Dr. Noone is Assistant Professor of Nursing, Oregon Health & Science University, Ashland, Oregon.
The author thanks Glenise McKenzie, PhD, RN, and Amy Miner Ross, PhD, RN, CNS, for their review of this manuscript.
Address correspondence to Joanne Noone, PhD, RN, FNP, Assistant Professor of Nursing, Oregon Health & Science University, 1250 Siskiyou Boulevard, Ashland, OR 97520; e-mail: firstname.lastname@example.org.
An emphasis on integrative learning in professional education recently has been advanced by the Carnegie Foundation for the Advancement of Teaching, an independent policy and research center committed to the improvement of teaching and learning. Recent comparative studies by the Carnegie Foundation’s Preparation for the Professions Program (Carnegie Foundation for the Advancement of Teaching, 2007a) explicated the necessary elements for preparation for professional practice in the fields of nursing, medicine, law, engineering, and clergy. Three necessary areas for development, called apprenticeships to the profession, were identified as critical to professional practice. These three apprenticeships are (Benner & Sutphen, 2007; Carnegie Foundation for the Advancement of Teaching, 2007b):
- Cognitive or intellectual apprenticeship. This apprenticeship includes conceptual or intellectual training to learn the academic knowledge base of nursing and the capacity to think like a nurse. In nursing education, the cognitive or intellectual apprenticeship traditionally is emphasized in the classroom setting.
- Skill-based apprenticeship of practice. This apprenticeship includes the development of skilled know-how and clinical judgment. In nursing education, the skill-based apprenticeship of practice traditionally is emphasized in the laboratory or clinical settings, with a focus on acquiring competency in skills and tasks.
- Apprenticeship to the ethical standards, ethical comportment or behavior, social roles, and responsibilities of the profession. This apprenticeship also is referred to as civic professionalism, or the responsibility of the profession to the community it serves and traditionally is part of the ethics course content.
Benner (2006) cautioned these apprenticeships are more complex than the traditional Bloom’s taxonomy of cognitive, psychomotor, or affective skill development and are critical elements to professional practice. Historically, undergraduate nursing education often has segmented or compartmentalized learning. Typically, there is a relegation of intellectual and cognitive development into theory classes, a skill and task focus in laboratory and clinical settings, and the discussion of ethical standards and behaviors in an ethics class with little opportunity to contextualize learning within the clinical practice setting.
Although nursing education historically has a strong theory and clinical practice base, the comparative study of nursing education by the Carnegie Foundation found limited integration of the three apprenticeships (Benner, 2006). Opportunities to integrate learning may be reserved for capstone courses or preceptorships at the end of the program of learning. More recently, an emphasis on integrated learning has emerged that stresses providing opportunities to think like a nurse while making connections to real-world, authentic experiences in the classroom, as well as in clinical and laboratory settings (Fink, 2003; Tanner, 2006, 2007).
This article provides an exemplar, teaching about sexually transmitted infections (STIs), as a design for learning activities to integrate the three apprenticeships of professional nursing practice into a specific curricular topic. Although this exemplar is provided to illustrate the application of these concepts, integrated learning experiences should occur at a broader programmatic or campus-wide level, rather than sporadically within courses (Huber, Hutchings, Gale, Miller, & Breen, 2007).
Integrating the Apprenticeships
A backwards design process (Fink, 2003; Wiggins & McTighe, 2005) was used to intentionally think first about the desired results or learning outcomes for the students before designing the learning activities. Wiggins and McTighe (2005) supported the use of a backwards design approach to integrated learning by first identifying “enduring understandings” (p. 128) or key learning for students within the context of professional practice and then designing learning activities to achieve these understandings. In identifying content priorities, faculty should first emphasize key big ideas and core tasks for students, then emphasize what is important to know, and finally emphasize what is worth being familiar with.
In addition, Wiggins and McTighe (2005) recommended moving away from the more traditional superficial coverage of information in didactic classes and developing learning activities that may or may not be linked to desired outcomes for learners. After identifying key knowledge and skills, learning activities and student performance expectations then can be delineated.
The author used her background as a nurse practitioner working with clients with STIs to think about what the key professional practice elements are for RNs in caring for clients with STIs. Sutphen and Day (2007) recommended interviewing nurses with expertise to round out and validate key elements or enduring understandings of nursing care for a specific client population if the faculty does not personally possess expertise with the client population. Specific attention was given to developing learning outcomes and results for each of the three apprenticeships within the context of caring for clients with STIs.
