration when applying a particular curriculum or educational approach to the post-graduate nursing courses and clinical education.
Yura and Torres (1986: 173) stress that a curriculum must focus on the future and prevent the preparation of nurse whose practice is obsolete shortly after graduation. The emphasis on specific skills and knowledge within the behavioural objectives curriculum design cannot predict the future. Many of the specific terminal behavioural objectives in the current nursing education will become obsolete in the foreseeable future. Therefore, why is there such a heavy emphasis on any one aspect of nursing practice? While problem-based learning will not enable the future to be predicted it does encourage the development of critical reasoning and an analytical approach to problems (Engel, in Boud and Feletti, 2992: 24). For graduate nurses equipped with these skills, patient care becomes individualised and holistic. This type of programme appears to be ideally suited to post-graduate nursing courses and clinical education. In these situations there are small numbers of learners who have had previous experience dealing with patients and patient problems, have acquired a broad knowledge base and are adult learners. Problems which may inhibit the successful implementation of a problem-based learning programme are the previous experience of teachers and learners since the role of both teacher and learner in problem-based learning is very different to traditional education.
In traditional education the learners feel secure with specific behavioural objectives to guide their learning and are somewhat threatened by the notion of identifying their own learning needs and adopting self-directed learning. The teachers are accustomed to giving students information which they feel is necessary for the student to know. In problem-based learning the teacher must guide or facilitate learning, not dispense information, and students must progressively assume responsibility for their own learning (Barrows, 1985: 18). The educational preparation of nurses at all levels needs to embrace the principles of adult learning. These principles include:
The learning experience where adult learners often thrive is problem centered, real life, and addresses pertinent topics (Fuszard, 1989: 4).
Problem-based learning may not be the appropriate preparation for all nursing education. For example, problem-based learning may not be applicable for nurses engaged in preventative medicine where the focus is on prevention and health promotion rather than problem resolution (Drinan, in Boud & Feletti, 1991: 317). However, the hospital-based post graduate nursing courses are preparing nurses to function in an acute care setting, and hence, I feel, the problem-based learning would be the most appropriate approach. To be successful the teacher needs to be an expert in learning rather than an expert in all aspects of acute care nursing, therefore teaching the students effective learning strategies as the nurses skill of self-directed learning will be used throughout their lives (Engel, in Boud and Feletti, 1991: 23).
Self-directed learning skills are also of paramount importance in clinical education were nurses must take responsibility for their own learning and be accountable for their own nursing practice. It is simply not acceptable to blame the Clinical Nurse Educator if you are unable to perform a particular task. Likewise Clinical Nurse Educators cannot be responsible for teaching every nurse every clinical skill they require during their nursing career.
The Clinical Nurse Educator is a resource person to facilitate learning and teach learning skills, she/he is not just a transmitter of knowledge and information and should not be depended upon as the font of all knowledge and skills and the fixer of all problems (Blackford, 1992). The Clinical Nurse Educator could utilise the principles of problem-based learning to enhance nurses participation in their own professional development with the acquisition of critical analyses, problem solving and self-directed learning skills.
Nurse Educators and Clinical Nurse Educators need to formulate innovative teaching strategies which allow the learning process to enhance self-directed learning skills, embrace the principles of adult learning and be pertinent to current nursing practice. While the traditional behaviourial objectives educational approach and curriculum design appears too restrictive, it is the Problem-Based-Learning approach which allows the application of these principles in the teaching/learning process. Education becomes an active discovery of reality not merely providing the learner with ready made truths (Henderson, 1992).
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