Chapter 1&3

Mid 1800’s nursing was first recognized as a unique discipline

The responsibility for teaching was recognized as a major aspect of the nurse’s role.

Florence Nightingale, the founder of modern nursing was seen as the ultimate teacher.◦ Major focus was teaching the importance of

proper nutrition, cleanliness, fresh air & exercise.

1950 the NLNE (now known as the NLN) identified course content in nursing school curricula to prepare nurses to assume the role of teacher of others.

All state nurse practice acts include teaching within the scope of nursing practice responsibilities.

2006 NLN developed the first certified nurse educator (CNE) exam.

1993 the Joint Commission established nursing standards for patient education.

These standards (mandates) describe the type, level of care & treatment services that must be provided for an organization to receive accreditation.

To achieve this there is great emphasis on unit based staff education to enhance nursing interventions that will ultimately result in improved patient outcomes.

Most recently there has been a shift to interdisciplinary educational approach.

Joint Commission wants to see evidence of patient education and knowledgeable participation by patients & significant others that they were involved in care & decision making.

Patients Bill of Rights includes guidelines to ensure that patients receive complete & current information concerning their diagnosis & treatment in terms they can understand.

1995 The Pew Health Professions Commission published a broad set of competencies for health professionals.◦ Provide clinically competent coordinated care◦ Involve patients & families in decision making◦ Provide clients with education & counseling on

ethical issues◦ Expand public access to care

Pew Commission cont’d◦ Ensure cost effective, appropriate care◦ Provide for prevention of illness and promotion of

healthy lifestyles for all Americans Another recent initiative – Sullivan Alliance

◦ Recruit & educate staff nurses to deliver culturally competent care

Role of today's nurse is also to “Train the Trainer” through programs such as:◦ In-service◦ Continuing education◦ Staff development

Key to the success of nursing profession is for nurses to teach other nurses.◦ Clinical preceptors & mentors play an important

role as teacher.

Nurses are in a key position to carry out health education.◦ Most continuous contact with clients◦ Most accessible source of info◦ Most highly trusted of all health professionals

Role of educator is not to primarily teach but to promote learning and provide an environment conducive to learning.

Role of the nurse as teacher of patients, families, nursing staff & students should stem from a partnership philosophy.

A learner can not be made to learn, but an effective approach would be to actively involve learners in the education process.

Nurse should create an environment that motivates individuals to want to learn.

Instead of the teacher teaching the focus is now on the learner learning.

Lack of time ◦ Early patient discharge◦ Multiple work demands

Lacking confidence in teaching skills ◦ Few nurses have ever taken specific courses on

how to teach

Personal characteristics of the teacher◦ Motivation◦ Skill

Priority of Teaching◦ Until recently not given much priority

Environment◦ Setting where nurses are expected to teach is not

always conducive to learning

Absence of third party reimbursement for patient education

Some nurses and physicians question the utility of patient education ◦ Some patients have no desire to change behavior

Type of documentation ◦ Many times teaching is not documented because

of time constraints◦ Forms may not allow for elaboration ◦ Many nurses don’t recognize the scope and depth

of teaching they perform

Lack of time (rapid discharge) Stress of illness Low literacy &/or health illiteracy Negative influence of hospital

environment Characteristics of the learner

◦ Motivation◦ Compliance◦ Developmental stage◦ Learning style

Extent of behavioral changes needed Lack of support & reinforcement from nurse

or significant others Denial of learning needs

◦ Resentment of authority ◦ Lack of willingness to take control

Inconvenience, complexity inaccessibility of healthcare system.

A learning theory is a coherent framework of integrated constructs & principles that describe, explain & predict how people learn.

There are several major learning theories.◦ Have wide applicability (workplace, organization,

human resource management)◦ Form the foundation for education & psychosocial

counseling.

Learning theories can be applied to problem solving, changing unhealthy habits,& building constructive relationships.

Focuses mainly on what is directly observable.

View learning as a product of stimulus – response model.

Ignore what goes on inside the individual & observe responses to environment.

Manipulate environment to affect change. Usually used in combination with other

theories.

