Much of the information communicated to students during traditional nursing education is done so by using teacher-centered techniques, such as the presentation of discrete factual knowledge in a lecture-style format. These techniques and format allow the learner to assume a passive role in the educational process and produce primarily surface learning of memorized and disconnected facts, rather than a deep understanding of underlying principles and concepts and how they relate to one another (Carver, 2006). A lack of understanding about how nursing knowledge is organized and connected prevents novice nurses from transferring classroom theory to the bedside (Levett-Jones et al., 2010), which is identified as one of the most common causes of patient harm or death (Ebright, Carter Kooken, Moody, & Latif Hassan AL-Shaq, 2006).
Benner, Sutphen, Leonard, and Day (2010) asserted that facilitating nursing students’ knowledge connections during prelicensure nursing education will improve patient outcomes. When knowledge is connected, students are better able to recognize the relationships among patient assessment data and basic principles governing patient care decisions (Candela, Dalley, & Benzel-Lindley, 2006). Recognizing relationships and principles produces more generic knowledge that can be transferred from the classroom to specific patient situations.
Concept-based teaching is an innovative pedagogy that has shown promise in improving students’ knowledge building (Morse & Jutras, 2008) and transfer (Lasater & Nielsen, 2009). This pedagogy can be implemented most successfully when nurse educators understand the cognitive processes that occur during learning (Quintana, Shin, Norris, & Soloway, 2006). Nurse educators who understand these processes are better prepared to plan learning activities that enhance nursing students’ knowledge connections and develop strategies to assess student learning (Greer, Pokorny, Clay, Brown, & Steele, 2010).
Most nursing education programs have been based on the Tyler model of education in which the curriculum is content laden and teacher driven, rather than focusing on how learning might best be supported (Dillard & Siktberg, 2009; National League for Nursing [NLN], n.d., 2004, 2005; Sauter, Johnson, & Gillespie, 2009). The Tyler model, developed in the 1940s, was a valuable contribution toward a much needed curricular reform at the time, but it is not in alignment with contemporary, evidence-based educational principles (NLN, n.d.).
The State Boards of Nursing used the Tyler model as a framework to evaluate nursing education programs and grant approval and accreditation. This resulted in an emphasis on the specific programs’ adherence to a legislated list of content to be covered (Bevis & Watson, 1989). Many nursing curricula continue to fit this model, both in format and in assessment of student learning. The format is topic directed, linear, and inclusive of a continuously expanding volume of information related to the prescribed content (Ebright et al., 2006), and learning outcomes are assessed by testing how many facts and procedures students are able to recall after being taught (Sawyer, 2006).
The large volume of content presented in a Tylerian-based curriculum does not provide students with the cognitive processing time needed to recognize connections between related pieces of information (Ironside, 2005). The topic-directed, linear format does not facilitate students’ comprehension of how nursing knowledge is organized and linked, and the assessment methods reinforce the notion that knowledge recall is the only expected outcome. Many nursing students respond to this situation by relying on rote learning, or memorization of superficial facts, as a means of survival. Rote memorization creates a disorganized collection of facts in the student’s mind (Ausubel & Fitzgerald, 1961a, 1961b).
The lack of organization and inaccurate connections associated with rote learning limit information retention and retrieval (Ausubel & Fitzgerald, 1961a), which is somewhat analogous to how a scrambled electrical circuit impedes electrical transmission. The ultimate outcome is a novice nurse who possesses a great number of disconnected facts that cannot be recalled rapidly enough to engage in the decision making that is necessary for safe and effective patient care. In addition, the absence of purposefully created knowledge connections prevents the nurse from recognizing general conceptual principles that can be applied to similar, but different, patient situations. In contrast, the novice nurse with a well-organized and integrated knowledge structure is a more agile thinker and better able to process information in a more abstract or conceptual manner (Benner et al., 2010; Benner, 2001). Such a nurse is more adept at the rapid knowledge recall and knowledge transfer that is essential to sound clinical decision making.
Meaningful Learning Theory and Constructivism
Teaching and learning strategies that promote “meaningful learning” (Ausubel, 1963, p. 22) are key to the effective transfer of knowledge from the classroom to real-world situations (Novak, 2010). Meaningful learning occurs when learners connect new information “in a nonarbitrary and substantive [nonverbatim] fashion” (Ausubel, 1968, pp. 37–38) to their preexisting knowledge. Substantive refers to the unique knowledge created when a learner translates new information into a form that makes sense, or has meaning, to her or him and connects the new information to related preexisting concepts or ideas in her or his mind (Ausubel, 1968). The end result is a hierarchical organization of knowledge, referred to as “cognitive structure,” and a greater understanding of both preexisting and new knowledge (Ausubel, 1968, p. 38).
