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Towards a theory of student-centred nurse education: overcoming the constraints of a professional curriculum
Towards a theory of student-centred nurse education: overcoming the constraints of a professional curriculum Gary Rolfe
Student-centred learning is an educational philosophy which became popular during the 1960s but which has gradually fallen from favour as the educational and political climate has changed over the years. This is particularly true of nursing, where the transition to higher education ushered in by Project 2000 has signalled a return to traditional teaching methods such as the lecture and the seminar. This paper argues that the current demands for holistic practice, professional autonomy and primary nursing can best be met by educationalists by employing a student-centred approach to learning. However, it is recognised that a radical student-centred approach will conflict with the constraints imposed on curriculum writers by a professional body, and that a modified strategy is required. The paper goes on to identify several of the more pressing constraints, and suggests some methods for overcoming these problems within a student-centred framework, while maintaining the requirements of a professional training which confers upon the students a license to practise. The paper concludes by suggesting that most problems will only be identified once courses are up and running, and that a new student-centred framework can only emerge from educational practice. Teachers and curriculum writers are therefore encouraged to come together to share ideas and experiences in order to carry forward the theory and practice of student-centred nurse education.
INTRODUCTION The theory and practice of student-centred education was popularised by Carl Rogers Gary Rolh BSc MA RMN PGCEA Senior Lecturer, School of Health Studies, University of Portsmouth, Kquests for offprints to GR) Manuscript accepted 9 November
1992
Correspondence to: Gary Rolfe, Education Centre, St. James’ Hospital, Locksway Road, Portsmouth PO4 8LD, UK
(1969) as an application of his general theory of person-centredness. It takes as its starting point, the principle that human beings have an innate predisposition towards growth and development which is often stifled by traditional educational approaches. It places trust in the motivation and ability of students to plan, organise and implement their own learning, and argues that it is the role of the teacher to ensure that the physical, psychological and social conditions to facilitate this process are in place. This humanistic approach to education was in tune with the romanticism of the 1960s (Jarvis 149
150
NURSE EDUCATION
1985),
and was eagerly
sophical
underpinning
TODAY
adopted for
as the philo-
a wide
range
of
courses for 5-year-olds through to degree students. Rogers published descriptions and evaluations, both positive and negative, of many of these ventures (Rogers 1983), but most even-
from
autonomous
argued
students,
that autonomous
and
it could
students
be
are students
who have a major part to play in what and how they are to learn. Furthermore, the empty called student-centred
tually failed, due either to inertia or active opposition from the institutions in which they
will not resolve
were taking place.
genuine
grow
application
methods
the situation.
naturally
from
of so-
and techniques Methods
should
a philosophy
commitment
by the course
of,
and
tutors
to,
student-centred learning. The aim of this paper, then, is to discuss some of the problems and difficulties
STUDENT-CENTRED LEARNING AND NURSE EDUCATION The writer’s experience
in nurse education
encountered
by the writer in attempt-
ing to move towards a humanistic centred over
approach
to learning
and student-
for nurses, and to
suggest some possible ways forward.
the past 13 years, both as student and tutor, has been of a gradual move away from student-centredness
towards
the
traditional
higher
edu-
cation model, a move accelerated by the transition to Project 2000 which began in 1989. With
hindsight,
this move
was a predictable
CONSTRAINTS ON THE STUDENTCENTRED COURSE The
principle
feature
approach
nation to play safe when writing the first Project 2000 curricula. The response of many curricu-
course
lum writers has been to retreat to the well tested
will depend
methods
willingness of the students to assume control,
of lectures
and seminars,
that these are the most appropriate,
in the belief or indeed
to learning
of the student-centred
response to the demands of larger student groups, a more academic syllabus and the incli-
degree of influence
is that the students
exert a
over both the content
of the
and the methods
by which the material
will be learnt. The exact degree of that influence
willingness
on many of the
factors,
teacher
including
to relinquish
that
the only ways to teach to groups of 50 or more. This belief is reinforced by the notion that all
control,
students must be presented with the same core material, and that the most cost-effective way of
source of difficulty. Rogers found that, whereas younger students adapted well to the freedoms
doing
of a student-centred course, degree students in particular often had problems with the sudden
this is to gather
them
orally deliver it to them. lecture is usually perceived higher education, academic credibility However,
all together
thus contributing of nursing courses.
