Nurse education: learner-centred or teacher-centred?

John F Sweeney

Although the characteristics of an ideal ‘ward learning climate’ have been well

documented, nurse educationalists have devoted less attention to the learning climate in schools of nursing. Several commentators have noted the profession’s

failure to treat students of nursing as adult learners. The contrasts between learner-centred and teacher-centred approaches are

explored in the context of differing ideologies of education. Major themes from

adult education such as self-directed learning, student-centred learning and

andragogy, are discussed in relation to learner-centred education. Teacher-centred learning, implicit in many schools of nursing, stressing a rofe-based, asymmetrical

power relationship between teacher and student, provides a poor role mddel for empathic nurse-patient interactions. Its emphasis on treating nursing students as

a passive homogeneous group conflicts with the philosophy of individualisation inherent in the nursing process.

The consequences for nursing of maintaining a teacher-centred approach to learning include failure to develop critical thinking, in its students research

mindedness and a positive attitude to change and a self-directed attitude to continuing education.

The term ‘learner-centred education’ (Boydell

1976) is not one which appears frequently in

relation to nursing education. It was chosen to

embrace three concepts which reflect a gradual

change in emphasis from teaching to facili-

tation of learning. This transition, with its

origins in adult and higher education, has

assumed greater prominence in nurse education

over the last decade particularly in North

American literature. The first concept, ‘self-

J F Sweeney MSc DANS RMN RNMH Senior Tutor Mental Health, School of Nursing, Manchester Royal Infirmary Manuscript accepted July 1986

directed learning’, reflects the move towards

increasing personal responsibility for and auto-

nomy in determining what should be learned

and how, according to individual needs. The

second, ‘student-centred learning’, reflects the

humanistic influence on education which

stresses the importance of holistic learning, the

democratisation of the teacher-learner relation-

ship and the notion of personal growth for both

through an interactive learning process. The

third aspect, ‘andragogy’ the philosophy of

adult learning, unites these two concepts in a

manner which emphasises the fundamental dif-

ferences in approach between adult learning

and pedagogical instruction. Andragogy arose

257

258 NURSE EDUCATION TODAY

against a background of changes emerging in

the theoretical underpinning of adult education

based on research into individual variations in

adult learning styles and a conceptual review

of cognitive development in adulthood.

Learner-centred education refers to a

programme of learning which is self-directed,

student-centred and which acknowledges the

individual variations in cognitive styles among

adults by providing a wide variety of teaching/

learning approaches. Its purpose is to assist

learners and facilitators to discover knowledge

and skills which lead to self-fullilment and

personal growth through the development of

the critical, relativistic reasoning which is

essential for self-motivated, life-long learning.

This paper will examine the background to

learner-centred education and will consider its

relevance for students and teachers in nursing.

The increasingly complex demands made

upon ‘today’s nursing practitioners, in terms of

technical, managerial, educational and inter-

personal expertise, have been accompanied by

calls on nurse educators to teach in a learner-

centred way which fosters the development of

critical thinking and self-direction in study. It

is suggested that the vast increase in knowledge

in nursing obliges educators to move away

from an orientation of teaching ‘facts and bits

of information towards a more subject-

centred approach and towards a student

learning-centred approach’ (Watson 1982).

The transition in nursing from a ‘perpetuation

of a doing culture’, (Watson 1982) to theory-

linked, research-based clinical practice is not an

easy one. The proposition that the nursing

profession requires a rational, theoretical

basis derived from empirical observations

(McFarlane 1977) is seldom questioned yet the

difficulty it poses for traditional nurse edu-

cation programmes is becoming increasingly

apparent. Part of this difficulty in Britain

stems from nurse education’s isolation from the

influences of higher education (Pinkney-Atkinson

1983) and from its failure, over many gener-

ations, to secure ‘student status’ for learners

(Beckett 1984). However, given that these

constraints appear intractable, at least in the

immediate future, other reasons need to be

considered.

