The social and economic reform of China has opened the country up to the Western world since 1979. Nursing education in China has also opened up under the influences of Chinese policy and regulation. To strengthen the nursing services in China and integrate into the international nursing community, the local government of Shenzhen has established a collaborative relationship with a large tertiary institute in New Zealand aiming to expand the Shenzhen nurses' experiences of nursing education outside China.
A 12-week international nurse training program was designed by a large tertiary institution in New Zealand in response to the request of local hospital officials within Shenzhen, China. The purpose of this program was to promote the professional development of Shenzhen nurses by expanding their experience of nursing education outside China. This study was designed to survey the participants' experiences in the program in regard to teaching methods, assessment practices, and overall content appropriateness.
In recent years, the concept of learner-centered teaching (LCT) has become widely recognized, with its focus on knowledge construction through collaboration among individual learners, as distinguished from traditional ways of knowledge transmission from the teacher to the learner (Clarke, 2010; Elen, Clarebout, Léonard, & Lowyck, 2007). Advocates of learner-centered learning contend that students thrive when they make sense of the learning materials through the real-world experience (Robb, 2012). Weimer (2013) further developed the concept of LCT that emphasizes the learners' active participation in knowledge construction from their past learning experiences and current new information.
In recent literature, educators often use different terms to describe LCT styles. Many teaching approaches fit into the umbrella term of LCT pedagogy, including the flipped approach (Sams & Bergmann, 2013), inquiry-guided teaching approach (Chu, Reynolds, Tavares, Notari, & Lee, 2017; Lee, 2012), and blended learning (Blissitt, 2016). It has been argued that LCT promotes students' critical thinking skills, resulting in deep understanding rather than surface learning (Biggs & Tang, 2011; Weimer, 2013). The growing awareness of the importance of LCT is evidenced by various teaching strategies in nursing programs, such as online learning and reflective learning (Betihavas, Bridgman, Kornhaber, & Cross, 2016; Langley & Brown, 2010). The notion of LCT rooted in constructivist learning theory requires that the teaching methods, the teaching contents, and learning assessments are constructively aligned to the learners' cultural and social backgrounds (Baeten, Dochy, & Struyven, 2013).
In China, with the launch of quality education reform and the influence of global education, teachers are working through the transition from traditional didactic teaching to a more LCT approach (Chan & Rao, 2009). Traditional classroom teachings in China are often criticized as too strict and rigid to meet learners' needs (Yu, 2008). However, some researchers argue that it could be challenging to implement LCT in China because of various cultural and social factors, such as a great respect for teachers' authority underpinned by Confucianism and a focus on textbook teaching enforced by government policy (Clarke, 2010; Wang, 2011). Consequently, higher education in China is mainly a teacher-centered and examination-driven approach (Wang & Farmer, 2008). In other words, LCT approaches cannot be proven effective when taking into account the dominant Confucian educational philosophy that emphasizes the role of the teacher as a knowledge expert and moral symbol (Nguyen, Terlouw, & Pilot, 2006). By comparison, the LCT in Western countries is considered to be effective in facilitating individual students to construct knowledge (Weimer, 2013).
Based on the above assumptions, it could be questionable to implement an LCT approach in teaching Chinese nurses. This brings up the essential question of this study, namely: “How helpful was this nursing training program provided by a Western tertiary institution in facilitating Chinese nurses' learning using an LCT approach?” The purpose of this study was not simply an evaluation report, but rather it aimed to assess the appropriateness of using LCT approaches to supporting Chinese nurses' learning.
Implementation of the Nursing Training Program
A call for attendees was widely distributed by the Health and Medical Continuing Education Centre of Shenzhen in 2016. Criteria included being able to speak, read, and comprehend English. Three groups (10 nurses in each group) were selected through an English examination and interviewing process to demonstrate their levels of English. So far, a total of 30 Chinese nurses had attended the program.
This 12-week international training program was designed by a large tertiary institution in New Zealand. The nursing faculty developed and revised the curriculum to reflect the specialized needs of Chinese nurses (Table 1). All teaching and learning materials were written in English.
Agenda of the Nursing Leadership and Management Training Program
To meet the Chinese nurses' learning needs, an online course module was developed under the title “Nursing Leadership and Management” to outline weekly learning activities and provide convenient access to learning resources. The program coordinator convened each week to assess the response of participants to each week's learning topics and activities. In addition to the fixed content, extra reading and learning materials were uploaded to the online course weekly based on trainees' requests and feedback. All trainees had access to online learning resources at any time during their training period.
