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The nature of learning from the clinical experience of nursing students Goldie, Norma Elizabeth 1992

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THE NATURE OF LEARNING FROM THE CLINICAL EXPERIENCE OFNURSING STUDENTSByNORMA ELIZABETH GOLDIEB.S.N., University of British Columbia, 1973A THESIS SUBMITTED IN PARTIAL FULFILMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTS (EDUCATION)inTHE FACULTY OF GRADUATE STUDIESDepartment ofAdministrative, Adult and Higher EducationWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril 1992© Norma Elizabeth Goldie, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of APM bk.1 IS -neokrt VC ADLI ^i-311 al 14 ev, e"..bc_icra77 014The University of British ColumbiaVancouver, CanadaDate  apt,Zei A8 .) /99:•Z •DE-6 (2/88)ABSTRACTThis research project began with a discussion of the centrality of the clinicallearning experience in nursing education. It went on to discuss the literature thatidentified the need for a better understanding of learning from this experience. Thisresearch project was designed to address that need. It attempted to describeconceptions of learning from clinical experience. The questions posed by thisresearch project were: What are nursing students' conceptions of learning from clinicalexperience, and what is the relationship between the different conceptions of learning?The subjects were 13 nursing students in the fifth semester of a two year nursingprogram in a large urban centre. A qualitative methodology called phenomenographywas used to systematically examine conceptions of learning from clinical experience.The data base were transcriptions of taped interviews of students' descriptions oflearning. The analysis of data proceeded inductively through the reduction ofunimportant differences in expressions in the interviews to the identification of a coreof elements that represented the process and content of learning. These elementswere then grouped according to similarities and delimited according to differences.The findings were the identification and description of three qualitatively differentconceptions of learning. These conceptions of learning from clinical experience were:iiConception A - Learning as reproducing facts and procedures, Conception B -Learning as an interpretive process, and Conception C - Learning as the discovery ofrelativism. The main difference between these conceptions was between ConceptionA where learning was seen as reproducing facts and procedures and betweenConception B and C, where understanding was achieved. In Conception A learningis characterized by a quantitative view of knowledge, dualistic thinking, attention toparts rather than wholes, and repetition. In Conception B, learning is described asqualitative, analytical and concerned with a way of knowing. Learners use aphysiological framework in understanding and seeing relationships. In Conception C,learning is focused on interpreting the person-in-situation as a basis for decision-making. Thinking in this conception is relativistic and contextual. The differencebetween conception B and C results in a difference in the quality of interpretationachieved.Conceptions of learning are tools that can be used when planning learning andteaching activities, when communicating with students about learning, and whenevaluating the success of teaching. The findings of this research project suggest thebenefits of modification of the clinical learning environment. This research projectsuggests the need for further studies of conceptions of learning from clinicalexperience including longitudinal studies and studies in which nursing students fromdifferent types of programs are used as subjects.iiiTABLE OF CONTENTSABSTRACT ^iiLIST OF FIGURES ^viI. DEVELOPMENT OF THE RESEARCH QUESTION ^1Description of Clinical Experience in Nursing Education ^1History of Clinical Experience in Nursing Education ^2Toward a Research Problem ^8Concerns about Various Elements of the Clinical Learning Environment^8General Concerns about the Clinical Learning Experience ^14Statement of the Research Problem 15Importance of the Research Project ^16Summary ^17II. A PERSPECTIVE ON LEARNING ^18The Original Learning Experiment ^18Description of Conceptions of Learning ^20Conceptions of a Learning Experience ^21Personal Elements of Conceptions of Learning ^22Situational Elements of Conceptions of Learning ^24Description of Related Concepts ^26Implications for Teaching ^28Focus of this Research Project ^30Summary ^31III. LITERATURE REVIEW ^32Literature Search ^32Research Priorities in Nursing Education ^33Studies Based on Students Perceptions ^36Studies that Examine an Aspect of Personal Context ^38Studies that Examine Aspects of the Clinical LearningEnvironment ^41Conclusion ^51IV. RESEARCH DESIGN AND IMPLEMENTATION ^53Phenomenography ^53Process of Phenomenography ^54Outcome of Phenomenography ^55IVFramework for Analyzing and Describing Conceptions of Learning  ^57Uses of Conceptions of Learning as Research Findings ^59Compatibility of Methodology and Topic ^60Level of Generality of Clinical Experience ^60Understanding as the goal of the Clinical Learning Experience  ^61Data Collection ^62Selection of Subjects ^62Description of Subjects ^64Interview Process ^64Data Analysis ^69Reliability and Validity ^71Summary ^73V. OUTCOME OF ANALYSIS^  74Aspects Common to All Conceptions ^74Conception A:Learning as Reproducing Facts and Procedures ^77Conception B:Learning as an Interpretive Process ^83Conception C:Learning as the Discovery of Relativism ^90Relationship between conceptions ^96Summary ^97VI. INTEGRATION OF FINDINGS AND SUMMARY^  98Limitations ^100Relationship to Existing Research ^101Discussion ^102Implications ^107Implications for Nursing Education ^107Implications for Further Research ^113Summary ^114VII. REFERENCE LIST ^116VIII. APPENDICES  ^122Appendix A: Consent  ^122Appendix B: Course Outline ^123Appendix C: Result of Interjudge Reliability Test ^131Appendix D: Definition of Terms Used in DescribingConceptions of Learning  ^137vLIST OF FIGURESFigure 1. A Perspective on Learning^  21viCHAPTER IDEVELOPMENT OF THE RESEARCH QUESTIONThis chapter introduces the topic of this research project and puts the researchquestion in context by describing the history of clinical experience in nursing educationand the problematic nature of this experience as expressed by several authors. Itconcludes with a statement of the research question and an explanation of theimportance of this investigation to nursing education.Description of Clinical Experience in Nursing Education The topic of this investigation was the clinical learning experience of nursingstudents. This experience is an integral part of the total educational experience ofthese students. It has been described as "the most important part" of a nursingprogram (Infante, 1985, p. v), the "heart" of nursing programs (McCabe, 1985, p. 255)and as "the core of nursing education" (Jones, 1985, p. 349). Pugh (1983) notes that"the major portion of a nursing student's learning experience, comprising 12 to 20 ormore clock hours each week, is spent in the clinical setting" (p. 62).The value of clinical experience in the education of professionals is widelyappreciated and has been described by several authors (Burnard, 1987; Infante, 1985;Pugh, 1983; Wong & Wong, 1987). It provides the environment in which studentsmaster the process of applying previously acquired knowledge by being placed in1actual situations that require the service of the professional. In recent decades thefocus of this application process has shifted from an emphasis on performance to aconcern with understanding and the application of abstract as well as concreteconcepts. Students may go beyond this application process, however, testingalternatives and gradually gaining new insights into their practise. As well asknowledge application, the acquisition of professional attitudes and values has beenidentified as a major purpose of this experience.History of Clinical Experience in Nursing Education The history of nursing education has been well described (Infante, 1985; deTornyay & Thompson, 1987; Wong & Wong, 1987; Baumgart & Larsen, 1988; Kerr,1991). In Canada, nursing education began late in the 19th century. Its historyreflects assumptions and beliefs about the function of education and the nature ofnursing and, since most nurses are women, has also been heavily influenced bycultural attitudes toward women.Nursing programs in Canada began in 1874, as on-the-job training experienceswhere students learned in the clinical environment under the supervision of practisingnurses or more advanced students. Learning took place chiefly by trial and errorthrough "hands on" experience. These programs have been described asapprenticeship programs without a master craftsman. Instruction was incidental ortook place for one or two hours a week.2Hospital training programs flourished as hospitals came to depend on nursingstudents for service. The programs, however, were found to be haphazard, poorlyorganized, and concerned primarily with the development of manual skills and thestrict adherence to rules and regulations. Nursing students were taught to obeyorders and were discouraged from much independent thinking. Baumgart and Larson(1988) observed that "standards varied from school to school and the training ofteninvolved long, arduous hours of work in trying conditions" (p. 316).By the 1920s awareness of the limitations of such programs resulted in theCanadian Medical Association and the Canadian Nurses Association (CNA) appointingDr. George Weir, Head of the Department of Education at the University of BritishColumbia, to conduct a survey to address these matters and to makerecommendations for change. In 1932, the Weir Report was published whichdocumented the problems which existed and called for fundamental reform. Itemphasized that learning experiences should be shaped by educational objectivesrather than the service needs of hospitals. It also recommended that schools ofnursing should become part of the general educational system of the provinces andshould be financed on the same principle. Finally, it recommended that modernnurses required a liberal as well as a technical education and that universities shouldestablish programs and award degrees in nursing.3Although the Weir Report was only the first of several reports which made theserecommendations, even as late as the 1960s, 95% of nurses received their initialeducation in hospital training programs. In 1959, Dr. Helen Mussallem, ExecutiveDirector of the CNA headed a project aimed at measuring whether the quality ofinstruction in Schools of Nursing enabled them to meet criteria for accreditation. Dr.Mussallem found that only 16% of Schools of Nursing in Canada met accreditationcriteria and recommended a school improvement program that would lead toaccreditation in the future. This emphasis by the CNA on standards of educationbrought rapid change within hospital schools of nursing during the 1960s. As well, Dr.Mussallem continued to press for the move of Schools of Nursing to post-secondaryinstitutions. By the 1970s the majority of Canadian schools of nursing were includedunder the umbrella of educational institutions.Despite the move to educational institutions and other major philosophicalchanges, such as the development of nursing theory and a change in emphasis fromprocedures to patient-centred practise, the centrality of the clinical experience innursing programs has persisted. The focus of clinical experience, however, is one oflearning rather than service. Not unlike the education of other professionals, theprimary purpose of the clinical experience in nursing education is "to provide studentswith opportunities to have contact with actual clients in various situations and to usethose theories, processes and skills learned in other courses and settings. Theclinical setting is where validation of previously learned principles and concepts is to4occur and where the use of skills learned in simulated environments takes place (deTornyay & Thompson, 1987; Lillard, 1982). It also allows students to acquire thecharacteristics of professional roles and values. Infante (1985) goes even further andsuggests that "it is the place for students to go beyond what has been learned, tochange and adapt approaches to care, and to search for a higher quality of care"(p.15).Clinical teaching represents approximately 50% of the instructional activity of manynursing faculty (Wong & Wong, 1987). It goes beyond supervising students on theward to include teaching the essentials of nursing practise as well as supportingstudents in their learning of nursing in the clinical setting (McCabe, 1985; Wong &Wong, 1987). Nurse educators are to encourage students "to explore, question, doubtand criticize their own perceptions and to draw out their own meanings from theseexperiences" (Burnard, 1987, p. 193) and to strive to produce "independent, creative,decisive, assertive thinkers" (Infante, 1985, p. 21).The journey toward this emphasis has been a slow and tumultuous one which hastried the relationships between nursing education and nursing practise and hasnecessitated compromising values on both sides. In fact, Rovers and Bajnok (1988)suggest that half a century later many of the basic issues and controversies that arereferred to in the Weir Report remain unresolved (p.224).5This research project occurred at a pivotal time in the history of health care,nursing, and nursing education. Nurses are a vital part of the re-examination of healthcare that is occurring throughout Canada and North America related to the sky-rocketing cost of health care, the shift in focus from acute hospital care to preventionand home care, and technical advances such as life-support systems, organtransplantation, and crisis management.The changes that will be required have forced nurse educators to ask themselveswhat the implications are for nursing education. One response has been a movementfor change in nursing education that began in the United States in 1986 and which isreferred to as the "Curriculum Revolution" (de Tornyay, 1990; Tanner, 1990; Bevis &Murray, 1990; Bevis & Watson, 1989). Tanner (1990) has identified five themes ofthis movement: (i) social responsibility that is centred at the present time on the needfor transformation of the health-care system, (ii) the centrality of caring, since caringis what allows the nurse or the teacher to understand and to act on the concerns andissues of their clientele, (iii) an interpretive stance or the intent to unveil, understandand criticize beliefs and assumptions that guide practice, but which may be coveredover by formal theories, rules or procedures, (iv) theoretical pluralism or emancipationfrom singular or narrow views of what constitutes education such as an over-emphasison the rational-technical or Tylerian model, and, (v) the primacy of the teacher-studentrelationship which includes an egalitarian, shared responsibility for learning, a focuson the processes of learning, and individualized learning.6The changes that will be required in this revised health care system have alsobrought with them widespread acknowledgment of the need for additional educationalpreparation for nurses. In 1982 the Canadian Nurses Association adopted the positionthat by the year 2000, the minimal educational requirement for entry into the practiseof nursing should be successful completion of a baccalaureate degree in nursing(Entry, 1986, p.i). It is in this climate of change that curricula are being developed forthese new programs. Educators are being asked how clinical experience should beprovided and used. "There seem to be more questions than answers"; "the contentof the clinical experience is controversial"; "there needs to be greater flexibility indesigning clinical experience" are comments that have come out of one nursingeducation conference (Duncan, 1988, p.11).The research project presented in this thesis attempts to provide direction for andinsight into some aspects of these concerns about how clinical experience should bedesigned and used. These have been called "...heady times for nursing education inCanada" (Banning, 1988, p. 3). The former president of the Registered NursesAssociation of British Columbia told nurse educators at a forum on Excellence inClinical Teaching that "the decade is yours" (S. Rothwell, personal communication,February 21, 1989). The time seems ripe for a re-examination of the clinical learningexperience.7Toward a Research Problem Despite the importance and centrality of the clinical learning experience in nursingprograms, the literature review raises several concerns about it. The majority ofauthors raise concerns about various elements of the learning environment. Others,however, raise general concerns about the clinical learning experience in nursingeducation.Concerns about Various Elements of the Clinical Learning Environment Infante (1985), Wood (1987), and Heims and Boyd (1990) express concern aboutthe "total care concept" in the clinical experience of nursing students. This refers tothe common practise of having nursing students implement total patient care to thelevel of their preparation even in initial clinical experiences. It is this aspect of theclinical education of nursing students that is unique in comparison with the clinicalexperiences of other professionals. It may be overwhelming to many students. Infantesuggests that students may deal with this by organizing the experience in such a waythat it is manageable for them. This may mean paring down their focus to those tasksfor which they are directly accountable to hospital staff. As Infante points out, caringfor patients is believed to be synonymous with learning but the complexity of thisapproach has undesirable outcomes in terms of the overall goals of the experience."Curiously enough," Infante notes, "although beliefs about what the professional oughtto be have changed dramatically, the educational strategies used in the clinicallaboratory remain amazingly constant, except for the efforts of a few" (p. 20). Heims8and Boyd identify advantages and disadvantages of the traditional patient assignment,that is, the practise of assigning students to the total care of patients, in the clinicalsetting. Advantages include: contact with actual clients as a confrontation with reality,observation of the staff, which is useful for learning nursing actions and forsocialization, and opportunities for the application of knowledge to practice.Disadvantages include: it is dependent on an unstable patient population, students areoften too busy carrying out the prescribed patient care to think of alternatives, muchof the time the focus is on the worker role and performing safely and accurately, thereis limited discussion of variety among clients when the student takes care of only oneor two patients, and, there is often too little focus on the process of learning aboutnursing care, a skill that would help the student solve new patient care problems inthe future (p. 249). Of concern also is the level of performance that must beachieved. Creighton (1981, as cited in Wood, 1987) states that, legally, the nursingstudent's performance must be equal to that of a registered nurse, and is judged bythe same standard.Several authors have expressed concern about the level of anxiety related toclinical experience among nursing students and its effect on learning (Kushnir, 1986;Wong & Wong, 1987; Williams, 1988; Meisenhelder, 1987; Infante, 1985; Blainey,1980). Nursing students often report anxiety related to accidentally harming patientsby some action or by overlooking a change in the patient's condition. With theincrease in the cost of hospital care and the availability of home-care and out-patient9services, patients hospitalized in acute care settings are more seriously ill and exhibitless stable conditions. It is thus becoming increasingly difficult for instructors to assignstudents to uncomplicated patients. It can be expected, therefore, that the anxietythat students experience may be intensified. Blainey maintains that nurse educatorsare inclined to send double messages to students in the clinical setting encouragingthem to be independent, risk-taking and self-directed but warning that there is littleroom for error in this experience. Infante complains that the idea that the student isnot a nurse but is learning to become a nurse may not be recognized. Wong andWong (1987) relate the high level of anxiety to the frequency of students participatingin unplanned activities as well as the inclination of nursing professionals to beintolerant of mistakes, demanding near-perfect performance of themselves and theircolleagues.A study by Infante (1975), using 184 clinical nursing instructors, reported a strikingcontrast between what faculty said they believed in and what they practised. Althoughthey expressed belief in fourteen elements of the clinical learning experience, whichessentially defined the student as a learner rather than as a responsible care giver,fewer than 50% gave evidence of acting on these beliefs in practise. Two authors(Pugh, 1980 and Meleca, Schimpfhauser, Witteman and Sachs, 1981) replicatedInfante's research and obtained similar results.10Several authors (Windsor, 1987; Jones, 1985; Wong & Wong, 1987; Karuhije,1986, Quinn, 1980) have compared clinical teaching to classroom teaching and havepointed out the complicated, ambiguous context that it presents. Characteristics ofclinical teaching that are not present in the classroom can be summarized as follows:(a) there is a lack of control over environmental conditions including kinds of patientsavailable for learning opportunities, the quality of care given by hospital staff and evenin some cases the educational process; some instructors have complained of feelinglike a guest on the ward, (b) patient safety must be maintained while patients arecared for by a novice, (c) faculty must monitor patient needs as well as student needs,(d) students must combine the use of cognitive, psychomotor and affective skills torespond to individual client needs, (e) clinical teachers are faced with two differentdemands, competence in nursing and competence in teaching. Reynolds andCormack (1981) feel that a major difficulty faced by nurse instructors is that it is oftendifficult for them to spend any significant period of time with learners and patients.They, therefore, have limited knowledge of individual patients and have littleresponsibility for making nursing decisions. They may make a conscious choice toemphasize teaching motor skills as they are relatively easy to teach, have resultswhich are easily assessed and may be harmful to patients if badly performed.Lindeman (1989) states that very little is known about effective use of the clinicalenvironment and goes on to identify four paradoxes of clinical teaching in nursingeducation:111. Although it is considered essential in nursing education, it is becomingincreasingly difficult to find appropriate clinical placements for entry level programs.This is largely due to the increased acuity of hospitalized patients.2. Although it is considered essential to function in a real environment, currentlythe health care system is under attack by the public, legislators and many healthprofessionals. Nursing instructors have had difficulty finding positive examples ofbehaviours students are learning. As well, clinical experience exposes students to thechronic problems of the profession, which she identifies as low salaries, poor workingconditions, having limited authority, being overworked and lacking in professionalstature. Lindeman's concern is that students schooled in these negative aspects ofthe clinical environment will become desensitized and accepting of these conditions.3. Student access to the clinical environment requires evidence of instructors'and students' ability to perform according to professional standards. The paradigmthat is commonly used is that an instructor is responsible for the actions of 8 to 10students. This means that instructors are accountable for the care being provided tosome 16 to 20 acutely ill patients, a patient assignment that is heavier than that of theregular staff, as well as for the learning needs of their students. Lindeman states that,logically, evaluation rather than learning is given priority and that the instructor's stressmay be passed on to students. Lindeman also reflects on the need for students toperform according to existing standards. She says that when this situation exists, topractice, means to demonstrate one's ability to apply existing knowledge, and little12learning from experience will take place. Learning of the latter type, she says, is likelyto be more important for the rapidly changing world of health care.4. The problem-solving approach used in the clinical setting emphasizes theapplication of scientifically derived knowledge to the individual situation, and therebyminimizes the knowledge generated by the situation. Schon (1987, as cited inLindemann, 1989) states:professional schools still embody the idea that practical competence becomesprofessional when its instrumental problem solving is grounded in systematic,preferably scientific knowledge. So its...curriculum presents first the relevantbasic science, then the relevant applied science, and finally, a practicum in whichstudents are presumed to learn to apply research-based knowledge to theproblems of everyday practice (p. 62).Lindemann questions whether this approach prepares students for the real worldof practise. She believes that a new conception of practise competence andprofessional knowledge must be proposed that starts with the notion of artistry. Schondescribes artistry as "an exercise of intelligence, a kind of knowing that is differentfrom our standard model of professional knowledge that can be learned about bycarefully studying the performance of unusually competent performers" (p. 63). Shestates that professional practise requires applied science bounded on all sides byartistry. There exists, she says, "an art of problem framing, an art of implementation,and an art of improvisation..."