Meaningful learning theory stems from a constructivist paradigm. The basic tenet of constructivism is that learning is an active process, one in which the learner constructs unique knowledge while attempting to make meaning of the world (Kafai & Resnick, 1996). The educator facilitates this process by providing an appropriate environment and relevant experiences. These measures assist learners to create their own knowledge, rather than receive it intact and unchanged from others (Brandon & All, 2010; diSessa, 2006).
Contemporary educational and cognitive research studies provide evidence of the effectiveness of constructivist-based pedagogy (e.g., Bransford, Brown, & Cocking, 2000). However, constructivism is not a new teaching and learning philosophy. Constructivist philosophy is evident in the work of well-known educational theorists from the early 1900s, such as John Dewey (1859–1952), Jerome Bruner (born 1915), and David Ausubel (1918–2008).
Dewey, Bruner, and Ausubel each proposed that learners’ underlying knowledge and previous experiences influence their interpretation of new experiences and subsequent learning (Ausubel & Fitzgerald, 1961b; Bruner, 1960; Dewey, 1910). A learner’s recognition of connections between previous knowledge and events or objects encountered during formal or informal learning experiences results in the formation of abstract concepts (Ausubel & Fitzgerald, 1961b; Bruner, 1960; Dewey, 1910). Learners use concepts to organize their knowledge and as a means of understanding new, related ideas. However, understanding requires synthesis; the new idea is not merely added to the collection already existing in the learner’s mind, but it is integrated meaningfully into the network of related knowledge (Ausubel & Fitzgerald, 1961a; Dewey, 1910).
Integration and construction of new knowledge occurs when a learner actually transforms incoming information into a form that is understandable to her or him (Ausubel, 1961; Ausubel & Fitzgerald, 1961a; Bruner, 1960, 1963). The best indication that this has occurred is not what the learner knows but how he or she uses that knowledge (Ausubel & Fitzgerald, 1961a). When the learner establishes a clear understanding of the underlying concepts and ideas and how they relate to new information, the knowledge becomes usable. Bruner (1959) referred to this process as “generic” learning (p. 184), whereas Ausubel (1965) referred to the process as meaningful learning.
Meaningful learning allows the learner to organize knowledge into a coherent whole. It is this coherence that allows significant relationships between new information and the pre-existing knowledge to be recognized and the principles governing those relationships to emerge (Erickson, 2007; Marton & Säljö, 1976; Novak, 2010); thus, the learner acquires a deep understanding of the knowledge. Deep understanding produces usable conceptual knowledge, as opposed to inert factual knowledge (Anderson et al., 2001), which learners can transfer to real-world problem solving and decision making (Erickson, 2007).
Deep understanding and knowledge transfer are of particular importance in nursing practice. Clinical judgment and decision making depend on the nurse’s ability to quickly recall preexist-ing knowledge, to manipulate and connect underlying knowledge and new information, and to transfer underlying knowledge in an appropriate manner to the clinical situation at hand (Thompson & Dowding, 2009). Capacity for recall, manipulation, and transfer are influenced by an individual’s knowledge organization and number of connections in the cognitive structure (Ausubel, 1963, 1968; Ausubel, Novak, & Hanesian, 1978). When nursing students link new information to a concept that is already established in their cognitive structure, the new information attains stability and is thus more likely to be retained over time (Ausubel, 1963, 1965, 1968). In addition, the connected structure serves as a network that facilitates information retrieval.
Recent research from the field of neurobiology provides empirical evidence of cognitive structure as a physical network that responds to learning experiences and specific types of thinking. Brain imaging studies indicate that learning produces structural changes in the brain itself. For example, Kumaran, Summerfield, Hassabis, and Maguire (2009) focused on brain responses during learning and decision making and found that neuronal connections were created and expanded upon during every learning experience. The connections provided a physical manifestation of previous learning and appeared to serve as a pathway for information transmission (Kumaran et al., 2009).
Strong neural connections are important to decision making. These types of connections are activated during decision making, particularly when a novel situation is encountered (Kumaran et al., 2009). Understanding a novel situation requires knowledge that is conceptual and, therefore, not context bound (Ausubel et al., 1978). This suggests that conceptual thinking and strong neural connections are interrelated and that meaningful learning, during which learners forge and stabilize knowledge connections, has the potential to improve nursing students’ recognition and understanding of novel or unfamiliar patient situations. Nurses encounter novel situations regularly, so they require knowledge that is strongly linked and conceptual in origin. Concept-based teaching is a pedagogy that provides this foundation.
