Behaviourism

Behaviourism as a theory of learning was dominant in the 1960s. Its origins lie with the Russian psychologist, Pavlov, and the American behavioural psychologist, Skinner.

Classical conditioning is the type of learning made famous by Pavlov’s experiments with dogs where Pavlov found that if he rang a bell and at the same time fed the dogs, the dogs began to associate the sound of the bell with food. Eventually the dogs would salivate when they heard the bell despite not receiving food. This is called a ‘conditioned response’.

Skinner’s experimental work involved rats, pigeons and latterly humans. Skinner found that rats or pigeons placed within a cage-like box containing a food tray and a lever to release food would demonstrate trial and error behaviour until the lever was pressed. Over time, the animal learned the connection between pressing the lever and the release of food. Skinner’s work led to what is known as ‘operant conditioning’, by which a new behaviour can be taught assuming that rewards are related to the learner producing successive approximations to the desired behaviours.

Behaviourists assert that memory is the result of strengthening of associations between a stimulus and a response. It therefore follows, according to behaviourists, that almost all kinds of learning can be described and explained in terms of the gradual learning of stimulus and response. A stimulus is equivalent to an event, person or thing in an environment, whereas a response is something that the learner does. The theory of stimulus–response in learning is most useful in providing advice regarding how to teach simple knowledge and skills, and has also made a valuable contribution to training programmes for people who have a learning disability (Bastable 2003).

Any event that increases the probability of a piece of behaviour being displayed by the learner is called a ‘reinforcer’. Skinner proposed that by providing reinforcement to an individual in a particular situation displaying certain behaviour, they would be more likely to display this behaviour again when in a similar set of stimulus conditions. For example, when training an animal to perform particular tasks, the teacher looks for behaviour consistent with what is desired and positively reinforces that until the animal displays the desired behaviour. This technique is called ‘shaping’. Following shaping, prompting or guiding, or ‘chaining’ can be commenced.

Once each component of a task has been learned, the steps have to be joined together into a sequence so that completion of the first step becomes a stimulus signal-ling the second step, and so on. Backward chaining can alsobe useful, particularly when teaching children and peoplewith a learning disability (Box 4.1).

The learner is presented with a task with all the steps completed except the last one, which they must complete and the process of completion then reinforces the behaviour. In this way, the individual gains instant satisfaction of completing the task and is more likely to have a positive learning experience. In this type of learning it is important to use social reinforcement along with praise for completing the task because social approval is very powerful. Social reinforcers include non-verbal communication such as smiling, eye contact, winking, physical contact such as a hug or pat on the back, nodding or clapping (see Ch. 9). Social reinforcement can be particularly effective with children and young people and to some adults when given by people whose opinions are valued or respected (Box 4.2). It is vital that any form of social reinforcement is:

These Skinnerian techniques are reputed to be most effective in teaching social skills. They can also be used to decrease the occurrence of undesirable behaviours. To summarize, behaviour which is rewarded is likely to be repeated; conversely, behaviour which is ignored is likely to fade.

Another strategy to use in order to reduce behavioural problems is positive programming. LaVigna and Donnellan (1986) suggest this is the preferred strategy and provide an example of an individual who hits staff. Firstly, this behaviour needs to be seen within the context of the setting so that a judgement can be made as to whether it is inappropriate. Assuming it is, the reason for such behaviour needs to be identified. In this case, the individual hits staff when he’s engaged in an activity that he does not enjoy and hits out to signal that he wants a break. Using the positive programming strategy, the individual is provided with a card that says ‘Break’ and told that when he shows this to staff, they will allow him a 5-minute break before resuming the activity.

Cognitive theories of learning

Cognition relates to the mental processes involved in thinking, perceiving, problem-solving and remembering. The mainstay of cognitive theory is that thinking and reasoning play a major part in how people learn. Reinforcement is not an automatic process but rather the learner realizes the benefits of adopting certain behaviours. Through paying attention, the learner selectively observes and extracts what they perceive as valuable components of behaviour. Proponents of cognitive theory argue that people learn from experience, by ‘doing’, and that this learning is then inserted into their framework of existing knowledge. The act of doing involves repeated practice and the provision of reinforcement or rewards encourages further learning.