(p. 63). She calls for a "reflective practicum", that is, apracticum aimed at helping students acquire the kinds of artistry essential forprofessional practise.13General Concerns about the Clinical Learning Experience Concern about learning from clinical experience in general has been expressedby several authors (Tanner and Lindeman, 1987; Pugh, 1983; Infante, 1985;deTornyay, 1983; Windsor, 1987; McCabe, 1985). All of these authors commentedon the dearth of reported studies related to clinical experience. Windsor (1987)referred to the lack of research-based planning and implementation of the clinicallearning experience as a disturbing deficit in the nursing profession and called forresearch to identify what constitutes quality clinical education and to help developoptimum learning opportunities. Following an examination of reviews of research onclinical education, Tanner and Lindeman concluded that little is known about theeffectiveness of approaches to clinical teaching in terms of student learning. Infantecalled for an analysis of the process of clinical teaching using appropriate theory toguide this effort. De Tornyay (1983) reviewed empirical research on the teaching-learning process in nursing education. She observes that most of the studies dealtwith classroom learning. She calls for more research on nursing education andidentifies studies related to clinical experience as one specific need. She states thatit is clear from studies of teaching methods and materials that "no clear cut evidenceexists for the superiority of one approach over the other" (p. 206). She calls for thepostponement of research on isolated teaching methods and a focus on studies that"promote understanding of optimal conditions of learning" (p. 206).14Statement of the Research Problem The overall purpose of this research project was to add to the limited existinginformation on learning from clinical experience and to establish a basis for examiningthe learning environment in terms of students' interpretations of that environment.Specifically, the research problem was to identify and describe nursing students'qualitatively different conceptions of learning from clinical experience and to describethe relationships between these conceptions.Conceptions of learning have been described as "the core of education"(Ramsden, 1988, p. vii). Stalker (1989) has described conceptions as "the differentways in which people experience or understand or think about phenomena in theirworlds", and "as the filters through which the experience is viewed" (Stalker, 1989, p.41). Larsson (1984, as cited in Stalker, 1989) has described them as constituting"both the background or rationalizations for actions and the forward-looking intentionsof actions" (p. 42). As such, they are the basis for and a limitation upon students'learning activities. Perry (1988) refers to "the assumptions and expectations thatindividuals have that place knowledge, learning, hope, initiative, responsibility and theirteachers in certain relations" (p. 150) and to "the different constellations through whichstudents make sense of their worlds" (p. 150). Marton and Saljo (1984) point out thatstudents' conceptions of a learning experience "reflect their past experiences of similarsituations, and so mirror differences in their preconceived ideas of what it takes tolearn" (p. 52). Conceptions are also influenced by students' interpretation of the15context of learning or the learning environment which includes teaching, assessmentand course content and structure (Gibbs, Morgan & Taylor, 1984).Conceptions of learning, in this study, will be identified and described byexamining data obtained from interviews of students who described their livedexperiences of learning from clinical experience.The questions which guided this research project were:1. What are nursing students' conceptions of learning from clinical experience?2. What is the relationship between different conceptions of learning?Importance of this Research ProjectLars Dahlgren (personal communication, May, 1987) said it should be the dreamof educators to see the learning situation as the student sees it because then theywould know exactly how to teach. This statement reflects the overall goal of thisresearch project. By identifying and describing the different ways students understandlearning from clinical experience, teachers are provided with insight into the processof learning. These descriptions become tools that "teachers can use when planningteaching..., when communicating with students as a framework for understanding whatis being understood or misunderstood, and when evaluating the success of teaching"(Saljo, 1988, p. 44).16Summary This chapter has introduced the research topic, described the problematic natureof the clinical learning experience, posed the research questions, and defined therelevance of the proposed research project. Chapter Two is a discussion of theconceptual framework on which this research is based. Chapter Three is a review ofprevious research on clinical experience in nursing education with some reference toresearch on clinical experience in related disciplines. In Chapter Four themethodology and data analysis are discussed in detail. Chapter Five is a descriptionof the findings that are a product of that analysis. And finally, Chapter Six is adiscussion of the findings and implications of this research for nursing education andfor further research on this topic.17CHAPTER IIA PERSPECTIVE ON LEARNINGThis chapter presents a new perspective on learning. It describes a network ofconcepts that provide a broad picture of student learning (Marton, Hounsell andEntwistle, 1984). The purpose in doing this is to set the stage for this researchproject. The chapter begins by providing an overview of the original research that ledto this perspective on learning. The chapter goes on to describe conceptions oflearning, a core concept in this view of learning. Conceptions of learning arediscussed generally and then in relation to a specific learning experience. Two relatedconcepts, approach to learning and outcome space are then discussed. Followingthat, implications of this view of learning for teaching are described. Lastly, the focusof this research project in relation to this view of learning is discussed.The Original Learning ExperimentThe perspective on learning used in this study is the work of cognitivepsychologists in the field of higher education (Marton, F. et al., 1984). It is the resultof studies that began in Sweden at the University of Gothenberg in the early 1970s.These studies involved students' descriptions of their own personal experiences oflearning. In the original experiment, what university students learned from reading anacademic article about reform in higher education was studied. The researcherscarefully analyzed what students said when they were asked to describe what they18had been reading. They found evidence of qualitative differences in the outcome ofstudents' reading. The differences were not about how much the students couldremember, but about their understanding of what the author had tried to convey.Some students fully understood the argument being advanced and could relate it tothe evidence used to support it; others partly understood the author's message; otherscould only mention some of the remembered details. This experiment produced threeimportant results. The first was the development of a rigorous qualitative methodologycalled phenomenography which allows students' experiences of learning to be studiedsystematically. This methodology is described in Chapter Four. The second andprobably the most influential finding pointed to an "astonishingly simple picture" (p. 39)that was overlooked by previous researchers. That finding was that "students who didnot get the point of what they were learning failed to do so simply because they werenot looking for it" (p. 39). Students intention to learn and their learning activities weregoverned by their understanding of what it meant to learn, or their conception oflearning. Third, this study identified qualitative differences in the outcome of studentlearning. These differences reflected differences in understanding rather thandifferences in how much the student could remember. These findings were theimpetus for further research which resulted in the identification of a network of relatedconcepts (see Figure 1), that provided a description of student learning.19Situational Elements Personal ElementsEducationalorientationRelevanceConception/sofLearningExperienceSubject MatterContext ofLearningConception/s oflearningStudy orientationI Intention ApproachtoLearning7deep^surfaceKnowledgeI Cognitive AbilityProcessOutcomeSpaceFigure 1: A perspective on learning, adapted from Marton (1984).Description of Conceptions of Learning In this view of learning, conceptions of learning are seen as the core of education(Ramsden, 1988, p.vii). Stalker (1989) has described conceptions as the differentways in which people experience or understand or think about phenomena (in thiscase, learning) in their worlds, and as the filters through which experience is viewed.Larsson (1984, as cited in Stalker, 1989) has described them as "constituting both thebackground or rationalizations for actions and the forward-looking intentions ofactions" (p. 42). As such they are the premise for and place a limitation upon learningactivities. In this regard, Entwistle and Marton (1984) refer to the inevitableconnection between the way that students conceived the learning situation and theprocedures used in learning. Perry (1988) refers to "the assumptions and20expectations that individuals have that place knowledge, learning, hope, initiative,responsibility and their teachers in certain relations", and to "the differentconstellations through which students make sense of their worlds" (p. 150).Conceptions of learning are described as quantitative, where the emphasis is ona quantitative increase in knowledge, or qualitative, where the emphasis is onunderstanding. Dahlgren (1984) points out that conceptions of learning form a veryimportant component of the cultural basis of society. He points out that societallythere may be an emphasis on factual knowledge and thus a quantitative conceptionof learning may be reinforced. It has also been pointed out that experts' conceptionsof phenomena have varied between historical periods and that these historicconceptions can become commonplace and tenaciously held among the generalpublic (Ramsden, 1988).Conceptions of a Learning Experience Conceptions of learning are not inside a student but are between the student anda particular learning situation. Conceptions of learning from a particular learningexperience have both "personal and situational elements" (Ramsden, 1988, p. 20). Assuch, they describe relations between the student and the learning situation. Far frombeing solely individual characteristics, conceptions of learning are affected by thelearning environment or context of learning including the subject matter. Conceptions21of learning are the student's personal interpretation of content and context. As suchthey are not static but variable.Personal Elements of Conceptions of Learning Concepts that relate to personal elements include: general or previous conceptionof learning, study orientation, experience of relevance, or interest in the learningsituation, and educational orientation (Gibbs, Morgan & Taylor, 1984). These refer tocharacteristics of the learners themselves that relate to the ways in which learning isinterpreted.Entwistle and Marton (1984) point out that students have habitual or customaryways of approaching a learning experience that reflect their previous experiences oflearning (p. 221). Marton and Saljo (1984) point out that students' conceptions of alearning experience "reflect their past experiences of similar situations, and so mirrordifferences in their preconceived ideas of what it takes to learn" (p. 52). It was alsofound that those individuals who held quantitative conceptions of learning remainedwedded to those conceptions since their conception of learning did not include thepossibility of extracting meaning. Those with more sophisticated conceptions acceptedlearning as taking different forms according to different circumstances or taskrequirements (Entwistle & Marton, 1984). This previously formed conception oflearning or understanding of learning generally, is thus a personal characteristic thataffects students' conceptions of learning in a given situation.22Study orientation refers to the ways in which students customarily approached thetasks of everyday studying. A meaning orientation, which has been related to intrinsicmotivation, has been found to be associated with qualitative conceptions of learningwhile a reproducing orientation which has been related to extrinsic motivation or fearof failure has been associated with a quantitative conception of learning (Entwistle &Marton, 1984, p. 221).Students' experience of relevance or interest in the learning situation wasdescribed as intrinsic when there was an interest in the content of what was beinglearned or extrinsic when the concern was with completing formal requirements. Asmight be predicted, intrinsic experience of relevance was associated with a qualitativeconception of learning while extrinsic experience of relevance was associated with aquantitative conception of learning. However, a third dimension of relevance, that ofvicarious relevance, was also demonstrated. This refers to "the teachers ownconviction of relevance, enthusiasm or use of striking illustrative examples" (Entwistle& Marton, 1984, p. 217). It was shown that vicarious relevance can bridge the gapbetween extrinsic and intrinsic experience of relevance.Educational orientation refers to the student's aims, values and purposes forstudying. It is not an invariable characteristic but can change and develop over time.The four orientations identified - personal, social, academic or vocational - reflectedwhat the students wanted to get from their academic experience and their courses.23Studying was directed towards these personal goals, leading students to eitherqualitative or quantitative conceptions of learning.Situational Elements of Conceptions of Learning Context of learning refers to all aspects of the learning environment. It includes"the teaching, assessment, and course content and structure within the natural settingof academic departments" (Ramsden, 1984, p. 144). The students' perception ofcontext and their interpretation of the demands that it makes was found to have astrong influence on conceptions of learning. It was found that the students'perceptions of assessment requirements were especially significant in leading studentsto adopt either quantitative or qualitative conceptions of learning.In discussing the importance of the context of learning Entwistle (1984) makessome important observations. He points out that "there may be only a tenuousconnection between teaching objectives (what teachers say they want to do) andteaching activities (what they actually do)" (p.4). Entwistle differentiates between theformal curriculum as defined by faculty, and the "hidden curriculum", the messagereceived implicitly but strongly by students which often depended on teaching methodsand especially on assessment procedures. Laurillard's (1984) study on learning fromproblem solving supports Entwistle's perspective. She found that "...the (learning) taskmay itself make minimal demands. For many such tasks, there is a standardprocedure which students are wise to adopt, but which need not engage them in24thinking about the subject at a deeper level" (p. 142). Ramsden (1984) points out thatan overwhelming amount of curricular material pushes students into rote methods ofdealing with the material and results in incomplete understanding of the subjectmatter. Ramsden also points out that adverse anxiety and a feeling of threat was alsolikely to encourage a mechanical, rote learning approach to learning tasks. InRamsen's discussion on context of learning he points out that "the single mostimportant message to emerge from this research is that intense effort must be madein course planning to avoid presenting a learning context which is perceived bystudents to require or reward surface approaches" (p. 163). He further states that"only by studying the internal relationships of how students perceive course demandsand how they approach studying can the complexity, and apparent paradoxes instudent learning be understood" (p. 163).Another important feature of context of learning in relation to conceptions oflearning became apparent in a study in which learning in two contrasting disciplines,Psychology and Engineering, was examined. The psychology students describedtheir way of studying in terms which could be readily classified as reflectingquantitative or qualitative conceptions of learning. But the experience of engineeringstudents was very different. At first there seemed to be no evidence of qualitativeconceptions at all. However, further analysis indicated that in a tightly controlledenvironment and in an applied science, qualitative conceptions took a rather differentform. Ramsden (1984) found that "it was essential, in these cases, to pay much more25attention to factual and procedural detail, particularly in the early stages of masteringa topic" (p. 218). Emphasis on either understanding or reproducing remained theidentifying feature of the conception of learning, however. Conceptions of learning canbe defined in terms of these two consistent features but particular indicators will varyfrom context to context. Conceptions of learning are thus discipline-related.Description of Related Concepts The concept approach to learning refers to the ways in which learners act on theirinterpretation of the learning situation or their conception of learning. It encompassesthe notions of intention to learn or, what the learner is looking for, and process oflearning. Process refers to the learning activities and includes the enactment of thestudent's intention to learn but also depends on previous knowledge and cognitiveability.Approaches to learning were described as surface where the emphasis was onreproducing knowledge, or deep where the emphasis was on understanding. Asurface approach is characterized by memorization and an unreflective interaction withsubject matter. A deep approach implies a vigorous interaction with the subject matterand the ability to see relationships. Ramsden (1988) points out that deep approachesexemplify the type of learning that employers and teachers expect students todemonstrate. Only through using these approaches can students gain mastery ofconcepts and a firm hold on factual detail in a given subject area. In contrast, surface26approaches epitomize low-quality learning, are geared to short-term requirements andfocus on the need to faithfully reproduce fragments of information presented in thelearning experience. Surface approaches lead to misunderstanding of principles andconcepts.A quantitative conception of learning has been associated with a surface approachto learning while a qualitative conception of learning has been associated with a deepapproach to learning. However, this is not sufficient in itself. A deep approachdepends as well on previous knowledge and cognitive ability.Outcome space is a term used to describe the qualitatively different levels ofunderstanding that represent responses to a particular learning situation (Dahlgren,1984, p. 26). As such, they can be thought of as representing different conceptionsof phenomena or subject matter. Dahlgren goes on to point out that "from this sameperspective, we can go further and define learning itself as a change in conception"(p.31). In other words, he explains, there is a shift from one conception to anotherwhich is qualitatively distinct when learning has occurred.A close relationship has also been demonstrated between approach to learningand outcome space. A surface approach rules out the possibility of a deep outcomesince it carries with it an implicit decision to ignore meaning.27Entwistle and Marton (1984) point out that it is now possible to trace a chain offunctional relationships from conception of learning to approach to learning, tooutcome of learning with something akin to logical inevitability. They emphasize,however, that each link depends on a personal interpretation of content and context.This means that the "reaction of each student will, to some extent, be different but thefindings suggest that there are general effects" (p. 223).Implications for Teaching The view of student learning described points to the importance of students'conceptions of learning in the learning process. It demonstrates the role thatconceptions of learning in a given situation play in governing and directing theexperience and in affecting the outcome of learning. Their central role in learningunderlines their importance to teaching. From this perspective, improving learningrequires a sensitive grasp of the differences between the learner's understanding andthe expert's understanding and taking steps to change the learner's understanding.This approach focuses the teacher on "the pathways along which understanding ispursued" (Hounsell, 1984, p. 197). A consideration of conceptions addresses themisconceptions underlying errors rather than simply the achievement of right answers.The findings of these studies revealed that students did not just misunderstand butthey misunderstood in different ways suggesting that interventions need to beindividualized. Guidelines for general teaching activities have been suggested and are28outlined below (Marton & Ramsden, 1988; Ramsden, 1988; Bowden, 1988; Hounsell,1984; Entwistle & Marton, 1984):1. Teachers must learn about students' conceptions of learning and apply whatthey learn to improve teaching. Doing this will provide teachers with informationabout how they can help students develop different ways of thinking about learningin a particular situation. It was suggested that it may be more useful to know aboutan inappropriate model that a student has assembled rather than knowing aboutmissing knowledge. Information about conceptions should be used to devise ways inwhich changes toward desired conceptions can occur.2. Learners' conceptions should be made explicit to them. Changing conceptionsinvolves more than simply telling students what the correct conception should bealthough this is recommended. As well, it means making them aware of their own andother conceptions. It must be stressed that this is only a beginning since changeinvolves an active working upon and interaction between the old way of thinking andthe new.3. Inconsistencies within and the consequences of learners' conceptions shouldbe made evident to them. The teachers' role is in arranging situations that challengethe boundaries of students' thinking so that they are confronted with discrepancies thatwill require new ways of thinking and seeing and that have personal value for them.Ramsden (1988) states that this type of change takes time. "Time," he says, "forcontemplation, reflection, working things out, and discussion with others learning thesame subject matter is thus not a luxury, but a necessity" (p. 22).294. Learners should be presented with new ways of seeing. Teachers need toprovide structures that enable students to understand how parts relate to each otherand to avoid focusing on discrete details. To do so is "to anchor knowledge in aframework of meaning" (Hounsell, 1984, p. 195).5. Teachers should test understanding and use the results for diagnosticassessment and curriculum design. Teachers should test students' understandingrather than their knowledge of concepts. This should be done informally as well asin formal assessments. To do so is to make assessment a window tomisunderstanding that serves as a guide to changing or modifying thinking.6. Teachers should use reflective teaching strategies. This means takingmeasures to gather feedback from students on their perceptions of learning taskrequirements in order to ensure that tasks are indeed encouraging changes inconceptions.Focus of this Research ProjectThis research project focused on conceptions of learning, a central concept in thisview of learning. It attempted to identify and describe the range of nursing students'conceptions of learning from clinical experience. The conceptions identified accountfor the various ways in which students understand learning from clinical experience.In the phenomenographic tradition that informs this research project, no attempt wasmade to explain or account for the conceptions of learning described in terms ofpersonal or situational elements. It was not the purpose of this research project to30explain cause and effect but only to describe the conceptions as they were presentedby the students interviewed. The value in describing conceptions of learning is relatedto the potential they hold for illuminating the process of learning from the particularlearning experience. As well, they are a tool that can be used in planning teachingand learning activities, in discussing learning and learning difficulties with students andin evaluating teaching.Summary This chapter summarized the perspective on learning that is the basis for thisresearch project. The discussion focused on conceptions of learning, a centralconcept in this view of learning. The role of conceptions of learning in directing theprocess of learning was emphasized. Concepts related to conceptions of learning andthe implications of this view of learning for teaching were also discussed. Thisresearch project focused on one aspect of this perspective on learning, conceptionsof learning. Conceptions of learning from the clinical experience of nursing studentswere identified and described. These conceptions of learning were described withoutinvestigating cause and effect relationships. The chapter concluded with a discussionof the role that such findings play in improving learning.31CHAPTER IIILITERATURE REVIEWThe literature review of this investigation is an examination of previous researchthat relates to this topic. The purpose of this literature review is to confirm theimportance of the topic and focus of this research study, to demonstrate the work thathas already been done on this topic, and to provide a backdrop for interpreting theresults of this research study. The grouping chosen to organize the selected studiesis meant to facilitate this purpose. The first section identifies important