Teaching and Learning in Nursing Practice (Clinical Practicum Analysis)

Introduction

Teaching is not the exclusive domain of academic institutions; there is pressure on the health professionals to satiate the ever-increasing demands of the patients and public for better and efficient services due to advancement in medical sciences which has made detection, diagnosis and treatment of diseases easier. Nurses play an important role in the education of fellow nurses and that of patients and public besides their own education. Increasingly, less doctors and nurses prescribe medicines in their consulting rooms to the submissive patients. Learning and teaching in nursing practices is an important activity that is being carried out on a regular basis; this requires them to update their knowledge and skills constantly. Evidence-based practices enable the health care professionals to explain or justify the procedures carried out in good faith.

Clinical teachings are conducted in most hospitals in Bhutan; it not only educates patients and their escorts but also enhances the learning and teaching techniques of the health professionals. The monthly clinical and mortality meetings provide good forums for teaching-learning activities. During these meetings, discussions take place on medical cases and ways to manage them effectively. Nurses make presentations on clinical topics and receive feed backs; they also conduct clinical presentations in the presence of the nursing superintendents.

This Paper is a descriptive analytical report on clinical teaching practicum conducted by the author. References are made to the relevant literature. The practicum was aimed at teaching mothers to manage children with diarrhea at home with the use of Oral Rehydration Salt (ORS), and to seek timely medical assistance when the ORS fails to produce the desired results. Observers (fellow nurses) used standard forms and formats to assess the presentation and provide feed backs (Annexure I). The outcome of the practicum is derived from the assessment made by the observers and author’s own evaluation of the performance of the participants. The practicum proves that given the right teaching strategies and techniques mothers could manage simple and common aliments at home.

Learners and Learning Needs

There are different theories on how the learners learn best based on their dominant perspectives, such as psychological theories, developmental theories and social theories (O’Corner, 2001). The learning need differs from group to group depending on their goals or objectives, which may change with time (Ray, 2004). According to Knowels (1980), it is the situation or circumstances which compel people, especially the adults, to learn; and the knowledge shared and perspectives formed by a group of learners become a source of new learning. In such a scenario, the educator simply facilitates learning rather than providing knowledge; the group learns itself.  Similarly, Friere, (cited in O’Corner 2001) states that “[l]earning is a collective process among individuals who, together, seek solutions to the everyday problem of life.”

Adult-learning or andragogy differs from children-learning or pedagogy (O’Corner, 2001). Children learn as a part of the overall development. Adults, on the other hand learn in order to fulfill specific needs like career advancement. This Paper, for instance is being written to update the knowledge of the author as well as for her career advancement. Similarly, conducting a practicum has a dual purpose. Firstly, it improves the teaching skill of the presenter. Secondly, it enhances the knowledge of the target audience.

The pre-assessment of the learners showed that most of the mothers did not know how to prepare the ORS correctly although most of them exhibited familiarity with it. There was confusion on the quantity of water required to dissolve the specific quantity of ORS.  They used bottles of varying capacities to dissolve arbitrary quantity of ORS. This was mainly due to inability or negligence of the mothers to read the capacities of the containers inscribed on them. Some mothers used either hot or cold water instead of boiled and cooled water. A few mothers fed ORS to their children in its original powdered form.

Clinical Practicum

Clinical teachings were conducted in the wards of Samtse District Hospital for the mothers who were caring children suffering from diarrhea towards partial fulfillment of the assignment. The number of participants varied from a minimum of three to maximum of five mothers in a group excluding the nursing collogues evaluating the author. The teaching sessions were conducted at five different times with different groups of mothers, each session lasting for about two hours. It was expected that at the end of the session, the mothers would be able to detect the signs and symptoms of dehydration and administer ORS to their children effectively; they were expected to be able to prepare oral rehydration solution correctly as well as decide when to seek medical help.

The session commenced with the pre-assessment of the knowledge of the mothers on diarrhea and its management, followed by the statement of the objectives of the sessions. Attempts were made to make the session as lively and informal as possible and keep learners interested and motivated through out the session; they were made to feel comfortable with minimum distraction. A baby patient was used as an example beginning with its condition at the time of admission. Gradually, the mothers were shown the signs and symptoms of dehydration – for instance, sunken fontanel, absence of tears when crying, dry mouth, slow retraction of the skin when pinched, the child is irritable and lethargic, etc.

