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Within a clinical environment the teacher has to bear several variables in mind in order to effectively facilitate clinical sessions. Like any teaching – learning situation, the first issue that the teacher has to consider is a theory of learning that will be used as the framework for designing the content of the sessions and used in devising effective strategies to deliver the desired objectives. When it comes to the actual facilitation of these sessions theory must essentially guide practice and practice needs to reflect theory. That is, the teacher must have a concept of who the learners are, their special characteristics, needs and desires as well as knowledge of the most effective approach to facilitation that could be used in teaching sessions and these approaches must be put into practice. By having theory and practice interlock this ensures that the needs of the learners are adequately catered for and the most conducive environment is created for learning.

Theories are the framework and blueprint of teaching strategies. Theorists such as Malcolm Knowles, Erik Erikson, Jean Piaget, Herbert Simon and Allen Newell have proposed theories that explain the characteristics of learners from childhood to adulthood. These theorists have been able to clarify for teachers the issue of how learning takes place, how material is processed and retained in the brain and the have suggested what strategies are appropriate to particular types of learners. Armed with this knowledge teachers can ensure that learning is meaningful, appropriate, relevant and effective.

Piaget’s cognitive development

Jean Piaget is probably the most renowned scholar in the area of developmental psychology (Fischer & Hencke, 1996); Flavell, 1996). He proposed a model that sought to delineate the stages at which development takes place throughout an individual’s life and the type of learning that is possible at each of these stages (Flavell, 1985). Piaget’s cognitive development model, during its initial phases, was very widely accepted as a useful model that helped teachers matched instructional content and method with the learner’s developmental stage.

Piaget suggests that there are four “distinctive and qualitatively different” (Siegel, 1993) stages of cognitive development which each individual goes through and from the earliest stage learning is going on. This is one of the primary strengths of his theory. By proposing that learners develop in sequential stages (Macpherson, 2004) teachers are able to modify their instruction according to the stage at which their learners are (Good & Brophy, 1995). The four stages are the sensorimotor, the preoperational, the concrete operational and the formal operational periods (Slavin, 2000). Piaget gives an estimate as to the age at which each child will enter either stage. From birth to two years a child is at the sensorimotor stage, from two to seven years a child is in the preoperational stage, from seven to eleven is the concrete operational and from age eleven into adulthood is the formal operational.

A further strength of the theory is that it describes what type of cognitive skills learners are capable of at each stage. In this way teachers are able to deliver instructional material that is manageable at the particular stage with which they relate. During the sensorimotor period “infants learn about their surroundings by using their senses and motor skills” (Slavin, 2000). Piaget believes that each child is born with built-in reflexes that they use in initial interactions with their environment (Wakefield, 1996). Because a newborn child has not yet developed a concept of his environment, his initial response to this environment up to one month old is instinctive. These reflexes, however, soon become the basis through which the learner acquires new perspectives and behaviours (schemes) in an attempt to learn about and understand his environment.

Learners progresses from simply interacting with and understanding their environment to intelligently adapting actions such as grasping a rattle (Fischer & Silvern, 1985, p. 634), then becoming less object-oriented, more observant and less preoccupied with self. They begin to display more coordination in their schemes (Case, 1993). Soon they become aware of what they want and begin to construct their own schemas in order to achieve their goals, using these later to explore new possibilities with objects in their environment. From 18 to 24 months learners begin to transition from this stage to the preoperational stage. They are developing the ability to function using symbolic representations.

At the preoperational stage learners begin to use symbols to represent things mentally (Slavin, 2000) but they still have a very narrow view of their environment (Crain, 1985). From two to four years learners are relatively egocentric (Wakefield, 1996). From age four to seven learners further develop their reasoning capacities but may still experience difficulty with some concepts (Slavin, 2000).

The third stage of cognitive development is the concrete operational stage which covers learners aged seven to eleven. At this stage children are able to form concepts and solve problems. However, they must be able to relate such operations to already familiar objects or situations. Their reasoning is also considerably more logical and can show interrelations between different objects and classes of objects. They are still limited, however, in that they are unable to reason in abstract terms but need concrete circumstances and examples as guides.

