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TEACHING AND LEARNING IN THE CLASSROOM AND SKILLS LAB
NURSING EDUCATION is sharply divided by location. Students and faculty alike discussed learning and teaching in clinical and classroom settings, including skills laboratories, as though they were entirely different from each other. For example, many students referred to what they learned in the classroom as “theory” that they then “applied” in clinical settings, implying that the nursing knowledge taught in classrooms is important but somehow different from the nursing knowledge students learn in clinical settings. It also suggests separation of learning and experiences, with theory being delivered in lectures and applied knowledge being gained through clinical situations. This terminology reflects a significant problem in nursing education, one we address throughout this book: the expectation that clinical and classroom teaching and learning will be separate and a narrow rational-technical approach is sufficient for using knowledge in practice. By “a narrow rational-technical approach” here we mean the assumption that a student in a clinical situation can learn formal criteria or decision rules for complex clinical situations with no adjustment for the variations in the situation. For example, even for advanced clinical life support (ACLS) rules, which are generally correct, a patient’s reaction to particular drugs, or particular cardiac pathophysiology or hemodynamic condition, may call for alterations in the ACLS. If the patient’s history is especially well known to the clinicians, there are usually exceptions or changes made.
One student explained that because of the division of learning into clinical and classroom settings, it is “difficult to get the full picture and understand the pathophysiology behind the disease processes. And without the background knowledge, I wouldn’t understand why I performed a task or how to explain the situation to a patient.” Although clinical and classroom learning does of course occur in differing settings, often taught by different teachers, students were expected to somehow integrate the parts into a whole.
As revealed in both student interviews and comments on the survey, students are distressed at the quality of teaching and learning in classrooms and skill labs and the lack of patient care simulations. A student who responded to the Carnegie-NSNA survey said that one of the biggest challenges in nursing education she faced was “being lectured on caring and building trust by instructors who don’t practice what they preach . . . learning from instructors who may be great nurses, but haven’t received training in teaching and communicating effectively as lecturers.”
Many students reported similar experiences with lecturers and lectures, and their responses consistently revealed uneasiness with how faculty lectured and the amount of information in their lectures, as well as the heavy reliance on such presentation tools as Microsoft PowerPoint. One talked about realizing how disengaged she was: “It’s really easy to sit there and agree with everything that [teachers are] saying and then an hour later if you try and recall it, you’re kind of hazy on what it was because you just don’t retain it when you just sit there and you watch these slides go by. And it got to the point where some of us stopped printing the slides and we’d just sit there and try to take notes. And we were learning better, but the problem was, they were going too fast.” Another student remarked, “there have to be other ways to get the information needed to be a nurse without being overloaded and relying on just memorization to pass a class. Remembering this information is important, memorization does help to a certain extent, but it doesn’t mean a student really understands the entire concept.” Indeed, a 2003 Institute of Medicine report warns of the many problems that arise when educators expect their students to rely too much on memory (Greiner & Knebel, 2003). Student nurses see problems with teaching and learning in terms of compromising or jeopardizing their ability to administer safe and effective patient care. They pointed out, in site visits and in the Carnegie-NSNA surveys, that they need more connections between what is taught in the classroom and their clinical experiences.
Teaching and Learning—Removed from Practice
As observers, we too were distressed at the approach to teaching in the nursing classroom. Experiential learning is one of the strengths of nursing education; we found a sharp contrast between the classroom situation, where it was for the most part absent, and clinical situations, where it is common. Teachers in classrooms often rely heavily on automated presentation software and use pedagogical strategies that are significantly less effective than teachers generally use in clinical settings and skills labs, where knowledge acquisition and use are more integrated. Although we note and applaud the exceptions to this finding, classroom teachers who make an effort to integrate the classroom and clinical experiences, and the even fewer who make the classroom a setting for rich, experiential learning, the research team was struck by the variability and even poor quality of teaching in classrooms and skill and simulation laboratories. This situation has grave implications for the extent to which students will develop skills of clinical inquiry and the ability to use knowledge in specific clinical situations.
