This is the second of three articles explaining theories of learning with particular relevance to clinical areas.In the story so far, the Director of Nurse 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. Last week she interviewed the candidate representing the school of behaviourism. This week, the candidate from the school of cognitivism makes his presentation.

Key Words - Nursing Education: Methods, Clinical Teaching.

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

The DNE welcomed the candidate into her office and began the interview. 'In your application you claim to have the ideal theory for the 21st century. You say that your theory will produce a truly educated nurse, who is knowledgeable, questioning, research-minded and able to problem-solve. Please tell me more.' (Figure 1)

The young man leaned forward in his chair and began to explain enthusiastically that his theory was not like the behaviourist view, in which learning involves little thinking and is observed to be a change in behaviour. In contrast, the cognitive psychologists believe that learning is an internal purposive process concerned with thinking, perception, organisation and insight.

He referred to Woolfolk and Nicolich [1], who suggested that this type of learning could not be observed directly as it involved a change in the capability of the individual to respond. The learner was actively involved with problem-solving, seeking out new information, and drawing on past experience in order to gain understanding.

He began to state his case by explaining the significance of Gestalt psychology to the origins of cognitive learning theories.

Referring to Child [2], he described Gestalt, a German word that means pattern or form, and the work of the early Gestalt psychologists-Wertheimer (1880-1943), Kohler (1887-1967), and Koffka (1886-1941).

These men were initially concerned with the study of perception and their work emphasised the ability of the individual to organise and integrate what is perceived into an overall pattern or Gestalt.

Wertheimer believed that breaking down behaviour into constituent parts obscured the full meaning of the total behaviour. From this stemmed the Gestalt phrase: 'The whole is greater than the sum of its parts.'

Wertheimer believed that perceptions were organised by the individual, using the principle of 'pragnanz', into as simple a structure or form as possible, in order that meaning could be imposed. Pragnanz was made up of four laws of perception-similarity, proximity, closure and continuity. Referring to Quinn [3], the candidate continued to explain how Koffka believed that these laws of perception could also be used as laws of learning, and from this grew the Gestalt theory of learning by insight.

Insightful learning occurs when a problem is suddenly solved by the restructuring of the component parts into new relationships, so they are perceived as a whole. Kohler demonstrated insightful learning in 1925, using a chimpanzee in a cage with some bananas suspended out of reach. The chimpanzee also had some boxes, which, if stacked, could be used to reach the bananas. After various futile attempts, the chimpanzee suddenly perceived the relationship between stacking the boxes and reaching the bananas. This insight to the solution of the problem could be transferred and repeated in similar future situations. Thus learning had occurred.

The DNE grinned and said excitedly: 'Yes, I see. So this could apply to the situation where students cannot initially make any sense of the squiggles that make up an ECG rhythm strip. Then, when the students understand cardiac conduction, and relate the activity of the heart during the cardiac cycle to the ECG readings, they are able to understand the significance of the P wave and the QRS complex... But, hang on a minute, doesn't all this require previous knowledge?'

Pleased with this response, the candidate reached for his copy of Child [2] to explain that, rather than using mechanical repetition of stimulus-response bonds, insightful learning depends on the adaptation of past experience or existing knowledge to form new insights.

'Yes that is true, but how can nurse teachers use this in education?'

The candidate explained that a nurse teacher may use the principles of pragnanz to structure sessions so they are seen as a whole rather than as isolated facts.

For example, if a session on the structure and function of the respiratory tract is linked to a disorder such as bronchitis and to the activities of daily living, the students will then perceive the anatomy and physiology, the disordered condition, and the effect on the patient as a whole, rather than three unrelated units.

The use of problem-solving techniques may allow learners to undergo an insightful process. For example, rather than telling students about the nursing care of a patient with bronchitis, the teacher can explain the disordered physiology. The students can then work out what problems the patient may experience and identify the appropriate nursing care, relating all this to the physiology and to the patients they have nursed with this condition.

Bruner's theory of learning through discovery was introduced next. Bruner [4]suggested that the ultimate aim of teaching was to instill a general understanding of the structure of a subject.

He believed learning to be an active process, stimulated by curiosity. The knowledge is constructed by relating the incoming information to a previously acquired frame of reference. This frame of reference is a system of representation that gives meaning and organisation to knowledge and experience. There are three modes in Bruner's 'system of representation'-enactive, iconic and symbolic:

- The enactive mode of representation consists of a habitual set of actions, known without the use of imagery or words, that are appropriate for achieving a certain result. This often applies to motor skills.

- The iconic mode is based on imagery, and is used for knowledge, represented by images that 'stand' for a concept, but do not fully define it.

