Cost Benefit Factors
Nursing educators face increasing risks in the "real" world as they use patients in "real" life situations for teaching their students. However, structured learning experiences, removed from real life situations, not only decrease risk but also lower the students' and teachers' anxieties so that more knowledge can be acquired in a shorter period of time and efficiently transferred to real-life situations.
There is mounting evidence that a structured situation enhances the transfer of learning proportionate to the degree that students attribute reality to the experience. Consequently, new situations in the real world call for new approaches to learning - approaches that are reality based, risk free, efficient, and as cost effective as possible. Accountability and efficiency are as important to nursing education as they are to nursing service.
New designs in experiential learning, such as the structured experience, have an almost unlimited potential for learning in a risk free environment. A structured learning experience is defined by the writer as a situation designed to include specific learning content and processes which replicate a situation most likely to be found in real life. Students are introduced to the experience by a set of instructions which describe their roles and the situation which they are to assume. There is a teacher or facilitator who sets the climate for the experience and conducts discussion about the experience immediately following it. Consequently, the structured experience provides not only the needed "real" experience, risk free, but also the necessary content.
The structured experience permits control of certain learning variables identified by the teacher while allowing the learner to meet needs unique to that learner. Because it involves the learner so intensely, it is usually exciting, fun, and, ultimately, "real" for the learner. Information is also remembered longer than information gained through reading alone or other passive forms of learning. Probably the best argument for the structured experience, however, is that it is directly transferable to real-life situations with minimum risk.
Retention must also be considered in determining efficiency of learning. Pate and Mateja reviewed sixteen studies for the effects of simulation. The results for all sixteen were positive for the effect of simulation/gaming on retention, and three found an increase in student scores from the posttest to the delayed post-test (Pate & Mateja, 1979). The gain in scores beyond the posttest scores points to a gain in knowledge possibly due to the learning method. This study, therefore, identifies an area of needed research to determine the generalization of the effect of the experience over a length of time.
This effect could be one of the most important reasons for selecting a particular teaching method. The writer believes that there is a latent or additive effect of experiential learning and that it is often over-looked by the traditional educator who "has so much content to cover" and does not "have time to spend in experiential games." A cost-benefit as well as a low-risk benefit could be involved if the learner not only retains more but also improves the knowledge or skill over time.
Undoubtedly, there are risks of failure in the introduction of new learning methods. Puntillo and Duncan (1980) identified potential risks in an alternative learning experience for intensive care nurses, based upon Carl Roger's teaching-learning theory, in which students structured their own learning experience and shared experiences in seminars. They stated,
Nearly all nurses have been exposed primarily to structured, traditional methods of teaching-learning. An alternative learning experience that requires active participation and responsibility for meeting personal learning needs could easily meet resistance and resentment. Instructors may be viewed as threatening or lazy because they fail to fulfill traditional student expectations.
However, overall evaluations of learning of content and attitudes were positive. Students also expressed more confidence in their abilities. The instructors stressed the importance of orienting and reorienting the learner to their new learner role. They found, as did the writer, that instructors who are willing to orient students carefully and to establish a trusting climate can develop effective alternative learning experiences (Puntillo & Duncan, 1980). Thus, the risk involved in resistance to learning is outweighed by the potential for learning. Use of structure to insure inclusion of content is also desirable in high-risk situations.
Yantzie developed HELP, a simulation disaster game to reach nursing students to problem solve and make judgments in a simulated disaster. The students became very involved, and she found it to be a most effective method of teaching efficient delivery of health care in an emergency situation. Advantages identified for instructors were the opportunities to: 1) reinforce, challenge, or correct errors in judgment; 2) evaluate the problem-solving ability of their students related directly to judgment and priority of needs; 3) introduce new learning material related to organization, operation, and principles of a hospital disaster plan, e.g., triage, communications, and direction of activities and personnel; and 4) identify legal implications (Yantzie, 1980).
