Self direction: an appropriate model for teaching skills?
AEJNE Volume 4 - No.1 October, 1998.
Ms Amanda Kenny
Since the days of Nightingale the imparting of clinical skills knowledge has been part of the role of those individuals involved in nursing education. In most universities today the translation of basic knowledge into practice takes place in the safe, supportive environment of the clinical skills laboratory prior to students entering the reality of the health care system. The challenge within universities is to provide a clinical skills program that is cost effective and adequately prepares students to practice within an increasingly complex health care system. The adoption of programs that are based on principles of self-direction would appear to meet the challenge.
Clinical skills education
In defining the term clinical White and Ewan (1991:2) refer to the word as being derived from the term clinikos meaning bed. Whilst to some the term clinical could be related to the sick bed the term clinical teaching is widely accepted and recognised in fields outside the health professions. White and Ewan (1991:2) define the term clinical teaching as 'the translation of basic theoretical knowledge into practice'.
The clinical skills laboratory.
Nixon et.al. (1996:89) suggests that the primary function of the nursing skills laboratory is to enable students to apply theory to practice. The overall aim should be not only to acquire psychomotor skills but also to develop interpersonal skills, direction and confidence. Traditionally the laboratory used in nursing education is based on the concept of a practical room where students practice skills prior to proceeding to clinical practice (White and Ewan, 1991:43). The majority of nursing schools have developed their clinical skills program using a teacher/learner approach with a high degree of structure. The acquisition of clinical skills is teacher directed and therefore extremely costly (Infante, 1981, Nixon et.al.,1996:89).
Turunen et.al. (1997) recognises not only cost containment within the university but also the impact that social and financial change within the wider community is having on the delivery of nursing education. It is argued that the challenges that exist within the health industry to improve the quality of service to clients within budgetary restrictions further challenges those providing nursing education. It is vital that graduates are produced with the knowledge and skills to care for clients in an increasingly complex and changing health care system (Garity and Chari, 1997). Heliker (1994) suggests that: outcomes of (traditional) learning fail to exhibit a patient orientated critically thinking individual capable of adequate decision making in practice.
Nixon et.al. (1996:89) argues that the current practice of teacher led clinical skills laboratories does little to foster student responsibility for their own learning. Turunen et.al. (1997) states that the adoption of programs that increase students self direction in learning more adequately prepare them to meet the challenges of change in society.
Defining self directed learning.
Armstrong et.al. (1985) suggest a rather vague definition of self-directed learning 'the learner takes the initiative and responsibility for their learning process'. The definition developed by Knowles (1985) is used in much of the literature surrounding the concept of self-directed learning.
'On a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes (this) usually takes place not in isolation, but in association with various kinds of resources ie teachers, mentors, peers, and other human resources ' (Knowles,1985:274).
The definition of Knowles (1985) is based on the concepts of an andragogical approach to education. This approach refers to students being given the trust to develop their learning programs to suit what is relevant to their own lives and life experiences. This would appear to link with concept models of learning derived from educational theorists such as Ausubel (1963) and Novak (1977). It is argued that self-directed learning enables students to study what is relevant to their own needs and personal growth, learning activities are wholly or partly under the control of the learner (Thomas, Strage and Curley 1988 in Nixon et.al., 1996).
Iwasiw's (1987) conceptualisation of self-directed learning was based on Knowles (1975) definition. Iwasiw (1987) identified five components of self-directed learning.
DíA Slevin and Lavery (1991) developed a continuum of four models as part of their exploration of defining self-directed learning. The models ranged from total self-direction to total teacher direction with facilitation and partnership falling in the middle. Nolan and Nolan (1997a) define self-directed learning as a co-operative model which places emphasis on educators providing initial direction and leadership so that students can gradually develop the skills to become self directed acquirers of knowledge. It is suggested by Nolan and Nolan (1997a:105) that self-directed learning requires the use of pedagogical approaches which recognise the value of didactic as well as experiential teaching strategies. The term co-operative model was coined by Nolan (1993) and would appear to be an expansion of the approach taken by DíA Slevin and Lavery (1991). The model aligns closely with the partnership model described by DíA Slevin and Lavery (1991) but extends closer to the teacher led end of the continuum.
