Mr_Francis

learning zone CONTINUING PROFESSIONAL DEVELOPMENT Page 55 Promoting effective teaching and learning in the clinical setting Page 64 Clinical learning multiple choice questionnaire Page 65 Read a practice profile Page 66 Guidelines on how to write a practice profile Promoting effective teaching and learning in the clinical setting NS345 Hand H (2006) Promoting effective teaching and learning in the clinical setting. Nursing Standard. 20, 39, 55-63. Date of acceptance: September 20 2005. Summary This article explores the nature of teaching and learning in the clinical area. Many of the issues that mentors encounter in promoting a good learning environment and undertaking effective teaching are discussed. Demonstrate awareness of the role of teaching and learning within the context of the nursing profession. Examine the theories of how adults learn. Discuss the integration of theory to practice. Identify the characteristics of a good learning environment. Identify the qualities of a good teacher. Author Helen Hand is lecturer, University of Sheffield, Sheffield. Email: h.e.hand@sheffield.ac.uk Keywords Education: methods; Learning; Mentoring; Teaching These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords. Introduction The issue of good quality practice placement has been a focus of the Department of Health (DH) and professional bodies since 1999 when the DH launched the nursing strategy Making a Difference (DH 1999). This strategy proposed a new model of nurse education and a stronger role for the NHS in the management of preregistration nurse education. It also stressed the importance of practice placements in the education of health professionals as part of the DH’s plan to modernise the NHS. The strategy emphasised that placements needed to be of higher quality, accompanied by improved teaching support to help students gain better practical skills. The announcement that 6,000 additional training places were to be made available during the following three years made providing higher quality placements more difficult because it meant there were more students on placements, some of which were already struggling to provide experienced mentors for existing numbers. From September 2000, a new model of nurse education was introduced based on Fitness for Practice (UKCC 1999). This document stressed june 7 :: vol 20 no 39 :: 2006 55 Aims and intended learning outcomes Teaching is an important aspect of the health professional’s role and members of most healthcare professions are expected to teach students, patients, relatives or other staff at some point in their career. The quality of mentors and teachers will have a major impact on the quality of future practitioners. Although this article focuses on nursing, the principles of teaching and learning will be of use to anyone who teaches in the clinical area and who wants to make their teaching more effective. This article explores the nature of teaching and learning with reference to the clinical area, examining issues facing those who mentor students in healthcare settings. It is hoped that completion of the Time out activities will enhance the reader’s knowledge of clinical teaching. After reading this article, you should be able to: NURSING STANDARD learning zone education that students’ practice experience was one of the most important facets of their education in health and social care (Glen and Parker 2003). It was reinforced in A Health Service of all the Talents: Developing the NHS Workforce (DH 2000), and Placements in Focus: Guidance for Education in Practice for Health Care Professionals (English National Board (ENB) and DH 2001). In July 2001 the Quality Assurance Agency issued the Code of Practice for the Assurance of Academic Quality and Standards in Higher Education: Placement Learning (Section 9), which stressed the need for partnership between the NHS and higher education institutions (HEIs). This gave workforce development confederations and universities joint responsibility to provide and maintain satisfactory clinical learning for students covering the ‘full 24-hour day and seven days a week nature of health care’ (UKCC 1999). Junior members of the nursing team may increasingly be required to undertake the role of mentor, often without any preparation. This article addresses many of the issues mentors encounter in relation to providing a good learning environment and undertaking effective clinical teaching. without the underpinning rationale makes the practitioner unsafe. Similarly, having the knowledge but not the skill may lead to incompetence. Having the knowledge and the skill leads to informed practice, however, the practitioner is also required to display the correct attitude and professional manner. Learning in general does not have to take place in an organised way; it is a vital part of living and can occur in a variety of ways. Much of what we learn is unintended and happens by chance. Beyond this, though, there are occasions when purposeful learning must take place and must be assessed. As mentors and teachers in the clinical area this is the learning that we expect students to undertake and which will often contribute towards a qualification. Learning theories Psychologists have attempted to explain how the process of learning occurs. The main theories are explored in the context of the clinical environment, and lifelong learning. Behaviourism