research topicsand validates the research topic chosen, the emphasis of this research topic and themethodology. The second section contains studies that use students' livedexperiences of clinical experience as the data base as was the case in this researchproject. The last two sections reflect the perspective on learning used in this researchproject. The four sections are: (a) research priorities in nursing education, (b) studiesbased on students' perceptions of clinical experience, (c) studies that examine anaspect of personal context, and (d) studies that examine an aspect of the context ofclinical learning.Literature Search Methods used to locate studies were: (a) computer searches, two using the ERICTape Data Base and approximately five using the Medline Data Base (Descriptorswere used that did not narrow studies to the field of nursing but included studies about32clinical experience in all fields), (b) a manual search of the Cumulative Index toNursing and Allied Health Literature, the American Journal of Nursing InternationalNursing Index and the Dissertations Abstracts International from 1985 to the present,(c) a manual search of the indexes of issues of the Journal of Nursing Education,Nursing Research, Nursing Papers, Nurse Educator and the Western Journal ofNursing Research for the years 1987 to the present since these periodicals publishthe bulk of nursing education research, (d) a manual search of the indexes of theAnnual Review of Nursing Research for the years 1985 through 1991, (e) a searchof theses and dissertations produced at the University of British Columbia in AdultEducation and Nursing since 1985, and (f) a search of the bibliographies of relevantliterature.This review of the literature does not include research on isolated teachingstrategies or general learning outcomes, for example, studies that compareperformance levels of graduates from different types of programs. These researchstudies, while relating indirectly to the topic, have been omitted in an attempt to limitthe search to a manageable size and to focus on those studies that have the mostpotential for illuminating the thinking on the issues being discussed.Research Priorities in Nursing Education This section includes one study. The purposes of this study (Tanner & Lindeman,1987) were to identify assumptions about the nature of research in nursing education,33and to generate and rank order critical research questions regarding nursingeducation. A Delphi survey technique was used which consisted of three surveyrounds. The three rounds were described as: Round 1 - Identification of assumptionsabout the nature of research in nursing education and the identification of criticalquestions regarding the educational process in nursing. Round 2 - Response to atwo-part questionnaire indicating degree of agreement or disagreement to criticalassumptions about the nature of research in nursing education and theappropriateness and priority for nursing educational research for each specificquestion listed. Round 3 - Responses to the same questionnaire but withquestionnaire showing statistical summary of Round 2 responses. The statisticalsummary provided in Round 3 included (a) the individual panel member's response,(b) the median for the total panel, (c) the response range, and (d) the interquartilerange (the range in which at least 50% of the responses fell). Panellists were askedto write a rationale for responses outside the interquartile range. These responseswere compiled into a minority report. One hundred and twenty-one members of theSociety for Research in Nursing Education responded to three survey rounds. Ofthese respondents, the majority (61%) were faculty, 18% were administrators, 3%were students and 15% were in other positions or did not respond. Sixty-nine percentheld a doctoral degree, 23% held a master's degree, 2% held a bachelor's degree,and 4% did not provide information to this question. They represented 47 states, fiveCanadian provinces and seven foreign countries.34The assumptions that the panel identified that pertain to this research projectinclude the following statements: (a) research in nursing education should emphasizethe clinical nature of nursing, (b) research in nursing education must involve bothtesting the application of research in general education to nursing and research uniqueto nursing, (c) a variety of methods, both qualitative and quantitative, are appropriatefor the conduct of research in nursing education, (d) most research within nursingeducation should be either theory generating or theory testing, and (e) the phenomenaof research in nursing education are complex and do not readily lend themselves todirect observation; sound measurement is possible but extremely difficult. Of thefifteen highest ranked research questions, two-thirds focused on the clinical learningexperience. The top research priorities identified were: integration of research findingsinto curricula, development of problem-solving skills, approaches to clinical teaching,and level of practise of graduates of different basic preparations.The authors also examined reviews on the top five research priorities. Insummarizing their review of effective approaches to clinical teaching, they stated,"there is little known about the effectiveness of approaches to clinical teaching interms of student learning" (p. 58).Tanner and Lindeman's study validated the appropriateness of the researchproject presented in this thesis in terms of topic and methodology, in its identificationof effective approaches to clinical teaching as a top research priority, in its the35emphasis on the clinical learning experience in the fifteen top research questions andin the assumptions identified.Studies Based on Students' Perceptions of Clinical Experience Three studies describe the clinical experience from the nursing student'sperspective. Windsor's (1987) study is most representative of the spirit of thisresearch project. She used nine volunteer subjects in her phenomenological studywhich aimed to "better understand the clinical learning experience from the students'point of view" (p. 150). Several of Windsor's interview questions focused on student-instructor relationships or context of learning but one dealt with students' intentionsto learn and another dealt with students' perceptions of gains from the experience.In answer to the question, "What do nursing students say they do in their clinicalexperience?", Windsor's categorical findings were: practice nursing skills (defined asassessment, therapeutic communication and psychomotor skills), organize content,time management and professional socialization. Responses to the question, "Whatdo nursing students say they are learning in the clinical setting?", included: knowledgeand skill acquisition, time management and professional development. Windsor's dataalso revealed three stages of professional development. The first stage was markedby anxiety and focused on doing psychomotor skills. During the second stage thestudents "became less focused on psychomotor skills and began to explore otheraspects of the nursing profession" (p. 152). During the final stage they became moreconfident, independent and comfortable and "studied less" (p. 152). Windsor36concludes her study by calling for more research based on her findings including anidentification of what constitutes quality clinical education.Byrne's presentation (1987) at the Annual Conference on Research in NursingEducation recounted an attempt to describe professional socialization of nursingstudents, that is, the acquisition of knowledge, skills and a sense of professionalidentity. The subjects were five senior and five sophomore baccalaureate students.The data base consisted of paradigm cases, that is clinical experiences which standout in students' minds. Heidigger hermeneutics was used to analyze the data.Clinical experiences were found to be socializing experiences, helping the student tounderstand the experiences of patients and nurses within the context of the nursingculture. In her conclusion, the author calls for similar research on other aspects of theclinical experience since understanding the student's perspective, she found, can beuseful in restructuring clinical learning experiences in order to enhance learning.Byrne (1988) used various ethnographic methodologies in exploring "the humanexperience of learning to practise nursing" (p.2I23-B). Byrne found that all studentsfelt pressured by time; focused on activities, especially those related to assignments;valued being included in the social interactions of the clinical unit; experienced agamut of strong emotions; and perceived the clinical setting as unpredictable.Students emphasized observing and listening as essential initial stages in learning.37"Completing the course and doing something worthwhile for the patient" (p.2123-B)were the essential concerns of the students.Studies that Examine an Aspect of Personal Context Three studies were identified that dealt with personal context. Two examinedcognitive style using Kolb's experiential learning theory. Kolb suggested that eachindividual chooses a combination of ways of learning that he referred to as learningstyle. He defined these as "acquired consistent patterns of learner environmentinteraction" (1984 as cited in Highfield, 1988). Highfield (1988) set out to identifyprimary learning styles of baccalaureate nursing students within their first and lastyears of clinical studies and to examine the relationship between age and previousnursing education, and learning styles. The subjects were 29 junior and 25 seniorstudents between the ages of 20 and 42 years. Each student filled out the LearningStyles Inventory. Highfield found that the predominant learning style among thesubjects was "assimilation, a combination of reflective observation (watching) andabstract conceptualization (thinking)" (p. 31), with abilities to use 'inductive reasoningand create theoretical models' (Kolb, 1984, as cited in Highfield). This findingconflicted with previous findings about learning styles among nursing students.Highfield also found that age and progression through nursing education did not affectthe learning style of these students supporting Kolb's contention that individuallearning style remains fairly stable. The author concluded that nursing faculty shouldbecome familiar with the concept of learning style so that matching of learning38experience and learning style can take place, so that faculty could provide appropriatelearning assistance when students encountered learning tasks that required learningstyles other than their primary one and to assist in the development of curricula thatwas balanced in terms of learning experiences that required a variety of learningstyles. She also suggested that faculty should maximize current student learning andenhance future learning by assisting students to develop new learning styles.Laschinger's (1986) study examined the learning styles of 68 third yearbaccalaureate nursing students and their perceptions of environmental press (demand)differences in surgical and psychiatric clinical settings. Learning styles were found tobe predominantly "concrete" as was the perceived environmental press in both areas,providing support for Kolb's contention that individuals self-select congruent learningdisciplines. The author stresses the importance of the development of all learningcompetencies and suggests that opportunity for this development must be arrangedin disciplines that have a balanced environmental press as this study suggests nursingdoes.The last of these studies (Williams, 1988) examined three related elements:cognitive style, tolerance of ambiguity, and stress. The construct of cognitive stylethat the author uses is field independence versus field dependence. This constructdescribes "figure-ground relationships" and relates to "whether people perceive, andthus assimilate information in a global (FD) or in an analytical fashion (FI)" (p. 449).39Fl subjects were described as tending to be more successful in the natural sciencesand are described as preferring solitary activities, being individualistic, and being coldand distancing in their relationships with people. FD subjects preferred the socialsciences and the humanities and were described as sociable, gregarious andinterested in people. Past research has shown that Fl individuals are "more tolerantof ambiguity except when they are experiencing high levels of stress" (p. 450).Williams observes that students on entry to nursing programs have a background inthe natural sciences probably suggesting that they are Fl. They are then immediatelythrust into the clinical area where they must perform both global and analytical skillsand where the level of ambiguity is high. This he suggests may have an effect onperformance and the perception that nursing education is stressful. William's studyinvolved 66 sophomore students enrolled in the first clinical nursing courses of abaccalaureate degree nursing program. These students were randomly drawn froma group of volunteers. Each subject performed validated tests that measuredcognitive style, tolerance of ambiguity and stress. Williams' findings suggest that hissubjects were indeed FI, but that they were significantly more intolerant of ambiguityand had significantly higher stress responses than the norm group, which was asimilar group of college students, in contrast to what was predicted. In his conclusion,Williams suggests that admission requirements to nursing programs should includemore social sciences and humanities courses and that students should be helped tolearn ways of altering their cognitive style. The observed intolerance of ambiguitysuggests further research into whether or not this changes over time in the program.40Williams expresses concern that the reported high levels of stress may interfere withlearning and suggests that simply acknowledging the stressful nature of nursingeducation may help to alleviate it. The study showed no relationship between FI-FDorientation, tolerance of ambiguity and stress. The value of this study is in its attemptto relate personal ways of information processing to the clinical learning situationwhich is characterized by a high level of ambiguity and then relating this to stress.Although the author was not particularly successful in dealing with the interrelationshipof the variables, the approach is significant. It is an attempt to identify specific factorsthat influence learning which could serve as a guide to specific teaching strategy.These studies on cognitive style are attempts to understand the relationshipbetween personal attributes of learners and aspects of the learning context. From thepoint of view of this conceptual framework, the cognitive theories used are limited bytheir view of cognitive style as a relatively fixed characteristic of individuals asopposed to a view of approach to learning as variable and related to personal andcontextual interpretation.Studies that Examine Aspects of the Clinical Learning Environment Three reviews of research and three separate studies examined various aspectsof the clinical learning environment.41Pugh's review (1983) entitled "Research on Clinical Teaching" found that most ofthe studies on clinical teaching "have focused almost exclusively on the perception ofstudents, and have been undertaken primarily in an effort to identify importantteaching behaviours which could then be used for the evaluation of faculty" (p. 62).Besides these studies, however, she reviewed the five studies that examined facultyas well as student perceptions of desirable and undesirable instructor traits. In hersynthesis of these studies she says that despite "methodological and measurementproblems, there is some consensus of opinion about three categories of desirableteacher behaviour with undergraduate students in the clinical setting: (a) teacher-student relationships, (b) use of feedback, and (c) enactment of both teacher andnurse roles by nurse faculty" (p. 71). There was a call for faculty to demonstratepositive regard for the student and to demonstrate interest in and acceptance of thestudent as a person. It was found to be desirable that feedback was objective andfair and should be constructive. Regarding the nurse-teacher role Pugh stated that"it seems reasonable that faculty who teach students in a practise profession must beconcerned not only with the role modelling they do as nurses, but also with their roleas a teacher who manipulates the clinical environment to provide learning experiencesfor students" (p. 72).Pugh (1983) also reviewed investigations "analyzing the process of clinicalteaching" (p.62). The first is a study by Infante (1975, as cited in Pugh, 1983).Infante believes that emphasis in the clinical laboratory (Infante uses this term to42describe the clinical setting) should be on the application of theory rather than ongiving total care to patients. Infante identified fourteen elements of the clinical learningexperience which essentially defined the student as learner rather than responsiblecare giver, that served as the basis for the development of a questionnaire designedto assess beliefs and practices of 184 faculty in baccalaureate programs in NewEngland. Infante reported a striking contrast between what the faculty stated theybelieved in and what they practised. Although faculty expressed a belief in herlaboratory concept, few gave evidence of acting on these beliefs. In discussing thesefindings Infante recommended replication of her study in which direct observation aswell as questionnaires would serve as the data base.Pugh (1983) attempted to confirm Infante's findings and to discover the reasonsfor the discrepancy between beliefs and practise. In this study of fifty faculty, Pughused a three part questionnaire to identify faculty beliefs and then used investigatorand student observation of faculty to measure congruence between beliefs andpractise. Pugh's findings were in agreement with Infante's. Reasons for her findingswere related to the occurrence of a combination of factors rather than a single factor.Faculty role identification (i.e. as nurse, teacher, or nurse-teacher) "did not in itselfpredict the observed behaviour of faculty. However, when role identification wascombined with role preparation and value placed on teaching or clinical practisecongruence between the three variables predicted observed behaviour" (p. 69).43Pugh also reviewed a study by Mannion (1968, as cited in Pugh, 1983) on theprocess of clinical teaching in which the investigator developed a taxonomy of 1,560instructional behaviours. These behaviours were classified as (a) information-gathering about students and the clinical setting..., (b) assessment and interpretation,which involved a direct encounter between the instructor and the student in the clinicalsetting, and (c) instrumental, which implied active intervention on the part of theinstructor in the clinical instructional process.The findings in Pugh's review about desirable instructor traits are valuable butincomplete since they make no specific reference to the ways in which the instructorcontributes to learning in the clinical experience. Infante and Pugh's identification ofincongruence between faculty beliefs and practise is important. It has been suggestedin chapter one that the clinical environment designed as it is for the acute care ofpatients rather than as an educational environment may present difficulties for facultyin their attempts to provide an appropriate learning environment.McCabe's review (1985) provided a "summary of existing information oninstructional behaviours which are reported to make a difference in student learning"(p. 225). She noted the paucity of research in this area and suggested that this maybe due to the fact that the concept of clinical instruction has been so poorly definedin nursing. Faculty, she says, cannot agree on their purpose and function in theclinical setting. She stated that currently clinical instruction is viewed as a primary44responsibility of the nursing faculty and that student nurses are viewed as learnersrather than service providers. "The emphasis of the clinical laboratory is on knowingand understanding" (p. 256). McCabe reviewed nine studies on clinical instruction inmedicine and dentistry as well as in nursing. The first study was Infante's (1975)which was described in Pugh's review. Research by Meleca, Schimpfhauser,Witteman & Sachs (1981, as cited in McCabe, 1985) replicated Infante's finding of adiscrepancy between what faculty did and what they considered ideal. A study byBazuin and Yonke (1978, as cited in McCabe, 1985) which addressed problems in theclinical instruction of medical students arrived at a similar conclusion. The sixremaining studies dealt with teacher behaviours that positively influenced studentlearning. These studies, which used dentistry and medical students as well as nursingstudents as subjects resulted in surprisingly uniform findings which were similar tofindings previously identified in Pugh (1983). Some additional findings weresuggested. The medical students felt that active student participation and emphasison references and research were important. Nursing students added working withstaff in a manner which created an atmosphere conducive to learning, providing anopportunity to carry out self-directed activities in the clinical setting and guidingstudents to develop the ability to evaluate personal capabilities and limitations, to theirlist of positive instructor attributes. Wong's study (1978, as cited in McCabe, 1985)revealed that students in first year were particularly sensitive to how faculty madethem feel whereas students in the second year appeared to be more concerned withthe apparent competency level of faculty. Two studies (Brown, 1981; Coles, Dobbyn,45and Print, 1981; both cited in McCabe, 1985) indicated that baccalaureate nursingstudents regarded the instructor's relationships as more important than professionalcompetence. McCabe suggested that this may be due to "the degree of personalthreat the students perceive in the clinical area" (p. 257). The lesser degree ofimportance placed on professional nursing competence may also suggest that while"faculty may meet the students' expectations in this area, they fall short on creatingan atmosphere conducive to learning in the clinical area" (p. 257). In her conclusionMcCabe calls for clinical educators to develop more effective interpersonal skills andto expand their knowledge base in the area of teaching strategies.Zimmerman and Waltman's (1986) review of effective clinical behaviours of facultywas done for the purpose of organizing the behaviours in a framework that could beused to develop an instrument that would measure effective clinical instruction. Tenstudies were reviewed. The authors found that all characteristics identified could becategorized under the headings identified by Jacobson (1966, as cited by Zimmerman& Waltman, 1986). They included: availability to students, professional competence,interpersonal relations, teaching practises, personal characteristics and evaluationpractises. One of the studies (Craig and Page, 1981, as cited in Zimmerman &Waltman, 1986) concentrated on the questioning skills of the nursing instructor.Questions asked by faculty were classified according to the cognitive activity theymeasured using Bloom's Taxonomy of Educational Objectives. The authors foundfaculty lacked skill in using high-level cognitive questions and "uncovered the problem46of nursing instructors who use low-level questions while expecting students to developthe high-level cognitive skills of analyzing, synthesizing, and evaluating, which arecritical to nursing practice" (p. 33).Monahan (1991) focused on the fact that although clinical experience is seen asessential to nursing education, there is little reported research examining thecontribution of this component. She studied two reported outcomes of clinicalexperience: the ability to make sound clinical judgments and the development ofprofessional identity. A group of eight students formed the control group andcompleted the usual clinical course which consisted of 60 hours of clinical experiencein which the student provided nursing care to an assigned patient under thesupervision of an instructor. This was the third of seven clinical experiences in thecurriculum. A group of eight students formed the experimental group and received noclinical experience. At the completion of the clinical course validated simulation toolswere used to measure clinical decision making and the development of professionalidentity. Results showed no significant difference in results between the two groups.The author recognized limitations in the sample size and called for further study toidentify educational outcomes of clinical experience. This study is important in viewof the time and expense involved in clinical education. It points to a concern also withthe measurement tools used and the possibility that quantitative tools areinappropriate in measuring outcomes of this kind or at least that measurement could47be assisted by qualitative methods. It also points to a concern with the context oflearning in that it may be structured inappropriately for learning to take place.Concern about the conditions of learning in the clinical course was the impetusbehind the work of Heims and Boyd (1990). They designed an innovative clinicalteaching approach called Concept-Based Learning Activity (CBLA). The CBLAmaintains the advantages of the present clinical experience, that is, contact with actualclients as a confrontation with reality, observation of the staff which is useful forlearning nursing actions and for socialization, and opportunities for the application ofknowledge to practice. As well it adds to these positive aspects of clinical experience.In the CBLA the student studies the client but does not do all the treatments andprocedures. Instead they focus on learning selected concepts related to the client'snursing management. The role allows students time to observe, pose multipleanswers to patient problems, and verbally test specific ideas about nursing practisewithout endangering the client. As well as client study and care, other learningactivities were associated with this activity such as group discussion which includednursing staff as well as other students, and