An outline of the learning design according to the three apprenticeships is shown in the Table. Although the learning activities are delineated according to the desired student results for the purpose of intentional design, the learning activities could be part of a larger learning experience. For example, a progressive case study or simulated practice learning activity could be developed that prepares learners in all three apprenticeships. It is this type of integrated learning experience that most closely approximates true professional practice or as Sullivan (2005) stated “introduce(s) students to the full range of professional demands” (p. 208).
Table: Summary of Three Apprenticeships with Exemplar Design for Learning About Sexually Transmitted Infections (STIs)
Cognitive Apprenticeship Learning Focus
The cognitive apprenticeship focuses on the domain knowledge base of the discipline and usually is emphasized in didactic classes. Essential knowledge for students in learning about STIs is that they demonstrate an understanding of client risk factors for STIs and knowledge of STI prevention, presentation, and treatment.
Because issues surrounding effective STI diagnosis and treatment rapidly change, textbooks may not reflect current knowledge. Students need to know where and how to access current information on current STI treatment changes. Learning activities and experiences that would support meeting these outcomes could include a traditional lecture or discussion of risk factors, STI prevention, presentation, and treatment.
Case studies that focus on identification of risk factors and differential diagnosis may be helpful in presenting information to students as well as engaging students in the discussion, correcting their misconceptions, and eliciting their understandings of concepts. For example, the following case could be introduced to guide this learning experience:
You are working in a family practice clinic as an RN and see Jaclyn [a pseudonym], a 16-year-old adolescent who wants to start using birth control pills. What factors place this client at risk for an STI? What information about STI disease transmission and treatment do you as the nurse need to know?
The case could continue to progress with signs and symptoms, leading students to consider differential diagnoses and plan of care.
Another learning activity to promote development of the cognitive aspect of this topic would be one that guides students to locate current evidence-based resources and treatments in comparison to treatments outlined in their textbook. This may be a helpful experience to promote students’ understanding that STI disease treatment recommendations frequently change and how they can locate reliable resources to obtain current information.
Skill-Based Apprenticeship Learning Focus
To develop skilled know-how and clinical judgment related to caring for clients with an STI, students should demonstrate developing skill in taking a sexual history, talking about sexuality in a professional manner, and counseling for risk reduction for STIs. Tanner’s (2006) clinical judgment model was used to frame this learning activity. Noticing and reflection are two aspects of Tanner’s clinical judgment model that can be used to link students to their own experiences and performance. Connecting students with their own experiences as health care recipients can help them develop empathy and insight into aspects of helpful communication patterns.
Actual or simulated practice in sexual history-taking, communication, and counseling are examples of learning activities that would help students develop skill in these areas. An example of a learning activity to dialogue about these shared experiences would be to have students reflect on the following questions:
- When you have seen a health care provider and had to discuss something of an intimate nature, what were the provider’s behaviors that put you at ease?
- What were behaviors that blocked communication or disclosure?
Answers to these questions could be written and shared anonymously to show the spectrum of helpful and nonhelpful communication patterns.
To promote continued clinical learning and individualized skill development, the following reflective questions can be used:
- How comfortable are you talking about sexuality and counseling about sexual issues?
- How do you see yourself becoming more comfortable talking about these issues?
Ethical Comportment Learning Focus
The ethical comportment apprenticeship emphasizes the development of students’ ability to practice within a contextualized relationship of trust with clients and the community (Day, 2005). Sullivan (2005) referred to this as “the core commitments that define the profession” (p. 215).
Important elements for developing this apprenticeship in relation to caring for clients with STIs are that students demonstrate an understanding of their own biases related to STIs and sexual activity of minors that may interfere with authentic caregiving, issues of confidentiality and reporting regarding STI diagnosis and treatment, and issues regarding treatment of minors for STIs and state minor sexual consent laws as well as the need to balance individual client interests with the needs of public health. Learning activities that apprentice students to the social roles and responsibilities of nursing care of clients with STIs could include a reflection on their own biases related to STIs and sexual activity of minors, and discussion of state minor consent and STI reporting laws as well as case studies that focus on issues of confidentiality, partner notification, and issues related to the treatment of minors.
Students could be asked to reflect and dialogue on the following questions:
- What stigma may be attached to a diagnosis of an STI, particularly in a minor?
- What biases do have about STIs and Jaclyn’s sexual activity that may prevent you from providing individualized care to her?