Psychologists from the behavioural school believe that the environment is fundamental to learning: if the environment is right, learning occurs as connections are made between a stimulus and response, and response and reinforcement (Quinn 2001). Burrhus F Skinner, an influential behavioural psychologist, developed a theory of operant conditioning. He observed that rats rewarded with food when they accidentally touched a bar eventually learned to press the bar intentionally (Atkinson et al 1990). Further work in this field identified that behaviour is strengthened by positive or negative reinforcement. Applied to education, Skinner’s argument was that learning could be maximised through positive reinforcement with a reward, such as praise, and that this has to be given immediately and consistently to be effective. Delayed rewards were suggested as being meaningless because the reinforcement would not be linked to the operant behaviour. In teaching, rewards can take the form of what Hinchliff (2004) describes as ‘social reinforcers’. These include smiles, nods and verbal encouragement, all of which can easily be given to the student during or immediately following a successful event. Such action should encourage the student to repeat the behaviour and develop good practice, as well as promote self-confidence. Skinner also found that if behaviour was ignored, or not rewarded, the behaviour ceased. This principle can be applied to children who have tantrums. If parents occasionally reinforce this behaviour by giving in to the child they will experience more outbursts, while those who NURSING STANDARD Learning Our perceptions of learning will affect how we teach. It makes sense, therefore, that before we explore how to teach, we understand how people learn. Learning is a relatively permanent change, usually brought about intentionally (Reece and Walker 2002). It may be a change in knowledge, understanding or ability to do something new. Learning is often planned, for example, attending a course or reading a book. It can also take place through experience, without previous planning. Such experience usually results in a resolve to do things differently next time. Therefore, when learning has taken place, it should be notable through some observable change. A broader definition provided by Jarvis (1983) reflects the many ways in which learning can occur: ‘…the acquisition of knowledge, skills or attitude by study, experience or teaching’. This definition encompasses three domains of learning defined by Reece and Walker (2002): cognitive, affective and psychomotor. It highlights that learning can occur from teaching, study or the assimilation of information and skills as a result of experience. Learning in all three domains is important for any healthcare professional. Having the skill 56 june 7 :: vol 20 no 39 :: 2006 consistently hold out and refuse the demands should note the absence of such behaviour. However, it has little place in clinical teaching (Hinchliff 2004). Wrong or inappropriate behaviour could lead to unsafe or unprofessional practice and should, therefore, be addressed. Negative reinforcement might also strengthen behaviour if something unpleasant occurs as a result of the behaviour. For example, the prospect of remaining in hospital until a necessary skill for self-care is mastered may promote and strengthen learning and enable the patient to be allowed home. Although often criticised for emphasising performance at the expense of the individual’s thoughts and feelings (Quinn 2001), behaviourism has some useful aspects, particularly in the area of skills development. Skinner concluded that complicated processes need to be learned in stages, each stage being sequenced and built on previous ones. According to Hinchliff (2004), this has influenced the development of computer-assisted learning which provides structured sequenced learning with immediate feedback and enables learners to work at their own pace. Simulation is another method of learning that has its roots in behaviourist theory. This relies on the principles of feedback which should help the student progress towards a desired goal (Hinchliff 2004), for example, a competent performance of cardiopulmonary resuscitation on a mannequin, or an ability to deal with a difficult patient. Many schools of nursing and midwifery use simulation as a way of allowing the student to encounter a specific situation or skill in a safe environment, so that when the real event occurs there is a degree of familiarity for the student. Gibbs (1988) believes that simulation, although it cannot exactly represent reality, is invaluable. De Young (1990) suggests that simulation has the advantage of making the learning task less complex when it occurs in the real world, although, according to Quinn (2001), the amount of learning that can be transferred to the real life situation is debatable. Simulation presents a challenge for the teacher in that, rather than allowing the student to focus solely on mastering the skill, the concepts and principles underpinning the simulation also need to be brought to the forefront of the student’s mind (Joyce and Weil 1986). Hinchliff (2004) suggests that social learning theory can be considered as part of the behavioural approach, although it overlaps with the cognitive domain. It is defined by Atkinson et al (1990) as: ‘learning by watching the behaviour of others and observing what consequences it produces for them.’ It is often described as learning by ‘sitting next to Nellie’, and is probably one of the most common ways that NURSING STANDARD learning takes place in clinical areas. Quinn (2001) believes that complex patterns of behaviour as well as emotional responses can be learned by role modelling, although ultimately the quality of the learning depends on the quality of the role model. Classic research, for example Fretwell (1982) and Melia (1987), seeks to remind us that nurses’ behaviour is strongly influenced by colleagues, particularly the ward sister. This reinforces the importance of maintaining high professional standards in the clinical area at all times. Cognitive learning Cognitive theories consider learning as an internal process that involves higher order mental activities such as memory, perception, thinking, problem-solving, reasoning and concept formation. Cognitive theories were developed in response to behaviourist theories and include meaningful learning and discovery learning (Atkinson et al 1990). Learning occurs according to the interaction between new information that the individual acquires, and the specifically relevant structures that the learner already possesses (Ausubel 1968). This interaction results in the assimilation or incorporation of both new and existing information to form a more detailed cognitive structure (Quinn 2001). This implies that information is not simply added to the old in a cumulative way; rather it acts on the existing information and both are transformed into a new and more detailed cognitive structure. The student’s starting point is an important principle of Ausubel’s (1968) theory. However brief a session may be, asking patients, students or relatives to explain their current understanding and/or previous experience about a condition or skill, can enable the teacher to relate learning more closely to individual needs thereby achieving greater effectiveness and saving valuable time. Nursing students enter the profession from a variety of backgrounds. In the author’s experience more support workers, who already have a wealth of practical clinical experience, are now training to become nurses. Phillips et al (2000) highlighted that students on new placements often had to endure being treated as if they knew nothing, their previous learning and accomplishments being ignored. Levels of knowledge and understanding vary between students and should, therefore, be explored as well as examined for accuracy, to establish the baseline for teaching. One of the key strategies for learning advocated by Ausubel (1968) for the introduction of new material, and for its assimilation, is the concept of the advanced organiser. This consists of using ideas that are similar to the new knowledge that is to be learned but are more general. Advanced organisers form the link between learners’ prior june 7 :: vol 20 no 39 :: 2006 57 learning zone education knowledge and what they need to know, and should, therefore, be potentially meaningful and capable of being understood. The advanced organiser should contain all of the elements of the subject that follows it but at a more abstract level. A well used example is that of the comparison of the cardiovascular system to a central heating system (Bassett and Makin 2000). The exploration of the pump forcing fluid under pressure through a closed system of pipes allows students to conceptualise the body using something that they can visualise. Bruner (1961) explains that learning by discovery can be achieved by presenting a learner with a problem to consider using cognitive processes. This may be carried out as a planned activity or using trial and error. It is commonly used on management or leadership courses to encourage intuitive thinking, and although a solution may be reached, it often results in more errors than success. The role of the teacher in aiding learning through discovery is to pose questions or problems that motivate students to seek answers in an active discovery way. Bruner (1961) also explains that, when presenting new information to students, the way the material is structured is important to overall learning. He believed that if students understand the basic structure of a subject they will find out much of the finer detail themselves. An outline rather than a lot of detail is, therefore, necessary. A further cognitivist school of thought comes from the Gestalt psychologists. The three main exponents were Max Wertheimer (1880-1943), Kurt Koffka (1886-1941) and Wolfgang Köhler (1887-1967). The Gestalt view is that people see things as unified wholes, not as separate components (Quinn 2001). For Gestalt psychologists, the structure of the problem dictates the nature of problem-solving (Hinchliff 2004). If students are placed in a situation they know nothing about, then learning will occur through trial and error and the patient may suffer as a consequence. However, if presented with a problem for which it is easy to have a mental image, the solution may be easier to find (Hinchliff 2004). Humanistic psychology and learning Humanistic psychology is a general term for a group of theories that emerged in response to scientific explanations of the person. It is concerned with ‘the self’ – distinctly human qualities such as personal freedom and choice, and places value on subjective experience (Tennant 1986). Among