Gestalt learning theory is a form of cognitive theory that emphasizes that it is important to view the whole when learning rather than taking a reductionist approach which involves looking at small parts that make up the whole. For example, when teaching a skill it is best to demonstrate the whole procedure at normal speed so that the learner can gain a holistic view of what is expected. Thereafter, the skill is usually broken down into its component parts in order to learn. The aim is that, with practice, the learner will be able to perform the whole skill competently.

Another form of cognitive theory is the assimilation theory developed by Ausubel et al (1978). It is aptly named because it emphasizes the importance of integrating new knowledge with existing knowledge. Just before the preface of Ausubel et al’s (1978) book is an often-cited quotation by Ausubel:

Humanistic theories of learning

These emerged in the 1950s and 1960s from individuals such as Abraham Maslow and Carl Rogers. Both Maslow and Rogers rejected the behaviourist theory that human beings were unthinking and can be shaped and programmed by patterns of rewards and punishments. Instead they focused on people’s potential, believing that humans strive to reach the highest possible level of achievement.

Maslow (1954) is best known for developing the hierarchy of needs which is important in respect to learning as these needs play an important role in motivation. The hierarchy is usually presented as a pyramid with the most basic needs (physiological) at the base. The key aspect of Maslow’s work is that, before someone can learn effectively, their most basic needs must be met. For example, if people are hungry, thirsty or in pain they are unlikely to be able to concentrate in order to learn. The next layer in the pyramid relates to safety needs. If learners’ physiological needs are met but they fear for their physical or psychological safety, then their learning will be impeded.

The third layer relates to the need to belong and be loved. Even if the previous two levels are met, if a learner feels excluded from a group, this will affect their learning because their belonging and love needs will not be met. The fourth layer relates to esteem. Despite having their belonging and love needs met, if they perhaps ask a question and someone ridicules them for asking a silly question, then that too will affect their learning as their self-esteem needs would not be met. Individual self-esteem needs can be met through recognition, acceptance, praise and a belief that others acknowledge their worth. The final layer in the pyramid is called self-actualization. This, according to Maslow, is the highest form of achievement where the learner achieves their full potential.

Rogers (1994) argues that human beings have a natural potential for learning, which is most significant when what is to be learned is perceived as relevant and the learner is active in the process. Furthermore, Rogers argues that self-concept and self-esteem are necessary during any learning experience. The most lasting form of learning, according to Rogers, is that which involves the learner being self-directed. In other words, the self-directed learner is motivated to explore a topic at their own pace and in their own time and relishes the experience of being independent and creative. If, however, learning involves a change in someone’s behaviour or is viewed as a threat to how they organize themselves or to the way they live, it is often resisted. That is why, for example, attempts to change one’s eating habits or sedentary behaviour can be very difficult to achieve.

Rogers (1994) developed ‘client-centred therapy’ in which he aimed to provide his clients with the knowledge and skills necessary to find their own solutions to their problems rather than being told what they should do. Roger’s work led to what we know today as student-centred learning. This involves the teacher being the facilitator of learning: guiding students on how to learn, fostering their enthusiasm, initiative and responsibility, and providing them with a variety of learning experiences through which they can discover and learn. Student-centred learning is defined by Cannon (2000, p. 2) as ‘ways of thinking about learning and teaching that emphasize student responsibility for such activities as planning learning, interacting with teachers and other students, researching and assessing learning’. It also encourages the use of group learning so that, as well as having peer support, students also learn about working in teams (Bastable 2003). Learning how to work effectively as a team member is a fundamental skill for all healthcare professionals.

Andragogy

Malcolm Knowles coined the term ‘andragogy’ at the end of the 1980s to differentiate it from ‘pedagogy’. Pedagogy, in its strictest sense, relates to how children learn. The word pedagogy is derived from the Greek words paid, meaning child, and agogus, meaning leader of, and therefore pedagogy literally means the art and science of teaching children. Pedagogy involves:

Andragogy is about how adults learn. Knowles et al (1998) argue that adults learn best when they are involved in doing something or are active in the process. In short, andragogy reflects a student-centred approach to learning. Being active in the learning process facilitates the formation of meaning and provides depth to understanding. Knowles identified certain characteristics in respect to adult learning. Adults need to know why they should be learning something and how it will be beneficial to their work or other facets of their lives. Adults’ approach to learning is more problem-solving in nature as opposed to subject-centred. Adults prefer to take charge of their own learning or, in other words, to be self-directive and responsible. Adults use their varied life experience as a rich resource for learning and connect any new learning to their existing knowledge and experience. When planning any educational activity involving adults, it should be underpinned by adult learning principles (Box 4.3).

