NurrrEduatron T&v (1989) 9.23624 I 0 Longman Group UK Ltd 1989

Quality assurance in nurse education - the social context of learning

Peter A Morrall

In this article I will critically examine the social context of learning in nurse education from a sociological perspective. 1 will begin with a brief review of recent developments in the philosophy and practice of nurse education. The concepts of ‘tokenism’, ‘relative autonomy’, ’ de-mystification’, and ‘social control’ will be used to identify what the present socio-political status of the nurse-learner is.

Whilst it is recognised that major improvements in the quality of nurse education have occurred over recent years, the application of these concepts helps to highlight the need for further radical developments before students can be said to have attained educational ‘self-actualisation’.

Finally, I will suggest positive strategies aimed at advancing the quality of learning for nurses in the future.

INTRODUCTION

‘Quality . . you know what it is, yet you don’t know what it is. . . If no one knows what it is, then for all practical purposes it doesn’t exist at all. But for all practical purposes it really does exist . . . Why else would people pay fortunes for some things and throw others in the trash pile? Obviously some things are better than others . . but what’s this betterness? . . So round and round you go, spinning mental wheels and nowhere finding anyplace to get traction. . . . . .What the hell is Quality? What is it?’ (Pirsig 1974)

Peter A Mortal1 MSc BA(Hons) PGCE RNMH RMN RGN Principal Lecturer in Nursing Studies/Sociology, Department of Health and Community Studies, Teeside Polytechnic, Middlesbrough, Cleveland TSl 3BA (Requests for reprints to PAM) Manuscript accepted 14 December 1988

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The overall premise of the article is that ‘qualita- tive’ outcomes in nurse education are fun- damentally restricted by parameters laid down by institutions (educational or otherwise). In order to effect change and augment the quality of educational experiences, there has to be a ‘real’ shift of power and influence from the institution and its representatives (teachers and managers) towards the nurse learner.

Mezirow (1983) expresses this approach in educational terms:

‘It is almost universally recognised, at least in theory, that central to the adult educator’s function is u goal and method of self-directed

leanbng. Enhancing the learner’s ability for

This article formed the basis of a paper presented to a conference on ‘Quality Assurance in Nurse Education’ held on 21 and 22 March 1988 at Durham University, although additions and modifications have been made subsequently. The conference was initiated by the Northern Region’s Education Advisory Group, and was organised by Teeside Polytechnic.

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self-direction in learning as a foundation for a distinctive philosophy of adult education has breadth and power. It represents the learning characteristic of adulthood.’ (Mezirow 1983)

RECENT DEVELOPMENTS

Some progress towards this scenario has already taken place. For example, the movement towards replacing didactic teaching with exper- iential learning allows students to actively parti- cipate in the classroom. There is also a greater emphasis on the ‘learning’ process rather than the ‘teaching’ process. The change in role for the teacher from ‘wise owl’ to ‘facilitator’ gives credence to the student’s views and experiences.

The way in which the educational estab- lishment (whether this be the various National Boards or Her Majesty’s Inspectorate) has insisted on schools installing student evaluation procedures has, at least to some degree, affected future educational programmes at a local level. Acceptance of student representatives onto cur- riculum development teams theoretically pro- vides the learner with access to previously unobtainable information about how her/his course is being developed.

The ideology of ‘student-centredness’ (similar to that of ‘patient-centredness’) is perpetrated on contemporary teacher ‘training’ courses, and is an up-to-date piece of jargon which any pros- pective teacher would do well not to forget to use at interview! Hospital training wards and the community placements for nurse learners are required to organise learning objectives and learning experiences, together with teaching programmes for nurse learners. This (again, in theory) ensures that the student’s educational needs are directly attended to, and the student has the opportunity to monitor for her/himself the ward or community placement’s commit- ment in this respect.

RELATIVE AUTONOMY?

