1 Theoretical Foundations of Teaching and Learning

William Purkey (1992) put forward invitational theory as an educational framework of learning and teaching relationships based on human value, responsibility, and capability. Invitational learning is observed in the social context, in which learners should be invited by the teacher to develop their potentials. The four pillars of invitational theory are respect, trust, optimism, and intentionality. The invitational instructor invites learners in, welcomes them, creates warm and welcoming educational environments, provides optimum learning opportunities, and bids them a warm farewell at the conclusion of the learning experience.

In 1983, Parker Palmer introduced the term “invitational classroom.” He emphasized that “an air of hospitality” facilitates the inviting environment (1983/1993, p. 71). Hospitality in his words means “receiving each other, our struggles, our newborn ideas, with openness and care” (p. 74). Palmer concluded that both teachers and learners experience positive consequences when the classroom is invitational (see 1983/1993, 1998, 2007).

Constructivist thinking, as espoused by seminal educationalists such as Jean Piaget (1972) and Lev Vygotsky (1978), suggests that knowledge is constructed by learners themselves. Those who view the world through a constructivist lens believe that learners bring valuable existing knowledge to their learning experiences. They view the role of the teacher as building on that knowledge by providing personally meaningful activities.

Constructivist teachers also believe that learning will be enhanced by interactions with informed others such as teachers, practitioners, and peers. Therefore, an important aspect of any constructivist teacher’s practice is to plan for and facilitate opportunities for helpful social interaction. In clinical teaching environments, instructors who use a constructivist conceptual perspective will create impactful connections individually with students and ensure that opportunities for connections with other students and staff members are possible.

Melrose et al. (2013, p. 71) summarize constructivism as a conceptual framework:

Constructivist learning environments incorporate consensually validated knowledge and professional practice standards, and competencies are comprehensively evaluated. Students’ misconceptions are identified and redirected. Learners are viewed as having a unique and individual zone of ability where they are able to complete an activity independently. Working collaboratively, students and teachers determine what assistance is needed to move toward increasing that zone of independence.

Instructional scaffolding. Just as carpenters use scaffolds to support and prop up buildings during the construction process, so too educators use scaffolds to support learners temporarily. Scaffolds might be needed the most at the beginnings of learning experiences and are gradually decreased as students become increasingly able to achieve learning outcomes independently (Hagler et al., 2011; Morgan & Brooks, 2012; Sanders & Welk, 2005).

Scaffolds initially provide substantive foundational knowledge, offer sequenced opportunities for understanding new ideas, and are gradually withdrawn as learners construct their own ways of understanding the material. Learning activities are designed to link to students’ personal goals, connect theory to practice, and invite deep and critical reflection.

Clinical teachers can expect that instructional scaffolds such as a syllabus, course outcomes, and required evaluation activities are in place for student groups. However, each clinical area offers unlimited possibilities for additional innovative scaffolds. For example, clinical teachers can create specific activities for their clinical agency placement areas. They can tailor orientation activities to fit their specific practicum placement areas. They can create advance organizers such as concept maps and mind maps (Melrose et al., 2013) illustrating approaches to patient care or procedures that students will implement. Clinical teachers can also sketch simple diagrams to supplement verbal or textual instructions. They can pose thought-provoking questions that invite learners to view the world in new ways (Nevers & Melrose, 2016). They can model procedures and invite students to participate as much as they are able, turning the activity over to students themselves whenever possible. Clinical teachers can share their own clinical experiences, both those that involved clear professional responses and those that were ambiguous and without clear answers. Woodley (2015) suggests creating individualized orientation folders, either paper or electronic, to distribute to students at the beginning of their clinical rotation.

Before each clinical practicum, arrange a private one-to-one meeting with each of your students. Draw from the following “getting to know you” set of questions to guide your discussions.

