The teaching session commenced with identification of the goals and expectations for clinical learning and continued through assessing students, planning electrocardiography procedure activities, guiding students, and evaluating ECG procedure learning and performance. The goals and expectations provided areas of assessment, teaching guidelines, and the basis of evaluating learning. They were often expressed in the form of clinical objectives established for the entire teaching session for specific teaching activities. The ECG procedure teaching objectives specified knowledge acquisition, nurturing of values, and performance of psychomotor and technological skills (Braunwald, 1997).
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The use of constructivist model as an essential approach in the teaching actively interacted students with the material system and concepts in electrocardiography procedure domain. Through effective supervision, students’ were able to discuss their developing understanding and competences in carrying out electrocardiography procedure (Gaberson, 1999). This paper is based on: teaching session conducted with peers in week seven. It reflects on my effectiveness as a teacher; the creativity and efforts applied to engage and teach learners; and broadly linking all these to the teaching philosophy, learning theories, and teaching strategies. The paper also analyzes the literature related to teaching electrocardiography procedure; teaching strategies used and details recommendations on how to improve future teaching sessions in the clinical environment (Tanner, 2009).
Relevant Literature Review Including Pedagogies used in Clinical Education
Learning involves the process through which knowledge, is achieved and provided meaning; and comes from experience, reading, and living life. The result of learning is growth, that is, transformation in thinking, feeling or behaving. Many studies that endeavor to explain how learning occurs have been done through the years; and they been done through the lenses of disciplines such as psychology, physiology, and sociology (Vandeveer, 2005). Findings of these studies have led in the evolution of theories that try to explain how individuals learn. A theory is developed from fact analysis in relation to one another and is then applied to explain a phenomenon. The knowledge achieved from such studies has contributed to the theoretical underpinnings for entire theoretical structures or frameworks for education (Roberta, 2003).
Behavioral Theories of Learning
Education has been influenced more by behaviorism than any other single theory. Currently, behavioral principles continue to be used appropriately and successfully whereas others have been rejected. Behaviorism foundational principles were developed by psychologists Pavlov, Thorndike, and Skinner; these principles were derived from observations of learning in animals (Braungart, 2003). There were also other behavioral theorists who presented a variety of principles. However, all shared a common element that all behavior is learned, and that learning is influenced through environmental manipulation in which it happens and the rewards given to encourage it (Vandeveer, 2005).
Behaviorism was carried into a classroom where learning experiences were structured in a manner that would assist educators attain goals through the development of objectives. Tyler (1979) stated that “the most useful form for stating objectives is to express them in terms which identify both the kind of behavior to be developed in the student and the content or area of life in which this behavior is to operate”; and this was the foundation of behavioral objectives. Bloom et al (1956) continued to make a classification of educational objectives that addressed the cognitive domain, “the recall or recognition of knowledge or development of intellectual abilities and skills” through the application of observable actions. Krathwohl (1956) led efforts in the affective domain of knowledge with a behavioral inclination. The objectives here were mainly emphasizing on “an emotion, a feeling tone or a degree of acceptance or rejection; also attitudes, values, appreciations, and emotional sets or prejudices” (Krathwohl, 1956). Achievement of the objectives continued to be through highly structured, clearly delineated, and visible behaviors. Behavioral theories enabled teachers and students alike to learn to construct behavioral objectives to guide teaching and identify measurable outcomes as the basis for evaluating learning.
Behavioral theoretical learning aspects are common and continue to be applied in clinical educational settings, particularly in gaining of technical skills. Commonly, at the start of clinical nursing education, what is important to known, experienced and demonstrated is determined by the faculty. Even today, faculty still retains primary influence and authority despite increase in students” involvement in their own learning. Knowledge grows, that is, prior knowledge forms a reference point for both the assimilation of new knowledge and the application transfer of knowledge from one learning experience to another. Understanding prior knowledge available allows the teacher to help students connect new knowledge to old and hence, improve overall understanding. Classically, technical skills are learnt as procedures, following a designed approach. The behavioral objectives, designed keenly to identify the expected learning outcomes, prescribes both exposure of students to learning experiences and for their evaluation. The sequential procedural format of the nursing process, and the resulting nursing care plans are a direct outgrowth of behaviorism. Any activity learners participate in that follows this procedure, for instance, development of teaching plans, reflects behavioral learning theories. Written and verbal positive reinforcement provides a strong extrinsic learning reward; and rewarding the achievement of intended outcomes is a key behavioral aspect.
