This is the last of three articles explaining theories of learning with particular relevance to clinical areas.In the story so far, the Director of Nursing Education at the St Elsewhere Academy of Nursing is trying to create the ultimate programme of nursing education. In order to ensure that the very highest standards of teaching and learning are achieved, the DNE has decided to employ a theorist of learning. She first interviewed the candidate representing the school of behaviourism, and last week the cognitivist candidate made his presentation. The series now concludes with the humanist candidate-and the final decision.

Key Words - Nursing Education: Methods, Clinical Teaching.

These key words correspond with entries in the RCN Nursing Bibliography.

The candidate representing the humanist theorists appeared relaxed and self-assured as he walked into the office. He shook the DNE's hand firmly, introducing himself as Bob, and asked her first name. The DNE appeared a little surprised by his lack of formality, but the man seemed pleasant and very knowledgeable as he explained his ideas for nursing education.

The humanist theory of learning is concerned with feelings and experiences, leading to personal growth and individual fulfilment. Maslow [1] made a significant contribution to the humanist approach with his theory of motivation and hierarchy of needs. In order to ascend to self-actualisation, lower level needs (that is, comfort and security), must first be partially satisfied.

The goal of education is therefore to assist the achievement of self-actualisation, and fulfil the maximum potential for personal growth. This is closely linked to the work of Carl Rogers and Malcolm Knowles.

Rogers [2], who advocated a student-centred approach to learning, identifies a continuum of meaning. At one end of the continuum is material which has no personal meaning. This learning involves only the mind and not feelings, that is, it has no relevance for the whole person and therefore becomes futile. At the opposite end of the continuum is significant, meaningful, experiential learning, which involves both thoughts and feelings.

Rogers [2] believes that significant, experiential learning has five qualities:

- It involves the whole person-both feelings and cognitive processes

- It is self-initiated, with a sense of discovery coming from within

- It is pervasive and makes a difference in the behaviour, attitudes and maybe the personality of the learner

- It is evaluated by the learner, who knows if his or her needs have been met or not

- The essence of it has meaning.

The teacher is primarily concerned with permitting the students to learn by feeding their own curiosity. The students are given responsibility and freedom to learn what they wish to learn, as they wish.

'Hold on for just one minute,' said the DNE. 'This idea sounds all very well for school children, but I have a set curriculum that must be met in order to conform to UKCC and ENB guidelines. How can I possibly allow the students to study whatever takes their fancy?'

Pleased that this issue had been raised, Bob explained that, in order to decrease student anxiety and frustration at not being spoon-fed, there is a need for a perceived structure in the form of limits and minimal requirements. This gives enough direction for work to commence, thus ensuring that the content requirements of the curriculum are fulfilled, but the process remains free.

'Do the students like this method?' asked the DNE. 'Isn't it easier for them to simply take notes from a lecture?'

Bob smiled. He agreed that, initially, the struggle for personal growth may be painful. It may even evoke student hostility and resentment, but in the long-term, true learning will take place above and beyond the set curriculum. This learning will be remembered, utilised and valued for years to come.

'Yes, I can see that you're possibly right, but doesn't it require a rather special type of teacher to do this?' questioned the DNE. 'Some of my tutors have been giving lectures for years, and would not be best pleased to give them up!'

Bob reassured her that it did indeed require a rather special teacher, one who had been through a process of self-discovery for him/herself and was prepared to become a 'real' person to the students, sharing their own joys and disappointments, and not being a faceless embodiment of knowledge.

This teacher must also genuinely value, accept and empathically understand the students to allow a trusting relationship to develop. The role changes from that of a teacher and evaluator, to a facilitator of learning. The members of the class, including the teacher, become a community of learners.

The DNE was not quite convinced. 'I think some of my tutors would need a great deal of help to achieve that! It does sound interesting though, if not perhaps a touch idealistic. How do I know this approach will work in nursing education?'

Bob then reached for the work of Burnard, who has written extensively on the value of experiential methods and the facilitation of learning in nursing. Burnard [3]suggested that experiential knowledge is gained through direct encounter. Students learn either by direct experience in the present, or by reflecting on past experience in order to make sense of the present.

Students enter nursing as adults, bringing with them a wealth of valuable life experience. Many of the skills of nursing do not have to be taught, as they are already grounded in personal experience. A skilled facilitator is able to make use of these experiences, as well as providing new experiences. Burnard [4] believed that this is particularly relevant for the development of interpersonal skills.

