Nurse as Educator • After a few such pairings, the neutral stimulus alone, without the

Principles of Teaching and Learning for Nursing Practice unconditioned stimulus, elicits the same response. Often occurring
without thought or awareness, learning takes place when the newly
LEARNING conditioned stimulus (CS) becomes associated with the conditioned
•Learning: a relatively permanent change in mental processing, response (CR).
emotional functioning, and behavior as a result of experience. • Respondent conditioning highlights the importance of the
•Learning Theory: a coherent framework of integrated constructs “atmosphere” and staff morale in health care.
and principles that describe, explain, or predict how people learn. • Often without thinking or reflection, patients and visitors formulate
these associations as a result of their hospital experiences, providing
CONTRIBUTION OF LEARNING THEORIES the basis for long-lasting attitudes toward medicine, healthcare
facilities, and health professionals.
• Provides information and techniques to guide teaching and
learning RC: SYSTEMATIC DESENSITIZATION
•Can be employed individually or in combination
•Can be applied in a variety of settings as well as for personal growth • Systematic desensitization - is a technique based on respondent
and interpersonal relations conditioning that is used by psychologists to reduce fear and anxiety
in their clients (Wolpe, 1982).
CONTRIBUTIONS OF LEARNING THEORIES (CONT’D) • The assumption is that fear of a particular stimulus or situation is
learned, so it can, therefore, be “unlearned” or extinguished.
• Learning theories can be applied at the individual, group, and • Fearful individuals are first taught relaxation techniques. While they
community levels not only to comprehend and teach new material, are in a state of relaxation, the fear stimulus is gradually introduced
but also to solve problems, change unhealthy habits, build at a non-threatening level so that anxiety and emotions are not
constructive relationships, manage emotions, and develop effective aroused.
behavior. • After repeated pairings of the stimulus under relaxed,
• Behaviorist, cognitive, and social learning theories are most often nonfrightening conditions, the individual learns that no harm will
applied to patient education and healthcare practice. (Redman, come to him or her from the once-fear-including stimulus.
2001). • Finally, the client is able to confront the stimulus without being
• It is argued in this chapter that also need explicit focus in relation anxious and afraid.
to learning in general (Goleman, 1995) and to health care in
particular. RC: STIMULUS GENERALIZATION

Why? • Stimulus generalization - Is the tendency of initial learning

• Emotional reactions are often learned as a result of they play a experiences to be easily applied to other similar stimuli.
significant role in the learning process, and they are a vital • For example, when listening to friends and relatives describe a
consideration when dealing with health, disease, prevention, hospital experience, it becomes apparent that a highly positive or
wellness, medical treatment, recovery, healing, and relapse negative personal encounter may color patients’ evaluations of their
prevention. hospital stays as well as their subsequent feelings about having to be
• Ex: Diarrhea/Antibiotic Use/ Hypertension/ Healthy Diet hospitalized again.
• While not always treated as learning theories psychology (Hilgard • With more and varied experiences, individuals learn to differentiate
& Bower, 1966), psychodynamic and humanistic perspectives are among similar stimuli, and discrimination learning occurs.
included in this review because they add much to our • Spontaneous recovery
understanding of human motivation, emotions, and the learning -Although a response may appear to be extinguished, it may
process. “recover” and reappear at any time (even years later), especially
when stimulus conditions are similar to those in the initial learning
LEARNING THEORIES experience. With more and varied experiences, individuals learn to
differentiate among similar stimuli, and discrimination
• Theories are compared with regard to:
1. Their fundamental procedures for changing behavior OPERANT CONDITIONING
2. The assumptions made about the learner
3. The role of the educator in encouraging learning • Developed largely by (B. F. Skinner 1974, 1989), focuses on the
4. Sources of motivation behavior of the organism and the reinforcement that occurs after
5. Ways in which learning is transferred to new situations and the response (Alberto & Troutman, 1990).
problems. • A reinforcer is a stimulus or event applied after a response that
strengthens the probability that the response performed again.
BEHAVIORIST THEORY When specific responses are reinforced on the proper schedule,
behaviors can be either increased or decreased.
• Concepts: stimulus conditions, reinforcement, response, drive. • Learning occurs as the organism responds to stimuli in the
• To change behavior, change the stimulus conditions in the environment and is reinforced for making a particular response.
environment and the reinforcement after a response. • A reinforcer is applied after a response strengthens the probability
that the response will be performed again under similar conditions.
BEHAVIORIST DYNAMICS
CHANGING BEHAVIOR USING OPERANT CONDITIONING
• Motivation: drives to be reduced, incentives
• Educator: active role; manipulates environmental stimuli and • To increase behavior
reinforcements to direct change  Positive reinforcement
• Transfer: practice and provide similarity in stimulus conditions and  Negative reinforcement (escape or avoidance
responses with a new situation conditioning)
• To decrease behavior
BEHAVIORIST THEORY  Non reinforcement
 Punishment
• Focuses mainly on what is directly observable, behaviorists view
learning as the product of the stimulus conditions (S) and the OPERANT CONDITIONING
responses (R).
• To modify people’s attitudes and responses, behaviorists • The use of reinforcement is central to the success of operant
recommend either altering the stimulus conditions the environment conditioning procedures.
or changing what happens after a response occurs • For operant conditioning to be effective, it is necessary to assess
what kinds of reinforcement are likely to increase or decrease
RESPONDENT CONDITIONING behaviors for each individual.