it would appear
and
Furthermore, the as the hallmark of to
the
tion the ‘the medium is the message’, it could be argued that thinking, decision-making, problem-solving, autonomous nurses will never result from courses where the thinking, decision making, problem solving and autonomy are mainly the responsibility
of the course planners
Autonomous
practitioners
which governs the course.
transition
grow
groupwork,
of the curriculum
This in itself can be a
from very teacher-directed,
tion giving modes of teaching and the seminar,
that the need for
student-centred courses in nursing is as great now as it has ever been, with the current call for primary nurses, holistic practice and professional autonomy. Echoing McLuhan’s asser-
and teachers.
and the constraints
the the
informa-
such as the lecture
to the more liberal approach
free-discussion
of
and role play. Gibbs
(1992) presents several examples of this, and argues that the difficulty might be a function of the amount of time spent studying in the ‘traditional education system. Similarly, some teachers to whom the theory of student-centredness was extremely appealing, found themselves unable to cope psychologically with its implications for practice. Furthermore, particularly in higher education, the constraints of the curriculum and the assessment
system
were
often
seen
as insur-
NURSE EDUCATION
TODAY
15 1
the basis of a spiral curriculum (Brunner 1966) (Fig. 2). Each time the student travels round the cycle from experience to reflection to conceptuahsation to experimentation and back to experience, she does so at a deeper theoretical level and with more control over the process and content. There is thus a strong link between practice and theory, with practice generating theories and theory modifying practice, and each turn of the spiral becoming more student directed. In this way, students and tutors do not feel threatened by being immediately subjected to the sometimes alien demands of a student-centred curriculum. The third problem, of curricular and assessment constraints, is more protracted, and is exacerbated in this case by the fact that the course must not only satisfy the requirements demanded by higher education, but also the contraints imposed by a syllabus for a professional training. Clearly, there is a body of knowledge and skills which all nurses must possess if they are to be safe, competent practitioners, and any pre registration course for nurses must ensure that this material is included. However, it must also be recognised that this body of knowledge and skills is constantly being revised and updated, and therefore attention must also be given to how that material is presented to the student. As well as learning, the student should also be learning how to learn (Dewey 1916). Furthermore, the imposition from outside (and above) of course material raises the issues of professional paternalism and of relevance. If curriculum is ‘a selection from culture’ (Lawton 1980), then perhaps there is a need to examine the motives of those making the
-\ T EXPERIENC
ACTlVE EXPERIM~NTATON
OBSERATION & REFLECTION
mountable. These contraints are also beginning to be felt in primary and secondary education, where the National Curriculum appears to be mopping up any remaining vestiges of ‘progressive’ education. Thus, although it is not uncommon to find courses at all levels which employ student-centred techniques and methods, these are usually included as exercises or experiments within otherwise teacher-centred curricula.