guided reading. Questioning andencouraging the asking of questions was considered an important way of teachingstudents how to learn. This approach was used with 16 junior students in aBaccalaureate program. Informal evaluation data was collected from teachersregarding student learning and from student's regarding perceptions of their learningand their satisfaction with the new approach. Informal and formal evaluation data48were collected from staff. Teachers found students learned to select and to applytheir knowledge more visibly and were better able to present their ideas verbally andclearly, organize data collected from the client and integrate it with their readings. Thestudents were more widely read than traditional students and used all phases ofnursing process equally rather than focusing on assessment. Students' evaluationswere consistently positive regarding learning process and outcomes. They felt thatthey learned more and that the focus was on learning as opposed to doing. Staffnurses' reactions were mixed. They were sceptical of an approach that did not involvetotal care. Over time some nurses grew more comfortable with the new relationships,especially in regard to the relief of having to supervise students' care of patients. Thisstudy is important in its attempt to find alternatives to the existing context of clinicalexperience. It is unfortunate that more rigorous forms of measurement of changewere not used.Infante, Forbes, Houldin and Naylor (1989) studied the effectiveness of analternative mode of clinical teaching on the quality of student learning. It involved theuse of the Infante model of clinical teaching. The main components of this model are:(i) use of the college laboratory to insure the systematic practice of technical skillsusing audio-visual and simulated methods before performance in the clinicallaboratory, (ii) integration of nursing theory within clinical practice; students givesegments of care rather than total care to clients, (iii) flexible use of the clinical settingin terms of quality, quantity and breadth in order to maintain a learning orientation, (iv)49student participation in determining their clinical activities resulting in students meetingobjectives in different ways, (v) carefully designed use of agency personnel to allowthem to be resource people for students and to allow independent action on the partof the student rather than close supervision aimed at compliance, (vi) higher student-faculty ratio, possible because of increased flexibility and independence on the partof the student, (vii) intensified faculty-student interaction, since faculty are assignedto the same group of students over the entire semester or over the academic year toenable the development of strong working relationships. This longitudinal study wascarried out on 173 undergraduate baccalaureate nursing students in their junior year.The students were randomly selected to either the control or the experimental group.At the end of the experiment there were 86 students in the control group and 75students in the experimental group since 12 students chose to move from theatraditional to the traditional group. Throughout the study data were collected on bothgroups using the Mosby Assesstest, the college laboratory practicum performance testand grade point average. During the last quarter of the students' senior year,students were evaluated for critical thinking ability, clinical decision making, skillperformance and creativity. National Council Licensure Examination scores were alsoanalyzed. The results of this study support the hypothesis in part. The data supportthe premise that the atraditional approach led to more effective academic performanceand performance of technical skills. There was no significant difference between thegroups in tests that were designed to reflect decision-making, creativity, and criticalthinking skills. The significant results were attributed to the congruence between50college and clinical content and on the partnership of the student and the educator.The nonsignificant findings were attributed to the low numbers of students whovolunteered to do the tests that resulted in these findings; only 9 traditional and 13atraditional students participated. No validity data are provided for the tests of criticalthinking, decision-making and creativity. Students' anecdotal notes written throughoutthe experimental period reflected favourably on the design as did the response offaculty who participated. This research is important in its attempt to scientificallyexplore the relationship of teaching and learning in clinical experience. In doing so,it challenges time honoured traditions in nursing education in an effective way. Itdoes, however, focus on the outcomes of teaching strategies rather than on the effectof these strategies on the process of learning.Conclusion The literature review of research on clinical experience in nursing educationunderlines the need for further research on this topic. It reveals a demand fordescriptions of learning from clinical experience, for a description of quality clinicaleducation and a search of ways of optimizing learning. As well it reveals a concernabout the conditions of learning in clinical courses. A recognition of the importanceof the students' perceptions was indicated by the number of studies which used theseas a data base. A predominance of these were used in the studies on desirableinstructor traits. They were also used in broad ethnographic studies that wereattempts to provide understanding of the experience in order to give direction to51further research and for use in determining effective teaching. The studies of Infanteet al. and Heims and Boyd are concerned with identifying alternative teaching modes.They emphasize conceptual learning and acquisition of knowledge from clinicalexperience, rather than simply application of knowledge to clinical experience.This research project addressed the main concerns expressed in the literaturereview about the clinical learning experience. The goal was to better understandlearning from clinical experience as a base for planning teaching activities. Itrecognized students' perspectives as an important source of this understanding. Itshares a concern with improving learning by designing an appropriate learningenvironment. It differs from existing research in its emphasis on the process oflearning as well as learning outcomes and in its concern with variation in learning.52CHAPTER IVRESEARCH DESIGN AND IMPLEMENTATIONThe purpose of this chapter is to provide an understanding, both conceptual andprocedural, of the design of this research and of its implementation. This part of thethesis describes phenomenography, the research methodology, that was used. Aswell, it explains the appropriateness of the methodology to the topic, the selection ofsubjects, the interview process, the data analysis and discusses reliability and validityissues.PhenomenographyThe research methodology that was used in this study is phenomenography.Phenomenography is a type of qualitative research methodology that permits thesystematic study of learning. It emphasizes the learners' perspective on what they aretrying to accomplish. This, Marton (1981) refers to as a second-order perspective.It is concerned with how the world is construed by the actors. This is in contrast toa first-order perspective in which facts, which can be dealt with from the outside, arethe object of research. The importance of the second-order perspective is that peopleact on their interpretations of situations. For this reason access to the learner'sperspective is essential to a complete understanding of learning.53Process of Phenomenooraphv The data base in phenomenography is students' descriptions of learning. In mostphenomenographic studies, these have been obtained through the use of semi-structured interviews which are tape-recorded. Dahlgren (personal communication,May 1987) said that the Gothenberg researchers tried different methods to get at theinformation they wanted and found the in-depth interview the most beneficial method.The goal in interviewing is to obtain "as faithful and complete a description of whatwas lived through by the interviewee as possible" (Wertz, 1985, p. 161). Identicalintroductory questions are asked followed by questions aimed at eliciting answers inmore depth. Depending on the structure and comprehensiveness of an initial answerthe interviewer may have to ask for clarification, elaboration or examples. Theinterviewer must, however, avoid giving any clues about the desired direction in whichthe process should lead. The tape recordings are then typed and the typedtranscripts become the data base.The aim of analysis is to yield descriptive categories of the qualitative variationfound in the empirical data. Descriptive categories are the abstract tools that are usedby researchers to characterize the different conceptions found in the research data(Beaty, Dall'Alba & Marton, 1990). The process involves "the reduction of unimportantdissimilarities eg. terminology or other superficial characteristics, and the integrationand generalization of important similarities, that is, a specification of core elementswhich make up the content and structure of a given category" (Dahlgren, 1984, p. 24).54In describing the procedure used to do this, Marton and Saljo (1984) state that theydo not believe that there is any uniform technique which would allow other researchersto go from the data to the conceptions present. It is, they state, "a discoveryprocedure which can be justified in terms of results, but not in terms of method"(p.39). Specific details of the process used in this investigation are described in thesection on data analysis.Outcome of PhenomenogrartVThe outcome of phenomenographic research is the identification and descriptionof conceptions of learning. The term, outcome space, describes the range ofconceptions of learning identified (Dahlgren, 1984, p. 26).As research findings, conceptions are the researchers' attempt to identify anddescribe all conceptions of learning that are present in the research data. Stalker(1989) notes that "multiple and contradictory conceptions may be held within andbetween individuals" (p. 42). In this perspective, the researcher's focus is not theconceptions held by individuals but the conceptions present in the data.It has been found that conceptions can be expressed in a large number oflinguistic forms without necessarily changing the basic way in which the phenomenonis understood. Ramsden (1988) points out that "the variation in forms of talking aboutphenomena is reduced to a limited set of categories, usually between three and five,55that depict differences in ways of construing phenomena" (p.42). The outcome ofphenomenographic research then provides a kind of map of territory that representsthe different ways that learning is conceived by a large number of people. Mostconceptions of learning that have been identified have a hierarchical relationship. Thismeans that there is a sense in which one conception emerges out of the previous one.This relationship then demonstrates a learning pathway.Lybeck, Marton, Stromdahl and Tullberg (1988, p. 83) point out two features ofphenomenography that are important in considering descriptions of conceptions oflearning:1. A view of conceptions of phenomena as relational (i.e. as describing relationsbetween the conceptualizing individual and the conceptualized phenomena). In thisperspective there has always been great emphasis put on studying learning in relationto the content of what is learned. Ramsden (1988) points out that if learning is achange in conception or understanding of subject matter, then it makes little sense toseparate learning and subject matter. Conceptions of learning, then, describe not onlywhat it means to learn but what it means to learn specific subject matter.2. A concern with the "how" and the "what" of learning (i.e. the act ofconceptualizing and the meaning of the phenomenon as conceptualized). From thisperspective, the "what" or the content of learning, the "how" or the process of learning,and the meaning of learning are all parts of the same whole. Conceptions of learningthen include these interrelated aspects of learning.56Framework for Analyzing and Describing Conceptions of Learning Beaty, Dall'Alba and Marton (1990) developed a framework useful in analyzingand describing conceptions of learning. It was this framework which served as thebasis for the analysis of data in this research project. This framework consists of whatthese authors refer to as "the general aspects of conceptions" (p. 7). The generalaspects of conceptions referred to include: a "what aspect" and a "how aspect" oflearning, the two main component parts of this framework, each having a "referentialaspect" and a "structural aspect". The structural aspect includes an "internal horizon"and an "external horizon". These terms are defined in Appendix D. As well, theauthors describe the temporal extension of learning and the importance of identifyingcommonalities among conceptions of learning.The what aspect is described as the ways in which students interpret andcomprehend what they encounter in learning. It has two interrelated parts, anexpression of the understanding of the content and an expression of what learningmeans. As has been pointed out, learning must be understood in terms of content.The how aspect refers to the ways in which students interpret or comprehend howlearning takes place. It refers to the acts of learning or the process of learning. Itincludes overt and covert behaviour, for example, students study strategies and theirattempts to relate what they hear or read to what they already know.57The referential aspect is defined as "the global meaning of the phenomenon" (p.1). It can also be thought of as the student's way of seeing or understanding thephenomenon, here, learning from the clinical experience. As expressed by theseauthors, there is a way of seeing what is learned and a way of seeing how learningtakes place or a referential aspect of what is learned and a referential aspect of howlearning takes place.The structural aspect is described as "the way in which the phenomenon inquestion...is delimited from and related to its context and to the way in which thecomponent parts of the phenomenon and the relations between them are discerned"(p. 1). The external horizon of the phenomenon is identified as "the way in which thephenomenon is delimited from and related to its context" (p. 2). The internal horizonof the phenomenon is "the way in which the component parts of the phenomenon arediscerned and are related to each other" (p. 2). Three broadly defined componentparts of academic learning have been identified. They are "the learner, the world thathe or she is to understand better and the studies by means of which this is to happen"(p. 38). Beaty et al. describe a structural aspect of what is learned and a structuralaspect of how learning takes place.The authors also distinguish between the acquisition phase and the applicationphase of learning. Learning, they point out, means becoming or being able, implyinga temporal extension. This means that "when people think of learning, people think58of an occasion that is the acquisition phase and another (or other occasions) whichis the application phase" (p. 8). These points in time form the temporal axis oflearning. Conceptions may reflect both poles or only one pole of this axis.Examining commonalities among conceptions may result in a generalcharacterization of learning that applies to all of the conceptions. It points to "what theconceptions have in common that justifies seeing them as conceptions of the samething (i.e. of learning)" (p. 7). This common characterization of learning is useful inidentifying different conceptions since differences become more visible against thebackground of a common characterization of learning. Indicators of conceptions arethe characteristics of a conception that distinguish it from the general or commoncharacterization of learning.Uses of Conceptions of Learning as Research Findings Saljo (1988) describes the uses of conceptions. He states that they can be usedas the basis for planning learning activities. By examining the difference between thephenomenon as construed by learners and the conception of the phenomenon asconstrued by the discipline involved, the implications for teaching and learningactivities can be logically arrived at. Some guidelines have been presented in ChapterTwo. Saljo suggests that conceptions can be used as a kind of metalanguage usablein the context of understanding the process of learning and in terms of whichdifficulties in understanding can be made explicit and reflected upon. The hierarchical59relationship is useful in this regard. This relationship allows teachers to challengestudents in incremental steps. For students who misunderstand, it allows teachers totrace the pathway of misunderstanding. Conceptions can also be used to evaluatethe success of teaching. By observing students' interpretations of the learningenvironment, teachers can judge the effectiveness of the teaching-learning interaction.Compatibility of Methodology and Topic In considering the appropriateness of the clinical learning experience to this formof analysis, two characteristics of the experience needed to be considered: (a) thelevel of generality at which the clinical learning experience was to be studied, and (b)whether or not an understanding level is the object of the learning experience.Level of Generality of Clinical Experience A clinical learning course can be considered collectively as a single learningexperience or as a collection of individual learning experiences of several differenttypes. I have chosen to view it as a single learning experience for the purposes ofthis investigation since my concern is with the nature of learning from the experienceas a whole--i.e. students' conceptions of learning from clinical experience and therelationship between these. Support for examining other than specific learning taskscomes from Entwistle (1984) in his reference to the studies using this perspective onlearning that have been done in natural settings in which he states that "students havebeen asked questions about their everyday experiences in general or about particular60pieces of academic work..." (p. 17) and in Marton and Saljo's (1984) discussion of theapplication of the findings from naturalistic studies to everyday studying: "In everydaylearning situations "text" takes on a metaphoric sense. The studies as a whole canbe seen as the "text" on which attention is focused..."(p. 45). Further support is foundin Ramsden's study (1984) of the effect differing department contexts have onapproaches to studying. In this study he examined the general studying habits ofstudents in Psychology and Engineering departments. He points out that "we canbest try to understand the effects of the context of learning by examining therelationship between students' approaches and their perceptions of learning tasks ata number of separate but interconnected levels" (p. 147).Understanding as the goal of the Clinical Learning Experience Saljo (1984) cautioned "that the distinction between a deep and surface approachis not meaningful in all contexts." He says that in order to be appropriate the "text"should "present arguments, scientific principles and constructs, and/or is intended toprovide a coherent way of explaining or analyzing a phenomenon" (p. 86). The clinicallearning experience is designed as an opportunity to apply the content of coursestaught in the classroom setting to the real situation. The student is expected to drawon previous and concurrent classroom theory in designing and implementingappropriate care for selected patients. The context is not unlike that which Whelan(1988) describes in his study on medical students' clinical problem-solving (p. 199).Opportunities exist for students to choose to approach patient care (the learning task)61in different ways, for example, using a common-sense rather than a scientific (Lybecket al., 1988, p.83) or studied approach or by focusing on procedure rather than onprinciples, or by choosing to become actively and reflectively rather than passively andmechanistically engaged in the experience. It can be effectively argued that there aresome procedural aspects to this experience. In terms of interpreting approaches tolearning these will become important. It is the teacher's intention that these will haveminor significance in the experience. If they adopt more significance in the student'smind this will be significant since procedure will be the figure rather than the ground(expressed in Gestalt terms) rather than the reverse as intended by the teacher.Data Collection Selection of Subjects The subjects used in this investigation were thirteen students in the fifth semesterof a six semester (two year) diploma nursing program at Douglas College in NewWestminster, B.C.Students were approached at the beginning of their fifth semester and were askedto volunteer to participate in the study following a brief description of the purpose andprocess of the investigation. Confidentiality of the taped interviews was emphasized.Students were aware that the interviewer was a classroom and clinical instructor intheir program. While the problems associated with the researcher's previous role vis-a-vis the students is recognized, the advantages outweigh the potential disadvantages.62As a faculty member with experience in the R.N. program the researcher brought tothe interview and data interpretation a thorough understanding, albeit from oneperspective, of the structure and administration of the learning experience. She hadnot, however, taught any of the students in this class and was able to reassure thestudents that the researcher would not be teaching them subsequent to the interview.This added an element of neutrality that would not be present if the samplerepresented previous or impending students.Twenty-two students volunteered for the research project. Of those, 16 studentswere randomly selected, 3 for pilot interviews and 13 for the research project. In ameeting separate from the interview appointment, students were informed of the usethat would be made of the data, of their rights as participants in the research projectand were asked to sign a consent form (see Appendix A). Questions were answeredand students were given a copy of the consent form.The Ethics Review Committees at the University of British Columbia and atDouglas College and the Director of Health Sciences at Douglas College all approvedthe research protocol.63Description of Subjects The sample consisted of 12 female students and one male student who rangedin age from 22 years to 50 years. The average age was 34.5 years. The sampleincluded only those students who had started the program at the first semester levelexcluding those who had entered the program at a later semester because of theirexperience as practical nurses. The clinical experience that the students wereinvolved in was the ninth of ten clinical placements in their program. Their previousclinical courses had taken place in acute care settings in the following areas: threeeach in medical and surgical areas, one each in obstetrics, pediatrics and psychiatry.During this clinical course students had approximately 17 hours of clinical experienceper week over seven weeks in either a medical or a surgical unit in an acute carehospital (see Appendix B for the course outline). As well as their clinical course,students were concurrently taking courses in advanced medical-surgical nursing careof adult patients and professional nursing interactions.Interview Process Data were collected through the use of semi-structured probing interviews.Originally, each student was to be interviewed twice. They were, however, onlyinterviewed once. In most phenomenographic studies reported one in-depth interviewis the norm. However, at the beginning of this study it was thought that there wouldbe an advantage to interviewing twice because each subject could then verify theimportance of the meaning units identified by the researcher and fill any gaps in the64interviews. As the research got under way, however, it became clear that there wasgoing to be a large quantity of data available to the researcher on the basis of thesingle interview on which to develop the conceptions and therefore carry out theresearch without doing the second interview. Secondly, there was the practicalproblem of the timing of the data collection in that the subjects were no longerimmediately available to the researcher because they had completed the program.The interviews took place during the last two weeks of the clinical course. Theylasted approximately one hour each. They were carried out in a private room at atime that was mutually convenient for the subject and the researcher. Three pilotinterviews were done to ensure that the questions "got at" appropriate data and toprovide experience in the interview process.Completed interviews were tape recorded, and then transcribed at a later time.The students' names were not included in the interview transcripts. The resultingtranscripts made up the data base that was used for analysis.At the commencement of the interview, each student was asked if there were anyquestions that had been left unanswered. If there were any, these were addressed.The interview was then introduced in the following way: "During this interview I wouldlike to find out how you learn from clinical experience, or, what your personalexperience of learning from clinical experience has been. Some of the questions I ask65may seem difficult to answer. You may need some time to think about them beforeyou can answer them. Please feel free to do that. Please don't feel rushed orpressured. I am interested in an accurate and detailed expression of your experience.Also, there are many ways that people learn. So, there are no right or wrong answersto these questions. Before we begin, do you have any questions?""I will now turn on the tape recorder and test it to make sure it is working. Manypeople feel uncomfortable at the beginning of a taped interview. After a while mostforget that it is even there."The interview then began. Identical open-ended questions were asked followedby questions