In relation to the principles of adult learning, or andragogy, the models of experiential learning by Kolb (1984) and Race (1993) are now explored.

Kolb’s experiential learning cycle

Kolb (1984) presented a model of learning consisting of four phases, known as Kolb’s experiential learning cycle (Fig. 4.1). The cycle is based on the premise that people learn much more effectively when they are encouraged to be active in the process. Kolb suggests that learning results from two things: the way an individual perceives and the way the individual processes what they perceive. Kolb (1984) suggested that learning styles are composed of a combination of the four phases in his experiential learning cycle. He stated that individuals perceive either through concrete experience or through more abstract concepts and that they process information in one of twoways: through active experimentation or through reflec-tive observation.

Fig. 4.1 Kolb’s experiential learning cycle (reproduced from Kolb 1984)

Concrete experience

This phase starts with a concrete experience in that the individual begins by doing something. During the concrete experience, learners are actively involved and tend to rely on their feelings rather than using a systematic approach to problems or situations. According to Mills (2002) during concrete experience individuals use all five senses: sight, smell, touch, taste and hearing in order to deal with the obvious, i.e. the here and now.

Reflective observation

During this phase the learner requires to take time out to consider, or reflect, on what has happened during the concrete (or doing) phase. The learner relies on objectivity and careful consideration to search for meaning by studying things from a variety of different perspectives and asking questions (Bastable 2003).

Abstract conceptualization

This phase involves trying to make sense of what has happened. It involves individuals visualizing, using their imagination and conceiving ideas to move beyond the obvious to uncover the more subtle implications (Mills 2002). The learner makes comparisons between what they have done and what they have reflected upon, and draws on their existing knowledge. Learners may draw on theories, models and previous observations and experiences. During abstract conceptualization, learners tend to rely more on logic and ideas in regard to problems or situations rather than on their feelings (Bastable 2003).

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Active experimentation

This is the final phase of the cycle where the learner considers what they have learned and how they are going to implement it into practice. In other words, they place what they have learned into context so that it is both meaningful and useful to them (Bastable 2003).

Summary

The above way of thinking about learning follows the principle that learning is continuous, as people continually test out new ideas in practice and adjust their ideas and behaviour in light of their experience. Kolb highlighted two particular aspects:

• The use of ‘here and now’ experiences to test ideas

• The use of feedback to change practices and theories.

At this point it may be useful to think about an example (Box 4.4).

Box 4.4 CRITICAL THINKING

Learning to ride a bicycle

Student activities

• Access the following website and follow the example of learning to ride a bicycle: www.humanoptions.com/natural.html.

• Having read the example, think about any skill that you have recently learned using the process described in how to learn to ride a bicycle.

• Think about a nursing skill you have recently learned, or are still learning, following this process.

Race’s ripples model

Race, a British educationalist, presented his alternative experiential model of learning in 1993. This model is also based on experiential learning – or ‘learning by doing’ – and reflects Kolb’s view that by receiving feedback from others and reflecting on one’s learning is of paramount importance to the learning experience. Race’s model consists of four elements (Fig. 4.2), which together constitute successful learning. Race’s model differs from Kolb’s because, rather than using a cycle, Race’s model involves four processes that interact with one another rather like ripples on a pond.

Fig. 4.2 Race’s ripples model (reproduced with permission from Race 1993)

Wanting

This is the central process and lies at the heart of the model. Race believes that wanting or needing to learn is crucial to the internal motivation that drives the learner in the first place. Motivation ripples out from the heart of the model into the surrounding layers.

Doing

From wanting or needing to learn the next process is doing, which corresponds with the belief that adults learn best by doing or being active in the process.

Digesting

This has parallels with the second stage in Kolb’s cycle as both involve the learner reflecting on their experience in order to make sense of it and developing a sense of ownership.