• Learning occurs as the organism responds to stimulus conditions COGNITIVE THEORY

and forms associations.
• A neutral stimulus is paired with an unconditioned stimulus– • Concepts: cognition, gestalt, perception, developmental stage,
unconditioned response connection until the neutral stimulus information memory, social constructivism, social cognition,
becomes a conditioned stimulus that elicits the conditioned attributions
response • To change behavior, work with the developmental stage and
• Also termed classical or Pavlovian conditioning. change cognitions, goals, expectations, equilibrium, and ways of
• Emphasizes the importance of stimulus conditions and the processing information.
associations formed in the learning process.
• In this basic model of learning, a neutral stimulus (NS) stimulus that COGNITIVE DYNAMICS
has no particular value or meaning to the learner - is paired with a
naturally occurring unconditioned or unlearned stimulus (UCS) and
unconditioned response (UCR)
• Motivation: goals, expectations, disequilibrium, cultural and group 4) give close attention to their inability to remember or demonstrate
values formation
• Educator: organize experiences and make them meaningful;
encourage insight and reorganization within learner NINE EVENTS AND THEIR CORRESPONDING COGNITIVE
• Transfer: focus on internal processes and provide common PROCESSESTHAT ACTIVATE EFFECTIVE LEARNING (GAGNÉ,
patterns with a new situation. BRIGGS, & WAGNER, 1992):

GESTALT PERSPECTIVE 1. Gain the learner’s attention (reception)