Cognitive Theories of Learning
Behavioral theorists emphasize that which is external to the learner. On the other hand, cognitive theories emphasize on what occurs within the learner. According to cognitive theorists, mental processes involved in acquiring, processing, and structuring information are important aspects of learning (Braungart, 2003). They particularly identified six classes of cognitive learning; presented from simple to complex. These classes were; knowledge, comprehension, application, analysis, synthesis, and evaluation. Each class was broken down further into varying numbers of components. For instance, knowledge class may be broken into knowledge of specifics, then of ways and means to deal with those specifics, and the knowledge of the universals and abstractions associated with a given field of study. Each level is associated with specific learning behavior, also verbs descriptive of those behaviors, which are to be used when writing objectives (Bloom et al., 1956). Faculty formulates the appropriate objectives based on whether learning is new or constructed depending on prior learning, and the desired end point level of cognitive learning. Used verbs also give guidance for how the learning will be evaluated (Roberta, 2003).
Models of Clinical Nursing Education
Knowledge and understanding of models available in clinical practice empowers clinical education to work in a manner that suits teachers, students, and patients. Models have been defined as tools for generating ideas, guiding conceptualization, and generating explanations (Young, 2002). Clinical teachers can apply models in teaching to the procedure being experienced. Two approaches were used during the teaching session; traditional and constructivism models.
Teaching electrocardiography procedure requires careful design of an environment in which students get opportunities to build mutual respect and support for each other while they are achieving identified learning outcomes, that is, recording electrocardiography procedures. Teachers in clinical teaching form a crucial bridge to successful experience for students (Braunwald, 1997). Research in nursing education shows that effective medical teachers are clinically competent; are able to teach; have collegial relationships with learners and agency staff; and are friendly, supportive, and patient (Halstead, 1996). It’s essential for the teacher to be knowledgeable and able to share the knowledge with students in clinical setting. Such knowledge includes an understanding of the theories and concepts related to the practice of nursing, such as; recording electrocardiography procedure. Karuhije (1997) contends that attention to three teaching domains; instructional, evaluative and interpretational, facilitates achievement of teaching skills required to enhance success in clinical settings. Instructional infers those approaches or strategies adopted to facilitate knowledge transfer from didactic to practicum (Norton, 1998). Evaluative approach relates to making determinatives about performance and achievements as goals. Interpersonal approaches relate to relationships and interactions (Knox, 1985).
Competence in clinical practice of nursing has been documented as being necessary for effective clinical teaching. Gaberson (1999) revealed that best clinical teachers exhibit expert clinical skills and judgment. Expert skills have particularly been described by students to be important. They tend to describe effective clinical teaching as those who demonstrate nursing competence in a real situation (Horst, 1988). Knowing how to teach is also a prerequisite for effective clinical teaching. Wong (1988) adds that effective clinical teachers are expected to have expertise in the art of teaching. Equally important are teacher behaviors that facilitate learning and support students in their acquisition of nursing skills (McCarbe, 1985). Brophy (1998) reveals that empirical evidence exists that correlates specific teaching methods with enhanced student learning; examples of such methods are use of objectives, effective questioning, and responding to questions. A study conducted by Pugh (1988) revealed that preparation and the ability to explain concepts clearly and stimulate learning are also important. Other effective behaviors include being fair in evaluation, communicating expectations clearly, and providing positively timed and specific feedback (Nehring, 1990).
Adoption of constructivism approach to teaching in nursing gives nurse teachers with a new vision of teaching. It also parallels a paradigm shift in nursing practice from nurse centered to patient centered nursing practice (Bevis, 1989). In constructivist teaching, the teacher commences with the experience of the student and together they develop knowledge, skills and competencies for professional practice (Bergum, 2003). Teachers who embrace constructivist teaching not only prepare student nurses with the substantive knowledge necessary for competent practice, but also create an environment in students learn to think critically, practice reflectively, work effectively in groups, and access and use new information to support their practice, while modeling respect for meanings of lived experiences, learning and collaborative processes (Bevis, 2001).