the humanistic psychologists Rogers (1983) and Maslow (1968) developed theories based on their experience in clinical psychology. They shared the belief that humans have two basic needs – a need for growth and development and a need for positive regard by others. Their approaches focus on how individuals perceive and interpret events rather than on objective scientific interpretation. Rogers (1983) applied to education his extensive experience of observing clients learn through client-centred therapy, concluding that learning is essentially a helping process. This is reflected in the key features that form the basis of his humanistic approach to learning – that education should be student-centred and that the teacher becomes a facilitator of learning. The features of the humanistic approach are summarised by Joyce and Weil (1986): individuals have a natural drive to learn, learning can be maximised by using experience and self-evaluation encourages independence and creativity. To promote learning the teacher needs to develop a genuine, lasting, non-threatening relationship with the student. These skills include (Joyce and Weil 1986): Listening and responding consistently. Helping the student to identify feelings and personal knowledge. Sharing of him or herself with the student, rather than remaining distant. Being sensitive to the student’s needs. Valuing the learner as a person, respecting and caring for his or her feelings and opinions. Showing empathetic understanding. Being aware of personal strengths and weaknesses and their effect on others. By encouraging learner participation, a relationship of mutual trust can promote the natural potential for growth and development (Rogers 1967). It should also be remembered, however, that for some of us, the deepest learning and the best performances have occurred in the most anxiety-provoking situations. Adopting a humanistic approach does not mean that students are protected from NURSING STANDARD Time out 1 Devise an outline plan for a subject you teach in your clinical area. It needs to show how you will present information and what you will teach or ask the student to do to master the new skill or subject. 58 june 7 :: vol 20 no 39 :: 2006 such situations. Rather, they are supported and guided through them, unless the anxiety becomes intolerable in which case the student will be unable to learn and the event becomes counterproductive (Hinchliff 2004). Time out 2 What humanistic principles could you apply to help a student or staff member settle into a new environment' Think of any reasons why creating a safe, comfortable environment does not always contribute to effective learning. The humanistic approach depends on students taking responsibility for their own learning and in all clinical areas risk must be managed and learning made easier. Give some examples of how you could balance encouraging students to take responsibility for learning and guiding safe practice. Adult learning – the theory of andragogy Knowles (1984) argues that adult learners are psychologically different to children. He uses the term ‘andragogy’ to describe the way in which adults learn, and pedagogy to describe how children learn. Table 1 illustrates the difference between the two approaches. The andragogical approach to teaching consists of seven elements which mentors should take into consideration (Knowles 1984): Setting the climate for learning This involves both the physical and psychological climate and takes account of mutual respect, seating arrangements, collaboration, supportiveness, openness and authenticity and a climate of humaneness. TABLE 1 Differences between pedagogy and andragogy Assumption Learner’s need to know Learner’s self-concept Role of learner’s experience Learner’s readiness to learn Student’s orientation to learning Student’s motivation Pedagogy Involving learners in mutual planning This involves jointly organising and arranging learning opportunities in line with the student’s identified learning needs. Involving learners in identifying their learning needs This is usually achieved through discussion with the student in the light of a curriculum. Involving learners in the formulation of objectives This includes discussion with the student and negotiation of learning sometimes through the use of learning contracts. Involving learners in the design of lesson plans This is part of the learning contract and should ensure that teaching is centred on the needs of students and delivered at their level. Helping learners to carry out their learning plans This is made possible by the mentor. Involving learners in evaluating their learning This should include qualitative as well as quantitative evaluation. Reece and Walker (2002) believe that adult learning theory is highly relevant to professions such as nursing, suggesting that teachers need to provide patient-centred learning that is individualised and appropriate to the patient’s needs. Andragogy is similar to the humanistic psychology approach to learning as both favour shared responsibility for learning and a learnercentred approach. Nursing students are adults and, as such, are encouraged to take responsibility for their learning. They are made aware, via the university, of what must be achieved for each placement and, overall, to qualify and register as a nurse. Knowles’ (1984) seven elements provide a useful framework for encouraging