To use a concept borrowed from the work of sociologist Louis Althusser (1969) to describe

how free/unfree we are from the constraints of the economy, have students (even those on the most student-centred courses) simply achieved Relative Autonomy in controlling whether or not their educational needs and desires are met? Are we witnessing the emergence of a truly libera- lised and liberating system of educating adults, or is the ‘bottom line’ still that institutional and organisation requirements come first?

Weber (1978) described bureaucratic hier- archical organisations as ‘rational’ and ‘goal orientated’, and as an ‘ideal typification’ this also describes most schools of nursing and colleges. But it could be argued that the overall goals of an organisation can contradict some of its other stated goals or even undermine the needs of its ‘customers’.

For example, the Griffiths report on National Health Service management advocated improved budgetary and costing arrangements (Griffiths 1983), but can this doctrine really be synonymous with quality in health care provi- sion? The United Kingdom already donates a very small proportion of its Gross National Product to health services in comparison with other industrial countries (See The Economist, 31 May 1986).

Moreover, if quality and cost-effectiveness are not antithetical objectives then why are waiting lists for hospital operations still lengthening? (Moore 1988). Today, NHS managers are expec- ted to follow a ‘cost-effective imperative’ (Walker 1987) which can result in hospitals being closed or services lost if they are not functioning economically. That is, unless (and here lies another contradition between the goal of the organisation and the expressed need of the ‘consumer’) public pressure doesn’t reverse the decision (Sims 1988; Hall 1988).

With respect to organisational ‘goals’, Goff- man’s view of ‘total’ institutions (which edu- cational establishments virtually become for their student-‘inmates’) provides us with a useful insight. Many activities, argues Goffman, are justified as part of a rational plan to fulfil the aims of the institution rather than to help the individual (Goffman 1961). It may be very subjective but over the years I have frequently had the uncomfortable feeling whilst attending

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meetings at various levels in the Health Service and in educational institutions that much of what is being discussed has the covert and teleological aim of maintaining a cycle of employment for those present!

change one of the assessments you had pre- organised for us before we had even come on the course.’

STUDENT 3 ‘What about when we wanted to divide the group up so that we could have a choice in the programme? We couldn’t do it in the end because the college can’t accommo- date us having access to all of those resources.’ TOKENISM?

Are educators, consciously or unconsciously, conspiring to perpetuate the delusion of student-centred learning? Can the above men- tioned ‘developments’in nurse education merely be interpreted as ‘buying off student demands?

Using the analogy of the women’s movement, tokenism can be observed in other areas of social life. For example, are a few female executives in the business world and a woman Prime Minister an indication of a general improvement in the lot of women, or is this just a subtle way of defusing a potentially explosive reaction from women over continuing inequalities?

Another example might be taken from the anti-racist movement. Does the fact that there are a few black Members of Parliament imply that black people will be able to do something about racism and the inequalities which they are affected by, or again is this simply a more sophisticated way of preventing social unrest without in essence altering the plight of the ethnic minorities in this country?

Equally, does allowing students to have a ‘voice’ in their own education essentially alter anything in their favour?

DE-MYSTIFICATION

Recently, some of the students I ‘facilitate’ de- mystified the true reality of their situation. Some of their perceptive comments are paraphrased below :

STUDENT 1 ‘You keep telling us that things in the curriculum are negotiable, but often when we do make suggestions you say that ‘the ENB won’t allow it’.

The process of socialisation insidiously teaches students to conform to a set of pre-set norms, values, attitudes and behaviours which are diffi- cult (if not impossible) for the student to influ- ence. Eventually, the student ‘internalises’ the norms etc, and comes to think of them as natural’. They become part of the student’s own world view. Thus ‘self-regulation’ replaces ‘external regulation’. If these norms are not accepted then the student very rapidly becomes labelled as a ‘deviant’, which in itself is a method of controlling social behaviour.

STUDENT 2 ‘Yes, like when we wanted to The author experienced an example of this

STUDENT 4 ‘If this is meant to be OUT course, why is the course document full with content, aims and objectives?’

STUDENT 5 ‘Why is there a course document at all?’