Meaningful Learning Through Concept-Based Teaching
Concept-based teaching operates from the premise that learners must have an accurate understanding of basic anchoring concepts and be actively engaged in the learning process to construct new knowledge in a meaningful manner (Erickson, 2007). Discipline-specific concept-based teaching, coupled with active learning strategies, allows learners to develop conceptual knowledge that can be transferred from the classroom to the work world (Ausubel, 1963).
In concept-based teaching, foundational and discipline-specific concepts at a high level of abstraction are provided during initial learning experiences (Erickson, 2007). The abstract nature of the concepts makes them highly generalizable to a variety of related ideas. The concepts create a foundation on which learners can build and organize subsequent knowledge (Ausubel, 1968; Novak, 2010). Logically organized and accurately integrated knowledge, in turn, produces meaningful learning.
Ausubel (1965) referred to key abstract ideas as superordinate concepts. Superordinate concepts serve as linchpins to which related information is connected. They provide not only a foundation on which future knowledge can be built but a context to facilitate the learner’s understanding of related, but more specific, information.
For example, in a nursing curriculum, the concept of homeostasis, which is learned during a prerequisite science course, might be explicitly related to the concept of fluid balance during a medical–surgical nursing course. Homeostasis, as a highly abstract concept with which the student is already familiar, serves as the anchoring or superordinate concept. Knowledge about homeostasis provides the student with a context from which the understanding of a new, related concept, such as fluid balance, might proceed.
Nurse educators can provide activities that help students to achieve a greater understanding of the new information related to fluid balance, while acquiring a greater depth of understanding about homeostasis. Case studies or simulation exercises related to fluid balance are examples of activities that serve this purpose. However, it is essential that educators use explicit teaching to help students create knowledge connections. Explicit teaching consists of strategies that draw attention to connections. For example, educators might pose questions about how the ideas are related. Other strategies include directing students, either individually or in small groups, to create a graphic that demonstrates connections between concepts and principles or using a wiki for collaborative creation of a graphic in an online or blended course.
Concept-related ideas are presented to students as “exemplars” in a concept-based nursing curriculum (Giddens & Brady, 2007, p. 68). Exemplars are examples of how nursing-specific concepts manifest themselves in nursing practice. For example, congestive heart failure (CHF) and hypovolemic shock are exemplars of the concepts of homeostasis and fluid balance. The preexisting knowledge created by these concepts allows students to better understand the exemplars. The exemplars, in turn, expand the existing network of information in the students’ cognitive structures related to the concepts of homeostasis and fluid balance.
Each concept and exemplar is accompanied by an explicit description of how the concepts and exemplars are related to one another. When teaching the exemplar of CHF, for example, the educator might begin the learning session by questioning students about essential principles of homeostasis. The session would proceed to a presentation of CHF, followed by activities in which students must relate principles of homeostasis to the outcomes of CHF. This process helps students to create an integrated cognitive structure.
As students integrate more ideas into their cognitive structures, they develop a more nuanced understanding, not only of the anchoring concept but also of all other ideas and concepts that are connected to the anchor (Ausubel, 1963, 1968; Novak, 2010). This is because the entire network of related ideas becomes increasingly more differentiated when new ideas are connected to related, more abstract ideas (Ausubel, 1965). The more examples the student recognizes and relates to a general concept, the greater the student’s facility for recognizing other related examples in the future, regardless of context (Ausubel et al., 1978).
Teaching that explicitly demonstrates connections between students’ underlying knowledge and new information allows them to discern patterns and relationships (Ausubel, 1968; Erickson, 2007; Novak, 2010). When students recognize patterns and relationships, they become cognizant of principles that guide interpretation of observations. The principles provide a framework for responding appropriately to patient situations, regardless of the context (Benner et al., 2010). Clinical activities can help to facilitate this process.
Clinical activities that support context-free learning must be concept based, rather than exemplar based. Clinical assignments are made on the basis of the concept that is the current course focus, rather than on a specific health condition or diagnosis. For example, if the focus is fluid overload, assignments might include patients with diagnoses of heart failure, renal failure, and liver failure. The patient care experiences provide an opportunity for students to realize that fluid overload occurs in response to a variety of conditions and helps them to recall appropriate nursing actions, regardless of the associated patient condition.
