GREENWOOD J (1993) Joumal of Advanced Nursmg 18, 1471-1479. The apparent desensitization of student nurses during their professional socialization: a ...
Joumal of Advanced Nursmg, 1993,18,1471-1479
The apparent desensitization of student nurses during their professional socialization: a cognitive perspective J Greenwood SRN SCM DipN RNT DipED MEd PhD Associate Professor in Nursmg, The Flinders University of South Australia, GPO Box 2100, Adelaide 5001, Australia
Accepted for pubkcahon II January 1993
GREENWOOD J (1993) Joumal of Advanced Nursmg 18, 1471-1479 The apparent desensitization of student nurses during their professional socialization: a cognitive perspective It IS argued that the structures and processes of traditional patterns of pre-registrahon nurse education in the United Kmgdom led to an apparent and relative desensitization of student nurses to human need The processes underpinning this apparent desensitization were those which promoted both a 'compartmentalization' of concepts for theory and concepts for practice m the cognitions of student nurses and their habituation to examples of poor nursmg practice These processes are descnbed and their nursing pedagogical implications are discussed It is suggested that unless clmical learrung
environments are deliberately manipulated to foster the construction and utilization of 'appropnate' action schemata, the considerable opportunities offered by the implementation of Project 2000 to unprove both nursing education and nursmg practice could be wasted It is further suggested that this deliberate manipulation should mclude nurse tutors teaching theory and practice m clmical areas if they are senously concerned to render nursing care more mtelligently responsive to human need
INTRODUCTION
new programmes were developed precisely to elumnate
The last decade has witnessed enormous changes in preregistration nursmg education m the Uruted Kmgdom, cubninatmgm the gradual implementation of Project 2000, nationwide, beginmng in 1989 Project 2000 programmes require student nurses to be supemumerary to service requirements for four-fifths of theu 3-year preparation which leads to both professionai registration and the award of Diploma of Higher Education The granting of Diploma awards to these new programnws hinges on a strengthenmg of their theoretical bases This is to be welcomed however, unless eertam conditions are met these new programmes may exacerbate rather than rectify at least some of the weaknesses of earlier programmes This would be a sad irony indeed, for these
such weaknesses Accordmg to relevant literature (e g RCN 1985, UKCC 1986), the mam weaknesses of traditional nurse education programmes were service needs takmg precedence over education needs, theory-practice discrepanaes, madequate preparation for and madequate supervision dunng clinical placements, and alarming attnhon rates Clearly, these were senous problems However, my own view is that the most senous problem was a result of a combmahon of demands for service contnbution, theorypractice problems and madequate clinical supervision and it was overlooked m the reformist literature It was this professional soaalization mto nursing tended to lead to an apparent and relative desensitization of some student nurses to human need This m tum impacted negatively on 1471
7 Greenwood pahent care as a considerable literature, including that concerrung 'the unpopular pahent' bears wihiess Two factors seem implicated Firstly, the shuchires and processes of their professional education led to a 'compartmentalization' of concepts for theory and concepts for practice m the cognihons of student nurses (Meha 1987) Secondly, repeated exposure to less-than-canng nursmg practices resulted m some student nurses becommg habituated to them This IS, of course, of more than merely historical mterest, recent evidence (eg Kelly 1991, Seed 1991, Wilson & Startup 1991, French 1992) indicates that the processes underpinnmg such cogruhve compartmentalization may still be prevalent m some pre-registration nursing education programmes m the Llnited Kingdom It is possible, too, that they may be prevalent in some new pre-registration programmes in Australia and New Zealand
Importance These processes are of central pedagogical importance to nursmg For unless the future educahon expenences of student nurses are deliberately manipulated to prevent the construchon of different conceptual repertoires for 'theory' and 'prachce' situahons the considerable opportunihes to improve nurse education (and, thereby, nursmg prachce) afforded by the new DipHE programmes could go begging Accordmgly, I will attempt to eluadate the processes underpinnmg the acquisihon and deployment of such seemmgly distmct conceptual repertoires and also those underpinning habituahon This will entail a comparative review of nursmg theory and nursmg prachce and a review of concept and schema construchon and uhlization, the latter from a cognihvist perspective The major assumphons reflected m such a perspective will be detailed at the appropnate juncture m the discussion These reviews will be preceded and contextualized by some bnef, mtroductory comments concerning theory—prachce difficulhes in general The pedagogical unphcahons ansmg from the review will be discussed as they emerge, however, I will argue that nurse teachers must 'get mto the achon' with student nurses in clinical areas if nurse educahon is to help render nursing care more intelligently responsive to human need
