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Clinical Teaching for Health Professionals

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The principles of adult education are quite different from the ideas that are commonly used to teach children in schools (Wegener). The method of teaching a child, where all the relevant knowledge are simply spoon fed to him may not appeal to any adult patient’s learning, nor provide any effective results. Adults are thought to need special considerations that are different from that of children and teens when it comes to learning (Biech). Andragogy

The concept of andragogy was introduced by Malcolm Knowles in 1968 as “a new label and a new technology” distinguishing adult learning from children’s learning or pedagogy.

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Knowles’ concept of andragogy “the art and science of helping adults learn … is built upon two central, defining attributes: First, a conception of learners as self directed and autonomous; and second, a concept of the role of the teacher as facilitator of learning rather than present of content” (English, 2005).

As Knowles suggests “perhaps no aspect of andragogy has received so much attention and debate as the premise that adults are self-directed learners” (Knowles et al, 1998, pg.

135). There are two conceptions of self-directed learning: First, self-directed learning is seen as self-teaching, whereby learners are capable of taking control of the mechanics and techniques of teaching themselves in a particular subject; and second, self-directed learning is conceived of as personal autonomy (Knowles et al, 1998, pg. 135).

Andragogy presented six assumptions about the adult learner which provide a sound foundation for planning adult learning experiences. One assumption of andragogy states that adults need to know why they need to learn something before undertaking to learn it. Knowing why they need to learn something is the key to giving adults a sense of volition about their learning. Knowles et al found that when adults undertake to learn something on their own, they will invest considerable energy in probing into the benefits they will gain from learning it (1998).

Therefore, the first task of the facilitator of learning is to help the learners become aware of the “need to know”. Another assumption suggests that adults have a self-concept of being responsible for their own decisions; once adult learners have arrived at that self-concept; they develop a deep psychological need to be seen by others and treated by others as being capable of self-direction (Elcigil & Sari, 2006). Therefore, in adult learning situations, it is believed that sharing control over the learning strategies can make learning more effective.

Engaging adults as collaborative partners for learning satisfies their “need to know” as well as appeals to their self-concept as independent learners (Knowles et al, 1998). This is further reinforced by Wong et al that there must be collaboration between the educator and patient, and the adult patient needs to be involved as a partner and active agent of care (2005). It is also assumed that adults enter the educational activity with a greater volume and more varied experiences than do children.

Adults’ experience has a very important impact on the learning process. Kolb points out that learning is a continuous process grounded in experiences, which means that all learning can be seen as relearning (1984). This is particularly true for adults who have such a large reservoir of experiences. The next assumption suggests that adults have a readiness to learn those things that they need to know in order to cope effectively with real-life situations (Knowles et al, 1998, pg. 67).

Pratt states that adults’ life situations not only affect their readiness to learn, but also their readiness for andragogical-type learning experiences (1988). Adults generally prefer a problem solving orientation to learning, rather than subject-centered learning; they learn best when new information is presented in real-life context (Wilson & Hayes, 2000). As a result, the experiential approach to learning has become firmly rooted in adult learning practice. Kolb defines learning as “The process whereby knowledge is created through transformation of experience” (1984, pg. 8). The andragogical model of adult learning also makes some fundamental different assumptions about what motivates adults to learn. It is suggested that the most potent motivators for adults are internal ones: for example, quality of life. Adults tend to be more motivated toward learning that helps them solve problems or results in internal payoffs (Knowles et al. , 1998, pg. 149). This does not mean that external payoffs (for example, monetary gains) have no relevance, but rather that the internal need satisfaction is the more potent motivator.

Application and its challenges The central role of nurses in providing patient education is especially accentuated in the community setting where the patients spend large amounts of time getting treatments, with many opportunities for planned as well as spontaneous teaching (Wingard, 2005). This is a patient education session geared to promoting optimal self-management for patients with a secondary diagnosis of diabetes, regardless of the reason for admission in the community hospital. Only Type II diabetes patients who were on oral hypoglycaemic agents were selected.

A group size of four was chosen as “these types of group or cluster interventions may provide patients with powerful peer supports” (Corser and Xu, 2009, pg. 173). This was further reinforced by Zemke and Zemke that adults bring to a learning situation a background of experience that is a rich resource for themselves and for others (1984). Education of people with diabetes should be structured and delivered by healthcare professionals trained in adult education techniques (Wallymahmed, 2006). This program was held in a health education room during patients’ tea time.