aimed at eliciting answers in more depth. The researcher may haveasked for clarification or examples but avoided giving any clues about the desireddirection in which the process should lead. The questions that were asked weredesigned to collect information about different aspects of students' conceptions oflearning. The questions asked of each student were:1. To begin, could you tell me how you came to enrol in nursing?2. I would first like to talk about learning in general. When you think about learningis there a word or a phrase that symbolizes or characterizes learning for you?3. Can you give me an example of a learning experience that you've had thatincorporates (the above)?4. When you hear that word learning what does it mean to you?665. I'd now like to start talking about learning from clinical experience. I would like itif you could take me back to your first clinical experience. The questions that I amgoing to ask now, apply to that clinical experience. When you think back to thatexperience, can you tell me what was memorable about it?6. During that clinical experience what struck you as important?7. Was there anything that struck you as interesting about that experience?8. What were you trying to accomplish in that experience?9. What do you feel you gained from that experience?10. Can you describe a time or an event during that first clinical experience when youfelt you really learned or that stands out because you learned?11. Can you tell me how you went about learning from clinical experience then?12. When you hear that phrase, learning from clinical experience, what does it meanto you?13. I'd now like to move ahead to the present clinical experience. The questions I'mgoing to ask you now are almost identical to the ones I asked you about the firstclinical experience. What do you think will be memorable about this experience?14. Now, what strikes you as important in learning from clinical experience?15. In the present experience what strikes you as interesting?16. What are you trying to accomplish in this clinical experience?17. What do you feel you are gaining in this clinical experience?18. Can you describe a recent time or event when you felt you really learned or thatstands out because you learned?6719. How do you go about learning in clinical now?20. Now, when you hear that phrase, learning from clinical experience, what does itmean to you?21. We've talked about the first and last clinical experience. In other clinicalexperiences that you've had, can you describe any other time or event that stands outbecause you feel you learned?22. Over your several clinical experiences, do you recall a breakthrough in yourlearning?23. In coming to this interview, was there something you had in mind to tell me aboutlearning from clinical experience?24. Do you feel that your experience of learning from clinical is usual or different fromothers that you know? Can you explain? Do you know of anyone who goes aboutlearning from clinical experience in a different way? If so, who?The interview concluded with a request for the following information: (a) age, (b)educational background, (c) previous work experience, and (d) the following question,Can you describe a previous learning experience in which you were asked to applytheory to a real-life situation?68Data Analysis The aim of analysis was two-fold: (i) to identify and describe qualitatively differentconceptions of learning from clinical experience and (ii) to describe relationshipsbetween these conceptions of learning.The interviews were designed to provide data on three conceptions of learning.The first conception that the subjects described was general conception of learning.The last two were conceptions of learning from clinical experience. The first of thesefocused on the subjects' first clinical experience. The second, focused on their fifthsemester clinical experience. Current conceptions stood out against the backgroundof the others. A change in what learning was learned and how it was learned pointedto learning since learning is defined as a change in conceptions.The method used was similar to the four phases described by Marton and Saljo(1984, p.38-9, 55) except that a new step, discrimination of the general aspects of theconceptions, was added:1. Sense of the whole. The researcher read the text of the transcript as often asnecessary to get a good grasp of the whole. Any recurring similarities and points ofdeparture in the interviews were noted. The aim of noting similarities was to facilitatea general characterization of learning from clinical experience. Against thisbackground the differences in conceptions were more apparent. The reading andrereading continued until a criterion of relevance emerged from the data, that is until69the researcher could clearly differentiate significant quotes from other quotes. Inparticular, any quote that expressed what was learned, how it was learned, whatlearning meant, or a change in these was given close attention.2. Discrimination of meaning units. The researcher once again read through thetranscript with the specific aim of discriminating meaning units. Meaning units --comments or quotes which seemed in any way relevant to the enquiry -- wereidentified and marked. Care was taken to ensure that the context of the words wasnot lost. The parts of the interviews that contained meaning units were thenphotocopied. The meaning units were thus separated from the interviews.Boundaries between individuals were thus abandoned. Attention then turned from theinterviews to the pool of meaning units.3. Discrimination of the general aspects of the conception. The meaning unitswere then systematically examined for "general aspects of conceptions" using theframework described by Beaty, Dall'Alba, and Marton (1990).4. Categorization of meaning units and identification of the meaning embeddedin the quotes. Quotes were then brought together into groups on the basis ofsimilarity and the groups were delimited from each other on the basis of differences.Because the quotes were physically separate from the interviews they could be movedinto different and new groups and groups could be eliminated as the researcher triedto distinguish features that defined the different groups. In this way categories andtheir meanings were developed and modified. This process represents the iterativeprocedure described by Marton and Saljo (1984). The process continued until the70groups stabilized and were as homogenous as possible. The outcome was astructure of categories chiefly related to each other in terms of similarities anddifferences. A title was given to each category that signified its most distinguishingcharacteristic. Indicators were identified and descriptions written that distinguishedeach conception from the general or conception of learning.5. Decision made about the specific level at which the quotes should be seen inrelation to each other. The categories were then examined to identify whether or notthey were hierarchical in nature as has been the case in many of the studies.The steps described did not take place in a strictly sequential manner. Theexpected overlap of steps as the iterative process progressed took place.Reliability And Validity It is important to point out that it is not possible to prove that the conceptionsidentified and described are necessarily the only possible ones. The categories arethe construction of the researcher and there is always the possibility that anotherresearcher would have arrived at a different categorization. There are, however,different modes of dealing with the problems of reliability and validity.The process of interjudge agreement is used to assess the communicability of themeaning of the conceptions identified and described and to measure to what extentother researchers would put interview extracts into the same categories. Entwistle71and Marton (1984) stated that most studies resulted in interjudge agreement of 75%or more, with a more typical value being above 80%. Saljo (1988) stated that in mostcases interjudge agreement is between 80% and 90%. In this study two co-judgeswere used. Both were familiar with the phenomenographical process. One was aprofessor who had conducted phenomenographical research. The other judge hadconducted related research and was familiar with clinical experience. The judgeswere presented with the chapter of this research project which describes the findings,a list of 20 quotes from the interview data each of which was seen by the researcherto reflect one of the three conceptions identified, and a list of judgement instructions.The quotes given to the judges were not used in the descriptions of conceptions in thefindings chapter. The judgement instructions directed the judges to read the findingsof the research project and then each quote and to indicate which conception thequote reflected. In both cases interjudge agreement of 90% was achieved. In onecase, some brief discussion took place before the final judgement was made. Allparties decided that one quote provided insufficient data to make a judgement on (seeAppendix C for details of co-judging).Validity is based on the degree to which the study presents a "recognizable reality"to those who read it, or is consistent with the judgement of others. Validity is alsobased on the rediscovery of the main constructs by independent researchers indiffering contexts (Entwistle & Marton, 1984, p.226). Saljo (1988) agrees that cross-study comparison can be used to "scrutinize the applicability of categories across72investigations adopting a similar perspective" (p. 46). Saljo feels that appropriatenessof a set of categories can also be verified by the presence of internal logic of thecategories defined: "There may be an internal structure to a category system in thesense that what separates them is what is assumed to be in need of being explained"(p. 46). A further aspect of the internal structure of categories that depict differentconceptions of a phenomenon is that "learning can be described as the change fromone conception within this structure to a different one" (p. 46).Since internal validity can be threatened by inexperience on the part of theresearcher (Goetz and LeCompte, 1984, p. 228) the researcher piloted the interviewand analysis process using three subjects and had these assessed by an experiencedphenomenographer to establish the effectiveness of the questions and interviewtechniques in getting at the desired information and the accuracy of the analysistechniques.Summary This chapter described phenomenography which was the methodology chosenwhich guided the data collection and analysis process of the study. It then discussedthe appropriateness of this research question to the methodology. It also describedthe data collection and data analysis processes used in this study, and reliability andvalidity issues.73CHAPTER VOUTCOME OF ANALYSISThis chapter presents the results of the data analysis or the findings. It begins bydescribing aspects common to all the interviews. It then identifies three conceptionsof learning from clinical experience of fifth semester nursing students, and presentsdescriptions of each. In describing the conceptions, the present tense of verbs isused reflecting the fact that the conceptions are the researchers' construction ofconceptions of learning that were represented in the data rather than characteristicsof individuals. The chapter ends with a description of the relationship between theconceptions. A list of definitions of terms used in describing the conceptions oflearning is provided in Appendix D.Aspects Common to All Conceptions The outcome of analysis was three descriptions of qualitatively differentconceptions of learning from clinical experience that were hierarchically related toeach other. These conceptions were held by fifth semester nursing students. In allthe interviews, learning from clinical experience meant applying theory to nursingpractice. It was the students' understanding of this phrase that was the main point ofdeparture in this research. It was this assumption about learning from clinicalexperience that was at basis of each conception.74This common assumption implies that a conception of nursing practise was a partof each conception of learning from clinical experience. This was, in fact, an importantpart of sense-making for the students interviewed. The conception of nursing practisewas prior to, and directed what was learned and how learning took place. Thequestions the students asked themselves seemed to be: what is nursing practise andthen, what is required to be able to do that. Two students directly questioned thephrase, learning from clinical experience:Interviewer: "...when you heard that phrase, learning from clinical experience,what did it mean to you?Student: "...I don't think I've really heard learning from clinical experience before,until you." (Int 6)Interviewer: "...when you heard that phrase, learning from clinical experience,what did it mean to you?"Student: "How can you learn from a clinical experience was the first question, Iguess probably I didn't put much merit in that statement...it was learning but notall that muchInterviewer: "...you're saying (you) didn't really see it as a learning experience, itwas then an experience of...."Student: "Getting back into the work world, well, its learning to work if you want..."(Int 4)Other students indirectly suggested that they saw the experience secondarily asa learning experience. Each conception of learning from clinical experience, then,subsumes a conception of nursing practise. The conceptions are intertwined. Theborders between each are thus blurred and are at times indistinguishable.Other common features of the interviews that were significant in terms of analysiswere:751. Although many of the students expressed strong positive feelings about thislearning experience, each of the students expressed some strong negative emotionas well. The students expressed feelings of being uncomfortable, scared, awkward,stressed, anxious, nervous, timid, sad, depressed, reluctant, and/or guilty. Studentssaid that these feelings reflected fear related to evaluation, the possibility of causingaccidental injury to someone, not knowing what patients they were going to beassigned to and the possibility of unexpected deterioration in the patient's condition.But at times they reflected uncertainty about their ability. In these cases, they wouldoften express diminishment of these emotions or emotions such as being calm orunrushed or having confidence as an indication that they had learned.2. Similarly students often said some aspect of clinical experience had becomesecond nature to them or they didn't have to think about it anymore. This too was anindication that the student had learned.3. Clinical experience is a general learning experience that had differentcomponents. The components commonly mentioned were assessments, skills (forexample, changing dressings, giving injections, taking blood pressures), interventions,organization and independence. The ways in which the students understood theseterms in relation to the whole clinical experience were important aspects of theconceptions of learning.4. Most students mentioned learning from mistakes that they made. The natureof these mistakes was often important in terms of understanding what the focus oflearning was for the student.765. Many students used the phrases, "having it all come together" or "bringing it alltogether." The different ways that the students understood these phrases wassignificant.Conception A: Learning As Reproducing Facts and Procedures In this conception both poles of learning, which have been identified as theacquisition pole and the application pole, are present although the emphasis is clearlyon the application pole. Applying theory to practise in this case means reproducingand recalling what was learned prior to coming to the clinical experience. This is thedistinguishing feature of this conception of learning."I use the information I already have...and simply do what needs to be done...asefficiently as we can" (Int 2)"it's the same as if I would learn, for example, using a machine at home...saymaybe a new stove, or whatever... people explain it to you then you do it andthen maybe you push a few buttons a few times before you know exactly whatyou're supposed to do..." (Int 4)"there may be 7 or 8 ways of doing this but we would like you to do it this way...itwas going back to that rote learning thing...I learned that the system was to followthe path...you were just doing what you had learned previously and with thetheory stuff as well" (Int 2).In this conception, the external horizon is formed, in part, by the learnersconception of nursing practise. Nursing practise is viewed by these learners asinvolving primarily three activities: implementing procedures, carrying outassessments, and organizing. The other part of the external horizon is a test situation77which involves the learner being able to answer the instructors' questions and gainingtheir approval for procedures performed.The referential aspect of what is learned reflects the learners' conception ofnursing practise. Implementing procedures, largely in the form of skills such aschanging dressings or giving injections, involves performing the steps memorized andpractised prior to coming to clinical."...(l did) a lot of skills and I was doing a lot...it was just running around doingthings all the time and I had a lot of good skill experience" (int 8)"...if it's a skill...just taking it step by step and going through all the steps..."(Int 1)"by doing it, by looking up the procedure...actually I prefer to go to an instructorand say could you talk me through it..and then you try to apply it...learning bydoing rather than reading and then trying to remember and not remembering atall...and then just reinforcing by reading and going through it in your mind..." (int3)The task is to remember all the steps of the procedure, although one student saidthat there is a need to adapt the procedure. To learn is to perfect the procedure.Assessing involves recalling or retrieving from memory indicators of a particular healthproblem or it's complications and then observing for these things in the patient. Theprocedure is thus a matching one."I guess when we looked at a disease process there were certain things that youhad to look for and so when you went into your patient, you had to make surethat you looked for those things." (Int 7)The volume of knowledge required to do this is of concern to the learner. They feelthat they shouldn't miss any aspect of assessment.78"...you're not supposed to miss things anymore, like in your assessments...(Int 7)Learners also feel that this knowledge is endless, that they'll never know it all."there's always stuff to learn, that you can never learn it all...you just keep ongoing..." (int 4)In this conception, organization involves knowing what needs to be done for thepatient, sequencing the tasks and getting it all done in the allotted time frame.Learners felt that knowing what needs to be done is largely determined by collectinginformation about the patient but is also loosely related to the theory base, as is thesequencing process."...this is what I've got in front of me and this is what I have to do first...you haveto have some knowledge of what's going on, who is the sickest..." (int 8)"there are things that above everything else are priorities ...if they're notlife-threatening then you make the decision according to the next step..."(int 8)"I see the reality of it now...I realize that you can't go and do it just exactly thesame way in some situations because you just won't get it done...just knowingwhat is OK...sort of short-cutting..." (Int 8)These three facets of clinical experience, implementing procedures, carrying outassessments, and organizing are described in the interviews as separate and distinctentities. Any relationship between them is tenuous. In this conception of learning,learners lacked a sense of the whole in contrast to both the subsequent conceptions."I still feel like we haven't learned enough, like we haven't had a full day on theward to know how it really works...how the whole thing works..." (int 8)"...I go and do...patient teaching or whatever but it's sort of little bits here andthere..." (int 3)79This conception of learning from clinical experience reflects a dualistic view ofknowledge, that is knowledge is seen as factual and is thought of in absolute terms.It reflects a view of learning that can by described as quantitative and mechanistic,that is concerned with amounts of knowledge, repeating facts and procedures in anunreflective way. Learning means memorizing factual and procedural information andbeing able to apply it at appropriate times. Instructors and other authorities are theholders of knowledge. Instructors evaluate the students' knowledge. In this view oflearning, relationships and decision-making do not play a role. There is little tosuggest that knowledge was affected in any way by the learner or by experience.The internal horizon of what is learned can be characterized as: the learner withstored knowledge at a certain point in time, the learner at another point in timecapable of reproducing and recalling in a real-life situation, knowing what needs to bedone and getting it done within a certain time-frame, and the transition between these.The how aspect of this conception refers to how the transition described abovetakes place. Learning to perform tasks takes place by practising and throughrepetition. By practising or repeating procedures and assessments the learnerperfects them."just practising...skills and assessments...the variety of patients you see, you'll getmore skilled at assessing their particular health problem..." (int 3)"by having to keep doing it, just by practising" (int 8)80"...learning from clinical experience means that I can do the things repeatedly..."(int 4)"you look back...sort of try to put, fit the steps in...you can't memorize everythingand sequence it out...by just watching...it comes to me when I'm doing it...youhave a bit of a knowledge base..." (int 8)Learners use a device to assist them in remembering what to assess and theirassessment findings. In this case, this is the human needs framework."...I would go through the nine needs and it came together for me insteadof...forgetting half the stuff that I was doing...I could go to the chart, I couldremember, I would think resp(iration) and circ(ulation), oh yeah, dyspnea,right..." (I nt 10)Instructors, to a large extent, direct the experience. They observe the learner'sperformance and point out strengths and weaknesses of the performance."...if I miss something it has to be brought to my attention only once and the nexttime I'm fine...I take what the instructor's told me...and realize she's right, I shouldhave seen it" (int 3)"...the way I went about it...a lot has to do with the instructor" (int 3)"...the instructor expecting you to know a lot of pathophysiology behind differentdiseases...you really studied up on what these disease processes were or surgicalprocedures..." (int 3)"...the instructor would put out questions and you'd have to answer them...likemedications...why you're giving it, its actions..." (int 4)"...did what was required of me in order to get through the experience..."(int 4)The external horizon of this aspect is the same as for the previous aspect of thisconception. The internal horizon consists of the learner with stored knowledgerepeating procedures, assessments and organization.81There is also an acquisition phase to this conception that is less clearly described.Knowledge related to the three facets of learning identified above is acquired fromclinical experience by "keeping an open mind", by "taking it all in" and by "watchingand copying."Indicators of this conception are: reproducing what was learned previously,dualistic thinking, quantitative view of knowledge, pieces vs wholes, repetition,remembering, copying, keeping an open mind, watching the system.There is an important dividing line between conceptions A, and B and C. In thefirst conception knowledge is something that is picked up, stored and retrieved asnecessary. The learner does little to affect what the knowledge looks like. In thesubsequent conceptions learners see themselves as problem solvers. They seethemselves as agents in using relationships to build interpretations that will be thebasis for decision-making. As such, they are independent thinkers who are agentsin their own learning. The main distinction between conception A, and conception Band C is the achievement of understanding."it's sort of a two-way street, you learn from doing...and you can do thingsbecause you learn them...you have to take a certain amount with you before yougo...it doesn't solidify, I mean you can have it in your head, you can read it...youcan do it in the lab. a million times but there's always someone there, when youfinally have to work it through yourself and problem solve it throughyourself...then you finally learn it...in the lab. there's always somebody theresaying now don't do this, don't do that...and in the book it's ...very clean andsterile...you don't learn it until you actually have to do it on your own" (int 6)82In subsequent conceptions learners express a sense of being in control or incharge, a sense that was not present in the first conception.Conception B: Learning As An Interpretive Process This conception has an acquisition and an application pole with a clear emphasison the application pole of learning. In both poles the distinguishing feature isunderstanding.The learning task is to design and implement nursing care for a patient or groupof patients. The process involved in doing this is: the learner comes to the clinicalexperience with a theory base, the learner then collects information about thisparticular patient that relates to the patients' health status, such as multiple orpre-existing health problems and the patient's treatment plan. The learner thenconsiders how all of the variables interrelate. Based on the learners' interpretation ofthe situation, the learner decides on the nursing care, that is, the assessments andinterventions, that the patient requires. The learner then implements the plan.Learners aim to become self-reliant in carrying out this process. Thisinterpretation of the task reflects the learners' conception of nursing and forms theexternal horizon of what is learned.83In the interviews the students emphasize the designing of nursing care. In thisconception, skills or procedures are only one aspect of interventions, as opposed toconception A where they were the clear focus. What is learned is a way of seeinghow the patient's health problem/s affect the whole body. The learner sees the bodyas a set of systems that are interrelated. Visual metaphors such as being able to seethe whole versus bits and pieces, having a clear image, and being able to see howit all fits together, are used. Prerequisite to this way of seeing is a knowledge ofanatomy and physiology. The learners' knowledge of health problems involvesknowing how normal anatomy and physiology is affected by the health problems."you have to understand what's going on with your patients and, like looking at...signs and symptoms...you have to know the internal things that are going on soif you don't know your anatomy and physiology and what makes what work thenyou're not going to be able to pull it all together ...you need a good theory baseto put your nursing care into practise" (int 12)"I like to have the whole picture because I like to be able to think it through...andkind of problem-solve for myself...try to second guess what I think mighthappen... (we) went into a lot more depth and a lot more physiology and I sort offeel it all starts there, that you need to really understand that, so that you're notdoing things just by rote so that you're doing things because you understandwhat you're doing" (int 11)"everything started to come together, the biology that you learn and the skills youhad learned and the theory and you could look at lab. values and you could seewhat was going on with the patient whether it was metabolic acidosis or what, youcould see, and with the patient with renal failure you could look at the lab. valuesand know that the potassium should be doing this...being able to understand that,how it works and fits together" (int 9)This clear picture of what is going on with the patient provides the basis for decisionsregarding nursing care. Appropriate nursing care is a logical outcome of the learners'understanding of how the structure and function of body systems are altered by the84health problem/s. Having a rationale for action is stressed. Having this clearunderstanding of the patient's situation gives learners a sense of control and of being"in charge" of their task. Learners are actively involved in synthesizing thisunderstanding and in drawing on other aspects of their theory base indecision-making. Learners are thus actively involved in the learning situation and areusing knowledge in new ways."