Bergum (2003) envisions nursing as a dynamic, interpersonal, generative and caring practice. To be consistent with this view of nursing, teaching nursing should be a relational, generative practice that occurs formally and informally; between the student and the teacher; the student and the patient; the student and colleagues; the student and peers; and the student and professionals from other courses (Young, 2002). Such learning needs to occur in diverse settings including the classroom, lab, and clinical areas; hospitals as well as community sites. Teaching nursing requires facilitating a thoughtful engagement between the learners and learning materials to ensure that students gain skills and knowledge for rotational (Bergum, 2003).
Constructivism is a philosophy that applies well in clinical teaching. It bodes well in clinical teaching and learning since its central focus is the idea that students construct knowledge for themselves (Young, 2002). Students construct meaning individual as they learn. They attain this by reflecting on experiences. Under constructivist theory, students make their own rules and mental models which they apply to make sense of their experiences. Miranda (2005) provides guiding principles of constructivism, which includes: learning as an active process, searching for meaning. Therefore, it must commence with issues around which learners are trying to construct meaning actively; learning as a social activity associated with link to other people, such as, the teachers and peers; constructivist learning that concentrates on primary concepts, not isolated facts; understanding mental models in order to teach well (Wong, 1987). Learners use mental models to perceive the world and the assumptions they make to support those models; the learning purpose for individuals to construct their own meaning. Assessment requires being part of the learning process and gives learners information on the quality of their learning; time taken to learn. Students need to revisit ideas, think over them, try them out, and use them for significant learning to occur; and finally motivation as an essential tool for learning (Miranda, 2005).
Models, Theories and Principles of Teaching and Learning
In teaching ECG procedure, five steps followed in clinical teaching process; identifying the goals and learning outcomes of ECG procedure, assessing the learning needs of students, planning ECG learning activities, guiding learners, and evaluating ECG learning and performance. However, this process was not linear; instead each of these steps influenced the others. For instance, ECG procedure evaluation revealed data on further learning needs of the learners, which suggested fresh learning activities. Similarly, working with students, resulted to observations on performance that altered assessment, thus, suggesting different learning activities.
First, the session commenced by identifying the goals and outcomes of the ECG clinical experience. Teaching at this stage was formed by behavioral theories which contemplated learning as influenced through environmental manipulation. This theory was carried into classroom in a way that assisted in making learners understand: the different aspects of ECG; reasons of using ECG; emergencies which require ECG for diagnosis; how ECG is conducted in an emergency: and ECG recordings generally considered as normal and abnormal. These learning goals and outcomes provided clearly areas of assessment, teaching guidelines, and the basis for evaluating learning. They were often expressed the form of clinical objectives and established for the entire teaching session, and specific clinical activities. Gaberson (1997) stated that learning objectives ‘may specify knowledge acquisition, development of values, and performance of psychomotor and technological skills.
ECG teaching objectives addressed eight key areas of learning; knowledge, concepts, and theories applicable to perform an ECG procedure; assessment, diagnoses, planning, and evaluation; psychomotor and technological skills; values related to patient care, families and communities; communication skills, ability to build interpersonal relationships, and skill in collaboration with others; leadership abilities, role behavior, and management care; accountability and responsibility on the part of the student; and finally, self development and continued learning. Guided by the traditional approach in clinical teaching, a learning environment was designed in a way that provided students with opportunities to build mutual respect and support one another while they achieved competence in performing ECG procedure (Braunwauld, 1997).
The teaching strategy specified learning outcomes in terms of students’ competencies in demonstrating ECG procedure in full. They were able to have basic knowledge on carrying electrocardiography procedure in an emergency situation. As postulated by Lippincott (2008), electrocardiography is one of the essential and commonly used procedures to evaluate a cardiac arrest patient in an emergency circumstance (Braunwald, 1997). Through electrocardiography, the heart’s electrical functions as a wave form can be displayed. Electrocardiogram is able to monitor impulses moving through the conduction system of the heart producing electric currents that can be monitored on the body’s surface. Normally, the electrodes attached to the skin can sense these electric currents and send them to an electrocardiogram; an instrument that produces a record of cardiac activity (Lippincott, 2008).
