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The applicability of theories of adult education to district nurse education
Elizabeth Bolt, University of Surrey
As a result of the rapid acceleration in the rate at which not only knowledge and technology change but also the state at which attitudes and values within society change, the professional body for District Nursing has, along with many other ‘professions’, recognised the need for lifelong professional learning among its members. The aim of this paper is to consider the applicability of some of the theories in adult education to District Nurse education to facilitate this lifelong professional learning.
For those not familiar with District Nurse education it should be explained that a prerequisite for acceptance to District Nurse training is a basic qualification as a State Registered Nurse or Registered General Nurse. Prior to 198l District Nurse training, although considered desirable, was to a large extent optional, but in 1981 training became mandatory to practise.
With the increasing emphasis on Primary Health Care and the move towards increasing the numbers of patients being cared for in the community, it was felt by the profession that a more comprehensive training was necessary to equip the District Nurse for her changing role. Thus a longer period of training and a revised outline curriculum was introduced in 1981 at the same time as mandatory training. In addition to these changes there has also been a gradual change of location for District Nurse courses from Schools of Nursing into Colleges of Higher and Further Education. This change is now almost complete.
The District Nurse course now consists of two parts. Part one constitutes four months theory and two months practical experience in the field. The way in which theory is integrated with practice varies considerably between teaching centres. Written assignments are completed by the end of part one, at which time the students take their final examination and a practical assessment is made.
The second part of the course consists of a period of three months supervised practice. Part two does not at present involve any theory, therefore there is no integration of theory to practice at this time.
The concern of this paper is professional lifelong learning in District Nursing and how this can possibly be achieved. Griffin[1] writes that lifelong learning is a goal or concept rather than a theory, thus lifelong professional learning is to be a reality; in District Nursing an educational strategy or theory will need to be adopted or developed. Two models which are often considered in relation to lifelong learning are those of recurrent education and continuing education. Although the demarcations between these two models are not always clear, there do appear to be some essential conceptual differences between the two.
Continuing education is usually considered to be all the learning that occurs after a break or following the initial period of compulsory education. Recurrent education, on the other hand, is often seen as a radical alternative to continuing education. The emphasis in recurrent education appears to be on the whole span of education through life and initial education is seen as an integral part of the whole.
Griffin[2] cites Bock et al as describing continuing education as the learner laying aside his or her daily work and attending sessions where the material discussed may have no direct connection with the learner’s immediate working needs. Whilst continuing education is probably intended as a response to perceived need, the provision tends to be ad hoc and piecemeal. It is difficult therefore, to see how there can be any meaningful integration between theory and practice.
Duke[3] cites some of the principles from the OECD Report, Recurrent Education: a Strategy for Lifelong Education. Those which might be relevant to this discussion are:
1. Guaranteed access to post-compulsory education.
2. Distribution of facilities to make education available to all.
3. It should be possible to pursue any career in an intermittent way, meaning an alternation between study and work.
4. Curricular design, content and teaching methodology should be adapted to the interests and motivation of different age and social groups.
5. Degrees or certificates should not be looked upon as and ‘end result’ of an educational career but rather as steps and guides towards a process of lifelong education, lifelong career and personality development.
Houghton and Richardson[4] believe that recurrent education should aim at producing autonomous learners.
However, most of these factors could also be applied to continuing education, particularly if this becomes mandatory, since time and resources would then have to be made available.
As essential difference between the two models might lie in the difference in attitude to the initial compulsory education. Whereas in continuing education it is seen as a separate function, in recurrent education it is an integral part of the whole. Thus in continuing education the initial compulsory education is seen as an end in itself. In recurrent education theory it could be seen as a preparation for lifelong learning by developing the required intellectual skills.
The present policy in District Nurse education is that of an initial compulsory course leading to certification, followed by continuing education which is at present ad hoc, unstructured and dependent upon Health Districts’ policy and the availability of resources.
Since District Nurse training is now mandatory to practise, Health Districts, in order to meet service needs, are having to channel more resources into initial training and this is being exacerbated by the increasing costs of a District Nurse course which has changed from being a four month course in 1980 to a nine month course at the present time. Health Districts are having to manage the service on reduced funds during this period of recession, thus it is reasonable to assume that if the resources being allocated to the initial period of District Nurse education increase, resources allocated to provide continuing education opportunities will decrease.
It was mentioned earlier in this paper that the recurrent education theory implies an integration of initial and continuing education rather than as separate entities. Applied to District Nurse education this could imply a more equal distribution of resources throughout the professional life. This would give more opportunity to the experienced practitioner to become aware of and come to terms with change as it occurs, which is surely a characteristic of lifelong learning. This would also suggest a possible reduction of resources available to initial District Nurse training.
The initial or compulsory District Nurse training does of course lead to certification for practice and any reduction of the initial period of training could present real difficulties in determining at what stage a student could be considered qualified to practise.
The 1976 working party report on District Nurse education set out the aims of the course as being:
To prepare a District Nurse who is competent to undertake nursing duties in the community and able to accept individual responsibility for the professional standards of her work.[5]
The term competent in this context is suggestive of a particular standard or ability. However, since what constitutes competency is virtually impossible to define objectively but rather is a matter for individual perception, it could be argued that this aspect of the aim is questionable.
The competency of a District Nurse student is at present determined by assessment procedures and examination and as Jarvis rightly states:
Competency to enter the profession does not depend on reaching an objective standard but on the successful negotiation of whatever qualifying examination or system that a particular profession implements.[6]
Successful completion of the District Nurse course cannot ensure a particular standard of practice, neither can it ensure the maintenance of high standards of professional performance in the field. Jarvis outlines two possible aims for professional education:
1. That the professional school should aim to produce new recruits to the profession who at completion of their training have a sufficient level of knowledge and skills to enter practice and the profession will ensure thereafter that its standards are maintained.