Hot and cold drinks, and light snacks were provided at one corner of the room. Participants were seated at a medium-sized round table, placed in the centre of the room. We have to be aware of distractions that keep participants from concentrating fully (Loke & Jong, 2008). These include environmental matters such as noise, doors or windows. Hence, the door to the room was closed so as not to affect the learners’ concentration. Windows were also closed with the blinds drawn and the air conditioner adjusted to a comfortable level. The content of the program was delivered in an informal discussion manner. As

Wall suggested, “Learning is promoted best in an informal learning environment where participants have a great deal of control over their learning” (2000, pg. 59). The learning environment must be physically and psychologically comfortable; long lectures, periods of interminable sitting and the absence of practice opportunities rate high on the irritation scale (Zemke and Zemke, 1984). Discussions about the disorder was accomplished with the facilitation skill of questioning to invite learner’s participation and involvement, rather than just providing lecture and answers directly (Politi & Trofino, 2003).

This can be used to give feedback on what learning has occurred for the participants. Interactive learning also helps to ensure that the training makes a lasting impression (Wall, 2000). Wall also suggested that another key with adults is to use a variety of learning activities to help keep the participants motivated and stimulated (2000). A variety of instructional methods were used to create an engaging learning environment. First, an overview of diabetes was delivered through powerpoint. This was followed by flipcharts designed with coloured pictures to reinforce important concepts, highlighting the key points.

Then, further questions were asked to illicit understanding, followed by a discussion on the reasons about the teachings. Encouraging interaction will assist in drawing the learner into the learning experience (Wall, 2000, pg. 59). As mentioned earlier, adults bring a great deal of life experience into the classroom, an invaluable asset to be acknowledged, tapped and used. As Zemke and Zemke pointed out, adults can learn well and much from dialogue with respected peers (1984). Demonstrations were also used to equip patients with the technical know-how of what is needed to perform self-care (e. . self-monitoring of blood glucoses) and improve glycaemic control on a daily basis (Leow, 2008). The instructor demonstrates the use of a glucometer and participants were paired up to test each others’ blood glucose with the glucometer.

Besides providing theoretical knowledge, skills must be acquired through the actual doing, through directly experiencing the actual situations (Abdullah, 2007). This practical demonstration towards the end of the session not only provides feedback to the instructor to gauge the knowledge level of participants, it lso enables the learners to evaluate their own skills and knowledge. As mentioned earlier, adults seem to learn best when new information is present in real-life context. The patient education session directly applies to the patients’ condition. There was a short theory session where knowledge is imparted so that patients recognize and report conditions that could potentially aggravate diabetes. Another portion also focused on something practical that needs to be done on a daily basis at home like blood glucose monitoring.

Adults who are motivated to seek out a learning experience do so primarily because they have a use for the knowledge or skill being sought (Zemke and Zemke, 1984). Put into learning term, adult learners will be most motivated when they believe that the learning will help them with a problem that is important in their life. The teaching session provides the information and skills that diabetic patients will need to increase their knowledge for self-management and prevent deterioration of the disease. This is a classical scenario for adult learning based on the six assumptions that Malcolm Knowles addressed.

As mentioned earlier, the facilitator has to help learners become aware of the “need to know”. Thus, the purpose of the teaching was made known to the participants a week prior to the session. This tie in with the first principle of andragogy which states that adults need to know why they need to learn something before undertaking to learn it. Information leaflets on signs and symptoms of common conditions that aggravate diabetes were given to the participants to read through a week before the teaching session. This coincides with the assumption that adult learners are autonomous and self-directed in their learning.

In a study among diabetes patients, Hornsten et al. (2005) found that patient preferred to be responsible for themselves but needed support to accomplish self-care. By educating individuals about their level of risk, it is hoped that high-risk individuals would be motivated to adopt a healthy lifestyle (Wee et al, 2002). However, not all adult learners are motivated or self-directed. Some patients were there because they were simply told to do so or there to fill their time. Without any motivational factor, it can be difficult to engage the learners.

As Cameron pointed out, “Good health for its own sake hasn’t been found to be a strong motivator in the general population; in fact, the phrase may have the connotation of an impending sacrifice of something highly desired” (2002, pg. 28). The level of readiness of an adult to learn is also closely associated with the need to know. If learners feel that they are capable of controlling their own conditions, they will be unwilling to accept new information. Therefore, patients’ readiness to learn can be affected by their perception of how serious their condition is.

The role of the adult learners’ experience has become an increasingly important focus area. Although adults bring to a learning situation a background of experience that is a rich resource for themselves and for others, Knowles et al states that much of the recent emphasis has revolved around the notion that experience creates biases that can greatly impact new learning (1998). If patients have been managing their conditions well previously, they will have the natural tendency to resist new learning that challenges their existing belief.

Andragogical learning principles are tempered by an array of other factors that affect learning behaviour. The patient’s emotional state should also be assessed as an indicator of the patient’s readiness to learn. We have to contend with potential adult patient-related considerations like differences in learning styles, anxiety, physical discomfort or an inability to understand the information being presented. It is also a challenge in a multi-racial country like Singapore where people come from different dialect groups, cultural and religious beliefs.