The final stage, the formal operational stage, is felt to run from age eleven (11) to adulthood and this is the stage at which learners in clinical sessions fall. Learners are this stage are felt to be able to reason in abstract and to conceptualize situations beyond what they can see and touch. They have now developed the capacity to perform reasoning about events, actions or objects that they cannot see or that are strictly hypothetical and they are also able to use deductive reasoning. They begin to devise plans to solve problems and test their hypothesis against a variety of options.

One of the most fundamental weaknesses of Piaget’s theory is that the age categories appear fixed and exclusive suggesting that all children go through all stages at the same time and at the same rate. Wakefield (1996) points out, though, that “the age range for each stage is only an average” (p. 168).  A learner may enter a specific stage earlier or later than that estimated by Piaget. However, each learner, Piaget argues, must pass through each of these stages of development in the specified order and no child can skip a particular stage (Wadsworth, 1996). It must also be noted here that his theory is necessarily universal as it examines only how all learners will progress and does not seek to analyze individual differences among learners (Gindsburg & Opper, 1988).

Piaget’s theory is useful to adult education to the extent that it allows them to understand the different stages that learners have to pass through before they are able to function at an optimal cognitive level. Additionally the framework of Piaget’s theory is constructivism and Piaget holds that learners actively construct their own knowledge. This process occurs when learners “… act on their environments to integrate what is derived from maturation with what they gain from experience, and vice versa” (Reid, 1979). Adult learners particularly have a wide array of experiences to bring to learning sessions.

However, contrary to what is suggested by Piaget’s age-groupings, some adults may not even achieve the final stage of cognitive development. Additionally it is not reasonable to suggest that there is no delineation between categories of learners beyond age eleven. Piaget’s model gives the impression that all learners from eleven years are basically the same, which is far from the truth. As a result Piaget’s theory has been more applicable to early childhood education and has not been completely useful in understanding of adult learning.

Erik Erikson, on the other hand, as well as Malcolm Knowles, has developed theories of development that more closely address the adult learner. Erikson’s psychosocial development theory is probably the most widely known of its kind (Weiland, 1993) and is used extensively in discussions on adult development (McCrae & Costa, 1990). Erikson proposes that man goes through eight stages in life and even though his model encapsulates the period from birth till late adulthood, the model is very applicable to adult education since the final three stages are during adulthood (Slavin, 2000).

In Erikson’s eight-stage model individuals go through different levels of ‘psychosocial crises’ (Miller, 1983) which they have to be able to resolve in order for them to progress to a higher stage which has new challenges. These crises reflect two contrasting polarities (Erikson, 1963). Even if these crises are not effectively resolved at the requisite stage the adult still has to contend with them in the later stages (Erikson, 1968).

Erikson, like Piaget categorizes development into different stages. However, though age categories are assigned to the stages these are only approximations, much like Piaget’s stages. Stage one deals with the issues of trust and mistrust and covers the infant years up to 18 months. The aim during infancy is to establish some amount of trust in the world (Slavin, 2000) and of others. The mother is seen as the central figure in solidifying this trust. Stage two is autonomy versus doubt running from 18 months to three years. Children want to be independent as symbolized in their first attempts at walking and speech. Parents are also important during this stage. Stage three is between initiative and guilt from three to six years, there is industry versus inferiority in stage four (6-10 years), identity versus confusion (12-18 years).

The young adult years begin at stage six where there is the conflict between intimacy and isolation (young adulthood). There is the move towards solidifying intimate relationships and friendships. During the middle adulthood period of stage seven there is the conflict between generativity and self-absorption. There is, in this stage “the interest in establishing and guiding the next generation” (Erikson, 1980, p. 103). Generativity is usually accomplished through being a parent but guidance could be given in other circumstances such as teaching. In the final stage eight there is the conflict between integrity and despair. During this stage adults begin to reflect on their life and accept their accomplishments and failures (Slavin, 2000). There is also the prospect of death which has to be faced up to.

One primary strength of Erikson’s model is that it stresses the importance of the environment in affecting behavioural outcomes. It is by interacting in their social environment that persons meet with the various crises or challenges. It is also within the context of the environment that strategies to resolve conflicts are explored. The environment therefore provides a useful framework for understanding the forces that impact an individual’s behaviour.