Faculty provide a written template to guide students’ thinking as they provide patient care. The template is used to collect assessment data specific to the assigned concept and incorporates higher order thinking questions that stimulate creation of additional knowledge connections relevant to the concept. Question prompts for fluid overload might include “How did fluid overload occur in the patient?” “What might happen next if this patient’s fluid overload is not corrected?” “What measures can the nurse take to prevent further problems from overload?” and “Why do these measures work?” How and why questions are particularly effective in helping students make new knowledge connections and in assessing students’ understanding of science concepts and principles (Novak, Mintzes, & Wandersee, 2005).
Concept-based rounds is a conceptual learning activity that further enhances students’ creation of conceptual-based knowledge in the clinical setting. Concept-based rounds consist of assigning the student a concept and guiding the student in selecting two or three patients from the patient care unit in which the concept would most likely manifest itself. The student conducts a review of the selected patients’ medical records and documents patient data relevant to the concept’s manifestation. The student synthesizes the information by comparing and contrasting the signs and symptoms related to the concept, the medical and nursing interventions, and the patient response to those interventions.
The activities described in the preceding paragraphs encourage the higher order thinking processes of data interpretation, differentiation of relevant from irrelevant data, and generation of hypotheses to account for observations made. These processes are essential to clinical judgment and decision making (Anderson et al., 2001; Thompson & Dowding, 2009) and depend on the existence of accurately linked knowledge in the student’s cognitive structure.
Unfortunately, students do not always make connections to preexisting knowledge in an accurate manner. This occurs when students either make erroneous connections or fail to make any type of linkage. Erroneous connections are often created during integrative reconciliation, whereas absence of appropriate linkages results from arbitrary connections.
Integrative Reconciliation and Arbitrary Connections
Integrative reconciliation is a process whereby students make adjustments in thinking to resolve seemingly contradictory information (Ausubel et al., 1978). This occurs when students are confused, particularly when new information seems to contradict preexisting knowledge (Ausubel et al., 1978). Students reconcile contradictions between new information and what is already known by recombining ideas in the cognitive structure to create linkages that make sense (Ausubel et al., 1978). The process of integrative reconciliation sometimes produces misconceptions that prevent students from connecting and understanding related information in the future.
Arbitrary connections occur when students have no information in their cognitive structure related to the new information, are unaware of how new and preexisting knowledge are related, or do not have time to make meaningful knowledge connections (Ausubel, 1963). The cognitive disorganization associated with arbitrarily acquired information is what typically occurs in rote learning. A disorganized and inappropriately linked cognitive structure prevents students from efficiently recalling information (Ausubel, 1963, 1968; Ausubel et al., 1978).
Teaching strategies that help students to organize and connect their knowledge include providing explicit instruction about how new information and students’ previously learned knowledge are connected, identifying commonly held student misconceptions, and explaining why misconceptions are inaccurate. These measures help students to create appropriate, rather than arbitrary, connections and help to prevent persisting misconceptions.
A misconception held by undergraduate nursing students, for example, is that the respiration process consists solely of the transfer of oxygen from the blood to the body’s cells (Lazarowitz & Lieb, 2006). The nurse educator teaching an exemplar related to the concept of oxygenation, such as asthma, would begin the session by recognizing that common misconception and assessing students’ understanding. Questions testing this knowledge can be delivered via PowerPoint®, and student answers can be collected through an audience response system in a face-to-face or virtual environment. For an online course, a prelearning assessment or quiz can be administered electronically. Student responses not only allow the educator to evaluate their preexisting knowledge but also provide the opportunity to correct the misconception and, thus, facilitate accurate integration of new information.
Concept-based teaching, in which key nursing concepts provide a foundation for understanding new related ideas, can decrease students’ formation of arbitrary connections. However, to be effective, concept-based teaching must include teaching strategies that require students’ cognitive engagement (Erickson, 2007).
Creation of substantive knowledge connections, which is essential to meaningful learning, does not occur unless students elect to integrate the new information into their preexisting cognitive structure (Ausubel, 1968). Knowledge integration requires that students transform incoming information to a form that makes sense and aligns with their preexisting knowledge. This process requires significant mental effort on the part of the student and cannot be accomplished without cognitive engagement. Cognitive engagement can best be accomplished through active learning, such as that provided by advance organizers.
Advance organizers are teaching tools or strategies provided in advance of a learning experience. This is an active learning technique because the tools can stimulate learners to make meaningful connections between preexisting and new knowledge (Ausubel, 1965). Advance organizers are capable of serving this function because they are at a higher level of abstraction or generality than the information that follows, and they are based on what the learner already knows (Ausubel, 1965).
