Flanagan (2000) defines work-based learning as a collection of acquired knowledge, work experience and basic knowledge. It uses formal structure and the learner management to increase learning and professional development opportunities in the workplace. This definition also includes learning at work and educational activities which enables reflection, values the learners experience and learning opportunities in practice and which enhance the development of professional knowledge.
Barr (2002) suggests that learning can occur at the work place or outside of work with the plan of improving work performance. In the context of health care, work-based learning has the potential to meet the needs of nurses by promoting learning that is practice driven (Walker and Dewar 2000). It allow students to find the learning abilities of their experiences, link learning to practice and interpret learning for the purpose of assessment (Swallow et al 2001).
It is in view of these operational definitions that I delivered a training during one of my team’s practice development sessions on “Using KGV as an Assessment Tool”. KGV was first published by three Psychiatrists in 1977 by; Krawiecka M, Goldberg D, and Vaughn M. as a standardised psychiatric assessment scale for rating chronic psychotic patient (Gamble, C. & Brennan, G. 2000). It was later revised by Stuart Lancashier in 1996 called Manchester Symptom Severity Scale. This is to enables the user to express and measure the severity of those psychotic symptoms that are most commonly experienced by people who have psychotic illnesses such as schizophrenia and bipolar affective disorder.
Corrigan et al (2001) argues that there is evidence that work-based training which is interactive with staff and practice development approaches can bring improved outcomes (McCormack et al 2006). These focus on the team in the practice setting, enabling staff to learn new practices together. In this case the training delivered adopts a bottom-up approach tailored more to team needs and, as a result, stronger ownership of the practices being developed at the end.
Nine band 5 staff nurses and Six healthcare assistant, from two adjacent single-sex acute admission inpatient wards, took part in the session. This was a relatively mature group: six were over 40 years old and nine under 30 years of age. Some staff has never been formally trained and some need to be refreshed on the use of the tool to make them more versatile. Most had been qualified for many years and they had been working on the wards for over six years. Given the differing range of skills among participants, an important feature was flexibility of approach to meet each learner’s needs. The main components of the approach adopted included the following: Therapeutic skills teaching because of the topic. A key aspect was the development of a strategic approach to encounters with service users in preference to random dialogue in using this assessment tool. The overall approach aimed to enable participants to change by becoming more self-determined in their team and being more facilitative, rather than custodial, in their role with service users when using the assessment tool.
The session started by introducing myself and the rest of the team followed. The aim of the session was explained which is to further develop staff knowledge of the use of KGV as an assessment tool within the acute inpatient admission wards. The objective was also elicited; at the end of the session staff are expected to be able to use KGV as an assessment tool to enhance patient care. The team were asked open question to begin with to encourage participant to talk, and to ascertain their needs and expectation of the session. This is also to determine how much they know about the subject. This approach was achieved based on the psychological learning theory described by Kolb (1984), which relates to experiential learning. This involve asking questions which encourage reflection, conceptualisation, and ways of testing the ideas.
Psychologists have attempted to explain how the process of learning occurs. The main theories are explored in the context of the clinical environment, and lifelong learning. Behaviourism Psychologists from the behavioural school believe that the environment is crucial to learning: if the environment is right, learning occurs as links are made between what is offered and how people respond to it. (Quinn 2001). In this instance the room used for the session was spacious and well ventilated. The sitting arrangement was oval shape that enabled interactions between everybody in the room. It is secluded and away from the noisy environment on the ward that prevents interruptions. Although often criticised for emphasising performance at the expense of the individual’s thoughts and feelings (Quinn 2001), behaviourism has some areas that are beneficial, particularly in the area of skills building and this is particular relevant to the session. Skinner (1990) concluded that hard processes need to be learned in stages, each stage being organised and built on previous ones.
Cognitive theories consider learning as an unconscious process that involves higher order mental activities such as memory, perception, thinking, problem-solving, reasoning and concept formation. Cognitive theories were built in response to behaviourist theories and include meaningful learning and discovery learning (Atkinson et al 1990). Learning occurs according to the relations between new information that the individual accumulates, and the specifically relevant structures that the learner already has (Ausubel 1968). The session was delivered to ensure the interaction results in the assimilation or incorporation of both new and existing information to form a more detailed cognitive structure (Quinn 2001).
This implies that information is not just added to the old in a cumulative way; rather it acts on the current knowledge and both are changed into a more recent and detailed cognitive structure. The student’s starting point is an important principle of Ausubel’s (1968) theory. With this in mind one of the first thing I did was to ask all the participants to explain their current understanding and/or previous experience of using the KGV. This enabled me as a facilitator to relate learning more closely to individual needs thereby achieving greater effectiveness and saving valuable time.