Accentuating the observations made by these students, Boud (1981) remarks that the aim of producing ‘autonomy’ in learning:

’ . . . is such that it cannot be limited to peri- pheral topics or extracurricular activities, and it cannot be pursued partially. The exercise of autonomy cannot be realistically limited to any one part of the learning process: for example, in course content, but not assessment or in choosing one’s own pace but not one’s objectives.’ (Boud 198 1)

SOCIAL CONTROL

Holloway and Penson (1987) argue that nurse education is a form of social control because students are socialised into ‘role behaviour’ which is designed to meet a pre-organised agenda of producing ‘competent’ practitioners.

NI’RSE EDL’CATIOK TODAY 239

when a student was given a low mark for an academic piece of work. The comments to him were that he really needed to read more books, and attempt to appraise theories and research data so that he could then come to some logical conclusion about the issue in question.

Without any hint of ‘rationalisation’, he answered by explaining that if he did what I (and the institution) wanted and played the ‘academic game’ then his ‘creativity’, innovativeness and ‘free-expression’ would be stifled.

In his words, he would become an ‘educational automaton’ like most of the other students who did not question the rules. Many, he added insightfully, did not even know the rules were there.

Mostly this ‘agenda’ is implicit in nurse edu- cation. But if it accidentally becomes explicit then institutionalised strategies are frequently invoked to control the situation and maintain the status quo. These strategies can vary in their potency. There is at one extreme the regurgi- tation of platitudes and truisms at the inter- personal level (either in the classroom or during clinical practice). For example, ‘We would do it another way if we had time’ or, ‘This subject has got to be covered because it’s in the syllabus’ or, ‘We have always done it this way and it has always worked in the past.’ Going to the other extreme, when the organisation is feeling particularly threatened, disciplinary procedures may be implemented to overtly and crudely control behaviour.

The first set of strategies perhaps surface when students question the reason for con- tinuing with what appears to be ritualistic rather than ‘scientifically’ based practices, whereas the second can occur even when nurses can be perceived as actually acting in the best interest of the patient or humanity at large (as with nurses objecting to being associated with Electro- Convulsive-Treatment or abortions).

With the latter student nurses are told that they have to undergo certain experiences to become ‘certificated’. Consequently, the fun- damental issue, which is to do with undermining established inter-professional and intra-profess- ional power relations, is avoided. More impor- tantly, it demonstrates that the student has no

power or control over her/his educational experiences.

MOMENTUM FOR CHANGE AND CONCLUSIONS

Experiential learning and student ‘involvement’ in curriculum development and the learning process has improved the quality of educational experiences for nurse learners, but in effect this is mere tokenism. Power and control have not been expropriated from those with an invest- ment in maintaining ‘things as they are.’

Relative autonomy not ‘genuine’ autonomy exists for the learner even in those institutions which openly advocate ‘student-centred learn- ing’. In this sense ‘student-centred learning’ is in reality a myth.

Institutional and organisational constraints act to control the parameters within which experimentation and innovation can excel.

If the quality of nurse education is going to improve then the social context in which it operates requires structural and ideological alterations.

At the structural Ievel, there is a case for the ‘democratisation’ of the educational system if student-centred learning is to be seen to be taken seriously. Programmes which are created with student ‘representatives’ as opposed to student ‘activists’ will reflect the wishes of the teachers and the institution, not those of the learner.

One method of doing this is to work with an open curriculum.

In an article in The Guardian (16/6/87) Julia Hagedorn reported on the use of such an approach by a London Polytechnic when setting up a diploma in higher education:

‘Imagine yourself for a minute as part of an august professional body of men and women charged with the responsibility for validating courses in further and higher education. You are approached by a polytechnic asking approval for a diploma in higher education . . . which has no reading list, no set lectures.

All it offers is a building, some tutors and a set of procedures.

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‘ . . . after a full inspection the DipHE was given continuing and unconditional approval. . . [as was a] post-graduate MA and MSc. . .