2. Inform the learner of the objectives and expectations
• Perception and the patterning of stimuli (gestalt) are the keys to (expectancy)
learning, with each learner perceiving, interpreting, and 3. Stimulate the learner’s recall of prior learning (retrieval)
reorganizing experiences in her/his own way 4. Present information (selective perception)
• Learning occurs through the reorganization of elements to form 5. Provide guidance to facilitate the learner’s understanding
new insights and understanding (semantic encoding)
• Another central gestalt principle is that perception is selective, 6. Have the learner demonstrate the information or skill (responding)
which has several ramifications. 7. Give feedback to the learner (reinforcement)
8. Assess the learner’s performance (retrieval)
• First, because no one can attend to all the surrounding stimuli at 9. Work to enhance retention and transfer through application and
any given time, individuals orient themselves to certain features of varied practice (generalization)
an experience while screening out or habituating to other features.
• Patients in severe pain or worried about their hospital bills may not COGNITIVE DEVELOPMENT PERSPECTIVE
attend to well-intentioned patient education information.
• Focuses on qualitative changes in perceiving, thinking, and
• Second, what individuals pay attention to and what they ignore reasoning as individuals grow and mature.
are influenced by a host of factors: past experiences, needs, • Cognitions are based on how external events are conceptualized,
personal motives and attitudes, reference groups, and the particular organized, and represented within each person’s mental framework
structure of the stimulus or situation. or schema that is partially dependent on the individual’s stage of
• Moreover, because individuals vary widely with regard to these cognitive development and readiness to learn.
and other characteristics, they will perceive, interpret, and respond
to the same event in different ways, perhaps distorting reality to fit •Principal assumption is that learning is a developmental, sequential,
their goals and expectations. and active process that transpires as the child interacts with the
• This tendency helps explain why an approach that is effective with environment, makes “discoveries” about how the world perates,
one client may not work with another client. and interprets these discoveries in keeping with what she knows
(schema)
• The gestalt perspective is one of the oldest schools of psychology
and has strongly influenced a number of more recent cognitive • According to this view, children take in information as they interact
perspectives. with people and the environment and either make their experiences
with what they already know assimilation) or change their
INFORMATION-PROCESSING PERSPECTIVE perceptions and interpretations in keeping with the new information
accommodation).
• The way individuals perceive, process, store, and retrieve
information from experiences determines how learning occurs and SOCIAL CONSTRUCTIVIST PERSPECTIVE
what is learned.
• Organizing information and making it meaningful aids the • Learning is heavily influenced by the culture and occurs as a social
attention and storage process; learning occurs through guidance, process in interaction with others.
feedback, and assessing and correcting errors. • A person’s knowledge may not necessarily reflect reality, but
through collaboration and negotiation, new understanding is
STAGES OF INFORMATION-PROCESSING PERSPECTIVE acquired.
• Central tenets of this perspective are that:
The first stage in the memory process involves paying attention to • The learning process is influenced gly by the culture.
environmental stimuli; attention, n, is the key to learning. • Effective learning occurs through social action, collaboration, and
negotiation.
Thus, if a client is not attending to what a nurse educator is saying,
perhaps because the client is ary or distracted, it would be prudent SOCIAL COGNITION PERSPECTIVE
to try the explanation at another time when he is more active and
attentive. • An individual’s perceptions, beliefs, and social judgments are
affected strongly by social interaction, communication, groups, and
In the second stage, the information is processed by the senses. the social situation.
Here it becomes important to consider the client’s preferred mode • Individuals formulate causal explanations to account for behavior
of sensory processing (visual, auditory, or motor manipulation) and that have significant consequences for their attitudes and actions
to ascertain whether there are sensory deficits. (attribution theory).
Social cognition, sometimes called emotional intelligence, plays a
In the third stage, the information is transformed and incorporated major e in children’s social and emotional development.
encoded) briefly into short-term memory, after which it is either is • It is therefore important to understand at it is and how a child’s
disregarded and forgotten or stored in long-term memory. environment can affect the development of this skill.

Long-term memory involves the organization of information by using SOCIAL LEARNING THEORY
a preferred strategy for storage (e.g., imagery, association,
rehearsal, breaking the information into units). • Concepts: role modeling, vicarious reinforcement, self-system, self-
regulation
The last stage involves the action or response that the individual • To change behavior, utilize effective role models who are
makes on the basis of how information was processed and stored. perceived to be rewarded, and work with the social situation and
the learner’s internal self-mechanisms.
In general, cognitive psychologists note that memory processing
and the retrieval of information are enhanced by organizing SOCIAL LEARNING DYNAMICS
information and making it meaningful.
• Motivation: compelling role models perceived to be rewarded,
STAGES IN INFORMATION-PROCESSING PERSPECTIVE MODEL self-system regulating behavior, self
• Educator: model behavior and demonstrate benefits; encourage
active learner to regulate and reproduce behavior
• Transfer: similarity of setting, feedback, self-social influences.
INFORMATION-PROCESSING PERSPECTIVE
SOCIAL LEARNING THEORY
The information-processing perspective is particularly helpful for
assessing problems in acquiring, remembering, and recalling • According to early social learning theory, much of learning occurs
information. by observation—watching other people and discerning what
happens to them.
Some strategies include the following:
1) have learners indicate how they believe they learn • In health care, social learning theory has been applied to staff
2) ask them to describe what they are thinking as they are learning training and to interventions that address public health problems
3) evaluate learners’ mistakes
such as teenage smoking and alcoholism among the elderly (Akers,
1989, 1996). • Listening ---rather than talking– is the skill needed.