...like this one lady I had she had about 5 different health problems and two ofthem worked against the other three so it was really a challenge to...do hercare...you had to really compromise and kind of balance out what you were goingto do..." (int 1)"...you really do have to have a good understanding of what's going on with yourpatient...I'm much more comfortable and adept in evaluating lab. results andlooking back at patients' medications and interpreting what meds. they were onwith their lab. results...and the doctor's treatment plan, why he would order suchand such a medication as opposed to another one, those kinds of things, it sortof becomes a bigger picture instead of just working with little, little bits...being ableto go into report, get all the information on your patients and then going out,assessing your patients and then continuing to give care based on your reportand...just keeping generally on top of things...and make those decisions,prioritizing your patients...you decide because you're the nurse and they're yourpatients..." (int 12)The learners' interpretations also provide them with an expectation of what they willsee when they assess the patient and enables them to interpret their findings injudging the patient's status. It also has the effect of making any characteristic that isnot part of the students' expectation, stand out. This will require learners to makesense of that finding and further add to their understanding of the situation. In thisconception the learners' search is for a correct interpretation. Learners compare theirinterpretation with that held by authority, in this case, the instructor and other nursesand reflect on the correctness of their logic.85"...I'll look it up, research it and then after that I'll validate it with somebody justto make sure I've got the right picture" (int 11)"...I was doing all the checks and everything and I noticed a slight change but menot knowing everything that needed to be known, I didn't realize that he wasgetting worse and I talked to the nurses later...once they told me look at this,look at that, you realize...not knowing enough I didn't know how to put ittogether...I needed to assess him further...I should have been able to put the dataI did have together..."(int 9)This way of thinking is the solution to the problem expressed in conception Aregarding the volume of material to be learned."...I could use my knowledge base better like I understood better...theirbehaviours...before I could see it on paper...whatever they were supposed tohave, all these different symptoms...I could memorize it but all of a sudden...Iunderstood...I could relate it to any other kind of disease or diagnosis and I thinkthat's one thing that a lot of people don't do is they...learn from books but theymemorize things but ...they don't understand how the body fits together and ifthey can understand that then they can...relate it to all kinds of things...this isgreat, I don't even have to look at my book cause I understand how thisworks..and in my mind I wasn't seeing my book with words written on it I wasseeing their body and how things worked...different picture" (int 9)The internal horizon is composed of the following interrelated components: thelearner with knowledge rooted in an understanding of anatomy and physiologyconstituting meaning in a problem-solving situation and then making decisions to actbased on that understanding resulting in improved understanding, new knowledge andimproved ability in interpretation.The how aspect of this conception refers to how learning takes place. Learningtakes place by practising this particular way of seeing patients in relation to their86health problem and then making decisions to act in a particular way based on logicand then carrying out these actions. The learner comes:"...armed with knowledge that you want to learn to see" (int 6)"...I had to really think the situation through for myself to make sure that I wasdoing it correctly and so by doing that it just reinforced what I learned, I had touse what I'd learned, not just have somebody telling me which was just sort ofanother go over all the material again. When I had to really...dredge it up andmake sure I knew what I was doing and make sure I would be confident that Iwas doing it correctly" (int 11)"if you can do, even if it's just helping somebody do or teaching someone to doit then you really solidify what you learn or read...there's all the parts of doing it,the decisions and the problem-solving...just to be right there involved in it you canread it all you want but you won't know it until you've...experienced it" (int 6)"...having these patients that you'd learned about, knowing what to expect andsee...it makes it stick in your mind and helps you retain that information so thatthe next time you see it or the next time somebody talks about it you knowexactly what they're talking about" (int 9)Practising this problem solving process forms the referential aspect of how learningoccurs, in this conception. Practising makes learners able to interpret andproblem-solve more readily."...I have a lot more learning to do...I'd like to have that information more readilyat hand, now I have to stop and think, oh yeah, such and such, now how doesthat go again...it takes me awhile sometimes to ...work through the wholesituation..."(int 11)Experience tells learners if they are capable of this interpretative and problem solvingprocess. The instructor encourages understanding by asking why and by correctingthe learners' interpretations.87The external horizon of how learning takes place is the same as the externalhorizon of what is learned. The internal horizon is characterized by the followingcomponent parts: learners with the required knowledge, the application situation,learners seeing the patient in a particular way, deciding how to act based on thatunderstanding, carrying out that intention, and then reflecting on the effectiveness oftheir reasoning, resulting in further understanding, and improved ability ininterpretation.Although the application phase of this conception is emphasized there is a lessclearly described acquisition phase as well. A clearer understanding of the knowledgebase is what is acquired. Clinical experience reinforces and clarifies understandingand is therefore an important part of the learners' quest to see clearly and to interpretcorrectly. How this is acquired includes:"...I do a lot of watching, I asked a lot of questions, I ask if I can do things...if it'ssomething odd or out of the ordinary or something that I haven't come acrossbefore then I start asking...why" (int. 12)"...I had a couple of coma patients, I had to do neurological assessments on themand that was something that I learned to do on the person in the actualsituation...when you did it in school you can't replicate their condition...I learneda lot of incidental things and had a lot of things reinforced" (int 11)"...we were able to go down to the OR and follow our patient through ...I startedreally thinking a lot more, say the doctor prescribed medication every 3, 4 hours,I was always the first one to say...I'll let my patient ride a little...that reallychanged my attitude about that ...now ...I don't hold off...as long as you're doingdeep breathing and coughing and leg exercises and ambulating them andhydrating them then it's not going to be that bad, like you're doing all these otherthings that are good for them..."(int 5)88Clinical experience also exposes learners to different points of view. The learner thendecides whether to accept that point of view or not."it was a tremendous rotation from the point of view of staff relations...if it's apositive environment...you're much more open to considering what they have tosay and deciding whether you're going to accept that or not" (int 11).Indicators of this conception are: independent thought, use of a physiologicalframework for understanding, seeing relationships, seeing the whole, reasoning basedon logic, building an interpretation, ability to make judgements, decision-making.This conception of learning from clinical experience can be described asqualitative, analytical, and concerned with a way of knowing. As such it representsa significant departure from conception A. In this conception learners use a particularstructure, a physiological framework, in understanding and seeing relationships.Learners use this structure and logic in arriving at correct interpretations. Theirinterpretation is the basis for decision-making. As such, learners have an effect onknowledge. Teachers facilitate understanding and correct learners' logic. Learnersconsider other points of view to see if they represent a more accurate interpretation.The procedures that formed the focus of conception A represent only one aspect ofintervention in this conception.89Conception C: Learning as the Discovery of Relativism As in the previous conceptions the application pole is emphasized in thisconception of learning although an acquisition pole clearly exists. The distinguishingfeature of this conception is a view of knowledge as relative. Key to this developmentis the shift in emphasis away from the health problem, as in conception B, to seeingthe person in different ways.As in the previous conceptions, what is learned reflects the learner's conceptionof nursing. As in conception B, the nurse's task is seen as the design andimplementation of nursing care. However, the learner's conception of nursing isdifferent from the previous conception in two important ways. First, in this conceptionthe basis for the design and implementation of nursing care is a more complex■understanding of individuals and all the variables that affect them rather than focusingexclusively on their health problem/s. The health problem is seen as one of thevariables that affects the individual albeit a significant one. Nursing care is directedtoward the total well-being of the person including psychosocial and spiritual aspectsas well as physical. Second, nursing is seen as an interaction between twoindividuals, the nurse and the patient, each having an effect on the other. Thisconception of nursing forms the external horizon of what is learned."I never looked at all the different areas that a person has inside them and thatthey need to be fulfilled. I'd always thought of well if a person's sick they're sickand then once that's better then you don't have to deal with anything else, that'sthe only thing you have to deal with...but there's a whole ...realm of problems thatyou have to deal with before they leave...I really learned not to just deal withthat one problem but to deal with the whole person and all their health problems90and really research...and know what you're dealing with before you go in and carefor them" (int 1)As in the previous conception, the key to the application process is the design ofnursing care. Critical to this step is a way of seeing a person. This is what is learnedand forms the referential aspect. Learners' again sought to see the whole but in thiscase, the whole person and all the significant variables. They used a structure thatallowed them to consider different aspects of the person, but never lost sight of thecomposite whole from which the parts were taken. Indeed, the parts were understoodin relation to the whole rather than as separate from it. Learning in this conceptionthen is the ability to individualize care for a particular person. In this conception thelearner considers the person who comes to the experience of illness as well as theeffect that illness has on the whole person."...this time I started really looking at the person as a whole...I always metpsychosocial concerns but I didn't know that I'd really met them before, and nowI understood how, why I was meeting those needs...I really began to look at mypatient as somebody with all kinds of needs...I would do my (physical)assessment, I would also be assessing psychosocial and spiritual needs at thesame time...and then put this person together and when you can really draw thatperson together and try and meet all those needs...it's really different how youlook at people in general like even your own family members and anybody youmeet...now I look at people differently because I always think about certainthings...their accomplishments...or history, a little bit about the person, whatmakes them tick...it's interesting how I've changed my concept of people ingeneral" (int 5)"...being able to think about your patient and then take the knowledge you haveand use it to care for them...not everybody is a textbook case, you have to beable to look at your patient and say well I'm doing this and being able to say whyyou're doing it and...then be able to do it...that's where a lot of people have a lotof problem 'cause they have all the knowledge but it's really hard for them toapply it, to individualize it...'cause you find out...that there's always a hitch thatcomes in here and there..." (int 6)91"learning to look at people's whole and knowing how each problem affects theirwhole body and to be able to interrelate all that is really important...to be able tolook at the whole complexity of it" (int 6)"...now I try and look at people more in depth and try and really think about whatI'm seeing because a lot of times you look at things and you kind of pass themoff...it's putting more and more things together" (int 6)"...the clinical resource nurse went in to talk to this lady...she went through herassessment and she talked to the patient and asked how she felt about it andexactly what the stages where and what type of teaching she was given...she sortof dealt with all her psychosocial needs and then all the physical needs and anyknowledge deficit she might have but she did it in such an organized way...yousort of think that well some day you'll be able to go into a patient and be able tocover all aspects of what they're going through and do it in such a nice way forthe patient as well as covering all areas" (int 3)This way of seeing a person was applied to the learners themselves allowing thelearners to consider their participation in the nurse-patient relationship. Personalinterpretation is a theme that recurs throughout this conception."...I had a patient die...I think I learned basically ...that it wasn't my fault that hedied, I'd done everything for him that we could do and I just had to kind of dealwith my feelings for somebody when they die... the mourning process...I think alot of times you deal with families...their grieving but then I think that the nurse orthe doctor or whoever it is, they go through the grieving too and I think you haveto learn to deal with that yourself...I never really knew about the process...but welearned about it in 3rd semester, in class and so then once I learned that, thenI could...use situations in my life that had happened to me...and I just kind ofrealized that I was going through it too and that every time that I had a patientwho went through it that I would probably actually go through the same thingmaybe not quite as deep..."(int 1)Based on this perspective of individuals and the variables affecting them, the learnerthen decides on the care that was required. In this case, the learner's search is notfor right versus wrong answers. Right answers are conditional. They depend on thecontext that is presented by the patient and the environment and on personalinterpretation. Learners accept variation in individual practise.92"...being able to take what you learn and use it...to make accurate decisions orproper decisions ...to be able to make fast decisions, great decisions" (int 6)"...how you care for a patient...it's a very personal thing who you pick to get mostof your care and most of your time...you need to be able to look at all of thevariables...it's all how you look at things and what you know, it comes fromexperience too, I mean instructors pick different things because they have twentyor fifteen years experience and you have one." (int 6)The learners evaluate their decisions and actions based on individual responses. Inthis conception learners have come to realize that complete knowledge is anunattainable goal and that decisions can be made in a climate of some degree ofuncertainty. They are willing to make decisions based on the knowledge they have.They sense that they know enough to make the decisions."...being able to trust what you've learned, by this point you should be able totrust that you hold a certain amount of knowledge" (int 6)"...realizing that I had all this knowledge in me from the last two years and wecould use it and then I started putting everything together...I thought this is all thestuff I've learned in the last couple of years and this is what the College has saidyou have to learn, sort of, and now you can just take it and use it" (int 1)As in conception B, the internal horizon is cyclic in nature. In this case, thecomponents are: the learner with knowledge, the application situation, the learner ableto see the person-in-situation and on that basis deciding on the nursing care that isrequired, the learner with a better understanding of subject matter, individuality, andthe conditional nature of knowledge, than was previously held.Learning takes place by practising the structure that enables learners them to seethe person-in-situation. Once a clear sense of the person is obtained, learners reflect93on their understanding in designing appropriate actions, and then carry out thoseactions."...standing back and looking over someone else's shoulder and seeing whatwasn't working and trying to put yourself in the patient's shoes...take a bird's eyeview" (int 12)The learners evaluate the appropriateness of their knowledge and actions based onwhat they perceive to be the consequences of those actions. These learners are notlooking for absolute answers. Experience is seen as a source of knowledge enablingthem to make appropriate decisions versus correct ones. In this conception theinstructor is a "sounding board"."...we had a lot of freedom and (the instructor) did watch, I know she did...but shedid give us a lot of freedom to make our own decisions and to do our own thingand it really came together..." (int 6)"...by trying to draw back on previous experience now too" (int 6)The external horizon here reflects the conception of nursing as previouslydescribed. The test situation isn't mentioned.The internal horizon consists of the following components: the learner withknowledge, the learner seeing the patient-in-situation, the learner exposed tosituations that enable them to see different individual responses, different points ofview, the learner deciding on a plan of action and carrying out that plan, the learnermore skilled in contextual thinking.94As in the previous conceptions an acquisition phase is present although lessclearly described. Clinical experience exposes learners to experiences that enablethem to see different perspectives."...sharing your concerns with other nurses and physio and respiratory and talkingto the pharmacist if you're...unhappy about the patient's medication" (int 12)"...the more different ways that you can learn something, like from practicalexperience, hands on or something visual, something you read, something you'retold...every time you discuss something...everybody's got a different viewpoint...that would be one more...rung on the ladder...it was all interrelated...youincreased your knowledge by each part" (int 5)It also presents opportunities for new learning that enables the learner to understanda variety of individual responses within different circumstances."...I went to the OR...you understood why patient's have pain...when I sawpatients that had different surgeries I could really relate to what was done...youunderstand the enormity of what they had done...you can really relate to patientsbeing frightened going in and how they feel in the PAR when they come out..."(int 6)The new knowledge can then be generalized to other situations."