An_Analysis_of_Student_Learning

An analysis of student learning in undergraduate nursing. Introduction The delivery of quality healthcare in the 21st century is a complex job that requires higher level thinking processes such as clinical reasoning and critical thinking. These higher level processes enable the competent clinical nurse to make safe and effective decisions in complex and stressful situations (Adams, Stover, & Whitlow, 1999; Banning, 2006; Ferrario, 2004; Snelgrove, 2004; Standing, 2007). To ensure nurses are competent to deliver safe and competent care the state registering bodies expect undergraduate nursing courses to produce nurses with these skills. Universities use the National Competency Standards for the Registered Nurse developed by the Australian Nursing and Midwifery Council for curriculum development and for assessment of performance of students and new graduates (ANMC, 2005). While the author could find no direct studies comparing the approaches to learning adopted by undergraduate nursing students to the critical thinking and clinical reasoning skills of experienced, competent Registered Nurses working in the clinical area, it could be argued that the understanding and meaning achieved by using deep approaches to learning would likely lead to development of the thinking and reasoning skills required by a competent clinical nurse. To support this argument the author will discuss the theory of approaches to learning and teaching and use interviews from two undergraduate nursing students to illustrate how the students learn in the clinical setting and it’s ramifications for clinical teaching. Data Collection Two final year undergraduate nursing students were interviewed about their experiences of clinical placements in this, their final year. Both students were female, mature age students. Both were Endorsed Enrolled Nurses (EENs) doing a transition to Registered Nurse (RN) course and both were currently working in the public health system when interviewed. The first interview was obtained by the author approaching the EEN when she attended annual mandatory training which the author was conducting. The second interviewee was a friend of the first and offered to be interviewed for the purpose of this study. The interviews were designed to elicit information about the students’ conceptions of learning and their experiences on clinical placement. The interviewees were encouraged to discuss experiences from all their hospital based clinical placements, which included surgical, medical and aged care placements and some specialist areas such as paediatrics and burns unit but they had not yet been placed in critical care areas. The interviews were then reviewed and responses collated to ascertain factors that would enable the author to understand each of the students’ approaches to learning. The names of the interviewees have been changed to protect their identities, the first being referred to as ‘Lisa’ and the second as ‘Natalie’. Both gave permission for the interview notes to be used in this essay. Approaches to learning There has been considerable research and exploration of learning and knowledge since the mid-late 1900s. In 1970, Perry identified the epistemological levels of students learning, noting that students ranged from a dualism approach – where knowledge was seen as absolute, through to relativism – where students used evidence to reason with and there was a commitment to reasoned interpretation (Entwistle, 2000). In the latter part of the 70s Marton and Säljo identified students concepts of learning, which ranged from a level of reproducing (in which students believed they acquired information and built up knowledge routinely) through to transforming, whereupon students would make sense of ideas, and were able to apply it to the real world and develop as a person (Entwistle, 2000). Comments made at interview by the two students gave hints to the learning conceptions they each held. Lisa showed a mix of conceptions of learning. She stated that what helped her learn was “hopefully getting a good teacher who can explain things simply so that I do learn and retain the knowledge” implying that she is ‘an empty vessel’ that needs to be filled up with knowledge and have it available for recall. However she also said that “ I want to understand things as I hate feeling dumb so very much have a need to know”. This statement could be interpreted as her having a desire to learn, but it is also driven by fear of being thought of as ‘dumb’. Natalie showed quite strongly that her conceptions of learning were at the dualist, reproductive level as evidenced by her comment “what I would like learning to mean is that I am being taught clinical skills” and “When I am doing a procedure I focus on the technique, like doing a wound dressing. I don’t think about the significance of it”. Natalie viewed clinical learning as being shown how to perform the tasks of nursing without having any understanding of the relationship of tasks to the overall patient care. In each of the above frameworks of conceptions of learning, the level that a student had reached was shown to significantly impact on that student’s approach to learning and the learning outcomes they could achieve (Entwistle, 2000). Statements from the interviews supported this. Lisa, who had more mixed conceptions about learning, also had mixed approaches to learning. On the one hand she would “try to find out about the ward placement I am going on so that I know what to expect” and “I try to step out of the box of being a student and observe the role of the RN and try to take on the responsibility of all the duties the RN does as this is how it will be when I finish uni.” However she also expresses some reliance on being taught and