learning, based on the identified needs of students. Andragogy Adults need to know why they must learn something Self-direction; adults take responsibility for their own learning Adults have greater and more varied experience that serves as a rich resource for learning An adult’s readiness relates to the need to know and do in real life Adults have a life-centred orientation to learning that involves problem-solving and task-centred approaches Students must learn what they are taught to pass test Dependency; decisions about learning are controlled by the teacher The teacher’s experience is viewed as important. The learner’s experience is perceived as of little importance Learner’s readiness depends on what the teacher wants him or her to learn Learning equates with the content of the curriculum The student’s motivation is from external An adult’s motivation is largely internal, sources, such as teacher approval, such as self-esteem, quality of life and job grades and parental pressure satisfaction (Based on Quinn 2001) NURSING STANDARD june 7 :: vol 20 no 39 :: 2006 59 learning zone education Types of learning Most health-related learning requires learning in three domains: the cognitive, affective and psychomotor (Reece and Walker 2002). The competent recording of a blood pressure, for example, requires that the student understands the procedure and the need for it, applies the cuff correctly, takes the recording accurately and does so in an appropriate, professional manner. Stengelhofen (1996) agrees that preparing students for professional work needs consideration of what is involved in professional practice, namely skills, knowledge and attitudes. BOX 1 Descriptions of learning styles Activists Are bored with implementation and long-term consolidation. Are enthusiastic about anything new. Are gregarious and involve themselves with others. Are open-minded and not sceptical. Dash in where angels fear to tread. Enjoy the here and now, happy to be dominated by immediate experiences. Involve themselves fully without bias in new experiences. Like brainstorming problems. Seek to centre all activities on themselves. Pragmatists Are keen on trying out new ideas. Are practical and like making practical decisions. Like to act quickly and be prompt. Like to experiment. Positively search out new ideas. Respond to problems and opportunities as a challenge. Tend to be impatient with lengthy open-ended discussion. Reflectors Adopt a low profile. Are cautious and meticulous. Collect data and analyse before coming to conclusions. Do not take the lead in meetings and discussions. Enjoy observing people in action. Have a slightly distant, tolerant and unruffled air. Like to stand back and ponder thoughtfully. Listen to others. Observe from many different perspectives. Tend to postpone reaching conclusions. Theorists Are perfectionists. Integrate observations into complex logical theories. Tend to be detached, analytical and rational. Tend to feel uncomfortable with subjective judgements. Think problems through methodically. (Adapted from Honey and Mumford 1989) Learning in the cognitive domain progresses from the acquisition of factual information, to some understanding, for example, when patients are able to explain their illness in their own words. Learning in this domain is highly individual and much work has been done on the student’s learning style. Bastable (2003) suggests that not only is it possible to identify the learning style, but also all students should be given the opportunity to learn through their preferred style – although they should be encouraged to diversify. Honey and Mumford (1989) suggest that there are four different styles and that it is important, where possible, to allow the student’s style to influence your choice of teaching method. They describe learners as activists, pragmatists, reflectors or theorists (Box 1). Honey and Mumford (1989) found that many people were a mixture but usually had a preference for one style in particular. It is often impossible to discover, and take into consideration, the style of every student because of the size of groups or type of learning situation. Sometimes, however, particularly with small numbers, it is possible to adapt the session and attempt to maximise learning. This may be useful, for example, when teaching how to record blood pressure you might consider whether to let the student with an activist style of learning experiment with the equipment first, or to begin with a theory session for the learners with a theorist style. Time out 3 Think about a student that you have supported recently. What was it about his or her behaviour or the way that he or she spoke and interacted with you that suggested that he or she might have favoured a particular way of learning' How might you identify such learning styles in future learners quickly at the start of placement' The affective domain relates to the area of values, attitudes and beliefs – involving feelings and emotions – and represents an area of teaching that has received less attention than the cognitive domain (Jarvis and Gibson 1997). The right attitude is important in health and enhances the care provided. It is usually left to assessors in the clinical area to assess whether the student possesses an appropriate attitude and other affective behaviours because clinicians witness these behaviours and abilities first-hand. Issues such as what