- The symbolic mode is the transformation of the iconic imagery into a symbolic system-usually language.

Although these three stages develop during childhood in the order presented, they extend more or less intact throughout adult life.

The DNE was becoming a little impatient. 'Will you please get to the point. What is the use of these icons and things to nursing education?'

The candidate quickly responded with an example of blood pressure recording. When a student initially learns the motor skill of measuring blood pressure, but has no concept at all of the significance of that recording, it will be an enactive representation. Later, as the student begins to grasp the concept of 'blood pressure', it may be in the image of a pump (the heart), connected to a series of narrowing and widening tubes (the blood vessels), with blood circulating around the body. This will be iconic representation. Eventually the student will reach the symbolic mode, being able to define blood pressure and describe the significance of cardiac output and peripheral resistance.

The DNE nodded approvingly. 'I see, so if a learner is having trouble grasping a concept, the teacher could help by using imagery or making analogies to everyday things that are understood-like comparing the effects of vasoconstriction to someone standing on the garden hose.'

The candidate nodded and proceeded to explain that as well as describing a hierarchical structure of learning-that is action, image, and symbol-Bruner also suggests there is a coding system that makes up the pattern of enactive, iconic and symbolic representations.

This coding system allows the thousands of perceived facts to be grouped and related to each other. This allows learners to go beyond the information given and formulate new ideas by deducing additional information from previously learned principles stored in the system.

For example, if given the specific information that hypovolaemic shock is caused by a reduced circulating volume, a learner with a sound understanding of the concept of blood pressure and its control will be able to deduce that this will lead to a reduced cardiac output and result in a decreased blood pressure and increased heart rate.

Sequence is important and sessions should be structured to make use of relevant existing knowledge. Bruner [4] advocates the use of a spiral curriculum, in which all important concepts and subjects are introduced in a simple form at a very early stage of the programme, and then built upon with more complex ideas.

The candidate then referred to the work of Bigge [5] to discuss the advantages of Bruner's theory of learning by discovery.

- Once a situation is mastered, the individual alters the way in which new situations are approached in the search for information, so the student learns how to learn.

- The student is encouraged to discover the value of intuitive guesses, and try out his/her own hypotheses.

- The student's ability and confidence in problem-solving will increase as he/she acquires understanding of basic concepts and the ability to transfer knowledge.

- There is increased self-motivation and accountability for learning.

- Curiosity is aroused and the student is encouraged to adopt a questioning, research-minded approach.

The DNE smiled smugly. 'That might well be so, but according to my friend Mr Myles [6], this approach to learning may be difficult to structure in large groups of mixed ability learners, and it can be very time consuming, as well as expensive getting lots of fancy equipment; not to mention that a few 'bright sparks' might be doing all the discovering, leaving the rest feeling bewildered. What else have you got to offer me?'

The candidate described the work of Ausubel [7], which suggests that students learn more efficiently when they are presented with material in an organised, sequenced form that can be assimilated to their previous knowledge. This is the basis of the theory of reception or assimilation.

Ausubel [7] believes that learning is a deductive process that should move from an initial understanding of general concepts, to an understanding of specifics. This is unlike Bruner [4], who suggests that learning occurs inductively, using specifics to discover general concepts.

He advocates a method of expository teaching in order to enhance 'meaningful learning'. This method of teaching is very closely linked to the students' previous knowledge, and involves high levels of interaction between the teacher and the students. Meaningful learning is suggested to be more efficient than rote learning, which is unlikely to be retained because it is not connected with existing knowledge.

Ausubel [7] describes a sequence of learning that considers the students' existing knowledge and the processes by which they are most likely to assimilate new material into their existing conceptual structures. This is achieved by the use of an advance organiser, followed by the subordinate content. Quinn [3] describes an 'advance organiser' as a concept that is introduced in advance of the new material in order to provide an anchoring structure for it. This conceptual statement may be in the form of prose or a diagrammatic flow-chart.

For example, when teaching about pressure sores, a broad statement can introduce the session, such as: 'Pressure sores are known as decubitus ulcers. They are skin ulcers which occur over bony prominences, due mainly to restricted mobility. They can be prevented by the principle of relieving pressure.' This can then be followed by the subordinate content such as the pathophysiology, aetiology and nursing care.

To emphasise this point, the candidate then quoted Bernard-Lovell, stating: 'The principle function of the advance organiser is to provide a scaffolding of ideas to bridge the gap between what the student already knows and what he/she needs to know before he/she can learn the new material in a meaningful fashion' [8].

The candidate continued by outlining the advantages of Ausubel's approach to teaching. First, it activates the relevant knowledge the student already has, and second, it enhances the assimilation of new knowledge into the established conceptual structure, which increases retention and makes rote learning unnecessary.