not understanding the relevance of reflection on learning when she says “Another hindrance is when there are no educators on the ward to take the time to teach students, or facilitators that take you off the ward for lengthy pep talks at a time when we could be learning.” Natalie’s approach was easily identifiable from her straight talking manner; “ I love the patient contact but I hate all this learning bullshit” and “ I don’t enjoy anything about my course. But at the end of it I’ll have the piece of paper that says I am an RN”. It is evident that Natalie’s dualist and reproductive conception of learning quite significantly impacts on her approach to learning. It also impacts on her results; “Marks are not important to me, P equals degree. I get mostly passes”. In learning research, initially two categories of approaches to learning were identified – surface and deep (Entwistle, 2000). The deep approach describes a student who actively engages in the learning process, seeing meaning, and gaining thorough understanding of the concepts, while a surface approach describes a student who uses rote learning and reproduction of given material with no real depth of understanding (Entwistle, 2001). Through interviews with students about their approaches to learning Biggs and Ramsden identified another approach – the achieving or strategic approach. This is a strategy that students can use with either a surface or deep approach and uses such techniques as time management and a structured approach to studying in order to gain better grades (Entwistle, 2001; Ramsden, 1992). From the interview with Lisa we can see she uses a mix of surface and deep approaches. She has positive emotions about learning and tries to make the most of opportunities. She states “I actually do seize the moment to take on the opportunity to do new things on clinical and don’t rush off home” and, “To date I have enjoyed all my pracs”. However she also has difficulty relating her theory with practice; “There’s a lot of irrelevant stuff we learn at Uni so can’t really link it with the clinical prac”. There is also evidence that she takes an achieving approach to her work when she says “I try to start the reading for all my assignments early and I make sure that I have read all the criteria for marking”. Her approach is rewarded with good grades; “I get mostly credits and distinctions, some passes and occasionally I get a high distinction”. Natalie, on the other hand, relies on a surface approach almost exclusively and does not enjoy her learning experiences as evidenced in her statement “ There’s nothing important about clinical prac if you are an EEN. It’s boring”. She also stated, in a very disappointed voice “nowhere are you spoon fed”. Natalie does not take an achieving approach though she explains that this is because of personal constraints; “ My study is very haphazard because I am a mum and I want my kids to have good childhoods with lots of activities”. From the above comments it would be very easy to dismiss Natalie as a surface learner and one not likely to become a critical thinker. However, approaches to learning are not inherent to an individual. Ramsden (1992) states that “one cannot be a deep or surface learner; one can only learn the content in a deep or surface way.” Students will vary their approach, though tend to maintain consistency in adopting approaches that they have previously used (Ramsden, 1992; Reid, Duvall, & Evans, 2007). Both the interviewees were EENs and had adopted an approach to learning that was successful for them in obtaining that qualification. As Natalie says “When I was doing the TEN course it was overwhelming so I picked out the important points and made study cards and rote learned them”. While successful as an approach for the EEN, it is not a useful approach for the development of higher thinking processes required to become a competent RN (Adams et al., 1999; Banning, 2008). Approaches to teaching The most common factors that affect approaches to learning are the students’ conceptions of learning, the nature of the learning environment, students’ prior experiences and their motivation for learning (Watters & Watters, 2007). Other factors may include self-esteem, family support and personal circumstances (Roman, Cuestas, & Fenollar, 2008). While student’s prior experiences, family support and personal circumstances are outside the teacher’s realm, the nature of the learning environment and enhancing motivation are factors that teachers can affect. A lot of research in higher education supports the notion that the learning environment and the approach to teaching will strongly influence the approach to learning that students take and consequently their learning outcomes (Entwistle, 2000; Lizzio, Wilson, & Simons, 2002; Ramsden, 1992; Reid et al., 2007). The student interviews gave a number of clues about their learning environment on clinical placement. Both students expressed dissatisfaction with RNs who were uninterested or unwilling to help the students. As Lisa put it, “RNs who don’t want to be bothered with students can make things dull and uninteresting and don’t help you get any further as you feel awkward asking them if you can do different things”. Natalie commented on the lack of understanding of learning needs of students by some RNs; “I sat down with a clinical facilitator the other day and told her I was bored. Most of them just say ‘our hands are tied with you as an EEN because you can only do what they say students are allowed to do’ which is less than an EEN is allowed to do”. Lisa went on to say “ Often NUMs on the ward make no effort with the students to make sure they are getting to work with experienced RNs who are capable of teaching students”. This perceived poor learning