reflected in both human action and human utterance They suggested that people can make claims to believe certam facts and hold certain values yet fail to reflect such daims m action They also suggested, conversely, that certam beliefs can be inferred from conduct yet fail to be claimed m utterance And lastly, they suggested that agents can be aware, or potenhally aware, of certain beliefs lrrespechve of their reflection in either action or utterance It was recognition of these diffenng manifestations of belief which inspired Dickoff & James (1970) to characterize belief as related to 'hoof (achon), 'mouth' (utterance) and 'head' (arhculated mental awareness) Similar distmchons were also noted by Argyns & Schon (1974), they charactenzed 'hoofed' beliefs as 'theones-in-use', because they issue m action, and assimilated both 'headed' and 'mouthed' beliefs to 'espoused theones', because these are the theones to which human agents claim allegiance The cntical point both sets of scholars seek to make, however, is that people can and do possess incompatible and mconsistent bebefs, values and action tendencies without being aware, or fully aware, that they do What this m tum necessanly presupposes, therefore, is that people can and do acquire and utilize incompatible and inconsistent beliefs, values and achon tendenaes without being aware, or fully aware, that they have Nursing students appear to acquire two such inconsistent repertoires of beliefs, values and action tendencies durmg their professional socializahon, the first they acquire from 'nursing theory', the second from nursing practice
NURSING THEORY
Nursing theory is meant to underpin nursing practice It mcludes three interrelated elements, conceptual models of nursing, the nursing process approach to the organization and delivery of care and the results of empincal nursing research Conceptual models of nursing can be categonzed accordmg to their pnmary focus (Salvage & Kershaw 1986) They represent different views concerning the reapient ofnursing care, the environment withm which the reapient exists, the health-illness continuum withm which the reapient falls at the hme of interaction with the nurse, and nursing interventions (Kozier & Erb 1988, Lewis & Timby 1988) Despite some superfiaal dissimilanhes, however, these conceptual models are all fundamentally similar m importTHEORY-PRACTICE DISCREPANCIES ant and mterrelated respects (The author acknowledges In 1970, Ehckoff & James drew the attenhon of the nursmg that this relates more closely to totahty paradigm theones community to the diffenng levels of consaousness that are than to those of a simultaneity paradigm, however, smce 1472
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the impact of the latter on nursmg in the United Kingdom has been minimal the major pnnaples they reflect have been omitted This omission seems justified, moreover, smce they appear even further from practical realities than those of totality paradigm theones) Firstly, the conceptual models are all holistically onented m that they take account of the whole person in all her physical, psychological and sociocultural aspects Secondly, health is construed as an mdividual's optimum state of physical and psychosoaal weU-bemg Thirdly, the person is viewed as essentially active, stnvmg for independence, for meaning, for need fulfilment, etc, m her everyday livmg activities And, fourthly, nursing care is construed as focusing on the individual patients in relation to these meamngs and everyday activities The second element of nursing theory, the nursing process, IS a problem-solvmg approach to care It consists of four (or five) phases, namely, assessment of needs/ problems, (diagnosis of nursmg problem) identification of nursmg goals, implementation of care strategies and subsequent evaluation of their effectiveness (McFarlane & Castledine 1982, Lewis & Timby 1988) The third element concerns the results of empmcal nursmg research Nurses are required to defend their decisions (McFarlane & Castledme 1982) and their actions (Madeod Clark & Hockey 1979) on saentific rather than intuitive or conventional bases and there is now an emergent research literature m nursing and related saences to assist them to do this
