Senior nursing students are adult learners by virtue of their chronological age and perceived maturity. In nursing school they are recognized as seniors in the process of becoming nurses and upon graduation they are called professional nurses. It is a source of wonder that they are graduated with so little preparation for entry as adults into the adult world. In a university system, the focus of the teaching-learning process tends to be directed toward the art and science of teaching children rather than the art and science of helping adults learn.1 To facilitate entry into the adult "real" world, we believe that a conscious transition of the teachinglearning process should be instituted before or during the senior year of matriculation so that senior nursing students can become more self-directing, self-confident, and self-propelled as adults.
Education is a lifelong process and must be continued by all professional nurses according to their individual perspectives. desires, capabilities, and goals. Recognizing the essentiality of maintaining, through education, up-to-date knowledge and skills in this rapidly changing world is the responsibility of every professional nurse - all the more so because new graduates are insufficiently prepared to become self-directing learners. They are exposed to "reality shock" when they are cast out as "children" from an educational system and are expected to function as adults in a professional work environment.
Historically, all learners have been conditioned to pedagogic teaching methods and few have questioned the persistent application of pedagogic principles. They have become accustomed to playing a dependent role, receiving and storing up information that adults or expert teachers have considered important. They have accepted the practice of receiving grades from a teacher who passes judgment on their performances. They have attended innumerable classes and listened to lengthy didactic presentations, regardless of whether they were ready to learn the content of these presentations. They have endured, at the hand of their teachers, such parent-emulating jurisdictions as the teachers have chosen to impose on them. Ironically, many of these students who, in time, become adults and meet the criteria for teaching others, perpetuate the same pedagogic methods by which they were taught, without questioning the appropriateness or Tightness of these methods.
By consciously changing teaching methods in the universities away from a pedagogic orientation and toward adult learning principles, senior nursing students can be better prepared to cope as professional nurses in any health care system they enter. They can learn to function as self-directing mature adults and future nursing leaders by demonstrating professional characteristics such as autonomy, objectivity, self-acceptance, integrated self- identity, rationality, tolerance for ambiguity and responsibility. They can consciously use their cumulative nursing experiences as learning resources. They can be socialized to accept themselves as responsible individualistic human beings capable of making sound judgments and right decisions. They can learn to function as creative persons when faced with problems requiring solutions. All that is required to facilitate such a transformation is a change of the teaching-learning process.
An Experiment in Teaching Novice Community Health Nurses
The Community Health Nursing faculty at the University of Washington, Seattle, planned a workshop designed to facilitate student entry into the community health nursing field setting. They adopted four crucial assumptions about senior nursing students: that they are self-directing human beings; that they are a growing reservoir of experiences that can be used as a cumulative learning resource, that they are ready to learn the developmental tasks of social roles; and that they have a time perspective which accepts immediate application of knowledge to problem-centered situations.1 The purpose of the workshop was to ease the transition of students from structured institutional settings to the unstructured community environment, by consciously recognizing senior nursing students as adult learners. The challenge of the workshop consisted of stimulating senior students to begin community health nursing visits to families and communities with a sense of intellectual curiosity and some degree of comfort. The stated goals of the workshop were:
1. To develop the comfort level and skill of students in making their first family or community contact.
2. To assist students to apply nursing principles and concepts in establishing relationships and exploring families' problems firsthand.
3. To increase students' awareness of familial behavior patterns.
In getting the workshop started, we instituted pedagogic principles such as teacher-directed activities which presume to know learners' needs, plan for the incorporation of learners' needs, provide for timing and design of learning experiences, and encourage learners to assume responsibility for their own learning. We developed seven behavioral objectives describing the needs of the learners for carrying out the nursing process in their roles as community health nurses. By the end of the workshop, the learners would:
1. Understand the process of structuring the family-nurse relationship.
2. Know patterns of family structure and dynamics.
3. Know the process of problem identification and determine a beginning contract.
4. Identify problems that are blocking interpersonal- relationships in their families.
5. Participate in a group process experience to facilitate communication, exploring, and trust.
6. Foster tolerance and respect for group and individual differences.
7. Understand the importance of openness in human relations.
It was planned that all necessary content in the workshop would be covered in minilectures and through the use of experiential learning exercises. An incremental approach to the teaching-learning process was utilized, gradually moving from teacher direction toward self -directed learning. To ensure that the factors leading toward self -directed learning would be utilized, particular attention was devoted to:
1. Setting a climate for learning.
2. Modeling person-centered behavior.
3. Providing for practical application of new concepts.
4. Providing experiential techniques which facilitate unfreezing and learning from experience.
5. Evaluating self-learning.
Setting a Climate for Learning
To create a climate facilitating a role relationship between students and instructors which would move into an attitude of mutual inquiry rather than student-teacher dependency, the workshop was held in a very informal atmosphere, away from the Health Sciences complex. Several specific activities were planned to achieve this atmosphere. For orientation of students to the workshop schedule, the role that students would be expected to play was explained as consisting of mutual selfdirected inquiry. For example, in recognition of the potential contributions made by students because of their varied backgrounds and skills, members of the faculty emphasized the notion that instructors do not always have specific answers to situations encountered in community health nursing, but together, teachers and students can plan and evaluate interventions using a variety of conceptual frameworks.