Applying self directed learning to practice.
Purdy (1997) challenges the whole concept of self-directed learning and suggests that its application in the teaching of clinical skills to nursing students is problematic. It is argued that the adoption of models of teaching around theories of self-direction leads to tension between independent learning and required course content. Nolan (1993) supports this by stating that the adoption of a truly self-directed model is totally inappropriate for nursing. Nolan and Nolan (1997b) develop this argument further by identifying the limitations placed on nurse education by registering bodies. They suggest that by having competencies that need to be achieved and assessed for registration, total self-direction is an impossibility.
DíA Slevin and Lavery (1991) suggest that the partnership model is the only appropriate way of applying self-directed learning to nurse education. This model promotes the equality of student and teacher and involves various student and teacher led methods of learning, student and teacher directed assessment and group and individual approaches to learning.
Developing self directed learners.
There perhaps is a notion that adult learners are by their very nature self-directed. However, the literature strongly challenges this contention. Nolan and Nolan's (1997a) study into self-directed and student centred learning in nursing indicates that 'the skills of self-direction need to be cultivated and fostered' (Nolan and Nolan, 1997b:104). It is acknowledged that students who move into a program based on self-directed principles without having mastered the basic skills of self-direction experience anxiety, frustration and often failure. Iwasiw (1987) emphasised the importance of teaching students to become self-directed. The success of a program based on self-directed learning principles is dependent on the way in which the students are prepared for this model. Iwasiw (1987) warns against the notion that simply by setting up a program and establishing the right climate 'students will in some undefined, magical way, become self-directed learners'.
The impact on the student of this change of responsibility cannot be underestimated. It is the teacher's role to make this transition as smooth and as productive as possible. The teacher must describe and explain the purpose and methodology of self-directed learning. Students require a cognitive understanding of the self-directed learning process before they can be expected to engage in it. Otherwise, frustration and anxiety may be so overwhelming that learning may not occur. Didactic instruction about self directed learning is necessary. Helping students to achieve a cognitive understanding of the self directed learning process is a mandatory pre-requisite to their actual use of the method.
Knowles (1985) argues very strongly that self-directed learning does not mean learning in isolation. Knowles (1985) identifies situations where teacher directed learning is the most appropriate. Such instances as where the student is new to the subject or has little previous experience on the subject are given as examples. Knowles (1985) states 'all teacher directed learning is not necessarily bad and all student directed learning is not necessarily good. Iwasiw (1987) stresses the vital importance of maintaining the availability of support for students as part of their self-directed learning experience. Furthermore, it must be recognised that student's function at different levels and different levels of support are required.
It is clearly stated in the literature that for self-directed learning to be successful teachers must be familiar with the techniques and possess the skills necessary to assist students with this learning. Knowles (1985) describes his own initial experiences with self-directed learning as being extremely unsettling. Knowles (1985) indicates that it is vital that the academic forms a relationship with the student as a co-learner and discards the expert stance, so much a part of traditional hierarchical learning. It is vital that academics develop a clear statement of what it is that is meant by self-directed. This statement will allow strategies to be developed that assist in the implementation of models based on self-directed learning principles (Nolan & Nolan, 1997a).
Research on self directed learning.
The literature differs on the way in which students perceive notions of self directed learning. Much of the literature suggests that students dislike student centred methods of acquiring knowledge (Burnard, 1987; Ramprogus, 1988; McMillan and Dwyer, 1989; and Townsend 1990). The development of Nolan's (1993) co-operative model was based on research which indicated that whilst students want to be involved and consulted and freely accept some of the philosophies behind self directed learning they appear happier when teachers take the leading role.
Townsend (1990) states,
Students of nursing did not want to know about autonomy, freedom, process and change. They wanted direction, order and content.
Dyck (1986) suggests that by adopting methods of teaching that students are not prepared for or that students perceive as inappropriate academics may be viewed as not doing their job and abdicating their responsibility.