SOME WAYS FORWARD The problems of student and teacher willingness to become involved in a student-centred approach, can be largely resolved through a gradual transition within the course from being predominantly teacher led, where content, method and assessments are prescribed, becoming more student-centred as the course continues. Thus, introductory core material can be presented early in the course in order to equip the student with the basic skills and confidence to function in the clinical area. The student can then be encouraged to reflect on her needs and requirements to develop her clinical practice. Theory therefore grows naturally from practice, and the student can see the relevance of the theoretical material to what is happening in the ward area, thus effectively bridging the theorypractice gap. Rolb (1984) termed this process learning from experience or reflective learning, and proposed a learning cycle (Fig. 1). This cycle can be expanded into three dimensions to form
I-
TUTOR DIRECTED
STUDENT DIRECTED
Fig 2
c
_
A spiral curriculum
--
-x
._
SHALLOW UNDERSTANDING
DRRP UNDERSMNDWG
152
NURSE EDUCATION
TODAY
selection. In particular, is the selection of material being made in the best interests of the patients being cared for by the students, or in the interests of the profession? If the latter, then the students may have difficulty in seeing the relevance and application of syllabus material to clinical work, and as educationalists have demonstrated (Maddox 1963), this is not conducive to learning, and will only serve to widen the theory-practice gap. The problem for the nurse tutor wishing to facilitate a student-centred course is therefore one of allowing students to identify their own learning needs while at the same time ensuring that the prescribed syllabus material is covered. It could be argued that if the syllabus material is truly relevant to nursing, then it will be precisely this material that the students will identify through the reflective process described above. This requires faith in the students, and a greater faith in the syllabus writers! A more structured approach has been suggested by Abercrombie (1979), who proposed the use of free discussion groups, in which small groups of S-10 students are presented with written, audio or visual material which they study alone for a set period of time before discussing it as a group. It is a particularly useful technique when there is core syllabus material which must be covered, since it combines the advantages of the student-centred philosophy of Rogers with those of the more directed lecture method. However: in giving a lecture, the teacher organises the material in such a way that it will, he hopes, be comprehended or assimilated in roughly the way he intends it should be. Ideally, then, if he is successful, all the students receive the same information, and it is the information he intended they should receive. In free group discussion, on the other hand, the students are presented with the same information (for example, two radiographs or an account of an experiment), but it soon becomes clear that they do not extract the same information from it, and learning depends on the fact that each extracts something different, (Abercrombie, 1979) Thus, communication channels between student
and tutor, and between student and student are open, and students are encouraged to share their learning, but the material that is being shared is introduced by the tutor. A second method is to employ learning contracts within a framework of clinical or theoretical objectives, so that all the students are required to meet the same general objectives, but can negotiate with the tutor the exact content and process which will suit their specific learning needs. For example, all students undertaking a Common Foundation Programme in nursing might be required to meet theoretical and practical objectives relating to sleep. However, these objectives will have a different focus depending on the client group that the student is working with. Thus, a student working on a surgical ward might be faced with the problem of patients who find it difficult to sleep the night before surgery. She could explore the relationship between anxiety and insomnia and investigate ways of helping the patients deal with their anxiety and thus promote sleep without medication. On the other hand, a student working on an acute psychiatric ward might be nursing a patient suffering from depression, and would thus be faced with an entirely different set of sleeprelated problems to resolve. This problem-based approach to setting learning objectives ensures that essential curriculum material is covered, but in a way that is meaningful to each student, since it is related directly to clinical practice. Linked to the issue of curriculum constraints is the problem of assessment, which Gibbs (1992) considers to be the key element in a successful student-centred course. Rogers was a strong advocate of self and peer assessment, which again presents problems for a course whose aim is to regulate and restrict entry to a professional body. It is important, therefore, to distinguish between formative and summative applications of self and peer assessment. Whereas the former is employed with great success in many courses for professionals in the form of reflective diaries, critical incident work, role play, and a host of other techniques, self and peer summative assessment is fraught with difficulty. Thus, although some courses are beginning to introduce elements of summative self and peer assess-
NURSE EDUCATION