• What is your style of learning?
• What are some of your strengths and challenges?
• What are your expectations of your instructor?
• How can I help you as a learner?
• How will I know when you are anxious, stressed, or nervous?
• What are you looking forward to in this upcoming practice experience?
• Why did you go into your professional field, and where do you see yourself after completing your program?
• Do you have any health professionals in your family or any experience in your field yourself?
• Do you work outside of school?
• What are your hobbies or interests?
• Any other concerns I can address at this point?

LYNDA CHAMPOUX, BSN, INSTRUCTOR, AND COLLEAGUES, DEPARTMENT OF NURSING, CAMOSUN COLLEGE

Adult educator Jack Mezirow (1978, 1981, 1997, 2009) is credited with articulating transformational learning as a framework for teaching and learning. This worldview suggests that learning involves meaningful and transformative shifts in students’ established beliefs and assumptions. These shifts are expected to occur when disorienting dilemmas arise. In other words, learners can experience profound transformations when they have been deeply affected by a learning experience. Clinical learning environments offer limitless opportunities for both teachers and students to think in new and different ways and to experience transformational learning.

Teachers who ground their practice in transformative learning find ways to challenge learners. They look for clinical experiences that can trigger new insights and invite critical reflection. These teachers encourage students to question what they believe to be true. They also expect students to question what they are taught and what they see in practice. Critical thinking and critical reflection are key elements of this conceptual framework.

Critical thinking. Critical thinking involves analyzing, assessing, and reconstructing (Critical Thinking Community, n.d.). Individuals who think critically seek relevant information and make judgments, interpretations, and inferences based on evidence and context (Brookfield, 2012; Burrell, 2014; Hansson, 2019; Rowles, 2012; Turner, 2005; Zygmont & Moore Schaefer, 2006). Socrates was one of the first educators to espouse the use of questioning methods by teachers (Socratic questioning) to require learners to think deeply, challenge their own assumptions, and gather evidence before accepting new ideas (Paul & Elder, 2007). Two clinical teaching activities that promote critical thinking are reflective journalling and case studies.

Critical reflection. Clinical components or programs in health professions often use reflective journalling. As an assignment, it is well suited to adult learners, helps to bridge the theory-to-practice gap, and can promote reflective practice (Chelliah & Zain, 2016; Garrity, 2013). The process fosters development of higher order thinking skills (Jarvis & Baloyi, 2020) and promotes personal and professional growth, empowerment, and development of knowledge, skills, and attitudes (Garrity, 2013). As a transformative learning approach, reflective journalling creates needed introspective opportunities for students to identify and analyze their feelings of discomfort, stress, or anxiety (Ganzer & Zauderer, 2013; Waldo & Hermanns, 2009).

Journals are often used as a tool for student evaluation (Ekelin et al., 2021; Lasater & Nielsen, 2009; Ross et al., 2014; Waldo & Hermanns, 2009). Including reflective journalling in evaluation is a key advantage for students, providing an opportunity for them to articulate and share the experiences that transformed or shifted their thinking. Teachers or clinical staff members might not otherwise be aware of these experiences or their profound impacts. With reflective journalling, students can think critically, be creative, express personal views, and critique their own performance.

Yet an expected disadvantage of evaluating reflective journalling is the reluctance of students to self-critique fully and honestly if doing so might affect the grades that they receive. Teachers can find it difficult to mark journals objectively, and reviewing them can be time consuming (Chan, 2009). Guidelines for implementing reflective journalling assignments include providing clear explanations of what critical reflection means, what the approximate length of journal entries should be, how often they should be submitted, and the extent of privacy and confidentiality that students can expect (Chan, 2009). Timely feedback on student journal entries strengthens the reflective process.

Case studies or case methods are also widely used during clinical components of programs for health professions. Case studies promote critical thinking, problem solving, self-direction, active learning, and communication skills (Carnegie Mellon, n.d.; Gaberson et al., 2015; Popil, 2011; Tomey, 2003).