Feedback

The fourth process is feedback. Receiving timely feedback is viewed as essential since it is important to the quality of the learning experience to see both the results of one’s learning and to obtain feedback from others regarding how effective it was. According to Race’s model, feedback is as crucial as the central process of needing and wanting.

Summary

Figure 4.2 suggests that motivation ripples outwards in successive layers, with positive feedback sending the ripples back towards the centre; this in turn has a positive effect on needing and wanting. The position of feedback on the outside ring of the model symbolizes the fact that feedback is gained from external sources (teachers, peers, self-assessment) and needing and wanting are derived internally. In between these two are ‘doing’ and ‘digesting’, both of which are influenced by internally generated needing and wanting as well as by externally generated feedback.

Now carry out the activities in Box 4.5.

Box 4.5 CRITICAL THINKING

Models of learning

Student activities

• Focusing on Figures 4.1 and 4.2, think about how you learn.

• Which of these models best matches how you learn?

Learning styles

The term ‘learning styles’ refers to the way in which individuals choose to learn. According to Bastable (2003), learning style models are based on the idea that certain characteristics of learning styles are biological in origin, while others are developed as a result of environmental influences. Different people have different learning needs and bring their own individual knowledge, experience and resources to the learning process and learn in different ways. It is important to be aware of the differing learning styles because it is recognized that people learn better and more quickly when teaching methods match their preferred learning style. When someone learns successfully, their self-esteem increases, which in turn has a positive effect on their learning. Honey and Mumford (1992) built on Kolb’s work and identified four learning styles or learning preferences that individuals naturally prefer to use: activists, reflectors, theorists and pragmatists (Fig. 4.3). You should consider the activity in Box 4.6 as you read the remainder of this section about learning styles.

Fig. 4.3 Honey and Mumford’s learning styles (reproduced from Honey & Mumford 1992)

Deep, strategic and surface learning

Another facet to learning styles is the depth of effort to which learners exert themselves. Different intentions lead to contrasting study strategies and learning experiences. People do not usually just adopt one approach but rather, based on the circumstances, choose the approach that most suits a particular set of circumstances. Using deep or strategic approaches is associated with a better quality of learning (Table 4.1).

Table 4.1 Characteristics of surface, strategic and deep learning approaches (after Ramsden 1988)

Reflection

Essentially reflection is an active, conscious act in which an individual examines their experiences, beliefs, values, behaviour and knowledge that leads to a new understanding and appreciation of the situation which prompted the reflective process (Boud et al 1985). It is a process that involves looking beyond the immediate situation and delving below the surface in order to provide care relevant to the particular context of the patient or client. Stepping back in this way informs practice, creates learning and brings new meaning. From that understanding, judgements can be made on how to ensure one’s practice is based firmly on evidence.

Dewey (1933) initially brought the idea of reflection to nurses’ attention. In the 1980s, Schon’s work highlighted the central role of reflection in professional practice, predominantly in teaching and nursing (Foster & Greenwood 1998). Schon (1983) described reflection as having two constituents:

Greenwood (1993) added a third dimension to reflective practice – ‘reflection-before-action’. Greenwood argued that reflection-before-action was important as it related to practitioners reflecting about what they intended to do before they actually did it and in this way minimize the risk of making errors.

Reflection is therefore the process of examining and thinking about what we do within the context of the world around us. Reflection is more than just describing what we do or an event that occurred. It goes beyond that to thinking about why we do things, whether they have gone as intended, why they did or did not go well and/or why and how we might do things differently the next time.

Models of reflection

There are several models of reflection and three are considered below. They all contain the same principles but are differentiated by the level of detail they provide.

Gibbs’ reflective cycle

Gibbs (1988) presented a reflective cycle as a way of providing structure for practitioners to follow when reflecting. It consists of six sequential steps, beginning with the description of an event through to producing an action plan for future practice (Fig. 4.4A).

