EXPERIENCES IN PRACTICE
María del Carmen Tovar-Moncada,1 Silvia Crespo-Knopfler,2
1Programa de Licenciatura en Enfermería, Centro Universitario Valle de Chalco, Universidad Autónoma del Estado de México, Estado de México.
2Programa de Maestría en Enfermería, Facultad de Estudios Superiores-Zaragoza, Universidad Nacional Autónoma de México, Distrito Federal, México
Correspondence: María del Carmen Tovar-Moncada
Received: April 22nd 2014
Judged: October 27th 2014
Accepted: November 17th 2014
In clinical practices, the knowledge of a nurse is shared to the students; that is, it is first observed and then it is reproduced the closest possible way to the model, a situation that can be analyzed from the social learning theory, proposed by Albert Bandura. It is essential to promote the incorporation of clinical nurses in the definition and implementation of at least two of the characteristics of college students, such as reflective thinking and clinical judgment, developed from reflective practice.
Keywords: Nursing; Reflective learning
Considering university education as a cornerstone in professional training, this document focuses on the practice of teaching in the field of nursing. It reflects on clinical faculty and nurses so that nursing students acquire the skills necessary for their future roles as health team staff.
Specifically, the nursing career is done in classroom-based theoretical periods like any college education, plus complementary practical periods with school laboratories made for the purpose as well as practical performance periods in clinical settings where teacher-tutors have the task of monitoring and teaching in possible practical situations with groups of 15 or more students, greatly limiting the time spent on each student and yielding much of that responsibility to clinical nurses involved in direct patient care, who also act as teachers with one or more students per school that requests it.
Thus, in clinical practice, the knowledge of a nurse is shared with students through modeling, that is to say, first observing and then reproducing the model as closely as possible, a situation that can be analyzed from the social learning theory proposed by Albert Bandura.
Now it is imperative to promote the inclusion of clinical nurses in the definition and implementation of at least two of the characteristics of university students, those being reflective thinking and clinical judgment, ideally developed from reflective practice.
This ensures "social institutionalized" practice as the practical teaching of nursing, part of epistemological or ideological perspectives, or of rationality itself which is made from care and education, giving clinical practice and teaching the meaning to which each corresponds. However, looking at the diversity of concepts and prevailing discourses on care and those who practice it, there is increasing need to reassess the role that nurses play as teachers and which is inherent in clinical practice.1
Education is a socialization process that occurs through external mechanisms and transmission systems,2 which results in a complex picture. Complexity3 is part of our daily life. The intricate relationship of contextual elements and the different explanations that every human being formulates in this regard also permeate educational areas, making plain reflection and analysis of given situations in academia and clinical fields difficult, where interdisciplinary health teams, clinical tutors, and nurses all intervene, all of whom from their particular perspectives implement their teaching role, incorporating students into their everyday.
From a constructivist perspective, valuing and promoting student learning should be considered significant learning, that is, bringing as close as possible to reality the problem situations from which they can establish remedial measures, called nursing interventions; thus instructional learning also promotes comprehensive memorization and functionality of what is learned,4 which presumably must account for the performance of nursing undergraduates in the aforementioned clinical practices.
Clinical practice is the ideal medium for performance to be observed in a real context, where one reflects and acts, competencies are built, and students learn by accompanying and helping in solidarity as a creative and artistic nursing team.5
In this space students have the opportunity to generate creative solutions based on critical thinking, from which they reproduce the behaviors modeled by nurses as routine matters and, at the same time, this is the same repetitive daily trigger for proposing strategies for observing care as a human act, respectful and with consent and empathy for the other.5
Albert Bandura, a Ukrainian-Canadian psychologist of cognitive-behavioral tendency, in his "modeling" addresses elements on which behavioral theorists were deliberating such as reinforcement and observation, their influence on internal mental processes and interaction between human beings, elements supplemented with cognitive processes such as reflection and symbolization used in processes of comparison, generalization, and self-evaluation.6
From here, learning is considered earned and strengthened when there was already contact with the medium. Highlights include observational learning, the influence of environmental, personal and behavioral factors in learning in a relationship that is characterized as unidirectional.