‘Students devise their programmes and their reading lists in the first term. This must then be negotiated with a formal body of lecturers and the final assessment of the students work will adhere strictly to the criteria negotiated in this contract. . .

‘The student will also negotiate the format of his final assessment.’

At an ideological level, then the philosophy of ‘Andragogy’ I would suggest is the most appro- priate for nurse learners. Andragogy is defined by Mezirow (1983) 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 op tit)

For Mezirow, learners must be encouraged to:

4

b)

4 4 d

t)

g)

h)

progressively reduce dependency on the educator comprehend how to use learning resources - especially the experience of others, including the educator engage in reciprocal learning relationships define his/her own learning needs assume increasing responsibility for defin- ing their learning objectives, planning their own learning program, and evaluat- ing their progress make ‘real’ decisions, for example in rela- tion to making choices about learning experiences be involved in experiential and other ‘active’ learning approaches make use of learning contracts

Many of the principles listed in Mezirow’s ‘charter’ can be addressed by implementing specific teaching strategies. For example, ‘col- laborative’ approaches, which encompass exper- iential learning, group work, and specially designed work-sheets (Morrall 1988), have the potential not only to improve the quality of learning experiences but also to transform the

nature of the relationship between teacher and student.

Recommending ‘classroom collaboration’ for school pupils (and I would argue that there is an even greater justification for it to be employed with adults), Salmon and Claire (1984) state:

’ . . . collaborative modes carry very different political messages from traditional ones - and thereby must give rise to different political outcomes. Where straight teacher exposition essentially vests power in teachers. . [collabo- rative learning] . . . disperses authority within the classroom, giving children responsibility and power to organise their own learning.’ (Salmon & Claire 1984)

Collaborative learning, however, requires the support of radical policies outside the classroom. For example, I would suggest that students should make up 50% of curriculum develop- ment teams (with full voting rights). Further, as Francis Bacon stated, ‘knowledge itself is power’ (Cohen & Cohen 1960). Consequently, I argue that students should have direct access to all of the information relating to their course (from ENB circulars to tutor’s comments on the pro- gress of individual students).

There is only one restriction which cannot be ignored. The ‘safe practitioner’ remains the base-line product of initial nurse educational programmes so that the patient is protected. Pre-set summatively assessed ‘competencies’ easily meet this need. With only this one quali- fication (and only at the ‘basic’ level is it neces- sary) dynamic change is required in nurse education if Pirsig’s (1974) aphorism is to be challenged:

Quality for sheep is what the shepherd says’ (Pirsig, 1974)

References

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learning. Kogan Page, London Cohen J M. Cohen M J 1960 The Penquin dictionary of

quotations. Penquin, Harmondsworth The Economist 1986 Britain: the health crisis that isn’t.

The Economist Newspaper Ltd. London. 31 May: 2 l-22

h’URSE EDUCATION TODAY 24 1

Goffman E 1961 Asylums. Penguin, Harmondsworth Griffiths R 1983 NHS management inquiry:

recommendation for action. DHSS, London Hagedorn J I987 Going for it well alone. Guardian, 16

June Hall M H 1988 Crisis in the maternity services. British

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control. Nurse Education Today 7. 5: 235-241 Mezirow J 1983 A critical theory of adult learning in

adult learning and education by Tight M (ed). Croom Helm, London

Moore W 1988 Waiting lists are still lengthening. The Health Service Journal, 3 November: 1278

Morrall P A 1988 Television ‘soaps’ in the classroom. Nurse Education Today 8, 5: 296299

Pirsig R M I974 Zen and the art of motorcycle. Maintenance Morrow & Co, New York

Salmon P, Claire H 1984 Classroom collaboration. Routledge, London

Sims J 1988 Public action keeps hospitals open. The Health Service Journal, 3 November: 1279

Walker A 1987 The caring capacity of the community. International Journal of Health Services 17, 3: 369- 386

Weber M 1978 Economy and society (Vol. 2). University of California Press, Berkeley.