'Yes,' said the DNE, rubbing her chin thoughtfully. 'I suppose these advance organisers do help create the right learning set, and assist the student to focus on the relevant aspects of a session. In fact, I think they could even be a little more stimulating than the usual objectives that we churn out before a session. You don't seem very fond of rote learning, but I do believe that it has a place-how else do students recall the cranial nerves? Have you got any proof of the efficiency of this reception learning in nursing education?'

The candidate shook his head, but quickly pointed out the work of Woolfolk and Nicolich [1], which suggests that Ausubel's approach is particularly suitable when teaching the relationship between concepts, or for introducing novel or difficult material. It is also very appropriate for adult learners, who have a lot of previous knowledge and are able to manipulate ideas.

Moving on, the candidate next introduced the work of Robert Gagne [9], concerning the information-processing model of learning based on the study of memory. An analogy is often made between a computer and the human mind, as both go through a similar process of gathering information from incoming stimuli, organising the information, that is, encoding it, retaining it, and, when needed, retrieving it.

The candidate explained that, although the other cognitive theorists acknowledge the importance of existing knowledge, the information-process theorists emphasise the process of retaining and retrieving this knowledge.

Gagne [9] devised a model of learning and memory. He describes a process whereby stimuli from the environment affect the receptors and then enter the nervous system via a sensory register which codes the information into a patterned representation. The information remains in this form for fractions of a second, after which it is either lost through decay, or entered into short-term memory. Once in short-term memory it is coded into a conceptual form, where it remains for only a few seconds.

The short-term memory has a limited capacity to store about seven items. Rehearsal of the information may retain it for longer, or even allow it to be encoded into long-term memory.

From short-term memory the information is either lost through decay and interference, or it is once again transformed and organised, ready to enter the long-term memory, where it is stored for later recall.

Once in long-term memory, information is categorised, and the general meaning, rather than exact details, is stored.

The DNE now looked thoroughly confused, so the candidate produced a diagram to help clarify this model.

Retrieval of information depends on how it is stored in long-term memory, that is, the representation and organisation. As discussed previously, information that is linked or coded into the appropriate conceptual or cognitive structure is more likely to be recalled efficiently.

Although information is thought to be stored permanently once it is entered into long-term memory, retrieval can be obscured by interference. Retroactive is the term used when new information interferes with old, and proactive describes old information interfering with new.

'How can nurse teachers use this?' asked the DNE enthusiastically.

The candidate said there were many ways teachers could maximise learning and retention.

First, the teacher can help students to focus attention selectively by changing the stimulus regularly and making use of colours, movement, voice and varying teaching methods. Novelty and humour can be very useful, but may also distract attention if not used carefully. The students can be given cues as to which points are particularly important. The teacher must also be aware of fatigue, limited attention spans, and the amount of new information being introduced, to prevent information overload.

Second, the teacher can help make new information meaningful by linking it to that already known-this may involve helping learners to retrieve the relevant previous knowledge.

Third, repetition of information can aid the encoding process. The spacing of the repetition or practice can be important.

'Thank you,' said the DNE. 'I have another appointment now, so we must end. I must admit that I am not too keen on learning outcomes. They seem a little too precise and related to objectives. But I am interested in some of your learning theories. I particularly like the sound of Bruner's ideas. I think that Ausubel's advance organisers are excellent and, of course, an understanding of perception, insight and memory is imperative.

'I have one final candidate to interview, so I'll be in touch with you after that.'

1. Woolfolk AE, Nicolich LM. Educational Psychology for Teachers. Englewood Cliffe NJ, Prentice-Hall. 1980. [Context Link]

2. Child D. Psychology and the Teacher. Fourth edition. London, Cassell. 1986.[Context Link]

3. Quinn FM. The Principles and Practice of Nurse Education. London, Croom Helm. 1980. [Context Link]

4. Bruner JS. Towards a Theory of Instruction. Cambridge, Mass, Belknap. 1966.[Context Link]

5. Bigge ML. Learning Theories for Teachers. Fourth edition. New York NY, Harper and Row. 1982. [Context Link]

6. Myles A. Psychology and the curriculum. In Allan P, Jolley M (Eds). The Curriculum in Nursing Education. London, Croom Helm. 1987. [Context Link]

7. Ausubel DP. Educational Psychology: A Cognitive View. New York NY, Holt, Rinehart and Winston. 1968. [Context Link]

8. Bernard-Lovell R. Adult Learning. London, Croom Helm. 1987. [Context Link]

9. Gagne RM. Essentials of Learning for Instruction. Hinsdale, Ill, Dryden Press. 1975.[Context Link]