Humanistic psychology and learning is a general term for a group of theories that emerged in response to scientific explanations of the person. It is concerned with ‘the self’ – distinctly human qualities such as personal freedom and choice, and places value on individual experiences (Tennant 1986). Among the humanistic psychologists Rogers (1983) and Maslow (1968) developed theories based on their experience in clinical psychology. They indicated that humans beings have two main needs – a need for growth and development and a need for positive regard by others.
The above thoeorists focus on how individuals perceive and interpret events rather than on objective scientific interpretation. Rogers (1983) applied to education his extensive experience of observing clients learning through client-centred therapy, concluding that learning is essentially a helping process. This is reflected in the key features that form the basis of his humanistic approach to learning – that education should be student-centred and that the teacher becomes a facilitator of learning. The features of the humanistic approach are summarised by Joyce and Weil (1986): ‘individuals have a natural drive to learn, learning can be enhanced by using experience and self-evaluation which promotes independence and creativity’. The whole session was interactive and participants were encouraged to be expressive on the topic since some has been using it before.
Hinchliff (2004) suggests that social learning theory can be seen as part of the behavioural approach, although it relates with the cognitive areas. It is defined by Atkinson et al (1990) as: ‘learning by watching the behaviour of others and observing what consequences it produces for them.’ It is often described as learning by ‘sitting next to Nellie’, and is probably one of the most common ways that learning takes place in clinical areas. Quinn (2001) believes that people learn by the type behaviour they observe and how they express difficult feelings , although ultimately the quality of the learning depends on the quality expressed by the role model. The scoring system when using KGV is a bit complex, I went through this process with the team and actually completed one to make it practical.
Reece & Walker (2002) suggests adult learners are able to learn more using humanist approach rather than behaviouristic principle. A humanistic approach was used in facilitating this session because it emphasises the effective aspects of man as being of equal importance to the cognitive and psychomotor elements however a bit of each theory was used (eclectic approach). During the session I was able to encourage participant’s participation, a relationship of mutual trust can promote the natural potential for growth and development. It was also remembered that for some of us, the deepest learning and the best performances have occurred in the most anxiety-provoking situations. Adopting a humanistic approach does not mean that students were protected from such situations. Rather, they were all supported and guided through them.
Skinner (1990) argues that praises and rewards can be used as a positive reinforcement and should be given immediately and regularly to have an impact on the individual. When there is a delay in giving praise and reward, this would no longer have effective because it would not be linked to the behaviour. Hinchliff ( 2004) stated that reward can take form of smiles, nods and verbal encouragement, all these were put into use during the session with the learners.
Knowles (1984) explains the theory of andragogy as a process through which adult learners takes in knowledge differently to children. He uses the term ‘andragogy’ to describe the way in which adults learn, and pedagogy to describe how children learn. The andragogical approach to teaching includes of seven elements which a facilitator should take into consideration (Knowles 1984):
Setting the climate for learning This involves both the physical and psychological environment and takes account of mutual respect, seating arrangements, working together, supportiveness, openness and being real and a climate of humaneness. In this instance the room used for the session was spacious and well ventilated. The sitting arrangement was oval shape that enabled interactions between everybody in the room. It is secluded and away from the noisy environment on the ward that prevented service users from knocking at the door. Power point was used to present the teaching material that was projected to the wall, this made it visible and distance between the participants and the wall was appropriate.
Involving learners in mutual planning The two teams were involved jointly organising and arranging learning opportunities in line with the participants identified learning needs. This was led by two team leaders.
Involving learners in identifying their learning needs This is was achieved through discussion with the participants in the light of the focus on the topic. Decision was too focused on the application of KGV and to make it relevant to our client group.
Involving learners in the formulation of objectives Prior arrangement had taken place between the two leader of the two acute ward on re enforcement of using KGV on the two units. This was discussed in staff meetings.
Involving learners in the design of lesson plans all the participant were aware of the rudiments of practice development forum and the learning contract was tailored to ensure that teaching is centred on the needs of participants and was delivered at their level.
Helping learners to carry out their learning plans This is made possible by the facilitator. There was prior arrangement between the facilitator and the participants to read around the subject.
Involving learners in evaluating their learning This should include qualitative as well as quantitative evaluation. This was done at the end of the session and all participants filled in a form that has ten questions regarding the session. There was also discussions on how we can improve our forum to make it more relevant to our need. A follow up session was arranged to support staff progress.