In addition to classroom teaching, nurse educators also rely on skills laboratories, where they can demonstrate nursing practice outside the clinical setting. Skills laboratories are an intermediate zone between the classroom, where students learn nursing knowledge, and the clinical setting, where students learn to use that knowledge when caring for patients. In the skills lab, students can practice with equipment and technology or undertake simulation exercises that attempt to mimic practice and integrate knowledge acquisition and knowledge use.
In ticking off a list of things that overwhelm her and her colleagues, one educator summed up comments we heard: “The difficulty in recruiting more instructors, the very long hours, the very short pay, the change in textbooks, the need to continually improve and update our own knowledge of nursing while staying current with technology and improving teaching techniques, continual work toward maintaining accreditation, preparation for coursework each semester, and clinical prep and evaluation, the unrest in nursing, and the feeling that I am ‘throwing my students to the lions’ when they graduate, knowing the problems related to the nursing shortage and the lack of seasoned nurses to mentor the ‘young’ in the clinical settings.”
The sense of overwork is compounded by the faculty shortage. One educator deemed the situation as one of “crisis management! We have major issues with filling faculty positions. In addition, the aging of our faculty causes illness absences for themselves and because of family illnesses. We are scrambling to cover our responsibilities.” One simply summed up the challenges she faced in nursing education as “keeping up, and being engaged and passionate when I am dog-dead tired.”
We also recognize that educators struggle to stay current in nursing research and clinical practice. As one faculty member put it, it is hard to discern what to teach, “what is nice to know as opposed to what is needed. There has been an explosion of information and development and less time to discuss it.” We heard from many nurse educators that one of the stiffest challenges they face is how to convey a vast, ever-increasing universe of nursing knowledge (Diekelmann & Smythe, 2004; Ironside, 2004; Tanner, 1998). One nurse educator responding to the Carnegie-NLN survey said, “The constant change challenges us to keep current not only in teaching but practice itself, especially with all the new technology. Being in clinical practice while teaching helps, though, with this, and I think practicing also actually helps students respect you as you are in the trenches with them.” Another respondent explained, “I work and I read, talk with other practicing nurses, but there is always something I haven’t had experience with!” Another succinctly summarized the problem all nursing faculty face with finding the most up-to-date practices and information: “Often the new evidence in practice is not in the text.”
In every school we visited, we found teachers who, in their effort to bring order and organization to a vast amount of information and content overload, resort to cataloguing. In the classroom, for example, the teacher focuses almost exclusively on organ systems or their diseases, starting with a broad category such as the liver or nutrition, and then introducing subcategories with their sub-subcategories and their sub-sub-subcategories. The class opens with a brief review of the subject as a whole. The teacher might start with pictures of anatomy, move to some basic physiology, and continue with a list of all the parts of the body and signs of pathology a nurse would need to be aware of in assessment. From assessment, the next topic might be nursing diagnoses for patients, how to implement orders for interventions for patients, and special situations that arise in practice, such as nursing orders for patients with feeding tubes. We observed many classes in which all the information was organized around the nursing process: assessment, analysis and diagnosis, planning, implementation, and evaluation.
“Subsuming things under categories,” wrote Logstrup in 1995, “is not the same as productive thinking” (p. 150), and nursing students in these classrooms have few opportunities for developing the productive thinking necessary in nursing practice. Presenting ordered and classified information does little to prepare students to use knowledge. The categories, which are classifications or labels, do not give the students any heuristic or imaginative access to the use and relevance of the knowledge in practice situations. Because such frameworks are so abstract, the students struggle to grasp the relevance of all the parts of the catalogue and how the categories are relevant for understanding practical clinical situations.
Moreover, the categories are dim representations of the issues the students will see in practice: patients (especially older patients) seldom have only one category of disease or clinical problem, but they have a complement of social and interpersonal concerns as well. It is impossible for the students to gain a deep and nuanced understanding of the interrelationships of diseases from categories that are flat representations of diagnoses, signs and symptoms of one disease. The diagnoses, signs, and symptoms of a disease are often presented as abstract categories and students find it hard to imagine how these abstractions might guide what they would do in practice.