Fig. 4.4 Models of reflection. A Gibb’s reflective cycle (reproduced from Gibbs 1988). B Atkins and Murphy’s framework for reflection (reproduced from Atkins & Murphy 1993. The work is also available from www.glos.ac.uk)

Atkins and Murphy’s framework for reflection

Atkins and Murphy presented the framework for their reflective model in 1993 (Fig. 4.4B) and is more detailed than Gibbs’ model. This model emphasizes the skills used in the reflective process, namely:

• Self-awareness (see Ch. 9)

• Description

• Critical analysis

• Synthesis

• Evaluation (see p. 109).

When using Atkins and Murphy’s model it is important to recognize that the first step of awareness of uncomfortable feelings and thoughts can be stimulated by positive as well as negative experiences. For example, during a teaching session it becomes apparent that evidence demonstrates that an aspect of care you have been performing in practice is no longer appropriate. The experience is positive in that the teaching session involved disseminating up-to-date good practice, but it also produced uncomfortable feelings as the evidence supporting the new practice was more than 6 months old and in that time you have been practising unaware of the new evidence.

The final step in Atkins and Murphy’s model is also action as in all reflective models. Finishing a reflective account with an action plan is a fundamental premise because, as a practice-based profession, nursing is about seeking to learn from experience in order to improve practice.

LEARN framework for reflection

The College of Nurses of Ontario, Canada (1996) developed this framework. It is presented as a cyclical process containing the five steps that should occur during the process of reflection. LEARN is an acronym for these five steps (see Box 4.8).

Box 4.8 REFLECTIVE PRACTICE

[Reproduced with permission from the College of Nurses of Ontario]

Using the LEARN framework

Step 1 Look back at an experience or event that has happened in your practice recently. Review it in your mind as if you were watching a video.

Step 2 Elaborate and describe, verbally or in writing, what happened during the event. How did you feel and how do you think others felt? What were the outcomes? Were you surprised by what happened during the event or did it turn out as you expected?

Step 3 Analyse the outcomes. Review why the event turned out the way it did. Why did you feel or react the way you did and why did others feel/react the way they did? If the event or outcomes were not what you expected, consider how you could improve on them next time. This is an opportunity to really question your beliefs and assumptions, and ask yourself what the experience reveals about what you value. It is also a great time to ask for feedback from others.

Step 4 Revise your approach based on your review of the event and decide how, or if, you will change your approach. This might involve asking others for ideas for dealing with the situation next time or how to work on a learning need. With your new learning, you may decide to try a new approach, learn more about the subject, or decide that you handled the situation very well.

Step 5 New trial. Put your new approach into action. This may require anticipating or creating a situation in which you can then try out your new approach.

Student activity

Think of a scenario or an incident which you have either observed or been involved in while on practice placement and work through it using the five steps of the LEARN framework.

Motivation

Motivation influences what people do (if there is a choice), how long they do something and how well they do it. Motivation is a key factor in successful learning and is a central feature in most theories of learning. Without motivation learning does not take place, as we need to be motivated enough to pay attention while learning. There are two sources of motivation:

Internal, or intrinsic, motivation arises from within the individual and is made up of personal factors that make them want to learn. Internal motivation is longer lasting and more self-directive than external motivation. This is because praise or concrete reward or incentive must be provided repeatedly to reinforce external motivation (see ‘Behaviourism’, p. 99). For individuals who are externally motivated, the desire to learn is secondary to the reward gained from learning. According to Knowles et al (1998), adults’ motivation to learn is largely internally generated through self-esteem, quality of life and job satisfaction. Adults who are motivated to seek out learning experiences do so primarily because they have a use for the knowledge or skill being sought.

Since motivation is essential to learning it is important to be aware of the factors that enhance and diminish it, since there are many barriers to motivation. Factors that enhance and sustain motivation include a warm and accepting learning environment, incentives such as praise, feedback and knowledge of one’s progress, and the way in which learning materials are organized. As can be seen from Box 4.14, the factors associated with diminishing motivation are more numerous than those which enhance it. The best way, therefore, to motivate adult learners is to enhance their reasons for learning and decrease the barriers.

When thinking of motivation related to patient/client education, additional barriers must also be considered. The individual’s perception of their state of health can shape their motivation to learn as can their stage of development (Ch. 8) and ability to understand (Ch. 9). Confusion, pain, lack of sleep, noise, interruptions or lack of privacy can interfere with a patient’s/client’s ability to concentrate and therefore learn. The nurse as teacher who is insensitive to people’s cultural, spiritual and/or social needs can also diminish motivation to learn (Box 4.15).