Case studies are stories of real-life situations with complexities, dilemmas, and issues that are more abstract than concrete. Details in case studies are important, and the information presented must be specific. “Correct” responses and professional actions should not immediately be apparent. This lack of clarity provides learners with opportunities to practise identifying the kinds of problems that are present, to suggest different treatment approaches, and, most importantly, to consider new points of view (Carnegie Mellon, n.d.).

Clinical teachers can draw from their own experiences to create case studies, or they can access fully developed and peer-reviewed cases posted on health-care resources websites. When judging the merit of a case study for use in a specific area, assess whether the client situation and the setting are realistic and whether the information provided is detailed but brief. Discussion questions accompanying the cases should be open ended, inviting critiques and inspiring questions about the additional information that learners need to seek (Carnegie Mellon, n.d). Supplementing any case study activity with background information, such as anatomical and physiological reviews, lab test information, or excerpts from required texts, will help students to solve problems posed within the case in more informed ways.

It is beyond the scope of this book to provide an in-depth exploration of the many experiences that contribute to Indigenous ways of knowing. Considerable diversity exists among Indigenous peoples around the world, and our aim is simply to offer a sampling of some of the assumptions and beliefs that might undergird some Indigenous worldviews. As a way of inviting educators in the health professions to explore ideas associated with Indigenous thinking further (and in their own ways), we introduce the concepts of “coming to know” and “holistic thinking” with brief comments on each.

Coming to know is a key concept within many Indigenous worldviews. It emphasizes a process of reflecting deeply and personally and of finding a balance between Indigenous knowing and Western perspectives (Snively & Williams, 2016). This reflective process requires people to undertake both formal and informal learning tasks by calming their minds, turning their thoughts inward, and establishing a mindset that seeks to reveal a sense of harmony with nature. The experience of coming toward (or coming to) learning includes a belief that people have gained valuable wisdom from their ancestors and that it will support them in approaching tasks with an open mind and a kind heart and spirit (Snively & Williams, 2016).

Holistic thinking also plays an important role in Indigenous ways of knowing. Holistic (or wholistic) perspectives view people as whole beings, with interconnections among all aspects of their physical, emotional, spiritual, and intellectual selves (Cull et al., 2018). These interconnections extend beyond individuals and emphasize respect for, and connections to, the land. High value is also placed on belonging and on relationships with others, including family members, communities, and nations (Cull et al., 2018). Teaching approaches that include storytelling (discussed further in Chapter 5), and opportunities for Elders to share oral traditions, support holistic thinking.

Holistic thinking is reflected in a set of learning principles articulated by the First Nations Education Steering Committee (n.d.), the group collaborated with Indigenous elders, scholars, and knowledge keepers to develop the following nine principles that reflect Indigenous ways of learning:

1. Learning ultimately supports the well-being of the self, the family, the community, the land, the spirits, and the ancestors.
2. Learning is holistic, reflexive, reflective, experiential, and relational (focused on connectedness, on reciprocal relationships, and on a sense of place).
3. Learning involves recognizing the consequences of one’s actions.
4. Learning involves generational roles and responsibilities.
5. Learning recognizes the role of Indigenous knowledge.
6. Learning is embedded in memory, history, and story.
7. Learning involves patience and time.
8. Learning requires exploration of one’s identity.
9. Learning involves recognizing that some knowledge is sacred and only shared with permission and or in certain situations.

The developers of these principles acknowledged that, though the principles do not capture the realities and experiences of all Indigenous peoples, they do reflect the common values about and perspectives on education held by one Canadian group (Alberta Regional Professional Development Consortium, 2018; First Nations Education Steering Committee, n.d.). Educators can apply the principles as a foundation for increasing their understanding of some of the commonalities and cultural constructs inherent in Indigenous ways of knowing.