'I accept that it is useful, but doesn't the facilitation of all these experiences take up much more time than the traditional methods?'

Bob then explained that much propositional knowledge-concepts, theories, models and propositions-may be gained from reading books and articles. This leaves more classroom time for experiential learning.

Referring to Burnard [4], Bob quickly added that, if teachers control the learners' educational experiences too much, they limit the amount of personal growth that can occur. Nursing education will then churn out clones of the profession, who do not question what they see, and who neither trust nor know themselves.

'Yes, well that's certainly worth thinking about, but I do think there are times when learners need specific and structured teaching, for example, just before their final exams. Do you have anything else to offer?'

The candidate continued. Knowles [5] developed the theory of andragogy, the art and science of teaching adults. He acknowledges that adults have a vast range of experience, which forms a basis for new learning. Therefore, pedagogical methods of teaching were not appropriate in adult education.

Burnard [3] summarises the major differences of andragogical learning:

- Adults need to be able to apply what they have learned

- Adults have a wealth of personal and life experiences that should be used in education

- Adult learning involves an investment of self and any new learning will affect that self-concept

- Adults are mostly self-directed and their education should accommodate this.

The relationship between teacher and student should be one of mutual respect. Eduard Lindeman highlighted this in 1926 by stating: 'None but the humble become good teachers of adults. The student's experience counts for as much as the teacher's knowledge' [5].

Knowles [5] suggests that as adults, students should help formulate the curricula, rather than adapt themselves to what is offered. Burnard [3] says that, in nursing education, even though the national boards set out a syllabus, students still have considerable scope to decide how and when various topics were learned.

The DNE nodded: 'Yes, I agree that we must acknowledge that student nurses are adults, and treat them appropriately. Thank you Bob for such an interesting and illuminating discussion. I shall be in touch to let you know of my decision'.

Ms E Clectic, the Director of Nursing Education at St Elsewhere's, was faced with a difficult decision. She thought long and hard over which candidate to appoint.

Should it be the man from the behaviourist school with the classical, operant, and vicarious conditioning? Although she conceded that these approaches had made contributions in the past, their usefulness in the future appeared to be limited.

She contemplated the gentleman from the cognitive school, with the theories of learning by discovery, reception and information processing, which, she concluded, promoted meaningful learning, while recognising the students' previous knowledge and individual stage of development. This approach was of particular interest, as it was becoming increasingly less feasible for teachers to impart all the knowledge that a student may need. Teachers therefore have a responsibility to equip learners with questioning and problem-solving skills, and to instill a sense of curiosity and self-motivation to learn.

Finally, there was the man from the humanistic school, with his theories of student-centred and andragogical learning. Humanism, she concluded, provided an excellent basis for the teacher-student relationship and the creation of a learning environment that does not stifle or limit progress. One concern was, however, whether the teaching strategies would be useful for all aspects of the curriculum. (Figure 1)

Eventually, she recalled all three candidates.

'Well, gentlemen, I believe that an eclectic, flexible approach to learning is most effective. Students have individual learning needs and, although it is extremely difficult in group situations to completely meet those needs, the teacher can help by using a variety of teaching strategies that are appropriate to the students' learning style, their stage of cognitive development, and the subject being taught.

'I have decided that you all have something valuable to offer the St Elsewhere Academy of Nursing.

'I will be pleased to offer all three of you a position on the staff. However, I only have one spare office, so you will have to share and work together! Is this acceptable?'

They smiled and nodded in unison.

After a few minutes he behaviourist spoke up. 'How will our salaries be worked out? I think we should be rewarded for the amount of work we do!'

'No,' reasoned the cognitivist, 'Our salary should be linked to our previous experience and expertise!'

'Please, let's negotiate this like adults,' suggested the humanist.

1. Maslow A. The Farther Reaches of Human Nature. Harmondsworth, Penguin. 1971.[Context Link]

2. Rogers CR. Freedom to Learn for the 80's. Ohio, Merrill. 1983. [Context Link]

3. Burnard P. Teaching the teachers. Nursing Times. 1987. 83, 9, 63-65. SFXLibrary Holdings [Context Link]

4. Burnard P. Building on experience. Senior Nurse. 1988. 8, 5, 12-13. SFX Library Holdings [Context Link]

5. Knowles M. The Adult Learner: A Neglected Species. Second edition. Houston, TX, Gulf Publishing. 1978. [Context Link]