ment, it relies heavily on acceptance and cooperation by the students, and this in turn depends on the students seeing self and peer assessment as being meaningfully integrated into the assessment structure, and as having a real bearing on the outcome of assessment. However, if the nursing profession wishes to continue to regulate its membership, self and peer assessment can never pay more than a small part in the overall summative schedule. It is thus considered by the writer to be dishonest to allow students to believe that they have a real and meaningful say in whether they qualify as nurses, when in fact their contribution to the process is marginal. An alternative approach is rather to concentrate on making the assessment process as relevant to the students as possible, and to give them real choices in the material they are assessed on. This is particularly difficult when it comes to formal examinations, which the English National Board (ENB) still insist on as part of first level nurse training. They outline four conditions which must be met (ENB 1990), namely: All students must undertake the same examination(s). The exanlination(s) must be taken under controlled conditions. The examination(s) must be completed within a predetermined time period which should be sufficient to enable candidates to complete the examination. The specific content of the activity to be undertaken must not be known by students prior to the commencement of the examination(s). Beyond these conditions, little guidance is given regarding structure, although the ENB appears to be encouraging alternatives to the traditional state final exam format by suggesting that students may be given general topic material in advance, and by allowing students access to information during the exam. With regard to content, the exam must test ‘the depth of theoretical knowledge and concepts applied to practice’ (ENB 1990). The challenge for the assessor is to produce
TODAY
153
clinically relevant examinations which test for depth of knowledge in a student-centred way, and yet meet the ENB guidelines. In writing student-centred exams, the author has attempted to meet several criteria: The exam should test the depth of theoretical knowledge and concepts, that is, it should be a test of problem solving and higher order cognitive abilities and not merely a measure of recall or memory. It should test knowledge as applied to practice, that is, it should have meaning and relevance to clinical work rather than being a dry academic exercise. It should be llexible enough to assess each student on the unique and personal learning objectives that she has negotiated with her tutor. It should be responsive to the curriculum rather than determining syllabus material. In other words, the exam should be written to reflect what has been taught on the course, rather than the course being designed to get students through the exam. Two approaches will be briefly outlined here, both of which have been devised by the writer to meet the needs of specific learning groups. The first is an exam framework for mental health students, which takes the form of a simulation of a nursing situation, and comprises an audiotape of part of a clinical assessment or intervention, together with supporting material and associated literature. After a period of time in which the students read the written material, a tape of part of a real therapeutic session is played and the students are instructed to make notes while the tape is playing. They must then answer questions and perform written tasks related to the material on the tape. For example, they might be requested to make a hypothesis or formulation about the client, to write a short care plan, or speculate on aetiological factors. Thus, the first two of the above criteria, those of depth of knowledge and knowledge applied to practice, are met because the exam is a measure of the application of the cognitive skills of analysis, synthesis and evaluation to practical situations. It meets the third criterion of flexi-
154
NURSE EDUCATION
TODAY
bility towards individual needs by being openended and encouraging a wide variety of responses, as students are informed that there are no right answers, and that marks will be given for their justification of the methods and approaches being advocated. Finally, the fourth criterion of being responsive to the curriculum is met because the exam is predominantly a test of cognitive skills and application rather than just knowledge, of process rather than content. There is thus no narrow body of knowledge that the students can revise in order to pass the exam, since what is being rewarded is the application to the simulated situation of any one of a variety of theoretical approaches or models, together with a justification of why that particular approach was appropriate. The second approach to examinations to be outlined is a framework for an exam at the end of a Common Foundation Programme where students generated their own learning outcomes in relation to the patients they were nursing in the ward area. Thus, not only did each student identify different learning objectives, but also specified the depth to which each of those objectives was to be explored, depending on her patients’ needs. The challenge, therefore, was to construct an exam paper which met the ENB specification of being the same for each candidate, whilst acknowledging that each candidate had constructed their own unique programme of learning. The solution was to write a paper with general questions which the student had to relate to one of her own patients on whom she had been writing a portfolio. It can be seen that this approach elegantly meets the above four criteria, since it clearly assesses depth of knowledge applied to clinical situations, it is geared to assessing the individual learning objectives negotiated by each student at the appropriate level, and the students are free to direct their learning according to their own needs and the needs of their patients, rather than towards covering the narrow and prescribed range of material necessary to pass a traditional examination.
CONCLUSION This paper has only touched on some of the more obvious difficulties involved in writing a student-centred pre registration nursing course. Many problems are unique to individual courses, and will only become apparent once the course is up and running. Likewise, just as the problems cannot be anticipated, neither can the solutions to those problems. In the same way that studentcentred courses are based around the notion of reflective learning and the generation of theory from practice, so too with the construction of those courses. Thus, as problems arise and are reflected on, new theories will emerge to resolve them. Despite its relatively long history, the theory of student-centred learning is still in its early stages of development, and can only grow by being put into practice. The writer therefore welcomes correspondence from any tutors or curriculum planners currently involved in, or who wish to become involved in, the writing or teaching of student-centred courses for nurses.