Erikson’s model, like Piaget’s, is criticised for being too structured and seems not to cater for different levels and rates of development (Slavin, 2000). Many researchers now reject stage models of development (Weiland, 1993). Ryff comments of Erikson’s stage-type model that it “… formulate[s] spiraling progressions of improvement for the individual. … the individual c[an] continue to develop, to become more differentiated, and function at a higher level (as cited in Weiland, 1993).

A further weakness of the theory is that it fails to specify how and/or why development is to take place. There is little indication of the motives behind individuals progressing through one stage of development into another and, unlike Piaget’s explications, there is little or no discussion as to the direct implications of this theory to learning. There is, of course, some connection between learning and development as individuals are able to manipulate certain situations only when they are able to reconcile certain crises or conflicts.

The strength of Erikson’ model is that it gives a very good representation of the developmental stages that individuals go through from the moment of birth until the time of death. The model is therefore applicable to an understanding of early childhood, infant, adolescent, young adult and mature adults. Having a knowledge of the different conflicts with which individuals deal is useful to facilitators so that, like Piaget’s stages, tasks, instructional material and teaching strategies are developmentally appropriate.

Application of this model to clinical settings is, however, a bit problematic since the rate and stage of development is often very unpredictable. It is therefore difficult to estimate the corresponding stages of learners in the clinical environment simply based on their age as not all individuals progress through the stage at the same rate. It is the duty of the clinician therefore to familiarize himself with the learners with whom he interacts in order to gauge the needs requisite to their developmental stage.

Other theorists have proposed various methodologies with which to handle learning environments based on the characteristics of the learner. Malcolm Knowles, a renowned scholar, is known for his research into adult education and the works he produced on andragogy – “the art and science of helping adults learn” (Knowles, 1984b). Knowles believes that the processes involved in adult education ‘andragogy’ are distinctly different from those involved in ‘pedagogy’ the art and science of teaching children (Knowles, 1970).

Knowles lays out various characteristics of adult learners and these characteristics are felt to impact greatly on instructional situations. Knowles establishes that adults have a need have a positive self-concept as well as motivation to learn. This is fostered by involving them in the planning and evaluation of their instruction (Knowles, Holton & Swanson, 2005). Andragogy purports that intrinsic motivation is more powerful and effective with adult learners (Groome, 1999). Some intrinsic motivators are self actualization, self-esteem, recognition, greater self-confidence and better quality of life. Adults do respond to some external motivators. Some extrinsic motivators are salary increase and a better job. Adults also have been exposed to several experiences and therefore must be able to bring these experiences into the learning experience and these provide the framework for instructional activities.

Adults also have an appropriate time in which they are ready for particular learning experiences (Knowles, 1970). Often readiness is influenced by the learners’ interest in the subject matter and the relative relevance or value they place on the learning experience. Orientation to learn is also important. Instructors must make problem-solving and not content, the focus of instruction.

Andragogy further argues that learning must reflect real life and be relevant and personal to the learners. Adults wish to be able to apply new knowledge immediately and thus would shy away from learning situations that bear little in common with their immediate developmental goals (Knowles, 1984a).

Information processing theory was put forward as an alternative way of understanding how people learn but with specific focus on the way that information is stored and retrieved in the brain.  Information processing theory holds the view that the brain functions similar to computer in the way it processes information. The information processing model assumes that humans interact with their environment in a deliberate way and that the mind processes symbols from its external environment. The symbols are further encoded in the mind through distinct cognitive processes. This model therefore concerns itself primarily with discovering the kinds of information that are processed by in the mind, how such processing takes place in terms of organization, retrieval and recall.

This concept of human learning occurring in the form of information processing is inherent to the field of cognitive psychology is the. Also central to this model is the metaphoric equating of the human mind to the way a computer functions by processing information. According to information processing within the brain information is treated in three ways, information is received, information is stored and information is retrieved. These theorists further identify a model of how this process operates within the brain. They propose a model with three major components. The first contains information stores, the second cognitive processes and the third metacognition.