This program was taught and facilitated by content experts, including academic nursing lecturers and clinical nurse specialists, to enhance trainees' learning experiences using a variety of teaching strategies, such as face-to-face lectures, case-study analysis, simulation-based activities, reflective learning, and online learning. All teaching activities were observed by the program coordinator, who is fluent in both English and Chinese. During group discussions, trainees were invited to exchange ideas, ask questions, and reflect on their own practical experiences in China. Case studies were given to elicit more reflective discussion. Simulation-based education was introduced to cultivate clinical decision-making skills. Attendance was compulsory, and an individual presentation (maximum 30 minutes) with self-determined topics related to nursing management was required at the end of program.
The research instruments used in this study comprised an online survey and a semistructured focus group interview. The study procedure was reviewed by the research ethic committee of the involved tertiary institution. An online survey (Table 2) was sent to all trainees (n = 30), allowing them to reply anonymously, and the response rate was 86.7% (n = 26). All participants were female, and their ages ranged from 25 to 45 years. The third group of Chinese nurses (n = 10) who recently completed this course gave consent to be interviewed as a group. The interview was audiorecorded with a 1-hour duration. The main purpose of a group interview was to gain additional insights through the shared views from group members.
To get a more comprehensive review of the appropriateness of using an LCT approach in facilitating Chinese nurses' learning, the following qualitative data were analyzed: field notes from classroom observations, open-ended online survey questions, and an audiorecorded focus group interview.
Using a thematic approach, all data were analyzed with a constant comparison. Four essential themes emerged from the data analysis process: academically committed learners, amalgamated teaching methods, needs-focused learning content, and self-determined learning assessment.
Academically Committed Learners
Participants identified various motivations for attending this program, such as nursing skills development, promotion opportunities, and life experiences. During the interview process, participants further explained that professional development of nurses was greatly encouraged by the center and local governments of China, and many overseas training programs were funded by the government, including this particular nursing training program in New Zealand. They came to New Zealand with a strong desire to learn. From the classroom observations, all trainees actively participated in all kinds of teaching and learning activities with full attendance. They were inquisitive learners and asked many questions related to nursing practice in the class.
Amalgamated Teaching Methods
The most helpful teaching and learning methods mentioned in both online survey and during the focus group interview were nursing simulations, case studies, reflective writing, and face-to-face lectures. It was acknowledged that there had been a huge difference in teaching methods between China and New Zealand. In China, more didactic lectures with a teacher-dominated teaching style were used, whereas in New Zealand, a variety of teaching styles were experienced, including interactive classroom teaching, reflective writing, group discussions, simulation-based education, case studies, and independent online learning.
In the focus group interview, participants further noted that the simulation-based and case-based learning contributed to the integration of theory and practice, bridging the gap between theoretical knowledge and clinical practice. Participants stated that reflective writing and simulation-based education could be useful in teaching newly graduated nurses in China to promote clinical reasoning skills. An interesting comment voiced by one participant and agreed on by all other participants in the focus group interview was that they preferred teacher-directed lectures, even though they enjoyed the interactive learning process greatly. When further questioned, they explained that lectures could be a time-efficient way of receiving large amounts of information and they hoped that they could take as much information as they could back to China.
Needs-Focused Learning Content
This training program had predesigned teaching and learning topics (Table 1). Participants mentioned that the learning resources were vast and it was difficult for them to study all the topics in depth. Most preferred topics voiced by participants were nursing education, patient-centered care, clinical supervision, and professional development of nurses in New Zealand.
A majority of participants commented that a positive aspect of the training program was the collaborative decision making invited by the coordinator about the learning goals, topics, and content of the program. More learning and teaching topics, such as clinical triage and conflict management were added by the program coordinator based on the Chinese nurses' inquiries during the training period. They mentioned that the online resources were sufficient and always up to date. The content emphasized their learning needs.
Self-Determined Learning Assessment
During the interview process, participants mentioned they were surprised when told that no examinations would take place throughout the training process. Instead, they were asked to provide a 30-minute presentation focusing on topics of their own choice. Compared with the traditional test-driven learning, participants agreed that the presentation benefitted them in more significant ways. The self-determined topics allowed them to focus on their specialized nursing topics. In the process of preparing presentations, they had learned how to search for academic sources through databases and how to present in front of peers and interact with an audience using communication skills.