2. The professional school should aim to produce new recruits to the profession who have a professional ideology of seeking to ensure good practice as well as a sufficient level of knowledge and skills to enter practice.[7]
Both of these aims imply that professional education should be a preparation for practice which is arguably different from the achievement of competency.
The essential difference between the two aims proposed by Jarvis is that of who should be responsible for maintaining, and it is to be hoped, improving standards - the individual practitioner or the profession. Whilst both must surely accept this responsibility, it must be remembered that District Nurses work alone much of the time; they deal with a wide variety of individuals and circumstances within a system subject to change, therefore it is difficult for others to assess individual standards. The onus therefore of maintaining standards must rest with the individual practitioner. The most appropriate aim therefore for District Nurse education is that of a preparation for practice and to ‘develop in students a professional ideology of seeking to ensure good practice’. However, this will be meaningless if the profession do not provide sufficient resources to help them do so. Any change in the initial District Nurse training must be the result of rigorous enquiry and consideration and there is no real likelihood of any reduction in the present hard-won longer course. However, it is being argued here that neither the initial training nor certification can of itself ensure a competent workforce and that the achievement of this is more likely to be effected by an increased allocation of resources to post-basic education.
An important aspect of professional education that does need to be discussed briefly in relation to lifelong learning is that of socialisation. Goode writes that a
.. profession produces the next generation socially through its control over selection of professional trainees, and through its training processes it sends the recruits through an adult socialisation process.[8]
Jarvis[9] concludes that professional socialisation occurs concurrently with professional education but are two distinct processes, although it is not clear whether both processes are intentional, whilst Houle[10] offers the view that what he terms the ‘acculturation’ process probably does occur informally.
Although little is written about the hidden curriculum in adult education, it could be argued that the socialisation process is the function of a hidden curriculum and is probably informal rather than intentional.
This is an important area for consideration since if the socialisation process is in any way intentional, it follows that the profession would wish to control the lifelong learning of its members rather than encourage practitioners to be responsible for and direct their own lifelong professional learning. Informal socialisation will probably take place to some extent whatever strategy is adopted towards lifelong learning.
Having concluded that part of the aim of initial District Nurse education, and indeed reinforced post-basic education, should be to develop a professional ideology of seeking to ensure good practice, it follows that, as Knowles[11] proposes, if learning is to be a lifelong process, education must develop the skills of enquiry and be concerned with providing the resources and support for self-directed inquiries.
Theories of adult teaching and learning can be a valuable source of reference to District Nurse educators wishing to develop the skills of enquiry in their students.
The theory that adults learn by using a problem-solving process has been well documented by Jennifer Rogers[12]. The District Nurse curriculum has been designed ‘to emphasise the use of a problem-solving approach and reference is made throughout to the nursing process’. However, emphasising the use of a problem-solving approach is arguably different from enabling students to develop the knowledge, skills and conceptual understanding required to use a problem-solving approach. To be fair, however, this may well be implicit in the aim.
The nursing process is a problem-solving model intended to be used as a tool for providing patient care. However, if the skills and knowledge which are required to use a problem-solving approach are not fully developed, the nursing process can become a mechanical exercise. It must be pointed out that many District Nurses in practice have not been able to come to terms with the nursing process - a failure of continuing education?
Emphasis is placed on the adult learners need to be perceived as self-directed by writers such as Knowles and Rogers[13], but many adults may need to learn the skills necessary to achieve this. It is a curriculum which emphasises the process rather than content which they feel will help to develop these skills. In view of the rate at which knowledge becomes outdated there is certainly a case for suggesting that content should be subservient to the development of intellectual skills in District Nursing.
The notion of ‘critical reflectivity’ is posited by Mezirow[14]. This he describes as the development of self-awareness of ‘why we attach the meanings that we do to reality?’. He goes on to say that it is ‘only in adulthood that a person can come to recognise being caught in his or her own history and reliving it’.
The development of self-awareness and the ability to understand others and the moral issues underlying practice at a conceptual level are important for District Nurses in the light of their involvement in other people’s lives and the potential that exists for human beings to unwittingly project their own values, expectations and needs onto others.
To facilitate what Mezirow refers to as ‘perspective transformation’ emphasis is again placed on learning experiences which give students the opportunity to reflect on their own and others’ experience. This seems particularly applicable to District Nurse education since District Nurse students bring with them to the learning situation considerable experience of both life and work.
The outline curriculum for District Nursing is essentially content-based and although local centres are encouraged to innovate they are nevertheless subject to validation by the professional body. It is reasonable to assume that the professional body will, understandably, be concerned to ensure that the knowledge, skills and attitudes deemed desirable by the profession will be included.
However, taking into account the rate at which knowledge can become obsolete, an over-emphasis on content does seem short-sighted.
If high standards of care are to be maintained in District Nursing practice it has already been concluded that lifelong professional learning is necessary to cope with change.
There seems little doubt that the theories of adult education referred to in this paper are applicable to District Nurse education, although the extent to which they can be applied is difficult to assess within the present system of qualification for practice being determined in part by examination.
Another difficulty which might be experienced is that of students’ previous educational experience and socialisation process which may create resistance to new and unfamiliar methods of learning and thus adversely affect the learning process.
Perhaps to effect real change, these new methods and approaches will need to be introduced in basic nurse education or, better still, in our schools.
[1] Griffin, C., Curriculum theory in adult and lifelong education, Croom Helm, London, 1983
[2] ibid; p. 115
[3] Duke, C., ‘Evolution of the recurrent edu