...I had a patient...and he was in a lot of pain...I found that the nursing staffwere...really pushing this man really hard and he just physically was not fit to bepushed like that and when I was looking after him ...I allowed him to makechoices...I guess I learned...to acknowledge how patients are feeling ...like yourmind is on your task and you're not sort of cluing in to what the patient is sayingto you and what their non-verbals are...I'm pretty astute at picking up on subtlecues now and before I was not..." (int 12)The indicators of this conception are: seeing the person-in-situation, understandingdifferent perspectives, relativistic thinking, individualizing, contextual decision-making.95This conception of learning can be described as qualitative, relativistic, analyticaland contextual. As such it represents the most comprehensive conception of learningfrom clinical experience. It describes a way of seeing a greater complexity thanconception B. The health problem/s and altered physiology are only one variable thatis considered in this way of seeing. Learners use the physiological frameworkdescribed in conception B but the focus is on a way of seeing a person and on aninterpretation of the person-in-situation as the basis for decision-making. The use ofboth frameworks resulted in a difference in the quality of interpretation achieved. Theconsideration of what was referred to as the greater complexity pushed learnerstoward contextual, relativistic thinking. It forced students away from standards andabsolute answers, and an exact theory base. Looking at situations from differentangles became more important. Differing perspectives came to have more value.Decision-making in this conception involved personal and contextual interpretationencouraging learners to examine their assumptions about the nature of knowledge.Relationship between Conceptions The three conceptions described are hierarchically related. There is a logicalorder in which each new conception comprehends the former and represents an abilityto see and consider a greater relativity.96Summary This chapter detailed the findings that resulted from the analysis of data. It setsthe stage for the final chapter which integrates these findings into implications forteaching and for further research.97CHAPTER VIINTEGRATION OF FINDINGS AND SUMMARYThe goal of this research project was the identification and description ofconceptions of learning from clinical experience.This study began with a discussion about the centrality of the clinical learningexperience in nursing education. It went on to describe the concerns several authorshave about the lack of significant research on learning from clinical experiencegenerally and about the dearth of research that has examined the process of learning.It also examined different aspects of the context of learning from clinical experiencethat have been of concern to various authors. This research project was an attemptto address some of those concerns.This investigation was linked to a perspective on learning that presents a view oflearning that emphasizes the importance of students' conceptions in the learningprocess. Students' conceptions of learning direct students' learning activities andaffect the quality of learning achieved. Students' conceptions of subject matterrepresent the learning outcome. Learning is thus seen as a change in conceptions.Phenomenography was the methodology used in this investigation. It is aqualitative methodology that was developed to systematically investigate learning. The98data used to analyze learning were students' own descriptions of their experiences oflearning. A rigorous qualitative analysis is used in identifying conceptions of learning.Conceptions represent the variation in assumptions and meanings that students holdabout this learning experience and that account for their actions in the clinical area.They make apparent how students respond to teaching, tackle the demands oflearning and what kinds of difficulties they encounter, revealing a process that isusually the private domain of the learner. The conceptions of learning that wereidentified are representative instances of the ways in which a wide variety of nursingstudents learn from clinical experience. Conceptions of learning can be used inplanning teaching and learning activities and in evaluating the success of teaching.The findings of this research project were three qualitatively different conceptionsof learning from clinical experience that were present in fifth semester nursingstudents in a two-year College based nursing program. These conceptions were:conception A - Learning as reproducing facts and procedures, conception B - Learningas an interpretive process, and conception C - Learning as the discovery of relativism.These conceptions represent the variation in personal and contextual interpretationthat resulted from this learning experience. As such they are descriptions of learning.The common assumption that guided the three conceptions of learning was thatlearning from clinical experience meant to apply knowledge to nursing practise. Eachconception of learning therefore incorporated a conception of nursing. The conception99of nursing directed the conception of learning in an important way. The students sawthe learning experience as a matter of learning to practise nursing.The main distinction between the conceptions identified was between conceptionA where learning was viewed as reproduction, and between B and C, whereunderstanding was achieved. The basis for understanding was a framework thatpermitted a way of seeing. The distinction between conceptions B and C wasattributed to a difference in a view of learning as either interpretative or contextual andin a figure-ground difference. In conception B the health problem was the figure andthe individual was the ground whereas in conception C, the individual was in focus.The difference in conception B and C resulted in a difference in the quality ofinterpretation. The conceptions were hierarchically related in that each conceptionwas subsumed or comprehended by the conception above it. Conception Crepresented most closely the conception espoused by the nursing program that thesestudents participated in.Limitations This study was limited in terms of generalizability by several factors. Of primeconcern is the size of the sample (13), although it was appropriate in terms of thenature of the methodology in respect to the depth of analysis required.Generalizability was also limited by the sample. The subjects were all nursingstudents in the fifth semester of a six-semester two-year nursing program at a100community college in a large urban center. Their clinical experiences all took placein acute care settings. The students volunteered for the study, although since anexcess of students volunteered for the study, students who participated were randomlyselected from the group that volunteered. The study may have been limited finally bythe inexperience of the researcher. However, inexperience may play a part in thequality of findings of any research project.Relationship to Existing Research This study has been able to respond to several authors' concerns about theclinical learning experience in nursing education. These concerns have centeredaround the need for an understanding of learning from clinical experience, theidentification of what constitutes an optimum learning environment, and planning ofteaching and learning activities based on an understanding of learning. The findingsof this research project have addressed these needs. It is, as well, an expansion ofthe phenomenological descriptions of learning from clinical experience that werereported. This study has gone beyond the identification of learning per se, and hasidentified the different ways that people learn from clinical experience. It has, as well,provided detailed descriptions of each. These findings represent the ways thatnursing students learn from clinical experience and as such can be used for planningand evaluating learning and teaching activities.101Discussion In the phenomenographic tradition that informs this research project, it isunderstood that the conceptions of learning that are the outcome of the researchproject provide educators with tools that can be used in planning and modifyingteaching and learning activities. Prior to suggesting modifications, however, I wouldlike to step away from the phenomenographic process and suggest elements of thecontext that were suggested as promoting conception C and maintaining conceptionA and B, as I feel that doing so will clarify the suggestions for change.Of the three conceptions identified, it is conception C which is espoused by thenursing program these students were enrolled in. The findings point to personal andcontextual elements of the clinical experience that contributed to the development ofthis conception.1. An appropriate framework was an important part of sense-making for threereasons.^First it provided a way of seeing part-whole relationships andinterrelationships between parts. Secondly, it pointed toward the espousedconception, in this case one of greater complexity, rather than allowing the student tostop short of the bigger picture. Thirdly, it was an important part of allowing studentsto become independent, in charge of their own learning and their nursing practise.Finally, the framework that was used directed students to consider the individuality ofeach person. This was shown to encourage relativistic thinking.1022. Clinical experience exposed students to a world teeming with the complexityand intricacy of the human condition that is representative of the world of nursingpractise. As such it provided a wealth of variation in perspectives and responses thatfuelled challenges to existing conceptions. It also provided opportunities for learnersto become participants in problem-solving and decision-making and provided first handopportunities to experiment with different approaches and then to consider theeffectiveness of these approaches. It thus directed students to find ways ofsense-making and to make investments in appropriate decision-making.3. Clinical experience confronted learners in a powerful way with theinteractional nature of the discipline. They found themselves emotionally moved.Clinical experience made them aware of the personal involvement that would berequired in terms of costs and rewards and they were thus forced to find ways ofgiving meaning to that aspect of their learning experience. This also proved to be animportant part of the development of relativistic thinking.4. Clinical experience provided learners with opportunities to makedecisions based on their interpretations of situations and to find that they were ableto make appropriate decisions in an uncertain world where absolutes were oftentemporary and complete knowledge was an unattainable goal. The students felt thatmaking decisions teaches you that you have enough knowledge to make decisions.5. In clinical experience, teachers who promoted conception C wereteachers who role-modeled this conception of learning and who allowed learners the103freedom to problem-solve and who acted as a sounding board for students in theirattempts at sense-making.6. Clinical experience exposed students to a variety of practitioners, nursingand non-nursing. Being able to discuss different issues with these practitioners madestudents aware of differing perspectives.7. A developmental perspective is suggested in the interviews. Forexample students said that once they had learned the skills they didn't seem asimportant. Also, it seemed that once conception B was used as a sense-makingmodel, the limitations in it became apparent.8. In the interviews students frequently mentioned an aspect of classroomcontent and teaching methodology that promoted their ability to function effectively inthe clinical setting. In the particular semester that these students were in, only a fewhealth problems were dealt with. Students compared this with previous semesters inwhich many, often unrelated health problems were discussed and in which studentsfelt forced to memorize for the purposes of exams and didn't have time to gainunderstanding. In conjunction with the classroom content, simulations of particularcases were constructed and students were asked to enact their role in thesesituations. Students felt that this way of teaching provided them with a way of dealingwith the clinical situation that they were able to generalize to other situations.9. When asked about how their learning differed from others that theyknew, students were able to suggest attributes such as previous experience, life'sexperience and age as contributors to differing conceptions of learning.104Despite these several factors that directed learners to the espoused conception,two other conceptions persisted. This study suggested several factors that contributedto the persistence of these conceptions.1. The intention to practise nursing rather than the intention to learn whichwas expressed in the conceptions as a focus on the application pole at the expenseof the acquisition pole of learning, was a factor in maintaining conception A. Itfocused the students' on seeing learning as taking place in the classroom and seeingclinical as a place to prove whether or not learning had taken place rather than seeingthe experience as an invitation to attend to a different perspective or to modify or addto understanding of the theory base. This emphasis hindered a questioning attitudeand experimentation in favour of acceptance of the status quo and a focus onperforming at the RN level including working toward the same workload that RN'scontend with, at the expense of time for reflection.2. This study suggested that the structure of classroom content placed a certainemphasis that was influential in affecting learners assumptions about knowledge inthis discipline. Classroom content emphasized psychomotor skills and healthproblems. The volume of classroom content was stressed necessitating rote learningas the most efficient way of making the grade. Some students came to see this asthe nature of knowledge in this discipline.3. Two characteristics of teachers proved influential in encouraging learners tomaintain their hold on less mature conceptions. First, was the questions thatinstructors asked. Several of these students referred to questions that required factual105answers. These questions served as prototypes of the questions that learners askedof themselves as they gained independence. Secondly, how the instructor spent hertime was important. Some of these students saw teachers as emphasizing thesupervision of skills. This reinforced the importance of this activity as part of theirpractise.4. As Marton has observed (Ramsden, 1988, p. 20) experts' conceptions havevaried between historical periods in the development of disciplines and these historicconceptions can become commonplace and tenaciously-held among the generalpublic. The three conceptions identified in this investigation reflect stereotypical or layconceptions of nursing and conceptions of nursing presently held by nursing experts.Related to this and equally important in upholding or challenging conceptions was theconceptions of nursing enacted by the staff nurses.5. Clinical areas in acute care settings are structured for medical treatmentof patients. This emphasis was not lost on many of these learners and dictated anemphasis on understanding and on health problems and altered physiology ratherthan on the recognition of individuality.6. High anxiety, over-whelming emotion, and fear was a theme thatpresented itself over and over again in the interviews. Ramsden (1984) suggested thathigh anxiety and feelings of threat interferes with learning and can push learners torote methods of learning.106Implications The value of this research lies in the direction the findings provide for planningand evaluating learning and teaching activities. As is apparent from the discussionabove, the findings suggest strengths as well as areas of improvement. The value ofthis research also lies in the direction it gives for further research.Implications for Nursing Education In considering the implications for curriculum, content, teaching and assessmentchanges that are suggested by the findings presented by this research, three themesemerged:1. The value of conceptions of learning in directing learning and as areflection of learning needs to be recognized. Marton and Ramsden (1984) suggestthat the study of "subject didactics - the analysis and mapping of the different wayslearners experience and conceptualize various content domains" (p. 283) should bea part of instructor education and should be used in their practise. The findings of thisresearch project support that view.Conceptions of learning can be the basis of discussions with students aboutlearning from clinical experience. They can be used to inform students about theprocess and content of learning from this experience. It is recommended that learnersshould have their own and different conceptions made explicit to them and have thedifferences pointed out. This would make students aware of the possibility of different107conceptions, the importance of ways of thinking about learning and to consider theintent of the learning experience.Conceptions of learning can be used to guide the selection of experiences in theclinical area. Teachers, first, need to know how to identify students' conceptions.One recommended way (Entwistle & Marton, 1984, p.227) of doing this is by askingstudents to describe their understanding of concepts, subject matter or situations.Teachers should then use situations that present themselves in the clinical experienceto challenge or confirm existing conceptions. This approach enables teachers toadopt a diagnostic stance that would enable them to trace pathways ofmisunderstanding and to individualize learning experiences. Teachers can also useconceptions of learning to evaluate the effectiveness of learning experiences byassessing students for changes in conceptions.In recent decades staff nurses have been somewhat shadowy participants in theeducation of nursing students. In the interviews, however, students often mentionedthe importance of staff nurses in the formation of their conception of nursing. Thesepractitioners represented a reality as role models of nursing that instructors wereunable to fulfil. As such, their importance should be reflected in designing the clinicallearning experience. Master practitioners should be identified that reflect theconception of nursing espoused by the experts and they should be affiliated witheducational programs to serve as role models. Staff nurses should be aware of their108importance in the educational process of nursing students. Relations betweeneducation and practise should be improved and strengthened.The findings of this investigation point to the value of the problem-solvingexperiences presented by clinical experience. These problem-solving experiencespoint to limitations in a particular way of thinking and encouraged learners to considerdifferent ways of sense-making. As well they provide opportunities for students to usetheir ideas about subject matter in new ways. As such these experiences should bemaintained.2.^The acquisition potential of the experience needs to be developed. Thisresearch pointed to the underdevelopment of the clinical learning experience as asource of knowledge and understanding. This potential was overlooked by theoveremphasis on the application of learning that had taken place in the classroom andby studying prior to coming to the clinical experience. For decades the clinicalexperience has been seen as solely a learning experience by nurse educators. Thestudents in this investigation, however, indicated that that notion was secondary to thenotion of practising nursing. It may be that a contributing factor to this perception isthe lack of clarity about learning from this experience among nurse educators, as wasreported in the literature. The findings of this research project and others like it mayassist in developing a body of knowledge about learning from this experience and thusassist in the solving of this issue. This distortion may also have been promoted by109a traditional aspect of nursing education that has been a concern to a core of nurseeducators, that is, the practise of having nursing students, often in even initialexperiences, giving total care to patients. This practise has been a source ofconsiderable anxiety for learners and has played an important role in directing theactivities of instructors to that of a supervisory role in which the safety of the patientrather than the learning activities of the student has been paramount. This studysuggests that consideration needs to be given to selecting experiences for students,for having students participate with staff nurses and of gradually taking on moreresponsibility and of implementing this practise at a much later point in a program.Another aspect of clinical experience that interfered with conceptual changelearning was the pressure to increase the student's assignment close to the RN level.This had the effect of focusing the learner on maintaining the status quo andeliminated any opportunity for taking "a bird's eye view", for reflection, or for trying outdifferent ways of handling a situation. The learning potential of this experience couldbe emphasized by selecting only certain aspects of patient care for students toperform, by having students work with staff nurses and by decreasing the emphasison volume. Time should be built in for discussion and for reflection and for aconsideration of alternative perspectives.This study pointed to the value of student contact with patients and health relatedpractitioners of all kinds as suppliers of perspectives.110An emphasis on the learning potential of this experience would encourage aseparation of learning and evaluation which is promoted by the overemphasis onapplication and is a source of anxiety that may well interfere with learning.3.^Greater emphasis needs to be placed on the whole rather than the parts.The findings of this research study suggest that conceptions A and B weresubordinate aspects of conception C and may have been encouraged bytenaciously-held lay conceptions of nursing, by an emphasis in classroom content andin assessment, on learning of psychomotor skills and on disease processes andmedical management, and by the focus of health care in acute care settings. Thesecontextual elements may have encouraged a distortion of figure-ground relationshipsand may have led learners to stop short of the espoused conception of nursing. Theinclusion of the history of nursing in the curriculum would help learners to understandcurrent and past and present perspectives of nursing. Careful consideration needsto given to how classroom content is presented so that a balance is achieved and sothat the overall picture is not lost. Classroom content should also reflect the natureof knowledge as qualitative, relativistic and conceptual as well as factual.In all learning environments an appropriate framework should be used that directsthe student to the espoused conception.111The focus on acute care settings in hospitals as the sole environment for clinicalexperience, as was the case in this program, should be modified. This may includemoving some experiential components out of acute care settings and into thecommunity so that individuals can be seen in their usual environment. The issue ofindividuality can be addressed in the clinical area by providing experiences thatemphasize the limitations of stopping short of this consideration.Reflecting what was said above about classroom content, the teachers' role in theclinical area should reflect an emphasis on the larger picture rather than on thecomponent parts. This should be reflected in the types of questions that are askedof learners and on how and where teachers' time is spent. Teachers need to rolemodel an appropriate conception of nursing. As has been pointed out in Chapter One,the complex nature of clinical teaching may force teachers into a supervisory rolewhere they are not able to spend any significant time with patients and have littleresponsibility for decision-making and may focus on procedural aspects of learning.The solution to this dilemma is not an easy one but should be considered indiscussions about modification of context. Discussions involving a sharing ofperspectives among students and teacher and facilitating exposure to differingperspectives and the interactive nature of the discipline are valuable activities forteachers to engage in.112Implications for Further Research This research was conducted on a small sample of students in only oneeducational institution. It needs to be replicated using different groups of similarstudents as well as students in different types of programs including baccalaureateprograms in order for findings to become generalizable.As well as students' conceptions of learning, teachers conceptions of learning andteaching should be examined. Marton and Ramsden (1984) have pointed out thatteachers' conceptions of teaching usually parallel their conceptions of learning.Related to this, ways of changing conceptions not only in nursing students but innurse educators will need to be systematically investigated.The interviews conducted during this research project suggested a possibledevelopmental aspect in the conceptions. This should be examined through alongitudinal study. Such a study would confirm the existence of a developmentalprogression in conceptions held by individuals and would add to an understanding ofthe learning process in order to improve the teaching learning process.Any body of findings about clinical education would be incomplete without anexamination of the context in which it occurs. In particular, an examination of theconceptions of learning and nursing that practitioners hold would be appropriate since113practitioners are the role-models that inform the students conceptions of nursing thatformed such an important part of their conception of learning from clinical experience.This study looked at clinical education at the most general level. An examinationof more specific components of clinical education would prove enlightening. Inparticular, an investigation of students' and teachers conceptions of clinicaldecision-making would be important.This study has used the phenomenographic approach in isolation. Currently acombination of quantitative and qualitative methodologies are being recommended asthe findings of one methodology serves to illuminate and inform the other (Stalker,1989, p. 43). The findings of this study, for example could be applied to individualsand the findings related to quantitative measurement of performance.Summary This thesis began by describing the centrality of clinical experience in theeducation of nurses. It went on to describe the concern expressed by various nurseeducators about the lack of research that has focused on this experience, about thelack of research that has effectively studied teaching methods in relation to their effecton learning, and about various aspects of this complex but powerful context. Thisstudy has addressed these concerns by using a perspective on learning and amethodology that differs from those that dominate the literature in the field. 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Baumgart & J. L. Larsen (Eds.), Canadian Nursing Faces the Future (pp. 323-334). Toronto: Mosby.Saljo, R. (1988). Learning in educational settings: Methods of inquiry. In P.Ramsden (Ed.), Improving learning: New perspectives (pp. 32-38). London:Kogan Page.Saljo, R. (1984). Learning from reading. In F. Marton, D. Hounsell, & N. Entwistle(Eds.), The experience of learning (pp. 71-89). Edinburgh: Scottish AcademicPress.Stalker, A.J. (1989). Reframing the issue of participation in adult education: an interpretive study. Unpublished doctoral dissertation, University of BritishColumbia, Vancouver.Tanner, C. A. (1990). Reflections on the curriculum revolution. Journal of Nursing Education, 29(7), 295-299.Tanner, C. A., & Lindeman, C. A. (1987). Research in nursing education:Assumptions and priorities. Journal of Nursing Education, 26(2), 50-59.West, L. (1988). Implications of recent research for improving secondary schoolscience learning. In P. Ramsden (Ed.), Improving learning: New perspectives(pp. 50-68). London: Kogan Page.120Wertz, J. F. (1985). Method and findings in a phenomenological psychological studyof a complex life-event: Being Criminally victimized. In A. Giorgi (Ed.),Phenomenology and psychological research (pp.155-216). Pittsburgh:Duquesne University Press.Whelan, G. (1988). Improving medical students' clinical problem-solving. In P.Ramsden (Ed.), Improving learning: New perspectives (pp. 199-214). London:Kogan Page.Williams, R. A. (1988). The relationship of cognitive styles and stress in nursingstudents. Western Journal of Nursing Research, 10(4), 449-462.Windsor, A. W. (1987). Nursing students' perceptions of clinical experience. Journal of Nursing Education, 26(4), 150-154.Wong, J., & Wong, S. (1987). Towards effective clinical teaching in nursing. Journal of Advanced Nursing, 12, 505-513.Wood, V. (1987). The nursing instructor and clinical teaching. International Nursing Review, 34(5), 120-125.Zimmerman, L., & Waltman, N. (1986). Effective clinical behaviours of faculty: Areviewof the literature. Nurse Educator, 11(1), 31-34.121Appendix ACONSENT FORMI,^ in return for the opportunity of participating as a subjectin a scientific research investigation hereby consent to participate in the researchproject called "The Nature of Learning from the Clinical Experience of NursingStudents", the purpose of which is to identify different ways in which students interpretthe demands of this learning experience and how that affects the ways in whichstudents go about learning from the experience. I agree to participate in two tapedinterviews about my experiences of learning from clinical experience, the first lastingapproximately one hour and the second lasting approximately one half hour.This consent I give voluntarily as the nature and purpose of the experimentalprocedure have been fully explained to me by Norma Goldie, the investigator of thisresearch project, who can be contacted at 527-5082 or 943-9689 to answer anyquestions concerning the procedures involved, either before or after the interview hastaken place. I understand that there are no known risks associated with myinvolvement in this research project. I understand the potential benefits of theinvestigation to be the alteration in teaching methods to facilitate learning fromclinical experience.I understand that, as a participant, my rights will not be jeopardized, that myprivacy will be maintained and that the data obtained in this study will be used in amanner to maintain confidentiality and personal rights. No proper names will beused in the transcriptions of taped interviews. Only the researcher and her advisorswill have access to the taped interviews. The tapes will be destroyed one year afterthe thesis has been completed.I am aware that I may withdraw my consent and discontinue participation at anytime without penalty to myself.Any concerns I have about this research project can be addressed to Mia Gordon,Director of Student Services at Douglas College at 527-5321 or the ResearchSupervisor at U.B.C., Dr. Tom Sork at 228-5702.I have received a copy of this consent form.Dated .