The first component is information stores, which are repositories of data, and they are used to hold information. They are comparable to filing cabinets, address books, or computer disks where people store information. The information stores in the information-processing model are sensory memory, working memory, and long-term memory.

The second component consists of cognitive processes, which are internal, intellectual actions that transfer information from one of the information stores to another. Information retrieval, according to Macpherson (2004) is a complicated activity. Examples of cognition processes include perception, rehearsal, encoding and retrieval. Cognitive processes could be compared to the programs that direct and transform information in computers.

The third aspect is metacognition, which consists of knowledge about and control of cognitive processes. This dimension controls and coordinates the processes that move information from one store to another (Eggen & Kauchak, 1997). Taylor (2000) holds that because the information processing capacity of the human brain is not limitless, that learners and teahcers have to adapt to their limitations.

Information processing therefore attempts to explain human thinking. This theoretical approach began to gain interest in the late 1940s and a remained a useful method to understanding how the human brain works. As has been mentioned, in this approach the human brain is seen to function much like the computer. The hardware components of the human computer would be the brain and the software programs by which it operates and regulates all activities in the brain is the mind.

Theorists have lauded this model on its practicality. Lachman, Lachman & Butterfield (1979) believe that it is the most comprehensive and comprehensible model. They propose that “the information-processing paradigm made new questions interesting; it applied a new language to man’s mental processes; it suggested new analogies for research into cognition; and it used some basically new techniques.”(p. 34).

A set of contributors to research in information processing are Newell & Simon. In collaboration with Cliff Shaw, a computer expert, this pair of researchers made a considerable impact in investigating complex information processing. By 1955 they had designed a computer program that could discover proofs for theorems in logic by discriminatory search. They invented an entirely new class of computer programming languages and found ways of implementing the concepts of problem space and heuristic search. Heuristic problem solving and list processing created the discipline of artificial intelligence and occasioned the revolution in cognitive psychology (Newell, Shaw & Simon, 1958). The computer program they designed, Logic Theorist, was later used by George Miller, a leading cognitive psychologist (Crowther-Heyck, H. 1999).

With the varying criticisms of the methods and principles of the information processing aspect of cognitive psychology there have been various other approaches proposed. The information processing paradigm had as its basic framework, the concept of the human brain functioning much like a computer. The learner is portrayed as being an active information processor in the same way that the computer processes information. The computer metaphor of the mind and concept has been fundamental to the field of cognitive psychology.

Crowther-Heyck, H. (1999) highlights the usefulness of the computer metaphor to the field of cognitive psychology by suggest three primary areas of usefulness. He believes that it

“gave experimental psychology a basis in “hard” science—computer science and electrical engineering—without threatening to reduce psychology to that basic science … [it] meant that experimental psychology would be linked with one of the most powerful technologies of the twentieth century, giving experimental psychologists a claim to at least some of the vast resources that poured into the development of the computer and [it] enabled psychologists to claim that they had succeeded in operationalizing many mentalistic terms, thus legitimating a broadening of psychology’s domain” (p.38).


This model is very applicable to clinical instruction. Information processing has problem-solving as an important component and, in order to be able to effectively manipulate events on the job this skill must be mastered (Taylor, 2005).


Reflecting on my own methods and teaching strategies I have not taken much of what the theorists have put forward with respect to adults and how they function in learning situations. I support the position that individuals progress through different stages of cognitive development and I also acknowledge that these developments are usually time and age-specific. While the exact age at which transfer into the higher stages of development occurs has been questioned by researchers, there is some merit to the stage theory argument. It has been observed that children develop abilities to accomplish certain activities as they mature to that level. Even up to adulthood there are changes taking place in the individual. The type, degree and duration of the changes experienced as well as how they are addressed changes overtime as greater levels of maturity are attained.

There is the suggestion by both Erikson and Piaget in describing the stages of development, that the adult learner is at a very different stage of cognitive and psychosocial development than other categories of learners. In my practice I have espoused that view and I have ensured that the teaching strategies I used are appropriate to the learners. Lectures

I have, contrary to what is suggested by the research, tended to assume that all my learners are generally at the same level of cognitive development. I have been aware of learning styles and have used those in differentiating instruction. I have used various techniques in the learning environment such as group tasks, demonstrations, lectures, PowerPoint® presentations and many other techniques to diversify instruction. The guiding force behind my differentiating instruction was not based on the developmental age or stage but on the different learning styles that may be present in the clinical setting.