The mothers were then shown how to prepare the ORS emphasizing on the cleanliness to be observed during the process. Irrespective of the nature and size of the containers - soft drink bottles, wine bottles and mineral water bottles, mothers were shown to prepare a packet of ORS in a liter of water. It was made sure that the water was boiled and cooled before dissolving the ORS in it. Every mother was given opportunity to prepare the ORS for acquiring first hand experience. This was followed by discussion during which errors committed during the preparation of the ORS were rectified. The session concluded with recapitulation of the lessons learnt during the session.   

Teaching Strategies

The importance of the choice of the teaching strategies can not be overemphasised as they have to be appropriate for learners in terms of their abilities, experience, and other characteristics (Reilly and Oermann, 1999). As stated by Heidgerken (1982), “lecture is a teaching procedure consisting of the clarification or the explanation of facts, principle or relationships which the teacher wishes to the class to understand.” However, as can be deduced from its definition, this teaching method, which is time-consuming, monotonous and involves fewer physical activities. It may suit the literate learners, not beginners, or illiterates, as is the case in this practicum.

Demonstration method is extensively used to teach nurses. It is also used in hospitals to teach patients and their relatives or escorts about procedures or treatments which they are required to carry out at home on their own (Heidgerken, 1982). This practicum was designed to meet the normative need of the mothers for the effective management of children with diarrhea (Bradshaw 1972, cited in Wass, 2000).   Since the learners were illiterate, ‘lecture-demonstration’ method was used consisting of short lectures punctuated by demonstrations with the help of audio-visual equipment. This method prevents monotony and formalism, and keeps the session simple and interactive. This teaching method was effective with these learners since the objective of the session was to improve the knowledge and develop the skills of the mothers for independent preparation of the ORS.  The medium of instruction was Nepali, the local dialect of the people of this part of the country. Each session was made as informal as possible in order to motivate the mothers to participate and get the maximum benefit from the session in terms of all three domains - “cognitive, psychomotor and affective” (Ray, 2004).   

As stated by Kirkpatrick, Weaver and Yeager (1998), strategies to evaluate the learners must be set up along with the aims and objectives of teaching-learning (p. 381). Similarly, learning has to be evaluated to determine whether the objectives have been achieved. In other words, teaching-learning process must include assessment of the needs of the learners, setting the objectives to be accomplished, selecting the strategies for teaching and, finally, confirm whether learners have achieved what the session intended. In this practicum, ‘impact evaluation’ method was used to assess the immediate outcome of the teaching (Ray, 2004); mothers were assessed through return demonstrations and verbal questioning.

Learning Outcomes

Evaluation is an ongoing activity at all stages of the session. There are mainly two methods to evaluate learning outcomes: The formative evaluation is conducted when the event to be evaluated is in progress; the summative evaluation is conducted at the end of the session (Kirkpatrick, Weaver and Yeager, 1998).  In the context of formative evaluation, for example, mothers’ attention to the lectures, readiness to learn and participate in return demonstration, eagerness and promptness to understand and answer questions led to the inference that the session was successful.  Summative evaluation was carried by verbal questioning technique which revealed that most of the mothers could understood signs of dehydration as well as remember the steps for preparation and administration of ORS.  This shows that the teaching strategies vis a vis the learners was correct and the outcome of the teaching fruitful. Some mothers were exceptionally quick learners considering their background and the length of the session.

Conclusion

Learning never ends; more so in the medical field. However, it would serve little purpose if the knowledge and skills are not disseminated.  Effective teaching requires use of appropriate strategies. Besides, the varied needs, backgrounds and circumstances of the learners must be taken into consideration. As this Paper shows, nursing practices demand analytical and problem-solving skills and involves continuous learning and teaching. However, nurses can not be an effective educator if they are not confident or well-informed. Besides, teaching is more than transferring knowledge from teachers to learners; teachers increasingly play only facilitative role. Further, the benefits and effectiveness of teaching must be assessed and feed back provided for improvement. After all, learning is not simply acquiring, retaining and applying knowledge; it must be useful to the learners and make them think critically and laterally.