Personal Reflection on Exploring the Learning Experience
"Mentor will demonstrate giving hygiene care in a number of situations and explicitly model good hygiene practice" (from Skin Care learning programme)
When I was designing the learning programme, the very first part I considered was the modelling of good practice as being an essential basis of learning basic nursing skills. From my own experience, this comes from my memories of the significance of learning about nursing by observing other nurses' good practice, especially mentors and experienced nurses. I tried to organise the learning programme to allow a good amount of time where the mentor can work with student F directly and demonstrate good practice.
The "model" of learning I am using here informally and I suspect unconsciously is learning by first observing and then by doing with some feedback. This intrinsically makes sense to myself and is familiar and feels comfortable. However, when I came to describe a rationale for using this approach, I found myself a little unsure about how to justify it. I was unsure if this was the best approach to take with student F. Perhaps she would be uncomfortable with having to display the skills she has learned in week two and three. She may have been more comfortable with a less explicitly defined part of the programme
The question that arose for me was: if this the best learning "model" to teach these basic nursing skills? I was intrigued by the idea there may be an alternative way that I was unaware of.
The first question is whether this "model" or method of learning is a valid way to teach these essential nursing skills. Did it actually allow a student to learn a set of skills and knowledge? My assumption is that I had learned in my own training by watching an experienced nurse showing me a skill and then I had a chance to demonstrate the skill under the supervision of the same nurse.
However, I am not so sure that this was the full reality of my training as a nurse. Perhaps, I had learned more on an ad hoc basis; where for some things I had watched repeatedly different "exemplars" of a skill over a period of time. Then when I felt more confident, I would try a skill out with supervision from an experienced staff nurse, and get some guidance. I would then repeat the skill often to build up confidence and competence.
I think the difference I am trying to make in the learning programme is by making this method explicit, planned, and also assessable. I wanted to relate the practice by student F. of basic hygiene care to assessing her competencies. Perhaps, the planned structure of learning experiences linked to assessment means this is more valid than my own ad hoc experience of learning to nurse.
Next, I wanted to consider any alternatives to this method of learning? There are a number of different ways to learn and to teach, which may well be appropriate in the class room, and the laboratory, and in the tutorial room, and even at home by distance learning. However, which methods could fit in a clinical setting, and which could specifically teach essential nursing skills such as helping a dependant patient to wash and dress and to go to the toilet.
I knew that discussion and theory and case study were elements I had included in the learning programme especially around wound care skills. However, when it came to learning how to give essential care I struggle to see any effective alternative, unless removing the planned element and making it more ad hoc as I think it has been for my own training.
A further consideration is that I have not accounted for student F's previous experience as a care assistant. She may be very skilled at providing hygiene care or may feel she is competent. However, she may be skilled when working in a familiar environment such as a care home and needs to learn to apply her skills to a different area.
There appear to be two differing models in the literature: one is the called the traditional model which is teacher led and passive and about imparting of knowledge to the student. The second model called the modern model is about active learning, self direction and problem solving (Boud and Walker, 2003).
Jarvis and Gibson (2001: p67) suggest that low level skill learning is by a non reflective repetitive model which they state is appropriate to manual skills learning, and contrasts this with what they call reflective skills learning which involves a level of cognition, which with reference to professionals they call "thinking on their feet". They regard nursing practice ideally as lying within the realm of reflective skills training. However, they state that skill teaching frequently adopts the non reflective route (Jarvis and Gibson, 2001).
The way of teaching hygiene skills I have planned here seems to fit best with the first traditional model of learning. I am aiming to demonstrate the skill in an experienced manner and expect the student to learn how to model their skill on my own. It is a passive way of learning rather active and involving which may be a weakness. Payton (Hodge and Oates, 2005) provides a description of this type of model where a skill is first identified, then demonstrated then practiced (repeatedly) which leads to mastery of the skill. It would seem from theory that the informal "model" in this essay can be a valid way of teaching basic nursing skills.
The traditional teaching models have an authoritarian basis: the teacher or mentor is the expert and knows best. This may be sufficient in learning basic skills, however, when learning to practice competently then the student may have become too used to non reflective learning (Jarvis and Gibson, 2001). These models do not take into account what the student already knows and this could lead to non learning situations, where the student already knows enough to carry out the skill or task in one situation (Jarvis and Gibson, 2001). This could apply to the learning programme here for student F. as she has many years experience as a care assistant and may feel she is competent at these basic skills. A more facilitatory approach such as a constructivist approach might improve motivation and develop problem solving (Banning, 2005).
A possible alternative or indeed evolution to the traditional didactic model may be suggested in two articles by Ohrling and Hallberg (2000, 2001), based on studies in Sweden. The experiences of both mentors (preceptors) and students are examined and several common themes are identified.
One is "creating space to learn": being with students in genuine nursing situations and encouraging questions. Second is "providing concrete illustrations": acting as a role model and narrating during nursing situations (Ohrling and Hallberg, 2000). Another is "using different methods": demonstrating and talking about different ways of dealing with nursing situation or problem (Ohrling and Hallberg, 2001).
The idea of "nearness" is interesting where the mentor will work more closely with the student when new skills are being learned and part of the process is allowing the student to develop their own way of doing the skill by stepping back as the student practices, and grows in their competence with a skill (Ohrling and Hallberg, 2001).
It seems that Ohrling and Hallberg (2000, 2001) provide the basis for a possibly richer, useful and more effective model of how to teach nursing skills. There is some evolution from the traditional didactic model which is necessary if the aim is to educate capable and reflective practitioners. One of the challenges is to teach basic yet essential skills to nursing students.
When designing the Skin Learning programme, I did not take into account student F's prior experience as a care assistant. I would have to take this into account in assessing this in the first week. I would try and find out what she wanted to learn and what she felt that she knew well.
I would try and use the idea of "concrete illustrations" to demonstrate examples of hygiene skills. I would try and show different ways in which a task can be dealt with. I think that the use of narration during care deliver could be appropriate if done sensitive to the patient's dignity. I would use the idea of nearness/ distance to try and supervise students as they develop skills and confidence in their abilities.
I think in future I would adapt the programme to be more flexible and responsive to the student. My aim would be to involve the student and collaborate to produce a more useful learning plan.
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