The overall results from the study showed that the training program positively influenced the development of nursing knowledge of participants. Importantly, they mentioned that the information and skills they learned are transferable to the clinical settings in China, and that they had a desire to disseminate their knowledge gained from this training program in China.
At the beginning of this article, the study question was posed regarding the appropriateness of LCT approaches to facilitating Chinese nurses' learning. This section will address this study question through qualitative analysis reviewing significant themes mentioned in the Results section.
Andragogy highlights the differences between adults' learning and children's learning, which has been explained persuasively by Knowles (1984). Adults are more likely aware of the importance of using the learning to support their practice immediately, whereas that is not the case for children (Rogers, 2007). According to Biggs and Tang (2011), extrinsic motivation occurs when learners perform the task because of the value of learning. The most common extrinsic motivations are promotion, entry to a new career, and changes required to adapt to a new environment (Rogers, 2007). Intrinsic motivation, such as the need to socialize, is also a powerful propellant. In the Western learning theory tradition, adult learning is problem-centered and the motivation to learn is intrinsic (Knowles, 1984). Effective teaching must use the learners' motivations to achieve the intended outcomes, as lack of motivation is one of the main reasons that learning fails (Biggs & Tang, 2011; Rogers, 2007).
In the current Chinese social and political context, nursing education is a fundamental component in China's health care reform (Wang, Whitehead, & Bayes, 2016). To meet the needs of the population care, the Chinese government is making considerable efforts to address the challenges of health care services as evidenced by an increasing fund given to the health and education sector to promote the professional development of health care professionals (Li & Fu, 2017). In the current study, encouraged by the Chinese government policies, all participants were academically committed with clear learning goals. Most of them had already been or would become clinical supervisors after returning to China. They had deep appreciations of the given opportunity to study abroad and a burning ambition to learn. If information and learning resources are shared freely within global nursing communities, such as New Zealand and China, great potential exists for Chinese nurses to further develop their nursing knowledge through the international nursing communities of practice.
Under the influence of global education, teachers in China are working through the transition from traditional rote learning and didactic teaching to a more LCT approach (Chan & Rao, 2009). Although traditional classroom teaching in China is commonly criticized as too strict and rigid to promote students' critical thinking skills (Yu, 2008), some researchers argue that it could be challenging to implement LCT in China because of various cultural and social factors, such as a great respect for teachers' authority underpinned by Confucianism and a focus on textbook-teaching enforced by the government policy (Clarke, 2010; Wang, 2011). In the current study, participants noted a huge difference in teaching and learning styles between China and New Zealand. Participants acknowledged that conventional didactic teaching was the main learning method they had in China, whereas in New Zealand they experienced more interaction with nursing professionals and, as one of the participants mentioned, “the classes are more like seminars.”
Social constructivism has been regarded as one of the leading learning theories in Western countries, grounded on the belief that knowledge is constructed within socially situated contexts (Chu et al., 2017). Participants gave positive comments on various teaching and learning methods used in this training program. They mentioned that online study gave them flexible learning opportunities in terms of learning time and place. Simulation-based education with constructive feedback from teachers provided valuable opportunities for them to practice in a safe and supportive environment. These findings endorse the importance of providing learners with opportunities for active and meaningful engagement that allow them to develop skills through peer interactions within socially situated contexts (Chu et al., 2017).
Although participants enjoyed highly interactive, learner-centered learning styles, they also asked for more lecture-directive elements during the training process. In the traditional Confucian heritage educational context, teachers are considered as the symbol of knowledge, playing an important role in knowledge transmission (Clarke, 2010). Due to a strict and hierarchical relationship existing between teachers and students in Asian countries, it is unusual for learners to criticize teaching (Burnard, 2006). Consequently, teaching in China comprises mainly teacher-dominated and transmission-based approaches.
Although Confucianism focuses on the knowledge expert role of the teacher, Confucius also emphasized the importance of deeper thinking. One of the quotations from Confucius's educational philosophy that has been used for over 2,000 years in the educational field in China is “Learning without reasoning leads to confusion, thinking without learning is wasted efforts.” In this respect, it might be positive to integrate the Western educational theory of knowledge construction through reflective practice into a Confucian heritage educational context. It was indicated by participants in this study that they enjoyed a variety of learning methods and interactive teaching styles.