Readiness to learn

‘Readiness to learn’ means that a learner is receptive and wants to engage in the learning process. In other words, they are motivated and able to learn. This is usually signalled by the learner asking a question and is crucial to the learning process – if an individual is not alert and motivated, learning will not occur. Nurses need to be alert for these signals, or cues, from their patients/clients. Coates (1999, p. 75) presents four groups of factors affecting readiness to learn:

Readiness to learn influences the timing of useful teaching. Patients/clients are generally more receptive to information about their illness shortly after diagnosis or prior to treatment and want information that is immediate and personally relevant (Bastable 2003). There are a number of ways in which relevant information can be imparted and at a time when readiness to learn is often at its highest. For example:

Bastable (2003) presents four types of readiness to learn and uses the acronym PEEK to describe these:

All of these should be considered as they can have an adverse effect on the degree to which learning will take place.

Assessment of physical readiness is important, espe-cially when the proposed learning requires physical strength or capability. For example, learning to walk with crutches requires physical strength and coordination, learning to inject a drug requires fine motor skills and good vision. Children or people with a learning disability who are learning to do up buttons also need fine motor coordination. Learning also requires the individual to be alert and have enough energy to concentrate (Bastable 2003).

Emotional readiness relates to a number of areas. For example, a little anxiety can motivate learning but undue levels are counterproductive. If patients/clients are scared or anxious about something they have to learn, this must be managed before learning can begin. For example, learning to self-administer injections may produce fear because of the necessity to inflict pain on oneself. Furthermore, fear and/or anxiety may cause patients or clients to deny the existence of their illness, which severely limits their readiness to learn. Emotional readiness also extends to students and ‘fear of the unknown’ often causes them anxiety. Despite mentors orientating nursing students into a new placement, students’ high anxiety levels may mean that although they are listening to what is being said, they may be unable to hear what is actually being said.

Experiential readiness is related to individuals’ past learning experiences and whether these have been positive or negative. Someone who has had previous poor learning experiences is unlikely to be motivated or willing to risk trying to acquire new knowledge or skills. According to Bastable (2003), experiential readiness involves the level of aspiration, past coping skills, cultural background and motivation.

Knowledge readiness relates to the individual’s current knowledge, their level of learning capability and their learning style. It is important to establish the individual’s knowledge base, as teaching what is already known is boring, demotivating and can be construed as insulting. Teaching should move from the known to the unknown. For example, when teaching a patient about their diabetes and the need for insulin, the nurse could ask them whether they already know that many people with diabetes require insulin. If is the case, moving from the known to the unknown could be explaining that the reason why insulin must be injected is because it is broken down and digested if taken orally and therefore would not work if given in tablet form.

Cognitive ability should be assessed because factors such as developmental stage, illness, dementia or learning disability can impair this to an extent that explanations need to be broken down into simple and smaller steps with frequent repetition built in. Simple language should be used. Including pictorial information can enhance understanding and convey meaning more readily. Nurses must seek ways to help individuals with a learning disability overcome any problems with processing of information (see below).

Individuals disadvantaged when considering information needs

Consideration requires to be given to people with particular needs, e.g. those who use wheelchairs, those with visual or hearing impairments (see Ch. 16), those with mental distress or illness, and those with learning disabilities. With a little thought, the needs of people with such difficulties can often be easily met. For example:

Computers are another learning tool that can be used for many people, particularly since technology permits accessibility, i.e. the ability to access material regardless of a person’s needs. They can be used in various ways such as accessing the Internet to find information and sending email messages to experts so that individual questions can be answered.

The learning environment

Regardless of where learning takes place – at university, in placements, clinics or day centres – creating a supportive environment is essential to successful learning. A supportive or conducive learning environment:

Anxiety has a direct bearing on an individual’s ability to learn as, physiologically, the stress response limits ‘the available nutrients for learning. This limits the connections between neurones resulting in slow thinking and depressed learning. Even short spans of stress will destroy a learner’s ability to distinguish between important and unimportant information’ (Dwyer 2001, p. 313). A conducive learning environment includes acquaintance of group members and this is why many courses start with ice-breaking exercises. Over time, the peer group develops cohesion in which each member begins to feel secure and knows that their contributions will be valued.