It may be argued that moves towards more

individualised, theory-based, learning for

nursing students trace their origins to North

America where programmes in tertiary edu-

cation are more common (Dingwall &

McIntosh 1978). Without doubt, the emer-

gence of research-based, theory-linked nursing

practice has accelerated calls for the reform of

apprenticeship-type educational programmes,

which do not cultivate a questioning, rational

attitude and critical thinking (Murphy 197 1)

In contrast to the North American emphasis

on ‘learning how to learn’ (Smith & Haverkamp

1977) and the concept of learning as a lifelong

activity (Gelpi 1979), many British nurses

appear to believe that the skills acquired during

initial educational programmes provide them

with an adequate basis for professional practice

(Simpson 1979).

Smith (1982) comments that much of the

problem with British nurse education derives

from the influence of tradition dating back to

the Nightingale era. If a 3 year apprenticeship

training was deemed adequate then, given the

knowledge, technology and theory explosion of

the 20th century, such an orientation today

must be wholly inappropriate. Jones ( 1981)

contends that in a profession characterised by

rapidly changing knowledge, facilitating self-

directed learning skills is more important than

transmitting knowledge.

Although there is commitment to greater

autonomy of learning in continuing education

among nurse educators (Cooper 1980) and clini-

cal practitioners (Gardner 1979)) Alexander’s

(1984) findings suggest that it is undermined by

earlier nursing experience of learning as a

passive process, resulting from ‘spoon feeding’

and teachers’ insistence on ‘covering’ the

curriculum. In spite of evidence of the

differences in learning styles and in learning

needs, nurse educators tend to teach students

as passive members of a homogeneous group

(Gott 1982). Nothing challenged this ideology

more than the introduction of the nursing pro-

cess into British nursing, with its emphasis on a

NURSE EDUCATION TODAY 259

problem-solving approach, based on a theoretical rationale, to meet the needs of the individual. King & Gerwig (1981) caution that nursing students will not adhere to a philosophy of personalised care needs for clients if their role models fail to employ a problem-solving ap- proach in assisting them to meet individualised learning needs. Burnard (1984) argues that the greater the experience of student-centred facili- tation by the nurse, the greater the likelihood of the nurse fostering the autonomy of the client. Thus an asymmetrical power relationship between teacher and nursing student is likely to be mirrored in nurse-patient interaction.

Burnard’s proposition that the ‘student- centred’ approach to nurse education has democratised teacher-student relationships is not supported, however, by any empirical evidence.

The humanistic underpinning of the nursing process (King & Gerwig 1981) is echoed in Knowles’s (1978) concept of ‘andragogy’ as a philosophy of adult education as opposed to pedagogy. Andragogy may be defined as ‘an organised and sustained effort to assist adults to learn in a way that enhances their capability to function as self-directed learners’ (Mezirow 1981). Nursing students are adults by virtue of age and by virtue of the expectations and demands made on them in the clinical area. Nursing education, however, is pedagogical in orientation (Pinkney-Atkinson 1983) and, fail- ing to treat nursing students as adult learners, is an inappropriate educational strategy for a caring profession (Burnard 1984). Nevertheless, British nurse educationalists have been singu- larly blinkered in ignoring the literature on andragogy, individualised learning styles and self- directed learning until comparatively recently

(Jones 1981). Investigations into the ideal clinical learning

environment for nursing students (Fretwell 1980, Orton 1981, Ogier 1981) have high- lighted the importance of an empathic, helping relationship (Rogers 1969) between supervisor and student. This emphasis on the importance of the ‘ward learning climate’ (Orton 1981) has not been mirrored by an investigation of

the ideal ‘classroom learning climate’ in schools

of nursing. Nursing in Britain is prejudiced against

higher education, as evidenced by stereotyped cliches such as ‘nurses are born not made’, and it has come to equate ‘practical’ aspects of nursing with common sense, and ‘theoretical’ aspects with academic detachment (Reinkemeyer 1969). Bendall (1975) suggests that nurse edu- cators commonly express a belief in an ‘ideal type’ of nurse and a belief in an inverse relation- ship between academic and practical-caring behaviour, despite evidence to the contrary.

Advocates of the ‘hidden curriculum’ in nursing education (Clinton 1982, Crout 1980) extend the argument to reason that nurse educators ‘de-emphasise’ the theoretical basis of nursing since they seek to train learners to become conformist, non-critical and obedient employees.