The atmosphere is conducive to learning, demonstration of procedures, exercising skills, and corrective feedback as items close to real work. To this we must add that students start their own inferences and personal approaches to respond in ways that are appropriate, wrong, secured or unsecured, depending on the thoughts, feelings and attitudes that their life story and educational practice generate. In that sense, social learning theory proposed by Albert Bandura states that human beings are social beings who work to do it or fail to do it together and with the involvement or benefit of others; according to this theory, knowing has a direct and proportional relationship with the powers that one puts into function in real, everyday life: knowledge is participation and activity.7
Early formulations were made by Miller and Dollard in 1941, who were based in Hull's learning theory and in psychoanalysis. Reinforcing processes and assimilation stand out. Bandura at different times passes reinforcement to the second degree, when you learn vicariously, that is, by imitation, observing other people, anticipating the consequences of their own conduct.8
Observation and repetition are of singular importance because skills and operant or instrumental behaviors are acquired by reinforcement and observing social models that become references for the learner; between observations and imitations, internal cognitive processes let one to decide whether observed situations and behaviors are worthy of imitation.
In nursing, vicarious learning is obtained in the first instance because you have to memorize the techniques and procedures and repeat them exactly; the learner then observes with great attention and care in order to later produce an imitation as faithfully as possible, leaving aside elements such as reflection, analysis and criticism to improve these same procedures and focusing rather on the changes and transformations made by the clinical nurse, in particular because of the need to adapt what is described in manuals and procedures to their own experience without stopping to be conscious of their actions.
For Bandura, social behavior is due to different causal factors of external and even personal origin, such as vicarious learning, which is based in the memory of the effects of others and which makes it possible to anticipate the consequences of one's behavior as a kind of self-regulation; in fact, this author agrees with Skinner that behavior is learned, although for Bandura the influence of social context is more important on training and behavior modification.
According to social learning theory, we do not automatically imitate the behaviors we observe in others, but rather, consciously make the decision to behave in the same way. This mediation is carried out by the internal cognitive processes of each person in decision-making. Once we have seen and we want to replicate this behavior later, we remember the important aspects. To retain any conduct in particular, it is necessary to codify and symbolically represent it, by the fact that the information is retained in images or words.9 Attitudinal elements come into play, which must be considered from constructivism, as in the present case nursing students need every opportunity to practice and, if there is sympathy, initiative, and obedience, they may get to perform procedures themselves, which will be considered an achievement and, on the other side, the staff will think they have been able to teach their students more than what was planned.
Enhancers facilitate learning to occur; however, the context also provides elements for learning to occur, such as lights, sounds, unique environments, especially in practices that allow unique situations that facilitate modeling, but this is not an essential element; observational learning requires the individual to actively pay attention and remember the behavior of social models to choose what they consider appropriate to imitate.10 The "printing machine" effect expected based solely on behaviorism stimulus, response, and amplifiers does not occur in adults: the learner observes behavior, remembers it, produces it, and has enough motivation to reproduce it in future occasions.11
Vicarious learning also notices the influence of punishments and incentives to promote the acquisition of behaviors; specifically in the case of nursing, the permissiveness and unsupervised work that they aspire to, motivate students to reproduce as accurately as they can and, if not, the punishment is not being allowed to apply even the simplest technique alone on a patient.9
Bandura specifies a process with four elements that must be present for vicarious learning to be achieved: attention, retention, motor reproduction, and motivation. The reflection on this balance between enhancers, motivators and personal decisions, which is very much subject to social relations, depends on what Bandura termed an auto-system, consisting of a set of cognitive processes to perceive and evaluate oneself.11
Observation for subsequent repetition is vital in clinical nursing learning.12 Certainly experience generates knowledge, but if learning by imitation has flaws or concerns, those will recur, which will cause interference for professionals who keep making the same mistakes; the only requirement for Bandura is watching the other with interest, and from the internal cognitive processes this can be reproduced in an environment that allows it, combining thoughts and behaviors so that each student is able to direct their own learning; however, training should encourage reflection on personal performance and that of the nursing team for decision-making, developing strategies for solutions to various problems and, above all, leadership skills and creativity to achieve high-quality work.