Self-direction is a foundational element of andragogy. Individuals who are self-directed accept responsibility for their learning by selecting, managing, and assessing many of the activities that they need throughout their learning process (Brookfield, 1984; Guglielmino, 2014; International Society for Self-Directed Learning, n.d.; Knowles, 1975). Many practicum students in the health professions had their previous learning experiences directed by teachers who told them what to do, what to study, and which goals to achieve. When students have had limited opportunities to assume responsibility for their own learning, clinical instructors can help by clearly communicating that self-direction is expected and required. For example, instructors can ask “How do you direct your own learning and how can we best help in that effort?” (Douglass & Morris, 2014, p. 13).

Experiential learning, also termed “hands on” or “learning by doing, ” is a second foundational element of andragogy. Experiential learning theory suggests that, when learners are directly immersed in activities and then reflect analytically on their experiences, the process can integrate cognitive, emotional, and physical functions (Association for Experiential Education, n.d.; Dewey, 1938; Kolb, 1984). Each learner’s experience is uniquely personal and will vary with context.

Teachers can support experiential learning by becoming involved in learners’ ways of analyzing their experiences. Teachers can guide learners toward thinking beyond just the local contexts of their experiences (Moon, 2004). For example, Jacobson and Ruddy (2004) suggest posing questions such as Did you notice. . . ? Why did that happen? Does that happen in life? Why does that happen? How can you use that?

David Kolb (1984; Kolb & Fry, 1975) created an enduring model to explain experiential learning. He theorized that learning is a spiralling process of four steps. First, learners carry out an action or have a concrete experience. Second, they think about or reflect on that action in relation to that specific situation. Third, they try to understand the abstract concepts involved and look for ways to generalize beyond the specific situation. Fourth, they apply the knowledge and test what they discovered in new situations.

A third foundational element of andragogy is replacing the hierarchy between teachers and students with collaboration and shared responsibility (Brookfield, 1986; Brookfield & Preskill, 2005; Imel, 1991). Traditional university programs presented information primarily through didactic methods such as lectures and assigned readings. Motivation was extrinsic, usually in the form of grades. Students often worked alone and might have felt that they were in competition with their peers. However, as ideas from the field of adult education are integrated into higher education settings, shifts are occurring. Students are now more familiar with the notion that they are expected to be active participants in their learning. Motivation is becoming more intrinsic, and most university students have experience working in small groups (Kurczek & Johnson, 2014). Integrating collaboration among students and having them work together in clinical practice areas can be an effective instructional approach and one that is relatively easy to apply. In contrast, establishing a learning environment in which the hierarchy between teachers and students is eliminated is less straightforward. Ultimately, teachers evaluate students. Still, teachers’ relationships with students in higher education programs can be collaborative.

In academic settings, the teaching role is changing from authoritative professor to learning facilitator. One example is King’s (1993, p. 30) seminal call for teachers in higher education to be more like a “guide on the side” than a “sage on the stage.” Daloz (2012) urges higher education teachers to create mentoring relationships with students. Competitive thinking among students can be reduced by pass or fail grading systems rather than numeric or letter grades (Kohn, 2012; Melrose, 2017; White, 2010). In clinical settings, teachers are investing more in their relationships with students and making efforts to facilitate discussions rather than simply transmit knowledge (Beckman & Lee, 2009). Collaborative learning is not a matter of expert teachers transmitting knowledge to amateurs; rather, it is teachers and students working together to pursue knowledge (Barkley et al., 2005; Palmer, 2007).

Clinical teachers can collaborate and share responsibility for learning by inviting students to take on leadership roles within their clinical groups. In the following two “From the Field” strategies, instructors provide direction for activities that can help to facilitate collaboration.

Most teams of health professionals working together in institutions or agencies have someone designated as the team leader. This is often a rotating position. That is, someone is assigned to the role for a certain period, and then another person takes on the role. Often the team leader is someone who has several years of experience.

During their clinical placement experience, students can practise being the team leader for other students in their clinical group. Usually, a clinical group of approximately eight students will work a shift on the same unit.

This is how the activity is organized.