Modeling Person-Centered Behavior
A second activity for promoting a climate of mutual inquiry was the development of a fictional family situation in which the instructors played the roles of members of a family experiencing health and social problems. The purpose of having the faculty role-play a family situation initially was twofold. Students could experientially learn that faculty do not always have all the answers, that faculty can become frustrated, and that instructors can accept suggestions from students. Through this experience we hoped that students would feel more comfortable in communicating their own frustrations and feelings of uncertainty about participating as community health nurses.
The second purpose was to encourage students to use their knowledge and skills in analyzing the faculty role-playing. By so doing, students would get involved and acquire a feeling of mutual participation. As an aftermath of the family situation role-played by the faculty, an informal discussion was instigated and the students were asked for their reactions and suggestions regarding the role playing. The instructor's attitude while conducting this discussion was purposely planned to encourage students' comments, so that respect for all ideas and feelings of selfconfidence were generated. Each statement was heard and consideration given to students' analyses of different possible outcomes to specific approaches utilized in family situations. The faculty purposely withheld verbal judgments and opinions until the students had had ample opportunity to explore their own ideas and to formulate possible approaches. By behaving in this manner, the role of the faculty evolved into an advisory and consultative one. These activities thus provided a learning environment and assisted the students to move away from the pedagogic learning style and participate as responsible adult learners.
Providing for Practical Application of New Concepts
The level of a student's discomfort is often evident during preparation for first home visits, and many questions are asked which center on the difficulties of assessing family dynamics and establishing a reasonable contract with a selected family. In recognition of students' desire for learning experiences improving their ability to deal with early requirements for meeting and assessing families, we gave mini-lectures which provided theory as well as practical "how-to's" in dealing with families. This activity was consistent with the assumption that adult learners respond well to problem-centered orientations. Each lecture was intended to introduce new concepts based on the students' experiences and readiness to move into the new social role of community health nursing. The lectures lasted 15 minutes and were immediately followed by vignettes roleplayed by the faculty which highlighted the major points of the didactic presentation and provided a vehicle for discussion.
The first dealt with the problem of family assessment. A systems approach for looking at family dynamics was chosen and students were asked to reflect on their own family backgrounds and life experiences in terms of this model. A simple family assessment tool based on the work of Minuchin and Aponte was then presented.2'3 Learners were instructed to observe four basic areas in operation with every family: power, alignments, functions, and boundaries, which, when evaluated, serve as a means for determining a workable direction toward setting up a family-nurse contract. Examples of questions which focus on process communication were included to model ways of securing desired information from families.
A second mini-lecture was on the establishment of a contract with a family. Students of community health nursing often express difficulty in establishing a contract with a family because they are unsure of their own role boundaries in addition to the complexities of the family situations. It was emphasized that each student and the family members must agree on goals and that each must understand the responsibilities involved. The four patterns of responses that the student might expect from family members, the three levels of commitment they may encounter in working with a family to reach a goal, and the mechanics of designing and writing a contract were briefly described. Pointers on "selling" various nursing services rha t the community health nursing student is prepared to offer to families were given to stimulate ideas on the rich background of knowledge and skills that students already possess.
Provision of new concepts with practical "how-to's" enabled students to comprehend the existence of a "package of tools" which they might adapt to their own personalities and try out, first in a role-play situation and later in actual practice.
Providing Experiential Techniques Which Facilitate Unfreezing
and Learning From Experience Simulation, a technique oí combining role-playing and problem-solving, was selected as the teaching strategy in the second phase of the workshop.4 This consisted of students performing in simulated or contrived situations that duplicated real situations as closely as feasible. One of the major advantages of simulation is that it totally involves the entire class during the simulation exercise. This technique, then, places the teacher in a less dominant role and reinforces the students' skills in ultimately, making learning an active process.
Since the selection of the subject matter was crucial for meeting the stated objectives, the instructors were compelled to select the precise situations that would evoke self-directive learning, cooperation and group problem-solving skills. Questions that needed to be considered were: What experiences were necessary for students' learning? Should the experiences focus on content, skills or a combination of both? Should a real problem be presented or an imaginary one? Should emphasis be given to a small segment or the overall situation? Should each assigned role have its own unique characteristic? How would the instructors function? What were the time constraints for the practice session, demonstration and debriefing? What should the format be?