Neutral stimulus (NS) (one with no particular value to the learner) is paired with a naturally occurring stimulus (UCS)& an unconditioned response (UCR).

After a few pairings the neutral stimulus alone (without the unconditioned stimulus), elicits the same unconditioned response.

Example Person without much experience in a

hospital (NS) visits a sick relative. While in the patient room they smell

offensive odors (UCS). This makes them feel nauseous & anxious

(UCR). After this visit & later repeated visits

hospitals (now the CS) make the person feel nauseous & anxious (CR) even without the presence of foul odors.

In this theory the response will decrease over time if the conditioned stimulus is not accompanied by the unconditioned stimulus.

The hospital visit is not accompanied with the ;presence of foul odor so eventually the person will not always feel nauseous & anxious when visiting a hospital.

Systematic desensitization is a technique based on respondent conditioning.

The assumption is that fear of a particular stimulus or situation is learned so it can be unlearned.

First patients are taught relaxation techniques.

Then when they are relaxed the fearful stimulus is introduced in a non threatening environment.

After repeated pairings of the stimulus under relaxed, non-frightening conditions the individual learns that no harm will come to them from the once fear producing stimulus.

Finally the person is able to confront the stimulus without being afraid.

This is used to prevent anticipatory nausea & vomiting in chemotherapy patients.

Also used in advertising of meds◦ If you take drug X you will live a happy life.

Stimulus generalization is the tendency of initial learning experiences to be easily applied to other similar stimuli.

For example, if an individual has a positive or negative hospitalization experience they will expect that same type of experience if they have to be hospitalized again.

Discrimination learning has occurred when an individual learns to differentiate between experiences.◦ If one venipuncture was very painful all

subsequent ones need not be.

Spontaneous recovery – useful concept in relapse prevention programs.

Although response may appear to be extinguished it may reappear at any time – even years later when stimulus conditions are similar.

This helps us understand why recovery from drug, alcohol & nicotine addiction can be so challenging.

Operant conditioning – focuses on behavior of the individual & reinforcement that occurs after the response.

Based on positive or negative reinforcement.

To increase the probability of a response use positive reinforcement or removal of unpleasant stimulus.

To decrease the probability of a response-non reinforcement (no response) & punishment is most effective.

Keep in mind negative attention is better than no attention.

If punishment is employed it should be immediate & consistent. (Don’t smile while reprimanding a bad behavior.

Goal of punishment is not to do harm it is to stop a particular behavior.

The use of reinforcement is central to operant conditioning procedures.

In order to be effective it is necessary to assess what kinds of reinforcement are likely to increase or decrease a behavior. ◦ Not every individual likes to be called dear or

honey.

Another issue involves timing of the reinforcement.

Initially reinforcement needs to occur quickly and continuously.

If the desired behavior does not occur immediately then reinforcement of approximate or resembling behavior will eventually coax the learner into the desired behavior.

Once a response becomes well established it becomes ineffective to continually reinforce the behavior.

Operant conditioning provides a relatively quick & effective way to change behavior

◦ Ie. Chronic back pain suffers◦ Family members are taught to minimize attention

to patients complaints of pain & behaviors of dependency.

◦ taught to pay a lot of attention to patients when they attempt to function independently

Some patients respond so well they report a decrease in pain and an increase in independence.

Some criticisms to behaviorist theory:◦ Teacher-centered model, learner is passive

This raises ethical question Who decides what desired behavior should be?

◦ Theory’s emphasis on extrinsic rewards & external incentives reinforces materialism rather than self-initiative & love of learning.

Some criticisms cont’d Research is based largely on animal studies. Individuals behavior may deteriorate once

they are back in their old environment.

Cognitive theorist stress what goes on inside the learner.

Widely used in education & counseling. Key to learning is perception, thought ,

memory & ways of processing info. Believe reward is not necessary for

learning.

Gestalt perspective Principle assumption is that each person

perceives, interprets & responds to any situation in their own individual way.