References AbercrombieM L J 1979 Aimsand techniques of group
teaching, 4th ed. SRHE, Guiidford Brunner J S 1966 Towards a theory of instruction. Norton, New York Dewey J 1916 Democracy and education. The Free Press, New York ENB 1990 Devolved continuous assessment for courses leading to Parts 1,3,5,8, 12, 13, 14 and 15 of the professional register. English National Board for Nursing, Midwifery and Health Visiting, London Gibbs G 1992 Improving the quality of student learning. Technical and Education Services, Bristol larvis P 1985 The socioloev of adult and continuineU y education. Groom Helm, London Kolb D A 1984 Experimental learning. Prentic Hall, New Jersey Lawton D 1980 The politics of the school curriculum. Routledge & Kegan Paul, London Maddox H 1963 How to study. Pan, London Rogers C R 1969 Freedom to learn. Merrill, Columbus Rogers C R 1983 Freedom to learn for the 80s. Merrill, Columbus “I
Student-centred learning is an educational philosophy which became popular during the 1960s but which has gradually fallen from favour as the educational and political climate has changed over the years. This is particularly true of nursing, where the transition to higher education ushered in by Project 2000 has signalled a return to traditional teaching methods such as the lecture and the seminar. This paper argues that the current demands for holistic practice, professional autonomy and primary nursing can best be met by educationalists by employing a student-centred approach to learning. However, it is recognised that a radical student-centred approach will conflict with the constraints imposed on curriculum writers by a professional body, and that a modified strategy is required. The paper goes on to identify several of the more pressing constraints, and suggests some methods for overcoming these problems within a student-centred framework, while maintaining the requirements of a professional training which confers upon the students a license to practise. The paper concludes by suggesting that most problems will only be identified once courses are up and running, and that a new student-centred framework can only emerge from educational practice. Teachers and curriculum writers are therefore encouraged to come together to share ideas and experiences in order to carry forward the theory and practice of student-centred nurse education.
INTRODUCTION The theory and practice of student-centred education was popularised by Carl Rogers Gary Rolh BSc MA RMN PGCEA Senior Lecturer, School of Health Studies, University of Portsmouth, Kquests for offprints to GR) Manuscript accepted 9 November
1992
Correspondence to: Gary Rolfe, Education Centre, St. James’ Hospital, Locksway Road, Portsmouth PO4 8LD, UK
(1969) as an application of his general theory of person-centredness. It takes as its starting point, the principle that human beings have an innate predisposition towards growth and development which is often stifled by traditional educational approaches. It places trust in the motivation and ability of students to plan, organise and implement their own learning, and argues that it is the role of the teacher to ensure that the physical, psychological and social conditions to facilitate this process are in place. This humanistic approach to education was in tune with the romanticism of the 1960s (Jarvis 149
150
NURSE EDUCATION
1985),
and was eagerly
sophical
underpinning
TODAY
adopted for
as the philo-
a wide
range
of
courses for 5-year-olds through to degree students. Rogers published descriptions and evaluations, both positive and negative, of many of these ventures (Rogers 1983), but most even-
from
autonomous
argued
students,
that autonomous
and
it could
students
be
are students
who have a major part to play in what and how they are to learn. Furthermore, the empty called student-centred
tually failed, due either to inertia or active opposition from the institutions in which they
will not resolve
were taking place.
genuine
grow
application
methods
the situation.
naturally
from
of so-
and techniques Methods
should
a philosophy
commitment
by the course
of,
and
tutors
to,
student-centred learning. The aim of this paper, then, is to discuss some of the problems and difficulties
STUDENT-CENTRED LEARNING AND NURSE EDUCATION The writer’s experience
in nurse education
encountered
by the writer in attempt-
ing to move towards a humanistic centred over
approach
to learning
and student-
for nurses, and to
suggest some possible ways forward.
the past 13 years, both as student and tutor, has been of a gradual move away from student-centredness
towards
the
traditional
higher
edu-
cation model, a move accelerated by the transition to Project 2000 which began in 1989. With
hindsight,
this move
was a predictable
CONSTRAINTS ON THE STUDENTCENTRED COURSE The
principle
feature
approach
nation to play safe when writing the first Project 2000 curricula. The response of many curricu-
course
lum writers has been to retreat to the well tested
will depend
methods
willingness of the students to assume control,
of lectures
and seminars,
that these are the most appropriate,
in the belief or indeed
to learning
of the student-centred
response to the demands of larger student groups, a more academic syllabus and the incli-
degree of influence
is that the students
exert a
over both the content
of the
and the methods
by which the material
will be learnt. The exact degree of that influence
willingness
on many of the
factors,
teacher
including
to relinquish
that
the only ways to teach to groups of 50 or more. This belief is reinforced by the notion that all
control,
students must be presented with the same core material, and that the most cost-effective way of
source of difficulty. Rogers found that, whereas younger students adapted well to the freedoms
doing
of a student-centred course, degree students in particular often had problems with the sudden
this is to gather
them
orally deliver it to them. lecture is usually perceived higher education, academic credibility However,
all together
thus contributing of nursing courses.