Crancer and Maury-Hess (1980), in an evaluation of Games as a teaching strategy, identified that although Games implies win or lose the emphasis in more recent Games is interpersonal relationships and communication. They found that the use of Games increases student knowledge identified in course objectives.
Research in the use of games may have relevance for educators considering use of structured experiences. The goals and dynamics are quite similar. They provide high level involvement, an opportunity to try out solutions to problems and to attain immediate feedback on decisions made - all without risk to clients and with minimum risk to students. A number of findings support the superiority of active personal involvement in learning over passive traditional methods (Brickman, 1980; Crancer & Maury-Hess, 1980; Pate & Mateja, 1979; Puntillo & Duncan, 1980; Warrick, Hunsicker, Cook & Altman, 1979).
Jones and Pfieffer with the University Associates are leading proponents for use of the structured experience in implementing an experiental model of learning. They state the following advantages: 1) the emphasis on the direct experiences of the learner, as opposed to vicarious experiences; 2) the inductive process rather than the deductive process - the learner discovers for himself; 3) the learner's validation of his own experience based upon the premise that experience precedes learning and meaning from experience comes from the learner himself. The goal of learning from the structured experience is the application of that learning in the real world (Jones & Pfeiffer, 1975, pp. 3-5).
Brickman (1980) examined the relationship between internal correspondence (behavior corresponding with feelings) and external correspondence (behavior corresponding with consequences) and found evidence that both internal and external correspondence were important in the attribution of reality. However, the degree of attribution of reality was proportional to the degree of involvement. He cited games and sports which at their best became more real to players than was anything outside them (internal correspondence at that moment) (Jones & Pfeiffer, 1975).
Such examples illustrate how, to the participants, an artificially created situation could become more intense and "real" than some other situations in their environment. This phenomenon would seem to depend upon their internal and external correspondence and their ability to attribute reality to the situation.
Based upon the findings of the writer and other researchers, one goal of a nursing educator would be to create a situation in which the student could attribute reality through both internal and external correspondence without risk to self or patient.
According to Snygg(1971, pp. 93-113), one accepts the validity of methods that fit one's view of reality, but methods which do not fit ones personal concept of human nature and learning, or which one does not feel comfortable using, are regarded as "impractical" and are rejected. This reaction perpetuates "old methods" in that individuals view certain methods encountered from kindergarten to the present as essential to teaching. Likewise, nursing students have had similar educational experiences and expect more of the same. In sum, early classroom practices were devised when the chief task of the school was the communication of information and the desired outcome was memorization of information. However, present day nursing education requires methods which promote realistic and effective behavior. The structured experience provides not only a method of learning information but also one for applying the information in a lifelike situation that permits analysis of behaviors for effectiveness, revision, and development for use at the level of the learner's skill.
An Example of Teaching With a Structured Experience
The structured experience described here allows for differences in clinical settings and in knowledge, skill and cultural backgrounds of students. It is a teaching tool that involves students in a situation that is very nearly "real" without the risk of the real situation - and with benefits often overlooked.
The following method of structured experience has been field tested by the writer approximately twenty different times with nurses, nursing students, and paraprofessionale, all of whom met the teacher's objectives for the experience as well as their individual learning objectives. New knowledge and skills were transferred to the clinical area and documented by observation. The description shown in the Figure comprises the processes ) and content of the method tested.
Only the "Surians" were given the Suria script. The two groups then began their encounters, demonstrating similarities and variation in behaviors and feelings. Behaviors and feelings noted to be consistent from group to group were:
1. Hesitance of members of both groups to interact with the other.
2. Tendency of the Surians to feel that the health care workers saw the Surian behavior as a "problem" and a tendency to "talk down" to the Surians.
3. Almost immediate observation of the deviant behaviors of the Surians with great difficulty in defining meaning of the behavior.
4. Resentment on the part of the health care deliverers for lack of more direction on "what to do for the Surians."
5. A feeling of pessimism and doubt by the Surians that their situation was heard, understood or that anything could be done about it.