Advance organizers scaffold learning by activating specific preexisting knowledge in the student’s cognitive structure (Gurlitt, Dummel, Schuster, & Nückles, 2012). Learning activities that impel students to discover relationships between a previously learned concept and new information provide a context from which new information can be understood, as well as a means of connecting new information to preexisting knowledge (Erickson, 2007). These teaching tools are particularly successful with students who struggle academically because struggling students often have difficulty making knowledge connections independently (Bruner, 1960).
Perfusion is one example of a nursing-specific concept that is abstract enough to be developed into an advance organizer. A diagram illustrating the blood supply to the major organs of the thorax and abdomen can be used to prepare students prior to a presentation of renal and heart failure. Learning activities that stimulate discussion of the principles of perfusion provide a framework from which learners can create their own understanding of how renal and heart failure are related and how one might impact the other. The concept of perfusion thus creates an explicit linkage between the two health conditions, rather than the arbitrary connection that would occur during the rote learning associated with a more traditional teaching approach.
Implications for Nurse Educators
A recent synthesis of more than three decades of research from the fields of educational and cognitive psychology, neuro-science, and human development generated principles to guide educators in the expansion of constructivist-based learning environments that promote meaningful learning (Bransford et al., 2000). The results of this synthesis were made available in the National Research Council’s report, How People Learn: Brain, Mind, Experience, and School (Bransford et al., 2000).
The National Research Council’s findings indicated that teaching is most effective when (a) learners’ thinking processes and underlying knowledge are considered during the planning, implementation, and evaluation of learning activities; (b) depth, rather than breadth, of a subject is addressed, and (c) learners are cognitively engaged during the learning process (Bransford et al., 2000). These core learning science principles are in direct alignment with Ausubel’s theory of meaningful learning (1968) and the principles underlying concept-based teaching.
Nurse educators can apply these teaching and learning principles by explicating the relationships between nursing concepts and principles and those learned in general education courses and by embedding active learning strategies throughout the curriculum that encourage students’ development of knowledge connections. However, to develop a concept-based curriculum, educators must first identify the concepts most essential to safe and effective nursing practice. Some sources for concept identification include a nursing program’s philosophy, the NCLEX-RN® blueprint, the NLN’s Outcomes and Competencies (2011), the American Association of Colleges of Nursing’s Essentials (2012), the Quality and Safety Education for Nurses knowledge, skills, and attitudes (QSEN Institute, 2005), and Healthy People 2020 Topics and Objectives (U.S. Department of Health and Human Services, 2012).
Identifying essential nursing concepts and principles allows educators to determine what is most important for students to know. When faculty teaching time is used to emphasize essential information rather than extraneous details, more time is available for students’ cognitive processing and faculty assessment of students’ learning outcomes Both strategies promote students’ deep understanding of nursing knowledge.
National organizations have recommended that learner-centered pedagogies be instituted to facilitate nursing students’ ability for knowledge transfer—the ultimate goal of which is to ensure delivery of safe and effective patient care (Institute of Medicine, 2000, 2010; National Council of State Boards of Nursing, 2006a, 2006b, 2009a, 2009b; Tanner, 2011). Students must learn meaningfully to execute knowledge transfer (Ausubel, 1963). Concept-based teaching, a learner-centered pedagogy, has been found to significantly improve students’ meaningful learning in disciplines such as medicine (González, Palencia, Umaña, Galindo, & Villafrade, 2008) and college students’ understanding of science (Morse & Jutras, 2008).
Concept-based teaching facilitates meaningful learning by supporting learners’ knowledge integration, the discovery of emerging principles, and the development of conceptual knowledge (Ausubel, 1963; Novak, 2010). It enhances learners’ depth of knowledge by helping them to create a differentiated and well-linked knowledge structure.
Ausubel’s conception of a linked and hierarchically arranged cognitive structure helps to explain why knowledge depth, rather than breadth, has been found to improve student learning outcomes, specifically outcomes related to knowledge transfer. The increasing differentiation that occurs as subordinate concepts and principles are integrated into the structure permits the learner to detect gradations in connected knowledge (Ausubel, 1968). The detection of subtle differences, in turn, enables the learner to select the knowledge most relevant when interpreting familiar situations or trying to understand similar, yet unfamiliar, situations.
The strength and number of knowledge connections have been found to be significant factors in nurses’ performance. Specifically, decreases in both strength and number of connections negatively influence the nurse’s ability to attend to relevant data (Benner et al., 2010). It is essential that nurses, as “knowledge workers” (Ebright et al., 2006, p. 339), have a deep understanding of classroom-acquired, nursing-specific knowledge. Deep understanding produces context-free knowledge. Context-free knowledge allows nurses to recognize various manifestations of nursing concepts, regardless of the specific health condition associated with the concept, and to apply the principles needed for safe and effective patient care.
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