The following case progression is an example of initiating a dialogue about other ethical issues:
Jaclyn tests positive for Chlamydia and returns to the clinic for treatment. Is this a reportable disease? Can the nurse practitioner treat her without parental consent, according to state law? Jaclyn refuses to tell her boyfriend because then he will know she was unfaithful. Can you notify him? What are the duties owed to Jaclyn, her boyfriend, and the general public?
In designing integrated learning experiences based on key understandings for professional practice, less time may be focused on traditional content coverage. Intentional design that teaches students how to access the information and resources they need provides a link to that information. Contextualized learning that integrates theoretical knowledge and clinical practice within a social context provides students with a richer understanding of the complexity of professional nursing practice.
This article presents an exemplar of an integrated learning design to teach to the three apprenticeships of professional learning: cognitive, skill-based, and ethical comportment. Identifying learning and professional nursing practice outcomes and then designing learning activities and experiences to meet those key practice elements can be adapted to a variety of curricular topics and program levels within nursing to prepare nursing students for practice.
- Benner, P. (2006, October). Best practices in clinical nursing education: Preliminary findings from the Carnegie Foundation for Advancement of Teaching study of professional education. Paper presented at the Oregon Consortium for Nursing Clinical Education Summit. , Eugene, OR. .
- Benner, P. & Sutphen, M. (2007). Learning across the professions: The clergy, a case in point. Journal of Nursing Education, 46, 103–108.
- Carnegie Foundation for the Advancement of Teaching. (2007a). Preparation for the professions program. Retrieved June 23, 2008, from http://www.carnegiefoundation.org/programs/index.asp?key=30
- Carnegie Foundation for the Advancement of Teaching. (2007b). Study of nursing education. Retrieved May 21, 2008, from http://www.carnegiefoundation.org/programs/index.asp?key=1829
- Day, L. (2005). Nursing practice and civic professionalism. American Journal of Critical Care, 14, 434–437.
- Fink, L.D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco: Jossey-Bass.
- Huber, M.T., Hutchings, P., Gale, R., Miller, R. & Breen, M. (2007). Leading initiatives for integrative learning. Liberal Education, 93(2), 46–51. Retrieved April 13, 2009, from http://www.aacu.org/liberaleducation/le-sp07/featurefour.cfm.
- Sullivan, W.M. (2005). Work and integrity: The crisis and promise of professionalism in America (2nd ed.). San Francisco: Jossey-Bass.
- Sutphen, M. & Day, L. (2007, June). The Carnegie Foundation for the Advancement of Teaching study of nursing education: Findings, recommendations and implications for teaching a practice. Paper presented at the Ninth Annual Northwest Nursing Education Institute Learning Like a Nurse: New Strategies. , Portland, OR. .
- Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204–211.
- Tanner, C.A. (2007). Connecting the dots: What’s all the buzz about integrative teaching?Journal of Nursing Education, 46, 531–532.
- Wiggins, G. & McTighe, J. (2005). Understanding by design (2nd ed.). Alexandria, VA: Association for Supervision and Curriculum Development.
Summary of Three Apprenticeships with Exemplar Design for Learning About Sexually Transmitted Infections (STIs)
|Apprenticeship||Definition||Learning Outcomes/Results||Examples of Learning Activities|
|Intellectual/cognitive||Cognitive or intellectual apprenticeship that includes conceptual or intellectual training to learn the academic knowledge base of nursing and the capacity to think like a nurse||Students will demonstrate knowledge of risk factors for STIs; STI prevention, presentation, and treatment; how to access resources for information on STI current issues and treatment recommendations||Case studies focused on identification of risk factors; differential diagnosis and treatment; locating and comparing current treatment recommendations with textbook|
|Skill/practical||Skill-based apprenticeship of practice, including the development of skilled know-how and clinical judgment||Students will demonstrate developing skill in taking a sexual history; talking about sexuality in a professional manner; counseling for risk reduction for STIs||Discussion and identification of caring and noncaring communication patterns; actual or simulated practice in sexual history-taking, communication, and counseling|
|Ethical comportment or behavior||Apprenticeship to the ethical standards, ethical comportment or behavior, social roles, and responsibilities of the profession||Students will demonstrate an understanding of their own biases related to STIs and sexual activity of minors; issues of confidentiality and reporting regarding STI diagnosis and treatment; issues regarding treatment of minors for STIs and state minor sexual consent laws; the need to balance individual client’s interests with needs of public health||Reflection of own biases related to STIs and sexual activity of minors; discussion of state minor consent and STI reporting laws; case studies that focus on issues of confidentiality, partner notification, and issues related to treatment of minors|