represents an acceptable attitude are contentious and even though the student has been taught certain values and attitudes and may demonstrate them, no one can NURSING STANDARD 60 june 7 :: vol 20 no 39 :: 2006 be sure whether the behaviour reflects what the students are thinking or believe (Jarvis and Gibson 1997). The psychomotor domain relates to the development of skills, which is a large part of most health-related teaching. In nursing, many skills can be simulated in skills laboratories allowing students to practise using equipment and techniques in a safe environment before doing it for real. However, authentic behaviour only occurs through practice in real situations when students begin to develop confidence in a supportive environment. The role of teaching in the clinical environment is, therefore, a skilled one embracing the furtherance of knowledge, skill, sensitivity and appropriate use of feedback, through which the learner feels free to practise and master the procedure. Time out 4 Ask a colleague and a student that you have recently worked with to identify your strengths and weaknesses as a teacher or mentor. The learning environment One of the major factors affecting learning is the environment in which it takes place. It is the responsibility of practice staff to create and develop an environment conducive to learning (Price 2004). This implies that the environment should be continually monitored to ensure that it provides appropriate support and experience for learners, and responds to the changes that take place. There are several well-known studies about what constitutes an environment conducive to learning (Orton 1981, Fretwell 1982, Ogier 1982, 1986), and although they were published BOX 2 Factors that affect learning Embarrassment or discomfort. Lack of assessment of the student’s intellectual ability and prior knowledge and experience. Lack of interest. Lack of structure in the teaching. Negative past experiences of teaching. Personality clash between the student and teacher. Poor motivation or poor self-esteem. Poor teaching ability. Student anxiety. Tiredness, pain, hunger and illness. (Hinchliff 1999) Factors that affect learning There are a variety of student, teacher and environmental factors that can affect the quality of learning (Box 2) (Hinchliff 1999). Physiological discomfort, as a result of tiredness, hunger, thirst, pain or other factors, will affect the ability to learn, although this can also act as a motivator. For example, a patient may be motivated by pain to learn how to use a new pain-relieving device to gain relief. Psychological factors also affect learning. It is possible for a student to be unable to learn because of the anxiety he or she feels about a new placement area or an assignment deadline, for example. A skilled mentor should explore these issues with a student before making an assessment decision (Stuart 2003). As already discussed, prior knowledge and previous experience are important. Phillips et al (2000) point out that: ‘all students know something, and some know a great deal.’ If the mentor fails to check the student’s stage of training or previous exposure to the topic, it is likely that the information given could be at the wrong level resulting in no new learning taking place and the student becoming demoralised. This also applies to patient education. The information should be presented at a level, and in a form, that the patient can understand without the use of jargon or inappropriate technical information. There is a need for current evidence-based knowledge and the use of different methods of teaching that will sufficiently challenge students but not cause them undue stress or anxiety. The qualities of the teacher are, therefore, the most significant factors in achieving lasting learning. Chambers et al (2002) identify the characteristics of a good teacher (Box 3). NURSING STANDARD BOX 3 The characteristics of a good teacher A good teacher will: Be a lifelong learner. Challenge the learner. Encourage the learner by giving positive feedback. Evaluate both the teaching and the learning. Have an appropriate plan to meet the learner’s needs. Involve the learner. Prepare well so that the context and content are clear and focused. Refine future teaching in the light of this evaluation. Stimulate the learner. Understand the learner’s needs. Use a style of delivery that suits the learner’s needs. (Chambers et al 2002) june 7 :: vol 20 no 39 :: 2006 61 learning zone education more than 20 years ago, they remain relevant. Students in all of these studies identified the following as aspects of a good learning environment: A humanistic approach where all staff related to learners with kindness and showed genuine interest in them as people. Staff who are approachable and promote self-esteem and confidence. A good team spirit with all staff working together towards joint goals creating an atmosphere of trust and respect so that students felt they belonged to a team. This reduced anxiety and promoted learning. A high standard of care being provided using efficient but flexible approaches. Patients being cared for as individuals without routine task-centred activity. Teaching and learning of students are key features and an integral part of the ward’s organisation of care. Staff who are keen to learn and where ongoing development is actively promoted. Information is shared and learning