From the classroom observation, participants were highly active in group discussions. Although they tried not to criticize peers' and teachers' views, they were willing to express their ideas. Although collective learning culture is prioritized in China, during this training program, participants preferred individual works over group works to avoid conflicts among peers. In this respect, Clarke (2010) suggested that a high degree of cultural sensitivity is a prerequisite when applying Western teaching methods. Although conventional didactic teaching approaches need to give way to a democratic way of learning for knowledge construction and information sharing (Chu et al., 2017), it might be helpful for educators to understand the difference in teaching and learning culture in terms of how it affects learners' preferred learning methods and their performance in the classroom so they can develop an appreciation of the difference.
To involve learners in an active learning environment, academic activities must be meaningful and valuable to learners. The LCT has a focus on the learner, considering that self-motivated leaners have the primary responsibility to determine the learning goals and issues they want to address (Kirschner, Sweller, & Clark, 2006). A truly learner-centered approach, stemmed from a Western educational philosophy of social constructivism, centers on authentic learning needs aligning with learners' own value systems and career aspirations (Blessinger & Carfora, 2015).
The course content in this training program was an important factor in providing LCT. Although participants' feedback in terms of the learning content was overwhelmingly positive, it was challenging to cover a wide range of nursing topics within 12 weeks to accommodate individual learners' learning needs. The need to cover all the content of the course could lead to a neglect of individual learners' learning needs (Wright, 2011). For Chinese nurses, it would be ideal that information gained from this training program could be taken back to China and used in clinical settings there. In this study, participants commented that a positive aspect of the training program was the collaborative decision making invited by the coordinator about the learning goals, topics, and content of the program. This finding highlights the importance of flexible learning content based on trainees' needs in providing effective teaching (Weimer, 2013).
In terms of learning assessments, Wright (2011) argued that the process of evaluation in a learner-centered approach is not to test learners' learning outcomes from an educator's perspective, but to promote learners' learning. The shifting power from the teacher to learners in the process of evaluation indicates that the learner takes the primary responsibility for his or her own learning. In this program, an individual presentation with self-determined topics was required at the end of program to explain what trainees had learned from this training program. Participants noted that the self-determined presentation topics allowed them to focus on their specialized nursing topics and further strengthened their learning abilities. This finding is congruent with literature findings that reveal that LCT needs to be constructively aligned with the learner's learning objectives throughout all academic learning activities, including learning assessments (Biggs & Tang, 2011).
Overall, this project demonstrated the feasibility of implementing such an international nursing training program using a Westernized learner-centric teaching approach. In this study, LCT approaches comprised the following elements: academically committed learners, amalgamated teaching methods, needs-focused learning content, and self-determined learning assessments. In the context of increasing cultural diversity in higher education, effective teaching is challenged with the complexities of social and cultural environments. Nurse educators may want to apply culturally appropriate teaching methods to their practice by taking into consideration both Western and Eastern teaching and learning philosophies.
Few studies have explored the culturally appropriate LCT methods in the context of international training program in New Zealand. This article presented the findings of assessing a learner-centered approach to teaching Chinese nurses in New Zealand. A key theme that runs through this study is the recognition of culturally appropriate LCT approaches. LCT can result in a win-win situation. Learners had a voice in the learning objectives, learning content, and learning assessments, and nurse educators positively engaged learners in the learning process and developed strong relationships with learners. Through LCT, Chinese nurses gained meaningful information and it is hoped that they will be able to disseminate their knowledge gained from this training program in their own country.
Although participants appreciated the opportunity to gain valuable educational experiences in New Zealand, further evaluations on how their nursing practice evolves as a result of completing this program would be beneficial in improving our teaching practice and promoting a global market for tertiary education.
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Agenda of the Nursing Leadership and Management Training Program
|Week 1||Health care system in New Zealand|
|Week 2||Nursing education in New Zealand|
|Week 3||Aged care and client-centered care|
|Week 4||Medication management|
|Week 5||Medical and surgical nursing|
|Week 6||Mental health nursing|
|Week 7||Critical care and emergency care|
|Week 8||Nursing simulation|
|Week 9||Pediatric nursing|
|Week 10||Nursing leadership|
|Week 11||Midwifery practice and the role of Plunket nurses in New Zealand|
|Week 12||Nursing research|
What is your age?
What are your motivations for attending this program?
Which aspect of the teaching content is helpful for your nursing practice?
What teaching methods would you prefer?
Have you found any cultural differences between China and New Zealand in terms of teaching and learning styles? If so, what are the differences?
What were the strengths of this program?
What were the weaknesses of this program?
What information have you learned in this program that might be useful in your future practice?