An alternative interpretation would be that, fearful of the risk of litigation and desirous of protecting the client against semi-skilled or unskilled practitioners, nurse-educators have felt the need to supervise closely and assume responsibility for every aspect of a student’s learning. This emphasis on ensuring that every student goes through an identical sequence and content of learning, regardless of her previous life experience, the assumption of a hetero- geneity of learning style (Laschinger & Boss 1984) and of learning needs (Bendall 1975)) may account for disturbing trends in British nursing.

Several writers (Lelean 1980, Hockey 1982, Kratz 1982, Alderton 1983, Blair 1983) con- sider how to interest practising nurses in re- search and to remain in touch with findings relevant to their area of expertise. Although research is not a substitute for professional judgement it does provide a basis for rational decision-making for the nursing practitioner (Crow 1981).

There is scant evidence, however, of ‘research-mindedness’ among British nurses. Many nursing practices are perpetuated by tradition (Smith 1982) and without empirical justification (Weatherston 1979). Sheahan (1982) comments that in spite of the amount of

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260 NURSE EDUCATION TODAY

research material available, there is evidence

that research findings are not widely incorpo-

rated into basic nurse education. This reflects

the failure of the profession generally to as-

similate research findings into practice (Hunt

1981). Dissemination of findings alone does not

necessarily result in modifications in clinical

practice (Lelean 1982) since there is evidence

that nurses rarely read professional journals

(Stodulski & Stafford 1982, Barnett 1981, Myco

1980), are unskilled in the use of libraries,

and need other-direction to identify, locate

and use nursing research findings (Stodulski

& Staflord 1982). Cooper (1982) points out,

however, that the introduction of a self-

directed learning component into a curriculum

is related to increased use of learning resources

such as libraries and is positively correlated

with greater reading of books, periodicals and

research journals.

Critical reading of research goes hand in

hand with the development of critical or diver-

gent thinking (Sherman & Kirsch 1978) yet

many nurses find the intrinsically questioning

approach of research to be incompatible with

established ways of thinking fostered during

nurse education (Lelean 1980). Furthermore,

there is some evidence that nursing education

not only fails to stimulate critical thinking but

actually stifles originality and creativity of

thinking in students (Eisenman 1970, Thomas

1979).

Crout (1980) and Clinton ( 1982) contend

that nursing students are actively discouraged

from questioning ‘the facts’ and are not taught

to argue logically or to substantiate their argu-

ments, in an attempt by educators to retain

power through the possession of knowledge. This

presentation of knowledge as unproblematic,

doubt-free with value neutrality equates with

what Alexander ( 1984) terms ‘learning discrete

rightnesses’. Her study revealed a low commit-

ment to self-directed learning and a high

commitment to spoon-feeding of learners, per-

petuating dependence and other-directedness

which has profoundly negative implications for

continuing education.

The problems outlined above reflect, to some

d egree, the type of relationship that exists

between teacher and student, and whether it

is person- or role-based. Clinton (1982) des-

cribing a first-level, psychiatric nursing

programme, found evidence of an authoritarian

attitude among nurse teachers towards nursing

students. Reilly (1977) points out that the very

values of caring, unconditional positive regards,

empathy and genuineness, which nurse

educators seek to develop in students, are often

undermined by practices and behaviours of

teachers in the school environment. Stephenson

(1984) reported the deliberate maintenance of

formality and ‘social distance’ by nurse

teachers as a means of social control over

students.

The education and training of students for a

practice discipline invariably impinges upon

the type of care received by the client group.

Failure to develop independent, critical

thinking affects the ability of practitioners to

influence decision-making in a multi-disciplinary

team setting since the nurse is unable to sub-

stantiate her argument with a theoretical

rationale.

This tends to perpetuate decision-making on

an ‘ad hoc’ or ‘trial-and-error’ basis or the

avoidance of decision-taking through reliance

on rituals, rules or routines (Menzies 1960).