Braunwald (2008) states that electrocardiography can be used effectively in diagnosing several conditions of the heart. Nurses who encounter patients in emergency wards must have knowledge on the importance of electrocardiography procedure in a life saving situation. The responsibility of caring patients with cardiovascular disorders cuts across every area of nursing practice. As a result, cardiovascular care is a rapidly growing area in nursing. Lippincott (2003) mentions cardiovascular care to be a dynamic field, with continued inventions of new diagnostic tests, new drugs and other treatments, and sophisticated monitoring equipment. Consequently, nurses need to keep up with these changing developments through relevant clinical education (Lippincott, 2008).
The students were able to demonstrate their specific abilities; and often reflected their proficiencies required to perform specific tasks on ECG procedure that assigned to them. Performance criteria were established to determine the level of learner achievement of competency in carrying out necessary ECG procedure. For instance, gauging performance criteria for competency of; understanding the value of ECG in an emergency situation, assessing potential cases that require ECG attention, interpreting the electrical activity of the heart and its recordings by using skin electrodes (Lippincott, 2008).
Constructivism model provided a new vision of teaching. Students were allowed to participate in the clinical objectives and competences established for carrying out ECG procedure from simple to complex. This approach made it possible for learners to be prepared with substantive knowledge necessary for performing ECG procedure. It also created an environment where students were able to think critically, practice ECG procedure reflectively, collaborate in groups, and others. Some of the outcomes were achieved by learners and had to add others to meet individual learning needs and goals. Student objectives were made flexible to the extent that they met essential ECG procedure objectives. Learning activities were directed by asking questions that provoked thought without interrogating them. Asking open ended questions about their thoughts and the rationale they applied for reaching at clinical decisions, enhanced their growth of their critical thinking skills. Queries were asked to assess students grasp of relevant concepts and theories and how they were used in clinical practice (Bergum, 2003).
The key principles of constructivism were applied to create sessions which assisted students to graduate with their own ideas. For instance, they were assisted in openly sharing their ideas through discussion strategy during and after each learning session. They were free to vary their concepts whenever possible. This enabled them remember the key concepts of electrocardiography. Frequent assessments on the students enabled to evaluate their strengths and weaknesses. conveniently asked and valued their interpretations of what they learnt. Teaching plans were also varied effectively at some points to cope with the intelligence and cognitive abilities of students. What students provided as feedback, was not considered in a prejudiced manner; neither were judgmental comments (Brooks, 1993).
Secondly, an assessment was conducted on the learning needs of students. The assessment was guided by cognitive theory which assisted in formulation of appropriate objectives on what the students had learnt. Teaching started at the level of the student. Therefore, assessed was done on; the present level of knowledge and skill of the students’, and other factors that may had influenced their achievement of objectives. Data was collected to determine whether the students had necessary knowledge and skills to carry out ECG procedure and complete the learning activities. The teacher’s assessment was important as it engaged learners in learning activities that developed on their current knowledge and skills in ECG procedure competencies (Young, 2002).
Third, instruction planned and delivered following the assessment of students’ learning needs. The plan for learning activities catered for clinical objectives and individual learner needs. Selected ECG learning activities met objectives of carrying out ECG procedure effectively. The learning activities included patient assignments where learners engaged in practical setting. Miranda (2005) contends that constructivism advocates for a curriculum that is related to learners’ prior knowledge and puts more emphasis on problem solving. Therefore, concentration focused on connecting between facts and fostering new understanding among learners. They heavily depended on questions that are open-ended and were encouraged dialogue among them. Constructivist model had direct application in ECG procedural setting, based on these facts. It centered in providing an overall approach that involved other theories and approaches, such as; experiential learning, reflection and problem based learning. It enabled teacher and faculty to direct educational experiences to suit their clinical setting and provide learners opportunity to integrate their learning (Bradshaw, 2006). More so, it accorded learners responsibility to make sense of what goes on in ECG clinical setting and motivates them grow and nurture a deeper understanding of ECG procedure (Cobb, 1999).