6. A feeling of some Surians that the health care workers really wanted to help them but barriers to communication were great. The feeling of someone wanting to "rescue" was most often stated as a barrier.
7. Discussion following the experience was always vigorous with full participation of members of both groups. The discussion at some point would relate to present or potential clinical experience.
LAND OF SURIA - A STRUCTURED EXPERIENCE
8. Statements of increased cultural awareness were spontaneous.
Variations noted from group to group were:
1. Accommodating behavior of the health care deliverers.
2. Intensity of emotional involvement ranging from "nervous laughter" to displays of anger at behaviors.
3. The meaning of behavior which was assessed quite well by some groups while others seemed only to use observations and inference.
The comments from the participants varied with each group; however, there were predictable themes which indicated surprise that behaviors and feelings so vividly reflected those from the "real world." They gained insight and awareness of how they felt, thought, and behaved in similar reallife situations. There was often a dramatic impact upon the participants who stated what they would do differently in future real life situations. Following several of the group experiences, the writer observed changes in nurses' and nursing students' approaches to clients of diverse ethnic backgrounds. In one instance the participants were experienced trans-cultural nurses and anthropologists. They exhibited similar behaviors and feelings toward the scenario to those of the groups previously tested. However, they seemed more open to discussion of their cultural biases and feelings.
The structured experience facilitated learning in an emotionally charged situation by reducing risk factors and the participants' anxieties. It also facilitated discussing and sharing ideas and feelings. The simple format of the Land of Suria enabled not only health care deliverers or students but also experts to learn at their levels of awareness. The learners were able to transfer the knowledge gained from the structured experience to real-life situations. The writer believes that the structured experience can be utilized as a risk-free method of learning prior to potential anxiety-producing situations (i.e., C.C.U., acute psychiatric crises, transcultural situations, etc.) and that the resulting knowledge can be effectively transferred to anxiety-producing, real-life situations.
The structured experience is not openended for the students to totally define out of their own experience. It is structured to include content and process which the instructor deems valuable. Specific nursing situations can be designed with outcomes predictable within a given range of behaviors. Many variables determine choices of nurses' behaviors, and the structured experience allows the students to bring past learning to the situation and examine what they did, how they did it, why they did it, and how they feel about it.
Because the structured experience is learning that encompasses both the cognitive and affective domain, it has the potential of greater impact upon the learner and a greater potential for transfer and retention. That these learners demonstrated enhancement of future learning in comparison to those learners exposed to traditional methods indicates that the structured experience also has an additive effect. The advantages identified through numerous and varied experiences of teachers and learners, strongly suggest that the structured experience is not just a way to make learning interesting but a method that has a cost benefit in efficiency of learning through transfer, application, retention, and enhancement of future learning.
- Brickman, P. (1980). Is it real? Journal of Experiential Learning and Simulation, 2, 39-53.
- Crancen J., & Maury-Hess, S. (1980). Gamee: an alternative to pedagogical instruction. Nurse Educator, 19(3), 45-52.
- Jones, JJB., & Pfeiffer, W.J. (1975). The 1975 annual handbook for group facilitators. La Jolla, CA: University Associates Pub Ushers Inc.
- Pate, S., & Mateja, A. (1979). Retention: the real power of simulation gaming? Journal of Experiential Learning and Simulation, 1, 195-202.
- Puntillo, K., & Duncan, J. (1980). An alternative learning experience for intensive care unit nurses. Journal of Continuing Education in Nursing, 11(3), 44-50.
- Snygg, D.L. (1971). A cognitive field of learning. In D.L. Avila, A. W. Combs, & W.W. Purkey (Eds.) The helping relationship sourcebook. Boston: Allyn and Bacon. Inc.
- Warrick, D.D., Hunsicker, P.. Cook, C. & Altaian, S. (1979). Debriefing, experiental learning exercises. Journal of Experiential Learning and Simulation, 92, 91-100.
- Yantzie, N. (1980). HELP a simulation disaster game. Canadian Nurse, June. pp. 33-36.