Psychological organization is directed toward simplicity, equilibrium & regularity. ◦ Patients want simple clear explanations

Perception is selective What individuals pay attention to is

influenced by:◦ Past experiences◦ Needs ◦ Personal motives◦ Attitudes◦ Reference groups◦ Particular structure of stimulus or situation.

This will affect how the nurse educator approaches a learning situation.

People may all act differently is same situation so teaching plan should be individualized.

Information processing – the way info is incorporated & stored.

Information processing First stage – pay attention to environment

◦ If patient is not paying attention perhaps they are tired, in pain etc.

Second stage – info is processed by the senses. ◦ Important to know learning style preferences.

Third stage – info is encoded into short term memory◦ Eventually info is either forgotten or stored in long

term memory.◦ Long term memory is enduring◦ Problem then becomes retrieving stored info

Final stage – action or response based on info

Cognitive theorist note that memory processing & retrieval of info are enhanced by organizing information & making it meaningful.

Jean Piaget – observed children's perceptions & thought processes.

Identified 4 sequential stages of cognitive development ◦ Sensorimotor◦ Preoperational◦ Concrete operations◦ Formal operations

Children take in info as they interact with people and the environment.

They either make their experiences fit with what they already know (assimilation) or change their perception & interpretations to fit with the new information (accommodation).

Within cognitive development perspectives there are some differences.

Piaget favored the discovery method Vygotsky advocated clear, well designed

instruction that is carefully structured to advance each persons thinking & learning.

Some children may learn best through discovery (putting pieces together on their own)

Other children benefit from a more directive approach.

Young children's learning is more solitary Older children learn better through social

interaction. As for adults – cognitive stages develop

sequentially but some adults never reach the formal operations stage.

These adults learn better through concrete approaches.

Psychologists & gerontologists have proposed advanced stages of reasoning beyond formal operations.

Older adults may exhibit an advanced level of reasoning based on wisdom & life experiences.

Or they may reflect lower levels of thinking due to lack of education, disease, depression, extreme stress or medications.

Research indicates that adults often do better with self directed learning, an explicit rationale for learning and a problem oriented approach.

Cognitive theory has been criticized for neglecting social context.

Now more attention is being paid to social & cultural context an individual finds themselves.

Individuals in a healthcare setting may have different perceptions based on their social & cultural experiences.

For example patients with certain religious or cultural upbringings may believe that illness is a punishment for sin.

The nurse educators prejudices & biases need to be considered as well.

Cognitive theory has also been criticized for neglecting emotions.

Recent efforts have been made to incorporate considerations related to emotions into the cognitive framework.

This is now known as the cognitive-emotional perspective.

Implication is that nurse educator should exhibit & encourage empathy and emotional intelligence in working with patients as a way to promote positive personal growth.

A significant benefit to cognitive theory is its encouragement in recognizing & appreciating individuality & diversity in how people learn & process experiences.

Cognitive theory has been useful in formulating exercise programs for breast cancer patients, bereavement support groups and dealing with depression in adolescent girls etc.

Difficulties lie in ascertaining what is transpiring inside the mind of each individual and designing individualized, appropriate learning activities.

Largely the work of Albert Bandura. Considers the personal characteristics of

the learner, behavior patterns & environment.

One of Bandura’s early observations was that individuals need not have direct experiences to learn.

Considerable learning occurs by taking note of other peoples experiences & what happens to them.

Bandura Learning is often a social process &

significant others provide compelling examples of how to think feel & act.

Role modeling is a central concept of this theory.◦ Using a more experienced nurse as a mentor

Vicarious reinforcement – involves whether role models are perceived as rewarded or punished for their behavior.

4 step process◦ Attentional phase (observe role model)◦ Retention phase (processing)◦ Reproduction phase (learner copies performance)◦ Motivational phase (influenced by vicarious

reinforcement)

Culture & self efficacy play a key role. Responsibility is placed on the educator to

act as an exemplary role model. In healthcare Social Learning Theory has

been applied to maximizing the effects of support groups.

A major difficulty with this theory is that it is complex, not easily operationalized, measured or assessed.

Based on the work of Sigmund Freud A theory of motivations stressing emotions Emphasizes the importance of the

conscious & unconscious forces that guide behavior.