In the nursing classroom, we often found the teacher posed questions in a call-and-response format, where the answer is known and factual. The teacher was clearly listening for one answer and moved on as soon as she heard it. The students did not appear to need to listen to each other, except to decide whether to hazard a guess. We observed students trying to bring in context, often a brief story about friends or relatives who had trouble with disease or illness. The teacher listened politely, made a comment or two, and turned back to the slides and thus the opportunity for engaging students in a discussion of clinical or related experiences was lost.
Some teachers recognize the flaws of their approach. Commented one, “We can teach in this program, we can teach in that program, and I don’t necessarily feel that that’s true education, when you become so multitask, that you put everything on a PowerPoint and you pull it out of a drawer.” Her colleague added, “Homogenized is what I call it.”
It was disheartening to hear a nursing educator describe struggling to fit in standardized lectures using PowerPoint slides: “I’m not so accustomed to…[such] structure in the classroom. For example, postpartum has something like 117 slides and the antepartum has 170. I’m more accustomed to not having so many slides and so many PowerPoint presentation handouts and instead presenting an idea and then having case studies and discussion in class and things like that. So it’s taking me a while to make sure that I get to other slides…. I’m almost afraid I’m the one that colors outside the lines here.”
We understand how nursing education could come to this point. On entering academia from hospital training schools (primarily in the early 1960s), nurse educators felt pressured to conform to academia’s style of presenting abstract, decontexualized, formal theories. For example, in the late seventies and early eighties, NLN’s accreditation criteria required one unifying theoretical framework for every nursing curriculum (Meleis, 2006). This presented many practical problems for a practice as broad and complex as nursing. No one theory could adequately fit the criteria of forming a framework for the whole curriculum. Some theories were too focused on acute care, illness, and injury, while others were too focused on community health, health promotion, and human development. Over the years, NLN dropped this accreditation criterion of a unifying, integrative use of one nursing theory (Meleis, 2006); however, it seems that excessive use of taxonomies, as a way of cataloguing information, replaced the quest for formal theoretical frameworks.
The newer taxonomic catalogues fit the notions and classificatory demands of nursing informatics. Bowker and Star (1999) cite the standardization, the clearance of past theories and knowledge as part of the motivation for creating an informatics nomenclature and classification of nursing work from the ground up. The drive for standardization of nursing language was in large measure a strategy for making nursing work more visible, explicit, and retrievable in the health care records (Bowker & Star, 1999).
Influenced by computerized databases and information, the task of the nursing faculty can come to be putting multiple frameworks for classifying and categorizing information on a series of PowerPoint slides. Of course, such a collection of classifications can in no way capture the complexity of the knowledge or the complexity of using knowledge in particular situations.
Thus nurse educators have been encouraged to literally teach North American Nursing Diagnosis Association-International (NANDA-I) Taxonomy of Nursing Diagnoses, Interventions, and Outcomes as the basic scaffolding for classroom teaching. This is the equivalent of using Psychiatric Diagnostic Classifications (DSM IV), which are rarely nonoverlapping, as the primary means for meeting and conducting therapy with particular patients in psychotherapy. In nursing and psychiatry, the taxonomy may be useful in retrieving records, receiving reimbursement, and understanding broad categories of mental illnesses, but the DSM IV does not replicate the thinking process, nor the actual practice of doing psychotherapy, and therefore is a poor portal for teaching the actual habits, skills, and practices of psychotherapy with particular patients with a unique illness history, pattern, and overlapping of symptoms and diseases.
The educational mistake we see playing out in the nursing school classrooms replicates the error of trying to force nursing knowledge and curriculum into one theoretical framework for nursing. In this case, it is not a theory that is concretized and reified across all nursing practice contexts, but a much more reduced, structured formal system designed to function within a formal informatics system. This does not help students imagine how they will take up and use relevant knowledge in caring for particular patients with a range of diseases and illness concerns.
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