opportunities are created and used well. Not all environments reflect these characteristics. However, to accommodate nursing students, clinical areas usually have to be audited by staff from the HEI which is providing the students to determine the suitability of the area. This includes negotiating with a learning environment manager about the number of students that a placement BOX 4 Clinical learning opportunities through which learning can take place Case conferences. Case notes. Experiential learning (learning by doing). Observing other ward staff. Observing procedures. Talking to patients or carers. The internet. Time spent with members of the multidisciplinary team. Time spent with specialist nurses. Visits to other departments. Ward learning packs. Ward reports. Ward resources, for example, books, journals or videos. Ward rounds. area can accommodate at any one time, and the academic level of the students who will benefit from the placement. These figures should remain flexible so that they can be reduced should the area encounter excessive sickness or insufficient mentors, so that the student experience is not jeopardised (Jacka and Lewin 1987). The criteria used by the HEIs for choosing an area for a student placement should be available for staff to access and often provide useful tools for those responsible for managing the learning environment or those interested in teaching and learning to evaluate their areas. Some clinical areas, particularly those which do not receive university students, may not be subjected to regular audit. However, there will always be learners of some kind – be it new staff members or staff from other disciplines – and staff in these situations should perform their own evaluation. Education in Focus: Strengthening Pre-registration Nursing (ENB and DH 2000) included a checklist for the clinical learning environment aimed at those involved in planning, providing and evaluating practice placement experience. It covered four aspects: providing practice placement, the practice learning environment, student support and the assessment of practice. Similarly, Price (2004) encourages mentors to conduct a strengths, weaknesses, opportunities and threats (SWOT) analysis to evaluate their learning environment. He offers a straightforward framework based on practical experience, practice resources, student support and an educational approach that could be adapted to any environment. Changes to a clinical area might invalidate the environment for some programmes but open it up to others. It is important therefore that evaluation is not seen as a ‘one off’ event but rather an evolving process (Price 2004). Evaluation should also take into account the views of students as well as staff. Most HEIs have their own form of student evaluation which should be fed back to ward staff so that it can be acted on. This does not mean that the staff cannot use their own evaluation mechanism and a questionnaire based on that suggested by Price (2004), for example, would be easy to implement. Time out 5 How does your clinical environment compare with the aspects of a good environment discussed' Make a list of all the possible learning opportunities available from your clinical area. Share your answers with colleagues and students and identify three things that you could do to improve the quality of your learning environment. NURSING STANDARD 62 june 7 :: vol 20 no 39 :: 2006 Clinical learning opportunities There is no doubt that, as Price (2004) suggests, all practice areas offer experience. You could probably identify further suggestions for clinical learning opportunities in addition to those listed in Box 4. It is important to remember that students should take control of their own learning and be encouraged to arrange some learning activities for themselves. It is equally important, though, to ensure that there are learning outcomes in place to establish whether learning has occurred, and that the activity is suitable for the type and stage of training that the student is at. Often, students have a set of competencies that have to be achieved throughout a placement. However, for short placements and visits to other areas this may not always be the case, for example, time spent with a nurse specialist. To maximise learning during such experiences, an initial discussion should take place to establish what the student wants to observe and achieve, and the level of participation that is expected of him or her. Conclusion This article has explored the concept of teaching and learning in health care. You should now be aware that learning is a complex and individualised process that requires thought, planning and skill NS Time out 6 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 68. References Atkinson R, Atkinson C, Smith E, Bern D, Hilgard E (1990) Introduction to Psychology. Tenth edition. Harcourt Brace Jovanovich, San Diego CA. Ausubel DP (1968) Educational Psychology: A Cognitive View. Holt, New York NY. Bassett C, Makin L (2000) Caring for the Seriously Ill Patient. Arnold, London. Bastable S (2003) Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. Second edition. Jones and Bartlett, London. Bruner JS (1961) Toward a Theory of Instruction. Belknap, Cambridge MA. Chambers R, Wakley G, Iqbal Z, Field S (2002) Prescription for Learning. Techniques, Games and Activities. 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