Childhood experiences have enduring effects.

The most primitive source of motivation comes from the “id” (basic instincts we are born with)

This includes “eros” (desire for pleasure & sex) & “thanatos” (aggressive, destructive impulses)

Patients who survive despite all predictions to the contrary provide illustrations of such primitive motivations.

The “id” (primitive drives) & the “superego” (internalized societal values) are mediated by the ego, which operates on the reality principle.

Healthy ego development is an important consideration in health fields.

Patients with ego strength can cope with painful medical treatments because they know the long term value of enduring pain to achieve a positive outcome.

Patients with weak ego development may miss their appointments or engage in short term pleasurable activities that work against their healing & recovery.

When the ego is threatened, defense mechanisms may be employed.

Short term use is a way of coming to grips with reality.

Long term use results in avoiding reality &acts as a barrier to learning.

Common defense mechanisms include:◦ Denial◦ Rationalization◦ Displacement◦ Depression◦ Regression◦ Intellectualization◦ Projection ◦ Compensation

Major assumption of this theory is that personality development occurs in stages, with much adult behavior derived from past childhood experiences.

Erickson’s 8 stages of development is most widely used models of personality development.

Erickson’s 8 Stages include:◦ Trust vs. mistrust (birht-18mos)◦ Autonomy vs. shame (18 mos-3 yrs)◦ Initiative vs. guilt (3-6yrs)◦ Industry vs. inferiority (6-12)◦ Identity vs. role confusion(12-18)◦ Intimacy vs. isolation (18-40)◦ Generativity vs. stagnation (40-65)◦ Ego integrity vs. despair (65-death)

Health education must always include consideration for the patients stage of personality development.

Personal difficulties arise & learning is limited when a person becomes stuck at an earlier stage of personality development.

Must work through previously unresolved crisis to mature.

What people resist talking about or learning is an indicator of underlying emotional difficulties.◦ Pregnant teenager refuses to engage in a serious

conversation about sexuality.◦ Staff member afraid to talk about dying

This theory is well suited to understanding patient noncompliance, palliative care, loss & terminal illness.

This theory has been criticized because much of the analysis ids subjective & is difficult to operationalize & measure.

Without special training it is inappropriate for nurses to delve into the feelings of patients & uncover deep unconscious conflicts.

Underlying assumption is that all individuals are unique & have a desire to grow in a positive way.

Positive psychological growth may be damaged by society.◦ Males are less emotional than females◦ Some ethnic groups are inferior to others◦ Money more important than people

Spontaneity, the importance of emotions & feelings, the right of individuals to make their own choices & human creativity are the cornerstones of the humanistic approach.

Compatible with nursing's focus on caring and patient centeredness.

Maslow was the major contributor to this theory with the hierarchy of needs.

An assumption of this theory is that basic needs must be met before individuals can be concerned with learning.

Interestingly, research has not been able to support Maslow’s hierarchy of needs.◦ Some people may engage in creative activities &

extend themselves to others even though their basic needs have not been met.

Humanists believe that the role of educator is to be a facilitator, to listen rather than talk.

Learner should choose what is to be learned.

Tell me how you feel is much more important than tell me what you think.

This theory is best suited for working with wellness groups,& palliative care.

Some criticisms include promoting self-centered learners that can not take criticism.

Charged with being more of a philosophy – too touchy feely to foster learning.

One of the newest & most rapidly growing areas

Information has been gained through advances in neuro-imaging techniques.

Generalizations:◦ Emotions interact with cognitive factors in all

learning situations.◦ Learning is a function of physiological &

neurological developmental changes that are dynamic.

◦ Brain processing is different for each learner.◦ Learning is an active process◦ Stress can interfere or stimulate learning.

Research in this field is in early stages and lacks integration.

Largely based on animal studies or highly selective human studies so generalization is difficult at this point.

There is no single way to best approach learning.

Educator must be sensitive to the unique characteristics & motivations of each learner.

Educator can facilitate what needs to be known, where to find the necessary info, & how to help individuals & groups benefit from a learning situation.