Reece and Walker (2002) believe that adult learning theory is highly relevant to professions such as nursing, suggesting that facilitators need to provide an appropriate and individualised patient-centred learning that meet patient’s needs. Andragogy is similar to the humanistic psychology approach to learning as both support shared responsibility for learning and a learner centred approach. Staff Nurses are adults and, as such, are encouraged to take responsibility for their learning. Knowles’ (1984) seven elements above provide a useful framework for encouraging learning, based on the identified needs of students.
Knowles (1990) believed that andragogy would give the field of adult education a balanced theory and a sense of unity. While pedagogy is defined as the art and science of educating young children, and viewed andragogy as any intentionally and professionally guided activity that aims to bring about a change in adults. Andragogy therefore supports a proactive approach to learning in which enquiry and freedom feature predominantly. It has much in common with the student-centred approach.
To achieve the goal of this session, andragogical process was used. By adopting the above learning strategies, participants felt effectively supported as adult learner and became relaxed. Two main principles that apply are; student-teacher relationship and learning environment.
Sutcliffe (1993) investigated whether nurses’ preferred learning styles varied according to subject area studied. The results suggested that there was a change in learning style as different subjects were studied. Other factors emerging were the importance of prior learning experience, they wish to share, acknowledge and the need for close relation between theory and practice. Thus, learning style preferences influence the way in which students respond to an educational programme in relation to mastering its goals and objectives. The topic of the session is familiar but we were trying to re validate it and see how we can better enhance patient care. At the start of the session when the an open question was asked not many responded considering the fact that it a familiar topic to some.
Kolb (1985) asserts that it is important for individuals to understand their learning styles so that they can increase their effectiveness as learners. Divergers excel in concrete experience and reflective observation. As with any behavioural model, these styles of learning are dynamic. Nonetheless, most individuals exhibit strong preferences for a given learning style. However, Kolb et al (1995) maintain that each individual’s learning style is not necessarily static and that in using them there is a need to prevent the danger of being stereotyped. Honey and Mumford (2001) developed their learning styles questionnaire as a variation on Kolb’s model. The four learning styles are:
Activists who are dominated by immediate experiences and mainly interested in the here and now. They like to initiate new challenges and to be the centre of attention. I realised most are not forthcoming in responding to some of questions asked and at times lots of prompts before any response.
Reflectors are observers of experiences and prefer to analyse them thoroughly before taking action. They are good listeners, cautious and tend to adopt a low profile. As the session progresses participants became more open and interactive possibly after they have ascertain and able to analysis the theory behind the subject in question.
Theorists like to adopt a logical and reasonable approach to problem-solving but need structure with a clear purpose or goal. Theorists learn least well when asked to do something without apparent purpose, when activities are unstructured and ambiguous and when emotion is emphasised. There was a great deal of participation when we work through a scenario.
Pragmatists are keen on trying out ideas and techniques to see if they work in practice. They are essentially practical, down-to-earth people, who like making decisions and solving problems. The four learning styles: activist, reflector, theorist and pragmatist overlap and are a product of combinations of the learning from stages of experience. On a whole it will be fair to say that the class is mixed with all the learning styles.
The session was evaluated by the way of interaction between myself and the participants. One of the highlights was the pace of the delivery, it was too fast but this was due to the time constrain. However the participants did commend the quality of handouts which can serve as reference point for individual and the knowledge of the facilitator of the subject matter. The participant did agreed that a follow up session will be useful to evaluate how much impact the session has on care delivery on the two wards and this will be in relation to multi disciplinary working.
With the complexity and degree of change in practice, nurses are being encouraged to take responsibility for their learning. Work-based learning aims to encourage the student to be an autonomous learner. The delivery of work-based learning moves away from the concept of the teacher imparting knowledge towards the model of the teacher being a facilitator of learning (Chapman and Howkins 2003). This method of learning is consistent with the underlying philosophy of adult-centred learning (Knowles et al 2005). This is where adult learners are responsible for their learning which is self-directed and have a readiness to learn. However, even when adults are willing to assume responsibility for their own learning, they will have different aptitudes for certain kinds of learning (Russell 1990).
McCormack et al (2006) reckons that work-based learning is not a panacea to providing effective learning that leads to effective practice, the consensus however is that it offers many benefits. Delivering the session on KGV has enhanced my port folio as individual and gives our practice development forum more recognition. It has also contributed to learning environment and training of staff within the clinical environment which will enhance patient care.