Although andragogy enjoys widespread recognition as a tested guide to working with adults in practice, it has been most severely critiqued for its assumption that the individual adult learner is autonomous and in control of his or her learning (Reischmann, 2005). As Reischmann (2005) pointed out, “Lacking is the recognition that both the learner and the learning that takes place are shaped by a person’s history and culture”. It was also recognized that some adults are highly dependent on a teacher for structure and guidance.

This did not sit well with the assumption that adults are self-directed learners. Further, adults may be externally motivated to learn as when motivated by curiosity; and adults do learn new things which may not be related to their work or social roles but rather just for the joy of it (Smith, 1996; 1999) Conclusion The broad assumptions which govern the theory of adult learning can be applied to many learning situations to a certain degree, especially so in the hospital setting, to adult patients and caregivers, or even in-service continuing education for nurses.

However, there are potential obstacles to adult education that should also be acknowledged and accounted for. It is therefore important for instructors to be flexible and willing to adapt to individual learner’s characteristics and situations. In fact, as suggested by Knowles “an essential feature of andragogy is flexibility” (Knowles et al, 1984, pg. 418). Aptly summarized by Knowles, “The andragogical model is a system of elements that can be adopted or adapted in whole or in part; it is not ideology that must be applied totally and without modification” (Knowles et al, 1984, pg. 53).

References

Abdullah, S. N. (2007). Collection of nursing papers. Brunei: Brunei Printer Sdn. Bhd. Biech, E. Enterprise applications documentation & training services: Helping adult learn in the classroom. Retrieved September 13, 2010, from http://www. themis. unimelb. edu. au/training/resources/refs/Adult_Learning. pdf Cameron, B. L. (2002). Making diabetes management routine. American Journal of Nursing. 102(2). Pg. 26-32. Corser, W. , and Xu, Y. (2009). Facilitating patients’ self-management: A primary care intervention framework.

Journal of Nursing Care Quality, 24(2), Pg. 172-178. Elcigil, A. , and Sari, H. Y. (2006). Students’ opinions about and expectations of effective nursing clinical mentors. Journal of Nursing Education, 47(3), Pg. 118-123. English, L. M. (2005). International encyclopedia of adult education. United Kingdom: Palgrave Macmillan. Hornsten, A. , Lundman, B. , Selstam, E. K. , and Sandstrom, H. (2005). Patient satisfaction with diabetes care. Journal of Advanced Nursing, 51 (6), 609-617. Knowles, M. S. , Holton, E. F. , and Swanson, R. A. (1998).

The adult learner: the definitive classic in adult education and human resource development. 5th ed. USA; Butterworth-Heinemann. Leow, K. S. , (2008). Initial steps in effective management of diabetes mellitus. Singapore Family Physician Journal. 34(2). Pg. 10-14. Loke, S. C. , and Jong, M. (2008). Metabolic Control in Type 2 Diabetes Correlates Weakly with Patient Adherence to Oral Hypoglycaemic Treatment. Annuals Academy Medical Singapore. Vol. 37. Pg. 15-20. Politi, R. E. , & Trofino, J. ( 2003). Diabetes Management: A patient-directed approach improves outcomes.

American Journal of Nursing. Vol. 103(2). Pg. 64A-64G. Pratt, D. D. (1998). Andragogy as a relational construct. Adult Education Quarterly. 38. Pg. 160-181. Reischmann, J. (2003). Why andragogy? International encyclopedia of adult education. Retrieved September 13, 2010, from http://Andragogy. net Smith, M. K. (1996; 1999). Andragogy. The encyclopedia of informal education. Retrieved September 13, 2010, from http://www. infed. org/lifelonglearning/b-andra. thm Wall, K. (2000). The health care training handbook. San Francisco: Jossey-Bass. Wallymahmed,M. 2006). Insulin therapy in the management of type 1 and types 2 diabetes. Nursing Standard. 21(6). Pg. 50-56. Wee. H. L. , Ho, H. K. , and Li, S. C. (2002). Public awareness of diabetes mellitus in Singapore. Singapore Medical Journal. 43(3). Pg. 128-134. Wegener, P. Principles of Adult education. Retrieved September, 2010, from: http://www. kyeemafoundation. org/content/userFiles/file/extension/Adult_education. pdf Wilson, A. L. , and Hayes, E. R. (2000). Handbook of adult and continuing education. 1st ed. San Francisco-Jossey-Bass. Wingard, R. (2005).

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Clinical Teaching for Health Professionals. (2017, Mar 13). Retrieved from https://graduateway.com/clinical-teaching-for-health-professionals/

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