it would appear
and
Furthermore, the as the hallmark of to
the
tion the ‘the medium is the message’, it could be argued that thinking, decision-making, problem-solving, autonomous nurses will never result from courses where the thinking, decision making, problem solving and autonomy are mainly the responsibility
of the course planners
Autonomous
practitioners
which governs the course.
transition
grow
groupwork,
of the curriculum
This in itself can be a
from very teacher-directed,
tion giving modes of teaching and the seminar,
that the need for
student-centred courses in nursing is as great now as it has ever been, with the current call for primary nurses, holistic practice and professional autonomy. Echoing McLuhan’s asser-
and teachers.
and the constraints
the the
informa-
such as the lecture
to the more liberal approach
free-discussion
of
and role play. Gibbs
(1992) presents several examples of this, and argues that the difficulty might be a function of the amount of time spent studying in the ‘traditional education system. Similarly, some teachers to whom the theory of student-centredness was extremely appealing, found themselves unable to cope psychologically with its implications for practice. Furthermore, particularly in higher education, the constraints of the curriculum and the assessment
system
were
often
seen
as insur-
NURSE EDUCATION
TODAY
15 1
the basis of a spiral curriculum (Brunner 1966) (Fig. 2). Each time the student travels round the cycle from experience to reflection to conceptuahsation to experimentation and back to experience, she does so at a deeper theoretical level and with more control over the process and content. There is thus a strong link between practice and theory, with practice generating theories and theory modifying practice, and each turn of the spiral becoming more student directed. In this way, students and tutors do not feel threatened by being immediately subjected to the sometimes alien demands of a student-centred curriculum. The third problem, of curricular and assessment constraints, is more protracted, and is exacerbated in this case by the fact that the course must not only satisfy the requirements demanded by higher education, but also the contraints imposed by a syllabus for a professional training. Clearly, there is a body of knowledge and skills which all nurses must possess if they are to be safe, competent practitioners, and any pre registration course for nurses must ensure that this material is included. However, it must also be recognised that this body of knowledge and skills is constantly being revised and updated, and therefore attention must also be given to how that material is presented to the student. As well as learning, the student should also be learning how to learn (Dewey 1916). Furthermore, the imposition from outside (and above) of course material raises the issues of professional paternalism and of relevance. If curriculum is ‘a selection from culture’ (Lawton 1980), then perhaps there is a need to examine the motives of those making the
-\ T EXPERIENC
ACTlVE EXPERIM~NTATON
OBSERATION & REFLECTION
mountable. These contraints are also beginning to be felt in primary and secondary education, where the National Curriculum appears to be mopping up any remaining vestiges of ‘progressive’ education. Thus, although it is not uncommon to find courses at all levels which employ student-centred techniques and methods, these are usually included as exercises or experiments within otherwise teacher-centred curricula.