This leads to resistance to change (Bennis

1966) and to lack of research-mindedness

(Sherman & Kirsch 1978), both of which

impede the implementation of research findings

in practice and the development of theory in

nursing. This is likely to widen the theory-

practice gap by a process referred to by Pope

( 1983) as a ‘two perspective outcome’. Namely,

if students learn material which has no per-

sonal meaning in relation to their everyday

experience, their alternative perspective, derived

from the clinical orientation (Webb 1981) will

assume precedence once the academic require-

ments of the programme have been met.

Clinical practice will further suffer through a

mirroring of the asymmetrical power relation-

ship between teacher and student in nurse-patient

interaction. The stifling of originality and

creativity is a greater cause for concern given

NURSE EDUCATION TODAY 261

the inverse relationship between creativity and Dingwall R, McIntosh J (eds) Readings in the sociology of

authoritarianism among nursing students nursing. Churchill Livingstone, Edinburgh

(Eisenman 19 72). Eisrnman R 1970 Creativity in nursing students.

Developmental Psychology 3 (3): 32&325

Authoritarian attitudes are inimical to Eisenman R 1972 Creativity in nursing students and their

Rogerian qualities in a helping relationship attitudes towards mental illness and physical disability.

and inhibit effective nurse-patient interaction. Journal of Clinical Psychology 28: 218-219

Finally, the effective use of the nursing process Fretwell J E 1980 An inquiry into the ward learning

environment. Nursing Times Occasional Paper 76 (161:

to meet patients’ individual needs requires a 69-75

problem-solving ability among nurses, who need Gardner 0 I 1979 A study of the opinions and preferences

of the staff nurse on in-service education. Unnublished

to demonstrate both convergent and divergent

thinking (Kissinger & Munjas 1981). It may

be seen from this discussion, that the degree of

learner-centredness of nursing programmes,

has significant implications for many aspects of

nursing practice beyond immediate educational

considerations.

References

.4lderton J 1983 Responsibility for research. Nursing Times

79 (471: 5657 Alexander M P 1984 Learning to nurse: beginning has

implications for continuing. Nurse Education Today 4

(1): 4-7

Barnett D E 1981 Do nurses read? Nurse managers and

nursing research reports. Nursing Times 77 150):

2131-2134

Beckett C 1984 Student status in nursing - a discussion on

the status of the student and how it affects training.

Journal of Advanced Nursing 9 (4): 3633374

Bendall E 1975 So you passed nurse. Royal College of

Nursing, London

Bennis W G 1966 Changing organisations. In: Thomas

J M, Bennis W C (eds) Management of change and

conflict. Penguin, London pp 21 l-226

Blair J M 1983 The application of research findings: whose

responsibility? Nurse Education Today 3 (2): 42-44

Boydell T 1976 Experiential learning. Manchester

Monographs 5, Department of Adult Education,

University of Manchester

Burnard P 1984 Paradigms for progress. Senior Nurse 1

(38): 24-25

Clinton M 1982-1983 Training psychiatric nurses: towards

a sociological analysis of the hidden curriculum. Nursing

Review 1 (3): 4-6, 1 (4): 13--15

Cooper S S 1980 Self-directed learning in nursing. Nursing

Resources, Wakefield, Massachusetts

Cooper S S 1982 Continuing education in nursing:

implications for practice. In: Henderson M S (ed)

Recent advances in nursing: nursing education.

Churchill Livingstone, Edinburgh Grout L 1980 From a learner’s point of view. Nursing

Mirror 150 (21): 14

Crow R A 1981 Research and the standards of nursing

care: what is the relationship. Jottrmtl III’ .\d\~anccd

Nursing 6 (6): 491-496

MSc Thesis, University of Manchester

Gelpi E 1979 A future for lifelong education. Volumes 1

and 2. Translated by Ruddock R, Manchester

Monographs 13, Department of Adult Education,

University of Manchester

Gott M 1982 Theories of learning and the teaching of

nursing. Nursing Times Occasional Paper 78 (11): 4144

Hockey L 1982 Defining the indefinable. Nursing Mirror

154 (9): 22-24

Hunt J 1981 Indicators for practice: the use of research

findings. Journal of Advanced Nursing 6 (3): 189-194

Jones W J 1981 Self-directed learning and student-selected

goals in nurse education. Journal of Advanced Nursing 6

(1): 59-69

King V, Gerwig B 1981 Humanising nursing education.