• Each week during the clinical placement a student is assigned the role of team leader.
• The student who is acting as team leader arrives 15 minutes early for the shift to review the patients whom each student in the group will be caring for on that shift. The student team leader talks to the nurse in charge and makes certain that the patients whom the students are caring for are stable and appropriate to be assigned to student nurses.
• During the shift, the student team leader uses leadership skills to remind the other students on the team about matters such as changes in doctors’ orders, incoming laboratory results, documen­tation requirements, discharge planning, and maintenance of professional standards. The student team leader organizes breaks and ensures that coverage is appropriate. The leader also provides feedback to and support for team members and acts as the liaison between the instructor and each student on the team.

Note that, if the student group is too large for one student team leader, the instructor can divide the group and assign one leader to every three or four students.

Taking a turn in team leading with a student group will help students with entry-to-practice competencies related to leadership in coordinating health care by

• providing practice in designing patient assignments based on factors such as acuity of the patients and nurses’ experience and skill level;
• providing experience in supervising and evaluating the performance of other health-care providers; and
• providing experience with facilitating continuity of client care.

JACQUELINE MANN, MN, ACADEMIC COORDINATOR, CENTRE FOR NURSING AND HEALTH STUDIES, ATHABASCA UNIVERSITY

Rounds, traditionally defined as “a series of professional calls on hospital patients made by doctors or nurses” (Rounds, n.d.), can be adapted to a student-led learning activity.

Permission for the instructor and clinical group to visit and gather at the bedside must be obtained from the patient and unit or agency managers.

In preparation for leading the clinical group in a professional call or round with their patient or client, each student presents the patient to the clinical group, noting diagnosis, treatment, and plans for care.

Then, at the bedside, each student leads the round on this patient while the instructor and other members of the group observe the interaction and the environment. The round can include an introduction to the patient and a quick priority assessment such as ABCIOPS (A: airway, B: breathing, C: circulation, I: intake, O: output, P: pain and comfort, S: safety). As appropriate, the round may also include a chart review to highlight vital signs, procedures, and equipment being used.

Ensure that private space is available for the instructor and the group to debrief and exchange feedback after the round.

AMELIA CHAUVETTE, RN, BSCN, MSCN, THOMPSON RIVERS UNIVERSITY

Learning styles. Another strategy for clinical teachers to facilitate collaboration is to provide an opportunity for everyone in the group to complete an inventory of preferred learning styles. This is especially valuable at the beginning of a course. The process of teachers and students working together to discover and then share the ways in which they learn best can offer valuable reminders that everyone learns differently. The process can also remind teachers intentionally to implement a variety of different instructional approaches, not just those that they are familiar with or prefer themselves. A quick Google search will yield an abundance of inventories for preferred learning styles. Many of them are unsuitable because they are lengthy, must be purchased, or are restricted by copyright law. One inventory, the VAK/VARK questionnaire, is suitable and readily available for public use on the VARK (n.d.) website.

The VAK (Fleming & Mills, 1992; VARK, n.d.) model suggests that people prefer one of three styles of learning: visual, auditory (aural), or kinesthetic. Visual learners prefer movies, pictures, diagrams, displays, and handouts. They appreciate the opportunity to observe someone else complete a task or demonstrate it before they do it themselves. They work well from written directions. They might use phrases such as “show me.” Auditory or aural learners prefer listening to spoken words or sounds. They value listening to instructions from experts. They work well from telephone or recorded directions. They might use phrases such as “tell me.” Kinesthetic learners prefer physical experiences such as touching, feeling, holding, and doing. They are most comfortable learning tasks by stepping right in and trying to do what they are expected to do. They might use phrases such as “let me try.” At different times and in different situations, people might prefer different ways of learning and combinations of learning styles.

An additional learning style, reading and writing, was later added to the VAK, which became the VARK (VARK, n.d.). Reading and writing learners prefer text-based information and materials. They are drawn to information presented in lists, manuals, textbooks, class notes, and PowerPoint lectures. They might use phrases such as “I read that.”