SOME WAYS FORWARD The problems of student and teacher willingness to become involved in a student-centred approach, can be largely resolved through a gradual transition within the course from being predominantly teacher led, where content, method and assessments are prescribed, becoming more student-centred as the course continues. Thus, introductory core material can be presented early in the course in order to equip the student with the basic skills and confidence to function in the clinical area. The student can then be encouraged to reflect on her needs and requirements to develop her clinical practice. Theory therefore grows naturally from practice, and the student can see the relevance of the theoretical material to what is happening in the ward area, thus effectively bridging the theorypractice gap. Rolb (1984) termed this process learning from experience or reflective learning, and proposed a learning cycle (Fig. 1). This cycle can be expanded into three dimensions to form
I-
TUTOR DIRECTED
STUDENT DIRECTED
Fig 2
c
_
A spiral curriculum
--
-x
._
SHALLOW UNDERSTANDING
DRRP UNDERSMNDWG
152
NURSE EDUCATION
TODAY
selection. In particular, is the selection of material being made in the best interests of the patients being cared for by the students, or in the interests of the profession? If the latter, then the students may have difficulty in seeing the relevance and application of syllabus material to clinical work, and as educationalists have demonstrated (Maddox 1963), this is not conducive to learning, and will only serve to widen the theory-practice gap. The problem for the nurse tutor wishing to facilitate a student-centred course is therefore one of allowing students to identify their own learning needs while at the same time ensuring that the prescribed syllabus material is covered. It could be argued that if the syllabus material is truly relevant to nursing, then it will be precisely this material that the students will identify through the reflective process described above. This requires faith in the students, and a greater faith in the syllabus writers! A more structured approach has been suggested by Abercrombie (1979), who proposed the use of free discussion groups, in which small groups of S-10 students are presented with written, audio or visual material which they study alone for a set period of time before discussing it as a group. It is a particularly useful technique when there is core syllabus material which must be covered, since it combines the advantages of the student-centred philosophy of Rogers with those of the more directed lecture method. However: in giving a lecture, the teacher organises the material in such a way that it will, he hopes, be comprehended or assimilated in roughly the way he intends it should be. Ideally, then, if he is successful, all the students receive the same information, and it is the information he intended they should receive. In free group discussion, on the other hand, the students are presented with the same information (for example, two radiographs or an account of an experiment), but it soon becomes clear that they do not extract the same information from it, and learning depends on the fact that each extracts something different, (Abercrombie, 1979) Thus, communication channels between student
and tutor, and between student and student are open, and students are encouraged to share their learning, but the material that is being shared is introduced by the tutor. A second method is to employ learning contracts within a framework of clinical or theoretical objectives, so that all the students are required to meet the same general objectives, but can negotiate with the tutor the exact content and process which will suit their specific learning needs. For example, all students undertaking a Common Foundation Programme in nursing might be required to meet theoretical and practical objectives relating to sleep. However, these objectives will have a different focus depending on the client group that the student is working with. Thus, a student working on a surgical ward might be faced with the problem of patients who find it difficult to sleep the night before surgery. She could explore the relationship between anxiety and insomnia and investigate ways of helping the patients deal with their anxiety and thus promote sleep without medication. On the other hand, a student working on an acute psychiatric ward might be nursing a patient suffering from depression, and would thus be faced with an entirely different set of sleeprelated problems to resolve. This problem-based approach to setting learning objectives ensures that essential curriculum material is covered, but in a way that is meaningful to each student, since it is related directly to clinical practice. Linked to the issue of curriculum constraints is the problem of assessment, which Gibbs (1992) considers to be the key element in a successful student-centred course. Rogers was a strong advocate of self and peer assessment, which again presents problems for a course whose aim is to regulate and restrict entry to a professional body. It is important, therefore, to distinguish between formative and summative applications of self and peer assessment. Whereas the former is employed with great success in many courses for professionals in the form of reflective diaries, critical incident work, role play, and a host of other techniques, self and peer summative assessment is fraught with difficulty. Thus, although some courses are beginning to introduce elements of summative self and peer assess-
NURSE EDUCATION