Regarding nursing there are several studies that have considered social learning theory to analyze professional performance. In Spain in 2011,13 the opinions of students about practice were reported; in the findings and discussion, what most stood out was the significant presence of the clinical nurse, who must know in advance the objectives of the practice in the first instance and then reconsider their role as teachers in educating the students in their charge, since their work goes beyond considering them as assistants to reduce the workload and, instead, they must assist and cooperate so that they resume their purpose of practice and actively participate in the achievement of its objectives.
To incorporate elements such as critical thinking and clinical judgment, it is highly recommended to incorporate so-called reflective practice as part of daily tasks, developed by Donald Schön in the Eighties, with a great boom in the United States, although in Mexico the studies on this are scarce.
For Schön, we know doing, reflecting and sharing with others as the artistic part, segregated until today; professions have an artistic part, a tacit part of knowledge that does not involve the scientific, rather sensitivity, and which is stimulated by the fact of being a changing and human process that is repeated identically day to day, and which deserves reflection. The training of professionals should reconsider its design from the perspective of a combination of teaching applied science with a tutored formulation, to the art of reflection in action.14
Nursing is among to the professions that promote debates about themselves and about the limits and responsibilities of each role, the way to realize and develop specialty knowledge and to recognize the role of clinical observation and direct contact with patients, their families and whoever needs specialized care based on clinical autonomy or participatory interaction, which facilitates decision-making with logical consistency, based on the search for expertise in one’s field.15
In today's society, in many everyday life situations we seek to put ourselves in expert hands primarily to solve problems in specific situations. In 1986, Welbank, described by Hart and taken up by Pozo (1989),16 stated that an expert has a broad base of knowledge in a limited domain and uses complex inferential reasoning to accomplish tasks efficiently.
The background in this field of study from the Eighties lists the following general features of skilled labor:
Recognizing and applying experience is reflected in being a person who lavishes care not as a matter of all or nothing, but rather as a path by which a person remains alert and questions, rethinks, in many circumstances, their actions and their presence itself, on the other, in others, and in the world.17
As a component of practice, reflection is essential in the continuous development of the professional and hence in the profession. Reflection is the element that brings awareness of the everyday, routine act; for Schön is there that knowledge is deepened and improved.
Knowledge in action is constructed and reconstructed by making this explicit and by symbolizing it after it is tacit and repetitive; we must not forget that knowledge in action is dynamic and that the procedures, rules, and theories are static.14
If an unexpected event or an error occurs, one will think of a surprise factor (such as failure of the usual patterns of development) and reach the reflection about the action. This is a different term for reflection in action that arises at the moment of performing. In this regard, according to Schön a sequence of events can be established: from action we observe routine responses and spontaneous responses, after routine responses there comes a surprise that does not correspond to our knowledge in common action. Surprise leads to reflection within a present-action, also called adverse effect, which should be taught as much as possible from nursing laboratory practice.
Reflection in action has a critical function and calls into question actions and performance. Finally, reflection leads to experimentation in the moment, with which actions are thought up and devised with which one takes actions seeking to explore the recent phenomena. Reflection and action carried out jointly refer not only to rote learning of knowledge and skills, but also bring into play artistic interaction and include attitudinal elements for decision-making.14
The training work in college nursing students goes beyond the physical barriers and covers clinical specialty staff that are responsible for teaching and promoting learning among students, with a view beyond them helping lighten the daily workload. It is for these clinical nurses to promote the application of reflective learning in practice as an inlay to be developed starting today to enhance their own professional future.
Tasks that promote reflective learning in practice have postponed assignments in the field of nursing, where they still need professionals with leadership characteristics, who are empowered, with a tendency to unite the professional group, and with high personal and professional commitment for the benefit of themselves and therefore for the profession.