In applying Maslow’s hierarchy of needs to the educational environment (see p. 101), Hutchinson (2003) explains that an individual’s physical needs must be met first. Being in a cold or overheated room, sitting for long periods without adequate breaks or struggling to hear because of background noise all impinge on the ability to relax and pay attention. In terms of safety, Hutchinson (2003) points out that all those involved in teaching need to ensure that the learning environment is safe enough for learners to feel able to voice concerns or ask questions. Fostering mutual respect and acknowledging that learners’ self-esteem and pride can be injured through humiliation and lack of sensitivity can enhance the latter. Mutual respect also falls into Maslow’s belonging level by ensuring that all learners have their voice heard and their presence acknowledged. Additionally it is important to include and consult learners about planned and actual learning experiences. Self-esteem needs are met by providing feedback to make them feel valued. As Hutchinson (2003, p. 811) states, ‘praise, words of appreciation, and constructive rather than destructive criticism are important. It can take many positive moments to build self-esteem, but just one unkind and thoughtless comment to destroy it.’

Stuart (2003) identifies four categories that make up what is often a complex learning environment, namely:

At university, academic staff are responsible for creating a good learning environment and many institutions use a personal tutor system where a named lecturer guides and supports learners through their programme by providing feedback on draft assignments and one-to-one discussions regarding their personal and professional development.

In practice settings, ward managers, members of the multidisciplinary team and mentors are responsible for creating and fostering a supportive learning environment. Mentors play a pivotal role in supervising, supporting, facilitating and assessing students’ learning. In addition, healthcare assistants, patients/clients and their carers and families can also be sources from which to learn. An effective mentor is a good role model who has the ability to enhance the learning experience by being approachable, planning a variety of different learning experiences and maximizing learning opportunities. They appreciate the need to provide detailed feedback on how their mentee is progressing and offer guidance and support to improve their practice (Gray & Smith 2000). The same characteristics apply to any teaching, including that involving patients and clients.

Action learning

Action learning describes a way of learning in which a group of people set about solving a problem. It involves learning in small cooperative groups, usually referred to as action learning sets. McGill and Beaty (1995, p. 11) define action learning as ‘a process of learning and reflection that happens with the support of a group or “set” of colleagues working with real problems with the intention of getting things done’. In other words, learners work together in a group to solve a real-life problem and reflect upon the actual actions required.

The fundamental premise of action learning sets is to work together on solving real-life issues and/or problems by learning from others and reflecting on the process. The emphasis on ‘real-life’ problems means that adult learners working in an action learning set bring their own problems to the learning set and work together on how these can be solved. There is no one correct answer or solution, so the task is to develop a workable solution for a particular context. Action learning is based on a number of educational beliefs:

Through team working individuals learn from each other by respecting different perceptions, perspectives, experiences and knowledge bases, all of which are harnessed in developing a solution to a problem or critical incident. Action learning is used to encourage team working in solving work-based problems, finding resources, preparing presentations and placement-related activities (Box 4.18).

Problem-based learning

Problem-based learning (PBL) has its origins in medical education at McMaster University School of Medicine in Canada. Its use is widespread in a variety of disciplines, including nursing (Rideout 2001). PBL is a learning and teaching strategy that promotes learning by encour-aging learners to actively engage with others to analyse and solve problems – a fundamental skill required of all healthcare professionals.

PBL is a student-centred approach to learning that develops thinking and reflective skills with the aim of facilitating deep learning which is relevant to practice (Wilkie & Burns 2003). PBL involves active learning and develops team-working skills. It also requires students to solve problems, make decisions and explain new information gained to others, all of which facilitate a deep approach to learning.

The teacher, acting as a facilitator, introduces a problem-based scenario to learners without any previous teaching input or study. Working in small groups of 5–10, learners attempt to solve the problem(s) by suggesting a number of possible hypotheses and in doing so realize that their knowledge base is insufficient to solve or explain how the problem can be solved. This leads to learners identifying areas for further learning and collecting material to build the necessary knowledge and evidence base in order to solve the problem. Learners work though the problem in a systematic way and then reflect on both the content and the process so that they can meet the learning outcomes associated with the allocated problem scenario (Rideout 2001). Box 4.19 contains seven steps to solving a problem that can be used in any context, not just in PBL.