ment, it relies heavily on acceptance and cooperation by the students, and this in turn depends on the students seeing self and peer assessment as being meaningfully integrated into the assessment structure, and as having a real bearing on the outcome of assessment. However, if the nursing profession wishes to continue to regulate its membership, self and peer assessment can never pay more than a small part in the overall summative schedule. It is thus considered by the writer to be dishonest to allow students to believe that they have a real and meaningful say in whether they qualify as nurses, when in fact their contribution to the process is marginal. An alternative approach is rather to concentrate on making the assessment process as relevant to the students as possible, and to give them real choices in the material they are assessed on. This is particularly difficult when it comes to formal examinations, which the English National Board (ENB) still insist on as part of first level nurse training. They outline four conditions which must be met (ENB 1990), namely: All students must undertake the same examination(s). The exanlination(s) must be taken under controlled conditions. The examination(s) must be completed within a predetermined time period which should be sufficient to enable candidates to complete the examination. The specific content of the activity to be undertaken must not be known by students prior to the commencement of the examination(s). Beyond these conditions, little guidance is given regarding structure, although the ENB appears to be encouraging alternatives to the traditional state final exam format by suggesting that students may be given general topic material in advance, and by allowing students access to information during the exam. With regard to content, the exam must test ‘the depth of theoretical knowledge and concepts applied to practice’ (ENB 1990). The challenge for the assessor is to produce
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clinically relevant examinations which test for depth of knowledge in a student-centred way, and yet meet the ENB guidelines. In writing student-centred exams, the author has attempted to meet several criteria: The exam should test the depth of theoretical knowledge and concepts, that is, it should be a test of problem solving and higher order cognitive abilities and not merely a measure of recall or memory. It should test knowledge as applied to practice, that is, it should have meaning and relevance to clinical work rather than being a dry academic exercise. It should be llexible enough to assess each student on the unique and personal learning objectives that she has negotiated with her tutor. It should be responsive to the curriculum rather than determining syllabus material. In other words, the exam should be written to reflect what has been taught on the course, rather than the course being designed to get students through the exam. Two approaches will be briefly outlined here, both of which have been devised by the writer to meet the needs of specific learning groups. The first is an exam framework for mental health students, which takes the form of a simulation of a nursing situation, and comprises an audiotape of part of a clinical assessment or intervention, together with supporting material and associated literature. After a period of time in which the students read the written material, a tape of part of a real therapeutic session is played and the students are instructed to make notes while the tape is playing. They must then answer questions and perform written tasks related to the material on the tape. For example, they might be requested to make a hypothesis or formulation about the client, to write a short care plan, or speculate on aetiological factors. Thus, the first two of the above criteria, those of depth of knowledge and knowledge applied to practice, are met because the exam is a measure of the application of the cognitive skills of analysis, synthesis and evaluation to practical situations. It meets the third criterion of flexi-
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bility towards individual needs by being openended and encouraging a wide variety of responses, as students are informed that there are no right answers, and that marks will be given for their justification of the methods and approaches being advocated. Finally, the fourth criterion of being responsive to the curriculum is met because the exam is predominantly a test of cognitive skills and application rather than just knowledge, of process rather than content. There is thus no narrow body of knowledge that the students can revise in order to pass the exam, since what is being rewarded is the application to the simulated situation of any one of a variety of theoretical approaches or models, together with a justification of why that particular approach was appropriate. The second approach to examinations to be outlined is a framework for an exam at the end of a Common Foundation Programme where students generated their own learning outcomes in relation to the patients they were nursing in the ward area. Thus, not only did each student identify different learning objectives, but also specified the depth to which each of those objectives was to be explored, depending on her patients’ needs. The challenge, therefore, was to construct an exam paper which met the ENB specification of being the same for each candidate, whilst acknowledging that each candidate had constructed their own unique programme of learning. The solution was to write a paper with general questions which the student had to relate to one of her own patients on whom she had been writing a portfolio. It can be seen that this approach elegantly meets the above four criteria, since it clearly assesses depth of knowledge applied to clinical situations, it is geared to assessing the individual learning objectives negotiated by each student at the appropriate level, and the students are free to direct their learning according to their own needs and the needs of their patients, rather than towards covering the narrow and prescribed range of material necessary to pass a traditional examination.
CONCLUSION This paper has only touched on some of the more obvious difficulties involved in writing a student-centred pre registration nursing course. Many problems are unique to individual courses, and will only become apparent once the course is up and running. Likewise, just as the problems cannot be anticipated, neither can the solutions to those problems. In the same way that studentcentred courses are based around the notion of reflective learning and the generation of theory from practice, so too with the construction of those courses. Thus, as problems arise and are reflected on, new theories will emerge to resolve them. Despite its relatively long history, the theory of student-centred learning is still in its early stages of development, and can only grow by being put into practice. The writer therefore welcomes correspondence from any tutors or curriculum planners currently involved in, or who wish to become involved in, the writing or teaching of student-centred courses for nurses.
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