As talent developers and facilitators for self-directed learning, the instructors considered ways to elicit talents of students during the practice sessions and yet promote transfer of learning. They wanted to minimize expressions of negative responses to role-playing and to encourage students to disclose their talents for planning, organizing, communicating, decision making, and forecasting. To elicit the unveiling of talents, four criteria were watched for: 1. students who could express themselves with ease, 2. students who could help the group to analyze the finer details of the simulation exercise, 3. students who exhibited the capacity to consider various solutions for handling a problem and for making decisions, 4. students with forecasting ability who could make logical predictions. The faculty recognized that an informal supportive and collaborative environment was essential for bringing out students with talents, so it was agreed that evidence of talents would be spontaneously supported and promoted.
After considerable deliberation, we decided to assign two situations for students to role-play as simulation exercises. The two situations were taken from real case studies. One focused on health teaching and prevention in a family with a newborn infant; the other focused on skills and content in dealing with a family with a chronically ill member. In each situation there were three briefly described family roles which typified characteristic behavior that most students might encounter during a home visit. Involvement of the entire student group was secured by having two groups of ten students practice the simulation of the family with the newborn and two groups of ten students practice the simulation of the family with the chronically ill member. To conclude this learning experience the decision was made to select two groups arbitrarily, by drawing straws, to role-play their version of the simulation exercise before the entire student group.
By previously using faculty role demonstrations as a means for portraying a wide variety of approaches for use in home health services, students were given several audio-visual examples from which to gain ideas before being assigned to the simulation exercises. When the situations taken from real life were introduced to the small groups of students, it was emphasized that in the practice sessions the idea was to create and execute a plan of action which would build upon 1. communicating the reason for the visit, 2. establishing a contract, and 3. predicting what might be expected before terminating the visit. The groups were warned that after the practice sessions they might be selected to present their version of the simulation exercise to the total group. Involvement of all students in analyzing the portrayals of the assigned simulations revealed their acceptance of the adult learner role as they expressed constructive suggestions regarding the enactment, outcome, and conceivable alternative directions feasible for each situation.
During the workshop, participant observation revealed that general student interest in the entire program was high. This was evidenced in the way they sat and by the way they expressed interest while presentations were being given. They appeared to enjoy most of the vignettes and role-played family situations done by the faculty. There was much positive interchange among students and an obvious feeling of relaxation, away from the customary classroom formality. In addition, while the students grouped together to plan their own role play for an assigned family simulation, there was a great deal of interaction and seeming interest in how to tackle the situations. The only negative comments came from the few students who had some difficulty in seeing and hearing the presentations.
Written evaluation forms were distributed, eliciting what students liked best about the workshop, what they liked least, and whether they felt the workshop was helpful in preparing them for their first home visits. They liked best the faculty role-playing. They also indicated that the informality of the instructors was conducive in facilitating their learning. As stated by one student, "Role playing by instructors first made student role playing less threatening. This has been by far the best teaching effort I've experienced at UW School of Nursing, Thank you."
In response to the question, "Did you feel this workshop was helpful in preparing you for your first home visits?," the majority of students answered yes. Reasons given were as follows: that the workshop relieved tension, generally reduced anxiety and made one feel more comfortable; that information about establishing a contract, that practical "how to's" for going into the home and planning for the visit were helpful; that information about what to expect in the home visit were helpful; that the workshop gave a format to follow in the home visit as well as pointers on how to look for and handle difficult situations, and that seeing someone do something before you do it yourself is always helpful.
In conclusion, as a consequence of the successful experiment in teaching senior students the beginning skills of Community Health Nursing, workshops have been routinely scheduled in the beginning weeks of every quarter. Subsequent workshops have been evaluated consistently as positive learning experiences by students.
We, the faculty, believe that a learning vehicle such as a community health nursing workshop is one example of a way to make a transition from pedagogic principles to principles of adult learning. We believe that serious consideration should be given to the teaching-learning process, that adult learning principles should be incorporated as feasible in nursing schools, particularly during the senior year of nursing education.
- 1. Knowles MS: The Modern Practice of Adult Education. New York, Association Press, 1970, pp 37-39.
- 2. Minuchin SiFamilies and family Therapy. Cambridge, Massachusetts, Harvard University Press, pp 138-157.
- 3. Aponte H: Organizing treatment around the family's problems and their structural bases. Psychiair Q 48(2):209-222, 1974.
- 4. Wentworth DR, Lewis DR: A review of research on instructional games and simulations in social studies education. Soc EÂUC 37:437, May 1973.