• First phase is the attentional phase, a necessary condition for any  Humanistic Theory contends that feelings and emotions are the
learning to occur. keys to learning, communication, and understanding.
• Second is the retention phase, which involves the storage and  Humanists worry that in today’s stressful society people can
retrieval of what was observed. easily lose touch with their feelings, which sets the stage for
• Third is the reproduction phase, where the learner copies the emotional problems and difficulties in learning.
observed behavior.  The humanistic learning theory has modified the approach to
• Fourth is the motivation phase, which focuses on whether the education and changing behavior by giving primary focus to
learner is motivated to perform a certain type of behavior. the subjective needs and feelings of the learner and by
redefining the role of the educator.

HUMANIST DYNAMICS

• Motivation: needs, desire to grow, self- concept

• Educator: act as facilitator who respects learner’s uniqueness and
provides freedom to feel, express, and grow creatively
• Transfer: positive or negative feelings and choices as well as
freedom to learn, promote, or inhibit transfer

GENERALIZATIONS ABOUT LEARNING

• Learning is a function of developmental changes

• Brain processing is different for each learner
• Learning is active, multifaceted and complex
PSYCHODYNAMIC THEORY • Stress can interfere with or stimulate learning

• Concepts: stage of personality development, conscious and ENVIRONMENTAL INFLUENCES (EXTERNAL)

unconscious motivations, ego defense mechanisms
• To change behavior, work to make unconscious motivations • stimulus conditions and configuration of elements
conscious, build ego emotional conflicts. • social and cultural influences
• role models, experts, and guides
PSYCHODYNAMIC DYNAMICS • reinforcements
• feedback
• Motivation: libido, life force, death wish, pleasure principle, reality
principle, conscious and unconscious conflicts, developmental LEARNER INFLUENCES (INTERNAL)
stage, defenses.
• Educator: reflective interpreter; listen and pose questions to • developmental stage
stimulate insights • habits
• Transfer: remove barriers such as resistance, transference • perception
reactions, and emotional conflicts • thoughts and reasoning
• schema
PERSONALITY IS MADE UP OF THREE PARTS: THE ID, EGO, AND • ways of processing information
SUPER EGO: • memory storage
• conscious and unconscious motivation
• The id is the primitive and instinctive component of personality. It • self-regulation
consists of all the inherited (i.e., biological) components of • subjective feelings
• self-concept
personality present at birth, including the sex (life) instinct- Eros
(which contains the libido), and the aggressive (death) instinct • expectations
Thanatos. • goals
• needs
• The ego develops in order to mediate between the unrealistic id
and the external real world. It is the decision-making component of HOW TO PROMOTE CHANGE
personality.
• The superego incorporates the values and morals of society which • Relate to what learner knows and is familiar with
are learned from one's parents and others. • Keep experiences simple, organized, and meaningful
• Parts of the unconscious mind (the id and superego) are in • Motivate learner (deprivation, goals, disequilibrium, needs,
constant conflict with the conscious part of the mind (the ego). This tension)
conflict creates anxiety, which could be dealt with by the ego’s use • May need incentives and rewards, but not always
of defense mechanisms.
HOW TO PROMOTE CHANGE
PSYCHODYNAMIC DYNAMICS
• Experiences must be at the appropriate developmental level
• Make learning pleasurable, not painful
• Demonstrate by guidance and attractive role models

HOW TO MAKE LEARNING RELATIVELY PERMANENT

• Relate experiences to learner

• Reinforce behavior
• Rehearse and practice in variety of settings
• Have learner perform and give constructive feedback
• Make sure interference does not occur before, during, or after
learning
• Promote transfer
• Have learner meditate and act on experience in some way
(visualize, memory devices, discuss, talk, discuss, write, motor
HUMANISTIC THEORY movement)

• Learning occurs on the basis of a person’s motivation, derived from

needs, the desire to grow in positive ways, self-concept, and
subjective feelings.
• Learning is facilitated by caring facilitators and a nurturing
environment that encourage spontaneity, creativity, emotional
expression, and positive choices.

• Cornerstones of Humanistic Theory Approach:

1. Importance of emotions and feelings
2. Right of individual to make their own choices
3. Human creativity