A study by Pedley and Arber (1997) on self directed learning, however indicated that the students in this study viewed it as a beneficial learning experience. Presentation skills, shared learning, choice and autonomy, taking responsibility and research skills all emerged as themes. A study by Love et.al., (1989) explored the learning experiences of second year undergraduate nursing students in the United States. The research clearly demonstrated that there was no difference between psychomotor skill performance of students who learned in a self directed manner and those taught in a structured environment.
Student feedback in quality assurance of clinical skills programs indicates that there is a wide range of needs and abilities within student groups. Many students stress their need for more formalised learning time in the clinical laboratories to develop their skills, for others they felt that they had mastered the skills and therefore would prefer to spend time in other learning activities (Nixon et.al., 1996). This would tie in with Knowles (1985) proposition that self-directed methods of learning need to be adapted to suit the needs of the individuals.
The research would indicate resistance amongst academics. Maghindu (1990) describes how academics more familiar with didactic methods of teaching experienced anxiety with more open approaches. Harris (1988) described difficulty in ensuring that the course content was covered with self-directed learning.
Self-directed learning implies that the individual directs their own learning. If taken to its logical conclusion some of the definitions of self-directed learning appearing in the literature would indicate that there is little need for teacher input at all. If one considers the characteristics of self-directed learning cited earlier by Iwasiw (1987), students identify their needs, develop objectives, pursue learning resources and evaluate their learning. Is there a need for any teacher input in this model? It is interesting to note that whilst Iwasiw (1987), Nolan (1993) and Nolan and Nolan (1997) all develop models that reject total self -direction they continue in their writing to refer to self-directed learning. If in fact what we are referring to is partnership and co-operation why is it that papers are still titled 'self-direction'?
Prude (1997) suggests that any model based on principles of self-directed learning is inappropriate for the education of nursing professionals. The individualistic characteristics of self directed learning denies the social reality of nursing and fails to empower nursing students by emphasising individual growth at the expense of social learning. The use of self directed models to reduce face to face contact with academic staff as part of cost containment is problematic. One must question whether this is merely adopting theories of skill acquisition as isolated steps, an educational theory rejected by Duffy (1986). The acquisition of skills is only one part of clinical nursing knowledge (Maslow, 1954., Rogers, 1969, and Benner, 1984). By increasing the self-directed component of nursing programs are students being denied the chance to develop feelings, intuition and caring as part of learning? If one adopts Benner's (1984) stance, that of clinical teaching being about exploring real nursing practice then is this limited if students are left to direct their own learning? The value of role modelling is well developed within the literature (Deanne and Campbell, 1985., Howie,1988). Are students who are directing their own learning being denied the value of learning expert practice from expert practitioners? The value of self-directed learning has been questioned with regards to competencies required by registering bodies but little consideration was given to safe practice.
A number of questions emerge from the literature that require further exploration. Tanner and Lindeman (1987) developed a list of research priorities that they perceived as relating to clinical teaching.
(Adapted from Tanner and Lindeman, 1987).
Whilst these research questions are acknowledged as still relevant today this paper has identified a number of gaps within the literature and a number of unanswered questions which relate specifically to self-directed learning.
Does self- directed learning deny the social reality of nursing and fail to empower students by its focus on individual growth?
Educating nursing students in clinical skills is an important part of nursing education. Theories of education would indicate that clinical learning programs should include elements of behaviourist, cognitive, humanistic and developmental theories. The clinical nursing laboratory is seen as an area where nursing students not only acquire psychomotor skills but also develop interpersonal skills, direction and confidence. Clinical skills programs are traditionally teacher led, costly and some suggest fail to produce graduates that are creative thinking with the knowledge and skills to care for clients in today's increasingly complex and changing health care arena. Self-directed learning has been suggested as a model that develops freedom, autonomy and direction, with the learner setting their own goals, selecting and generating resources and considering their learning in terms of personal goals and achievements. Whilst this would appear to be an ideal goal some research suggests that self-directed learning has a limited place in nursing education. What emerged as most evident from an analysis of the literature presented in this paper was that self-directed learning is a complex area that has not been adequately explored. It would appear that the research conducted into self-directed learning has been based on purely quantitative research approaches. In developing models of education that are suited to a humanistic profession such as nursing it would appear to be only logical that research conducted into these methods is based on qualitative research inquiry.
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