Wadsworth International, Netherlands

Kissinger J F, Munjas B A 1981 Nursing process, student

attributes and teaching methodologies. Nursing Research

30 (4): 242-246

Knowles M 1978 The adult learner: a neglected species.

Gulf Publishing Co, Houston, USA

Kratz C R 1982 Research - how can we challenge nursing

practice? Nursing Times Occasional Paper 78 (32): 128

Laschinger H K, Boss W 1984 Learning styles of nursing

students and career choices. Journal of Advanced

Nursing 9 (4): 3755380

Lelean S R 1980 Research in nursing: an overview of

DHSS initiatives in developing research in nursing.

Nursing Times Occasional Paper 76 (2): 5-6, 76 (3):

9912

Lelean S R 1982 The implementation of research findings

into practice. International Journal of Nursing Studies

19 (4): 223-230

McFarlane J K 1977 Developing a theory of nursing: the

relationship of theory to practice, education and

research. Journal of Advanced Nursing 2 (3): 261-270

Menzies 1 1960 A case study in the functioning of social

systems as a defence against anxiety. Human Relations

13 (2): 95-121

Mezirow J 1981 A critical theory of adult learning and

education. Adult Education 32 (1): 3-24

Murphy J F 197 1 Introduction: Theoretical issues in

professional nursing. Appleton-Century-Crofts, New

York

Myco F 1980 Nursing research information: are nurse

educators and practitioners seeking it out? Journal of

Advanced Nursing 5 (6): 637-646

Ogirr M E 1981 Ward sisters and their influence on nurse

learners. Nursing Times Occasional Paper 77 ( 11): 41-43

Orton H D 1981 Ward learning climate and student nurse

response. Nursing Times Occasional Paper 77 ( 17):

6.568

262 NURSE EDUCATION TODAY

Pinkney-Atkinson V J 1983 Nursing education as adult education: a philosophical standpoint. Curationis 6 (2): 8-10

Pope M 1983 Personal experience and the construction of knowledge in science. In: Boot R, Reynolds M (eds) Learning and experience in formal education. Manchester Monographs Dept of Adult Education, University of Manchester 1983, pp 26-43

Reilly D E 1977 Teaching values: theory and process. In: Reilly D E (ed) Teaching and evaluating in the affective domain in nursing programmes. Charles B Slack Inc, New York

Reinkemeyer A M 1969 The myths by which we live, International Nursing Review 16: 3948

Rogers C R 1969 Freedom to learn. Merrill, Columbus Ohio

Smith L 1982 The influence of tradition in nursing. Nursing Times Occasional Paper 78 (12): 45-48

Smith R, Haverkamp K 1977 Toward a theory of learning how to learn. Adult Education 28 (I): 3-21

Stephenson P M 1984 Aspects of the nurse-tutor/student- nurse relationship. Journal of Advanced Nursing 9 (3): 283-290

Stodulski A H, Stafford S M 1982 Disseminating nursing research information in the UK: Nursing Research Abstracts from the Index of Nursing Research. International Journal of Nursing 19 (4): 231-236

Thomas B 1979 Promoting creativity in nursing education. Nursing Research 28 (2): 115-l 19

Watson J 1982 Traditional vs tertiary: ideological shifts in nursing education. The Australian Nurses Journal 12 (2): 44-46. 64

,

Sherman K M, K&h A K 1978 Can nursing educators

Sheahan J 1982 The research interests of nurse tutor

_~ students. Nursing Times Occasional Paner 78 (5): 17-20

deal effectively with nursing students’ difficulty in critiquing nursing research articles? How can critical thinking be fostered? Nursing Research 27 (1): 69-70

Simpson I 1979 From student to nurse. Cambridge Universitv Press

Weatherstone L 1979 Theory of nursing: creating effective

Webb C 1981 Classification and framing: a sociological care. .Journal of Advanced Nursing 4 (4): 365-375

analysis of task-centred nursing. Journal of Advanced Nursing 6 (5): 369376