Piaget and Erikson’s work have been useful, therefore, in clarifying, first of all, that it is important to determine where the learners are situated in terms of their cognitive development and even the capacity that their brains have to process information. An individual who has not yet progressed to a certain stage of cognitive or psychosocial development, is unable to effectively complete tasks which require using skills at that level and learning would not only be ineffective, but also meaningless. Knowles has stressed the importance of ensuring that learning experiences are relevant to the learners and therefore failure to adopt learner friendly teaching practices will not abide well in the learning situation.

One thing that the theorists do not examine, to any significant degree, is the nature of the learning environment. I believe that an environment fully conducive to learning must be created at all times. Within the clinical setting the environment must allow the learners to feel comfortable and willing to participate in designed activities. Knowles has noted that when adults feel insecure they tend to react negatively and the integrity of learning is compromised. Especially for group tasks it is important that all members feel a sense of security within the group and there is an absence of fear or an unwillingness to participate.

The concepts put forward by the information processing model were, for the most part, novel to me and therefore these principles would not have been previously incorporated into my previous learning sessions. The ideas put forward by this model are quite interesting though and of use in clinical training sessions. Since adults have a limit to their capacity to store and retrieve information effectively, it goes to say that instruction should be paced to allow for proper processing and storing of information in the brain.

I have found that I have been guilty of ignoring this vital element of information processing in my instruction. Since I’ve never before considered the barriers that limited information stores and retrievers could have on learning my practice has tended to deliver material based on time constraints rather than on how much the learner would be able to manage and manipulate in the given period. During a presentation on the insertion of the nasogastric tube I allowed time constraints to dictate the pace at which I moved through the information. Time rather than mental capacity was my focus and as a result a few learners were dissatisfied with the pace at which instruction went. While in this case I was able to effectively ensure that objectives were accomplished even while moving through the instructions quickly,  I believe that the lesson would have been much effective if it had been paced to match the information storing and accessing capacities of the brain.


To ensure that future teaching – learning sessions achieve optimal effectiveness, my first area of consideration in designing instructional content and material is on the developmental stage that each of my students are at. There are few instruments that have been developed that can be used to measure an individual’s stage of cognitive development. However, these commercial instruments may not be necessary. By interacting with the learners regularly I would be able to determine what stage they are in based on their behaviour patterns. In any case during instruction I would ensure that the levels of questioning used and the assessment instruments sample a variety of cognitive and skill domains. In this way all individuals will get an opportunity to be challenged without making instruction and assessment too easy or too difficult to comprehend.

I think that it is also important that I try to incorporate more of the experiences of the learners into the learning environment. Adults see learning as meaningful when it is relevant to their own lives and when whatever skills they are acquiring are of immediate applicability. The skills that I pass on during clinical sessions are necessary skills that the learners would eventually use in their work situations. In this sense the skills passed on are relevant to the learners. However I have often failed to consider the experiences of the learner and have not made considerable attempts to incorporate their experiences into my instruction. Often the instructional content is decided on by a curriculum as represented in the courses being undertaken by the nurses. I have usually delivered the curriculum as is with very little modification as the programmes are often quite compact and specific.

I realize now that adhering to curricular requirements does not preclude me incorporating the different experiences in the instructional setting. In this aspect I hope to improve by ensuring that the learning environment is much more learner-centered.


The theories discussed are important in furthering understanding about the learners, the learning environment and how learning should take place. Whether the theory is in the form of developmental stages (such as those by Piaget and Erickson), or if the theory examines information processing, these theories are important to the instructor. An understanding of the theories furthers and understanding of the learners and this further impacts teaching techniques, instructional material and teaching-learning activities. Within the clinical setting these theories are important starting points in ensuring that sessions are both effective and maintain the interest of the learner. In all instances the instructor should ensure that there is a good understanding of adult learning theories and these theories should be used to shape and guide instructional practice.








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