^  Signature.^Dated .^ Researcher's signature .^122L. College Credit Transfer(PART CF BLOCK TRANSFER)College Credit Non-TransferIX I^M. Transfer Credit: RequestedI^II^II^IGranted^IX :Appendix BDOUGLAS CCLLEGE^ Date: ^^ New Course:Revision of CourseA. Division:^APPLIED PROGRAMSB. Department:^HEALTH SCIENCES'X IMarch 7, 1990Dated: February 1, 1989 C.^GNUR 510^D.^ADVANCED CLINICAL NURSING:ACULT^E.^3Subject & Course No. Descriptive Title Semester/CreditsF. Calendar Description:During this seven week pre-practicuu course, students will integrate andapply previous and complex concurrent theory and skills in the applicationof the nursing process. GNUR 510 includes: advanced psychomotor skilldemonstration and practice; participation in simulated patient caresituations; and provision of comprehensive nursing care, in an acute caresetting, to adult patients with multiple need non-fulfillment, complex needinterrelationships and various medical and surgical interventions. With theconsultation and supervision of the instructor, the student gains competenceas a member of the health care team.G. Type of Instruction:^Hrs. Per Week/; H. Course Prerequisites:All Semester IV GeneralLecture ^Hrs.^Nursing courses.Laboratory^3  Hrs.Seminar ^Hrs.Clinical Experience^15  Hrs.Field Experience ^Hrs.Practicum ^Hrs.Shop ^Hrs.Studio ^Hrs.Student Directed Learning^ Hrs.Other (Specify)^Hrs.;Summary of Revisions:;(Enter date and Section;Revised)!e.g. 1982-08-25;Section C,E,F, and R.;1987-03:Sections C,I,L,N,O,RI198802:Sections B,C,D,F,G,H,I,J,N,P,O,R:1989-02!Sections B, FI. Course Corequisites:GNUR 500 may be completed con-currently or before GNUR 510. J. Courses for which this Course isa Pre-requisite:GNLR 620;1990-03;Sections F, G, K, N, 0,P,O,RTotal (7 week course)K.18  Hrs.^LabLabMaximum Class Size:Demo 1:24; Lab Practice 1:12Simulation 1:3; Clinical 1:8Non-Credit(Specify Course Equivalents orUnassigned Credit as Appropriate)U.B.C.S.F.U.^Part of Block Transfer toU. Vic. BScN. U.B.C. and U. of Vic.OtherCourse Designer(s) Divisional DeanDirector/Chairperson^ Registrar(Rev. Aug./82)^123ADVANCED CLINICAL NURSING:ADULT - GNUR 510^Page 2 of ^8 NAME AND NUMBER OF COURSEN.^Textbooks and Materials to be Purchased by Students (Use BibliographicForm):1. Carpenito, L.D. (1987). Handbook of Nursing Diagnosis. 2nd ed.,Philadelphia:J.B. Lippincott. ($17.00 in 1987)2. Kozier, B. & Erb, G. (1987). Techniques in Clinical Nursing: ANursing Process Approach. Menlo Park, CA: Addison-WesleyPublishing Co. (Approximately $45.00 in 1987; also used in GNUR100, 110, 210, 310, 412, 510, 620)3. Lewis, S. & Collier, I. (1987). Medical-Surgical Nursing. NewYork:^McGraw-Hill CO. (Approximately $75.00 in 1987; alsoused in GNUR 200, 210, 400, 410, 412, 500, 510, 620)4. Douglas College General Nursing Student Learning Packets: GNUR112, GNUR 212 and GNUR 412 - Nursing Psychomotor Skills I, II andIII, First Edition. (Approximately $3.00 each in 1987)5. Douglas College General Nursing Student Learning Packets: GNUR 500Advanced - Nursing Theory:Adult; Professional Nursing Issues; GNUR510 - Nursing Psychomotor SkillsComplete Form with Entries Under the Following Headings: 0. CourseObjectives; P. COurse COntent; Q. Method of Instruction; R. COurseEvaluationO.^COURSE OBJECTIVESContext of Practice:In the nursing laboratory and under the supervision of the instructor, studentswill participate in three patient care simulations in the roles of nurse,patient or observer. In either a medical or surgical ward of an acute carehospital, students will provide comprehensive nursing care to 3-4 adultpatients of varying developmental levels with multiple patient problems/nursingdiagnoses associated with complex need interrelationships and a changing healthcare status.The student willNURSING CARE1.^apply knowledge of nursing and biopsychosocial sciences as a basis fornursing practice1.1 describe anticipated patterns of behavior and environmental factorsassociated with a variety of commonly-occurring health problemsaffecting adults1.2 describe anticipated patterns of behavior and environmental factorsassociated with the potential complications of health problems andtreatment plans relevant to assigned patients1.3 make appropriate inferences, with minimal assistance, about needinterrelationships for assigned patients with selected healthproblems1.4 analyze, with mdnimal direction, the outcomes of alternativenursing approaches124ADVANCED CLINICAL NURSING:ADULT - GNUR 510^Page 3 of ^8 NAME AND NUMBER OF COURSE1.5 state the rationale for own nursing actions and decisions verballyand in written assignments1.6 use a variety of resources in the clinical setting2. apply camunication theory and skills effectively with patients and theirsignificant others in stressful and non-stressful situations2.1 establish, maintain and terminate helping relationships2.2 use helping skills, with minimal direction, to assist patients toproblem solve concerning health2.3 direct and focus interactions to ensure optimal use of time2.4 adapt interactions to consider individual differences3. organize patient care assignments to provide safe, effective andefficient nursing care3.1 sequence selected nursing care and other ward activitiesconsidering the priority needs of 3-4 assigned patients, usualroutines of the unit and planned patient activities3.2 revise time lines, after validation with the instructor, toaccommodate changes and unanticipated events related to assignedpatient care and assigned responsibilities for ward activities3.3 implement nursing care to conserve energy of both patient and selfas well as the use of hospital resources3.4 complete nursing care activities within an appropriate time span4. perform a variety of psychomotor skills competently4.1 perform selected psychomotor skills in the nursing laboratory4.2 perform a variety of psychomotor skills in the clinical area5. demonstrate respect for the rights and dignity of assigned patients whenproviding care5.1 maintain safe care consistently5.2 maintain confidentiality5.3 recognize the patient's right to be informed by applying theprinciples of teaching and the principles of learning5.3.1 anticipate usual learning needs of adult patients related tohealth problems, associated treatments and discharge plans5.3.2 identify actual learning needs of patients and theirsignificant others5.3.3 recognize own limitations regarding providing information topatients and their significant others125ADVANCED CLINICAL NURSING:ADULT - GNUR 510^Page 4 of ^8 NAME AND NUMBER OF COURSE5.3.4 use appropriate teaching methods based on identified learningneeds5.3.4.1 use available patient teaching resourcesappropriately5.3.5 refer patients' and their significant others' learning needsto the appropriate member of the health care team as required5.3.6 evaluate the effectiveness of teaching with the patient,significant others and other members of the nursing team5.4 demonstrate respect for the worth of individual patients and theirsignificant others6. use the nursing model when applying the nursing process in the provisionof care6.1 consult appropriately with the patient and/or significant others ateach step in the nursing process6.2 assess patients' needs6.2.1 anticipate appropriate data to collect based on major need(s)affected by the patient's health problems, the treatment planand potential complications6.2.2 collect accurate, relevant data related to major needs usingappropriate sources and methods6.2.3 collect comprehensive data systematically by using specifieddata collection tools6.2.4 interpret data, with minimal assistance, to determine needfulfillment/nonfulfillment, need interrelationships andassociated environmental factors6.2.5 validate sufficiency and interpretation of data withinstructor6.2.6 recognize changes in the overall health status of patients6.2.7 identify actual and/or potential patient problems/nursingdiagnoses statements based on collected data6.3 plan nursing care6.3.1 prioritize patient problems/nursing diagnoses6.3.2 formulate realistic short term goals independently andvalidate long term goal statements for priority patientproblems/nursing diagnoses6.3.3 relate environmental factors and patterns of behavior to theselection of appropriate nursing actions6.3.4 adapt standardized nursing care plans, with minimalassistance, to meet the individual needs of patients6.3.5 validate plan with appropriate members of the health careteam126ADVANCED CLINICAL NURSING:ADULT - GNUR 510^Page 5 of ^8 NAME AND NUMBER OF COURSE6.4 provide comprehensive nursing care6.4.1 implement interventions relevant to stated short term goals6.4.2 implement interventions relevant to state long term goals andto the promotion of optimal health, with minimal direction6.4.3 provide nursing care according to the treatment planestablished in the Kardex6.5 evaluate effectiveness of own nursing care by assessing identifiedpatient responses and validate with instructor/R.N.6.5.1 judge progress toward goal attainment6.6 evaluate the effectiveness of nursing care provided on other shiftsand validate with instructor/R.N.6.7 revise the nursing care plan after consulting with theinstructor/R.N.THE NURSE WITHIN THE HEALTH TEAM7. provide patient care within the context of the nursing team7.1 seek assistance appropriately within the nursing team7.2 cooperate with other nursing team members in the provision of care7.3 coordinate own nursing activities with those of other nursesresponsible for assigned patients7.4 use the nursing team as a resource by validating own observationsand decisions as necessary with the instructor/R.N.8. consult and communicate effectively with peers and members of the nursingand health care team8.1 apply appropriate ccumunication skills in one-to-one interactions8.2 apply communication skills to facilitate effective group processes8.3 use appropriate lines of communication within the nursing team8.4 consult with appropriate members of the nursing and health care teamabout patient care8.5 give a verbal/taped report of relevant information regarding patientcare to appropriate members of the nursing and health care team8.6 record appropriate information according to charting guidelines andhospital policy127ADVANCED CLINICAL NURSING:ADULT - GNUR 510^Page 6 of ^8 NAME AND NUMBER OF COURSEPROFESSIONAL RESPONSIBILITIES9. act as an advocate for the patient within the health care system9.1 acknowledge, with minimal assistance, the rights of patients toself-determination regarding health and health care9.2 initiate contact with other members of the health care team, withassistance, on behalf of the patient and/or their significant others9.3 encourage patients and their significant others to participateactively in any plans affecting health9.4 facilitate involvement of patient and significant others indischarge planning, with minimal direction10. demonstrate accountability for quality of own performance and developmentas a student nurse10.1 follow consistently the program policies as they apply to clinicalexperience10.2 follow consistently policies and guidelines of the clinical area10.3 identify personal responses to stresses related to the student nurserole10.4 participate constructively in the evaluation process on an ongoingbasis10.5 demonstrate initiative in meeting own learning needs10.6 demonstrate consistency and dependability in quality of clinicalperformance10.7 demonstrate professionalism in the student nurse role10.7.1 seek supervision and assistance appropriately10.7.2 recognize and promptly report own errors/mistakes toinstructor and appropriate nursing team members11. apply knowledge of ethical and professional standards of nursing, aftervalidating with instructor11.1 perform within the specified legal guidelines which affect nursingpractice11.2 comply with the code of ethics of the profession11.3 describe how hospital policies determine the practice of nursing ingiven institutions128ADVANCED CLINICAL NURSING:ADULT - Q'UR 510^ Page 7 of ^8 NAME AND NUMBER OF COURSE11.4 report unsafe practices to appropriate persons, after consultingwith the instructor11.5 exercise judgment in carrying out medically-prescribed regimes, inconsultation with the instructor/R.N.P. OONTENTGiven the previously described context of practice, the student will applyknowledge to clinical experiences from all prerequisite and corequisite courseswithin the program.ESSENTIAL LEARNING ACTIVITIESThe student will1. interact primarily with the members of the nursing team rather than theinstructor regarding own responsibilities for patient care, on both dayand evening shifts2. provide selected nursing care to large groups of patients as a member ofthe nursing team: e.g. giving medications to many patients, doingdressings, providing p.m. care3. participate as a nursing team member in multidisciplinary ward activitiesconcerning patient care4. assume responsibility for selected ward tasks as a member of the nursingteam5. develop and revise a Kardex care plan in consultation with a R.N.6. _participate in three patient care simulations in the nursing laboratory todemonstrate integration of theory and skills and application of thenursing process to the care of patients with chronic renal failure,cirrhosis and diabetes complicated by a femoral popliteal by-pass graft.7. perform the following skills in the nursing laboratory:- administering intravenous-push medications- participating in cardiac arrest procedure- monitoring central venous catheters- performing tracheostomy care8. practise psychomotor skill performance in the clinical area to increasespeed and proficiency9. consult with a physician regarding patient care10. summarize and tape (where possible) an end-of-shift report for a group ofpatients11. review hospital policies which determine nursing practices within thatinstitution12. participate in patient referral to a community agency129ADVANCED CLINICAL NURSING:ADULT - GNUR 510^Page 8 of  8 NAME AND NUMBER OF COURSEQ. METHOD OF INSTRUCTION1.^Student performance of specified nursing care for selected patientswithin the context of a nursing team- patient selection based on course objectives and identifiedstudent learning needs whenever possible- oral and written feedback from instructor after observing and/orsupervising student performance- student relates to the hospital nursing staff as a member of thenursing team2.^Interaction with instructor will include:- discussion and questioning with individual students related toapplication of theory and use of nursing process in individualpatient care assignments and in laboratory simulations- planned student group discussions after clinical experience3.^Individualized learning plans- developed jointly with the student at midterm and wheneverindicated based on instructor's assessment and student self-evaluation of learning needs4.^Written assignments- related to course objectives.R. COURSE EVALUATIONThis is a MASTERY course. Evaluation of the course will be based on thecourse objectives and consistent with college policies on courseevaluation.Students will receive detailed outlines of performance expectations at thebeginning of the course.Evaluation of mastery will include the following components:i. completion of written assignments requiring application of thenursing processii. demonstration of critical components of selected psychomotor skillsin the clinical areaiii. participation in assigned patient, nurse, observer roles in threesimulated patient care situationsiv. student participation in evaluation of own clinical performancev.^satisfactory performance of objectives as assessed by the clinicalinstructor.Selected objectives related to ensuring patient safety and beingaccountable for own learning must be demonstrated by mid-term of therotation in order to continue in the course.130Appendix CResults of Interjudge,Reliabilitv TestQuote^ Desired^Co-judgeResponse 1 21. "you see progress...I was able to^B^B Brelate patient behaviours and I was ableto understand why they were on certainIV fluids and certain medications..."2. (a learning experience) "Obstetrics^C^A C...seeing, watching the mother go throughlabor and being there when the baby'sborn...taking care of the baby after...you experienced a whole lot of emotions...that was a real learning experiencefor me because we did a lot...you couldfeel the contractions and you could seewhat they were doing...there was a lot ofinteresting stuff to read urn lots ofdifferent points of view, lots of peoplewilling...to teach you...talk to you andshow and let you do...I saw C-sections..."3. "...in this semester when I was able^B^B Bto start putting things together likewith the lab. results and the medicationsand the doctor's orders and how they alltied in...like the instructor would saywell, why is this patient's blood countat whatever and you'd be looking back tosee well what kind of medications they'reon, then you would look to see well thiswas what they were on this date, wellwhat's her white blood count at this time...with antibiotics and all kinds ofstuff, sort of get a picture of what wasgoing on...you actually take the time tosay OK this goes here and what were theyon the week before that or what were they131on two days before that and what are theynow"4. (a learning experience) "Urn fourth^B^B Bsemester I had a patient who was adiabetic, she had gone for an amputation,she came back, uh her blood sugars werevery high and you could tell just bylooking at the wound that it was goingto be infected or was infected orwhatever, her temp(erature) startedgoing up and her blood sugar, theinsulins kept getting higher and higher...one day I had her she went intopulmonary edema and uh there was quitea commotion in the room and uh I had achance to talk to the uh respiratorytech(nician) and he had taken herarterial blood gases and everythingthat was going on, it was a reallearning experience to see how everybodycomes together, they had somebody come upfrom x-ray uh the respiratory tech. camein, half the nurses on the ward were inthere, they catheterized her, they startedan IV, they did everything you couldimagine and it was very interesting tosee how they come together and to knowthat, just to know what was going on andwhy they were doing what they were doingand to be able to understand it..."5. "...and just that I was a kind of^A^A Amulti-skilled person...like able todo different...skills, catheters or urngiving meds., or IM's or trach. care,just a whole different variety ofskills..."6. "...I had this one liver failure guy^B^B^Band I had to stop and really think aboutwhat...I had learned in class and what hewas presenting with and once I did and Inoticed...what his lab. values were and I132did his assessment and he had bruisingand he had petechiae all over, I, itreally came together...I didn't think sodeeply about things before as I did whenI finally got to this and I saw thisproblem and then I thought back to whatI had done and it just came together andit was like a bomb hit me and I kind ofwent wow..."7. "...we were finally looking after^C^C Beverything that had to do with thatpatient, diet changes, calling thedietician, getting some psychiatrichelp in for one patient, you were incharge of the whole patient...beingable to do it all and be in charge ofwhat you're doing...make our owndecisions..."8. " always being open urn always be^C^C Cwilling and make the time to learnsomething, always be ready for a newexperience and don't ever let it go by...even though you know a certain skillI think every time you go and do somethingthe situation is a little different somaybe you don't learn anything more aboutthat particular skill but maybe you mightlearn something else...some other thing(about) this patient that's maybe a littledifferent from somebody else...9. "branching out and doing things^A^A Aindependently uh once you're mastered indoing things you could go ahead and thatwas really nice to be able to just pick upthe stuff and go and do your dressingchange without having an instructor there...10. "prioritizing your patients (means)^A^A AI guess looking at the problems they hador the surgery, which room you should gointo first to check on and then looking133at all the things that had to be done andputting them in order"11. (learning experience) "I had a lot of^A^A Areally good learning experiences inpost-conferences, a lot of instructorsgive really good post-conferences whenthey actually, they bring people in andthey teach you new things, machinery,IVAC's, things like that..."12. (learning experience) " I think it^C^C Cwas probably when I finally got to lookafter this ....lady who was bedridden,aphasic, she'd had a CVA, she was totallycontractured up, she was the most totalcare patient I had ... looked after ...it finally made it all click into place,that I was a caring person and that I didknow how to care for someone like her andthat I could do a good job of it, lookingafter her you sort of solidifiedeverything..."13. (interesting) "you may (only) have^B^B Bhad abdominal surgery but that affectseverything from your toes to the top ofyour head and being able to interrelateall that is really important..."14. (important) "...you had big^ C^C Cdecisions to make... they're everydaydecisions for an RN but we were justlearning... once you've made a decisiona few times then you learn that you havethe knowledge to make them again andagain..."15. "...I learn best from doing things^A^A Band urn doing them in the lab. just isn'tthe same as doing them in clinical Iguess because it's just really hard tomake-believe that the dolls are real andto treat them as if they are real...13416. "...now that I know about all this,^B^B Bthe liver and all the problems and Ireally looked at someone who had liverfailure it really had solidified it,made my thinking more deep. I think I'mtrying, putting more and more thingstogether that I didn't really puttogether before...I think it's just kindof a process..."17. (learning experience) "...I had^A^A Atrouble with the sub-q. injections withdiabetics, she (instructor) didn't likehow I'd done them and I didn't reallyeither...I read on the techniques on howto do it properly...it's just therefining part of it she was quiteparticular about and I thought if that'swhat you want lady you're going to get it...I took a couple of times cause like Isaid she was a perfectionist, it had tobe perfect for her."18. (memorable) "the clinical instructor^A^A A... it was a case of a relationship withher...I didn't know quite where she wascoming from... she was a perfectionist...it made me be careful and make sure Ididn't do anything wrong..."19. (trying to accomplish) "...getting^A^A Athrough it...do the work that was requiredof me...applying the theory to clinicalexperience...answering, the instructorwould put out questions, then you wouldhave to answer them, like for medicationsfor instance, urn before you gave amedication you've got to research it tothe point that you know why you're givingit and it's actions... "20. "...with very few exceptions most of^A^A Athe things I'm doing now I've done beforeor I've learned before or I've been135exposed to before so there's not a lotthat I'm doing now that's new in the sensethat its new learning ...in clinical myonly interest is in doing what I have todo and to get it done and to do it right"136APPENDIX DDefinition of Terms Used in Describing Conceptions of Learning*Acquisition phase/pole of learning: The occasion/s when learning occurs as comparedto the occasion/s for using what is learned.Application phase/pole of learning: The occasion/s when what is learned is used ascompared to the occasion/s when learning occurs.External horizon: A part of the structural aspect of conceptions that refers to the wayin which learning is delimited from and related to its context.How aspect of learning: The ways in which students interpret and comprehend howlearning takes place. It refers to the acts or process of learning.Indicators of conceptions: The characteristics of a conception that distinguish it fromthe general characterization of learning that is common to all the conceptions in theinterview data.Internal horizon: A part of the structural aspect of conceptions that refers to the wayin which the component parts of learning are discerned and are related to each other.137Referential aspect: The global meaning of learning or the way of seeing learning ina particular conception.Structural aspect: The way in which learning, as described in a conception oflearning, is delimited from and related to its context and to the way in which thecomponent parts of learning and the relations between them are discerned.What aspect of learning: The ways in which students interpret and comprehend whatthey encounter in learning. It has two interrelated parts, an expression of theunderstanding of the content and an expression of what learning means.* Taken from: Beaty, E., Dall'Alba, G. & Marton, F. (1990). Conceptions of learning.Manuscript submitted for publication.138


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