environment was not inducive of a deep approach to learning. If facilitators and ward RNs understand the different needs of EENs transitioning to RN to those of undergraduates with no prior nursing experience, and clinical placements were more geared to learning the concepts of clinical reasoning, the placements may hold more value for these students. For many of them, including Lisa and Natalie, the placement becomes simply a place for learning new tasks and ‘just working’. This was summed up by Lisa when she said “Things that hinder learning on clinicals is poor staffing on the wards and we are used as AINs to do all the donkey work to help the poor staff get through their daily work”. It is important for educators and facilitators to tap into the motivations of their students (Diseth, 2007; Roman et al., 2008). Both Lisa and Natalie said that to become an RN was a “lifelong dream”. They were both already working in the health service and had ideas about what it was to be a nurse. They already knew many of the ‘tasks’ of nursing but had no concept yet of the clinical reasoning and critical thinking required of an RN. Finding ways that use the students motivations to become RNs and build on their previous experience may help the students to adopt a deeper learning approach. As Entwistle (2000) states, “Research findings have indicated that...it is generally explanation, enthusiasm and empathy which are most likely to evoke a deep approach. Similarly, it appears that assessment which encourages students to think for themselves…shifts students in a class towards a deep approach”. If the assessment on clinical placement focuses on the tasks of nursing then the students will take the surface approach to learning, ticking off the boxes for tasks they may have already achieved as an EEN, an approach that these students had previously found successful. In their interviews, the students gave hints of things that would work as motivators for them. Natalie said she enjoyed teaching; “When I was last on prac I was with some graduate students who had no previous nursing experience. I got used by the facilitator to teach these other people. And on the ward the NUM put me with a new grad to help out. I liked doing that. Maybe when I finish I will work as a TEN assessor”. She also stated her preference for learning style when she said “I enjoy learning hands on, but I don’t enjoy learning from a book”. Giving Natalie more opportunity for learning to think while doing practical work, using a kinaesthetic approach, and opportunity to teach what she has learnt, may motivate her to use a deeper approach to her own learning (Entwistle, 2000). From the literature on learning it seems clear that these students have adopted a mostly surface approach to learning while on clinical placement. They describe their experiences as having very little meaning for them and one gets no enjoyment from her clinical placements. The nature of the learning environment that they describe does nothing to encourage a deep approach. Further research would elicit the learning objectives that the students are given but nothing in their comments leads the author to believe they match the learning needs of the students by taking into account their prior experience as EENs. Conclusion The findings of the interviews indicated that the students believed learning was about accumulating information and developing psychomotor skills that enabled them to carry out the tasks of nursing. They showed a preference for adopting surface approaches to learning, consistent with the previous learning experience to become EENs and were frustrated by the university’s attempts to encourage them to use deep learning approaches in their theoretical learning and its apparent mismatch to their experiences on clinical placement. Nurses need to understand core concepts of scientific knowledge as well as have the capability to consider new information as research and technological advances occur throughout their professional career. They need to be able to use their conceptual understanding along with procedural knowledge and analytical skills to solve complex multidisciplinary problems. They have to be able to apply what they have learnt at university to real life meaningful problems in the clinical setting. Research shows that deep approaches to learning develop understanding and personal meaning. Entwistle (2000) in particular, shows how quality of student learning, namely deep learning, can be promoted through the teaching and assessment strategies utilised in the university curriculum. Universities are beginning to adopt strategies that encourage students to utilise deep learning approaches (Entwistle, 2000; Snelgrove, 2004; Watters & Watters, 2007). However the student interviews would suggest this isn’t yet occurring for those nurses transitioning from EEN to RN on their clinical placements. To help these students adopt a deep approach to learning there needs to be better approaches to teaching, approaches that will enhance the nature of the learning environment and build on the knowledge that these students already have. Changes may include learning objectives on clinical placement that match their learning needs of clinical reasoning and critical thinking. Secondly, skilled facilitation and student-focused teaching that encourages them to adopt a deep approach and make links between their prior knowledge as EENs and the new knowledge that they need as RNs. Furthermore, they require modes of assessment that will challenge them to become critical thinkers and develop clinical reasoning abilities and help them change their previously learnt approaches. References Adams, M. H., Stover, L. M., & Whitlow, J. F. (1999). 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