Portfolios

Tillema et al (2000, p. 270) define a portfolio as ‘a purposeful collection of learning examples collected over a period of time and gives visible and detailed evidence of a person’s competence. It serves as a tool to highlight progression in competence development under the control and responsibility of the person involved’. A portfolio can be used for a variety of purposes such as to:

Portfolios are a means by which learners accumulate evidence to demonstrate achievement of learning outcomes and/or competencies. As evidence is collected, a portfolio represents an individual’s learning, progress and achievement over a period of time. Portfolios encourage personal and professional development by the use of reflection, self-assessment, evidence of attainment of specific learning outcomes and competencies, and action plans for future learning. Reflection (see p. 106) is central to the learning processes involved in constructing and maintaining portfolios.

Having a portfolio to complete encourages deep learning, as the learner is required to actively engage in understanding the learning outcome and then compile evidence that demonstrates its achievement. Since portfolios are situated within practice, they encourage learners to make links between practice and its underpinning theory (Scholes et al 2004).

Portfolios provide a vehicle for discussion between learners and their mentor/tutor and, as such, are useful for monitoring progression. As a learner you should keep copies of all feedback from coursework and practice placements in your portfolio. Ensure that you read this through carefully before meeting with your personal tutor and/or mentor so that you can discuss the positive aspects of feedback and also those highlighted as requiring further development. Reflecting on your feedback, as well as the discussion with your tutor and/or mentor, should underpin your action plan to meet your personal learning needs. Portfolios are also the basis of Post-registration Education and Practice (PREP) and provide evidence of achieving both personal and specific professional learning outcomes.

Assessment

Before setting out to ‘teach’ someone, it is essential to identify what the person/patient/client or groups of peers/patients/clients (hereafter referred to as learners):

Assessment of learners’ needs prevents unnecessary repetition of known material and saves time and energy for all parties. In order to teach, it is essential to read around the topic area including all the up-to-date literature and evidence (see Ch. 5 for literature searching and sources of evidence). Once what the learners already know has been established, assessment of what should be taught can begin.

Planning

The purpose of this phase is to plan what, how and when the intended teaching will take place. Following assessment, it will be evident what is already known and what remains to be taught. Knowing what to teach is not enough and planning will identify which particular elements of the topic are essential to teach and those that are interesting, but not essential. Writing aims and learning outcomes helps in deciding what is essential and what is not. The nature of the learning outcomes provides the basis of deciding which teaching methods are most appropriate to use.

Consideration needs to be given to creating a motivating learning environment (see p. 112). To achieve this, it is important to involve learners in setting their own learning outcomes when possible and to ensure that the outcomes are at the appropriate level so they move learners to a higher level of understanding.

Implementation

The introduction to any teaching session should demonstrate the significance and relevance of what is to be learned. An explanation of the purpose of the lesson, its relationship to previous teaching sessions (if any), an outline structure of the teaching session and the learning outcomes for the session should all be provided as this creates shared meaning and an early rapport with the learners. Whatever teaching method is used, it is essential that through a warm and accepting learning environment, key points or issues are communicated by speaking clearly, using pauses and ensuring the pace is not too fast. The teacher should continually gauge their audience’s understanding by observing their non-verbal reactions and repeating or re-phrasing as necessary.

Effective teaching depends on two interlocking factors: explanations and questions. Learning how to ask questions (see also Ch. 9) and give explanations requires practice. Hints on how to use questions and give effective explanations can be found in Box 4.21.

Evaluation

In this last phase, the teacher needs to decide whether the teaching plan has been effective and achieved what it set out to do, i.e. have the learning outcomes been achieved? This judgement uses the reflective cycle to assess one’s performance and asking the learner(s) for feedback on the teaching session. Reflecting on the outcomes of evaluation is the basis for improving your practice as a teacher.

A judgement is made about how the learner has progressed in their learning including, if appropriate, how well they have assimilated learning a new skill. This can be assessed by asking the learner questions that test their knowledge and then observing them performing the skill. Having undertaken evaluation, it is then essential to give feedback.