Fourth, they were guided in achieving essential knowledge, skills and values for ECG practice through problem solving strategy. Facilitation and support of the process enabled students to achieve the intended outcomes; guiding them with their learning activities. Demonstrations were made to learners and they were questioned to enhance their levels of understanding ECG procedure. As a skilled person in this practice, the teacher was able to: observe learners clinical performance, make sound judgment about their performance, and planned for extra learning activities in instances necessary; and questioned students’ without interrogation. Observing learners as they performed the ECG learning activities enabled teacher to identify continued areas of learning and establish when help was needed (Gaberman, 1999).
The third session was conducted in a training class in the ECG room where learners were taught on how ECG procedure is taken. They were provided enough opportunities to perform electrocardiography procedure themselves. In collaboration with the technician on duty, learners were guided throughout the clinical practice. At the end of the session, the students were able to: examine the patient in the emergency room and understand the significance of ECG procedure in a life-saving scenario; perform an ECG as an initial step with patients who arrive with cardiovascular complications, chest pains or after an accident; interpret the electrical activity of the heart and externally by using skin electrodes; and perform non invasive procedure in patients (Lippincott, 2008).
Fifth, effective evaluation of clinical learning and performance was done on learners. The evaluation served two important purposes; formative and summative. Learners’ progress was monitored towards achieving clinical objectives through formative evaluation; through written examination. Demonstration strategy was also used to ascertain their competency in clinical practice. Through formative evaluation strategy, diagnoses for extra learning requirements of students and where additional clinical instruction was required for further instruction was realized.
Recommendations for Improving Teaching Strategies Based on Feedback from Peer and Analysis of Literature
Based on the feedback received from peers and analysis of the literature, the following recommendations to improve future teaching sessions in the clinical environment were suggested; one, identification of challenges learners are faced with. Commends made by peers indicated that teaching did not take into account the challenges the students faced. It was noted that initiation process of probing to understand students well was lacking. For instance, they may have been overburdened with family issues, language problems, fee problems, and many others. These factors impede effective clinical teaching as it heightens the fear of nurses to make mistakes that could injure patients or even fail a program (O’Connor, 2001).
Two, recommend extension of the possibilities of evaluation showing learners performance in relation to teaching and learning objectives. Ghazi (1988) noted that motivation for learners was sustained through strategies such as individualized learning, formative evaluations, and others. Teaching did not quite offer feedback on the areas of strengths and potential areas of development for students. Students were not given opportunities to evaluate their learning (O’Connor, 2001).
Three, recommend further research on effective characteristics of clinical teachers. The analysis of related literature reveals that students judged effective teachers as those having characteristics such as being clinically competent, knowledgeable, good interpersonal relationship, and enthusiastic (Gaberman, 1999). Laurent (2001) contends that teachers, who learners viewed as helpful, modeled competent behavior consistently and demonstrated a positive attitude and humanistic orientation. This will enhance responsiveness to the needs of students.
Four, recommend collaborative planning of learning activities. It was felt that the teaching lacked a bit of this element. Learners are usually receptive to selecting among a variety of learning activities and contribute suggestions.
Five, recommend different methods of assessing clinical performance. Teaching strategies were limited to only a few methods of assessing clinical performance, such as, discussions, lecture, question and answer, and rounds. Other important approaches involve role plays, case studies, group activities, and many others. More emphasis must have been made on case management also.
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In sum, minimum requirements for an effective teaching and learning; these included the environment, dialogue and the closure. Provision was accorded for sufficient lighting, ample sitting arrangements and adequate audio-visual aids that enhanced an environment that was conducive for teaching and learning. Dialogue in a formal, clear, and logical way; therefore, students did not miss any part of it. At the end of the teaching session, sufficient time for discussion and clarifying doubts was allocated. Teaching summery was submitted at the end of the session. McTaggart (1997) contends that teaching must end by educators being in a position to submit a summery. Young (2002) also insisted that a teacher must be able to use proper teaching and learning principles in the three domains of cognitive, affective, and psychomotor.
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