N U R S I N G IN P R A C T I C E The formal nursing theory with which student nurses are equipped by tutonal staff is of questionable assistance to student and/or newly graduated nurses when they encounter the real world of nursing, i e dinical facilities where they must render service, unsupervised and unprotected, to a number of patients/dients with a range of competing demands It is interesting to note that tutors are aware of this (Gott 1984) and that students are likely to encounter 'reality shock' (Kramer 1974, Mynck 1988) To begin with, care is till largely task-centred m many care facilities, despite thinly disguised pretensions to the contrary (Nursing Times 1985) Tnmary nursing' and 'total patient care' are the new labels for what amounts to one nurse, or a small team of nurses performing all the required tasks for a limited number of patients They still 'do obs' cind 'do beds' but for their own group of patients And it is now almost a cliche that total patient care is provided whenever workload permits In addition, student nurses admit to feelmg madequately prepared for their clinical expenences (RCN 1985, UKCC 1986), they feel that they have neither the practical nor the mterpersonal sblls that are required for nursmg (Gott 1984) Irrespective of this lack of knowledge, however, the workload in clinical facilities is generally such as to require immediate incorporation of students mto the workforce, this IS swiftly accomphshed by painng them off with another student, auxiliary or trained nurse who is already famihar with the ward routine (Reid 1985, Wilson & Startup 1991)
Person-centred In short, nursing theory construes each patient as an individual with physical, emotional and social needs which she expresses in her own unique way through her everyday activities It IS the person, not the disease, which is the focus of nursing Nursing care consists in helping people to mamtam/attam their individual, optunum state of weUbemg through the application of nursmg models, a problemsolvmg approach to care and msights from nursing and nursmg-related research These, then, are the espoused ('headed'/'mouthed') theones of nurse theonsts and nurse teachers, unremarkably, therefore, they are also the espoused theones of student nurses Student nurses learn them consciously largely through formal classroom teaching and from literature They appear, however, stnkmgly different from their theones-m-use ('hoofed' beliefs) which they learn from nurse practitioners who use them day-m and day-out m clmical nursmg practice
Routines Routines are major strategies for maintainmg order m the wards, each ward routme reflects the idiosyncratic preferences of the trmned nursmg staff and medical consultants (Orton 1983, Proctor 1989, McCaugherty 1991) Students feel that they must discover what the ward sister expects of them and 'fit in' accordingly (Melia 1981, Seed 1991) Moreover, ward routines, because they structure nursmg practice, help student nurses 'get through' their allocated tasks (Meha 1981, Chavasse 1992) and thereby fit mto the ward team all the more easily The necessity to 'get through' the workload actually justifies skimpmg tasks and using incorrect procedures (Meha 1981, Kelly I99I, French 1992), as far as student nurses are concerned, if they 'get through' they are seen to be 'pullmg their weight' and 'fittmg m' (Meha 1981, Seed 1991) Routines serve other functions, too First, as already indicated, they are efficient means of commumcation 1473
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because they are two-dimensional They possess a temporal dimension which tells a nurse when to do a particular task and a motor dimension which tells her how to do it (Fretwell 1982) The when and the how, as suggested above, usually depend on the idiosyncratic preferences of ward sister and/or consultant and smce the wards are arranged to group patients with common pathology (Roper 1976) routines tell nurses what to do for each type of disease or condition at particular times Thus, nurses tend to leam to give routine care to everybody with the same or similar condition rather than sf>eafic care to individuals Clinical facilities and the nursing care that takes place in them are, therefore, still largely disease-focused Second, routines appear to be primarily concerned with physical care, e g bed baths, dressings, observations, etc Nurses leam, therefore, that nursing itself is pnmanly concerned with physical care and this is consistent with a disease-onented model (Pearson & Vaughan 1986, Seed 1991) It IS hardly surpnsmg, therefore, that patients receive insufficient information concerning their condition and progress and that the type as well as the amount of information they receive is inadequate (Nicholls 1984, Walton & Macleod Clark 1986) This, in tum, is hardly surpnsing, up to &(y/o of student nurses' utterances are inhibitory to further communication (Gott 1984) and at least two factors seem implicated One has already been mentioned, le that nurses leam to construe nursmg m terms of physical care Another is that the minimal personal communication required for the performance of routme work makes detailed information concerning patients unnecessary Given the heavy workloads in clinical areas, trained nurses do not make time to keep juruor colleagues well informed as to the current condition of their patients (Melia 1981, Seed 1991) Third, smce nursmg care is dehvered through relatively simple nursing routines that do not seem to require much theoretical grounding, students leam to construe 'theory' not m terms of practical utility or relevance but largely as of use to pass examinations and assignments (Melia 1981) "Real' nursing However, student nurses leam more than just routines doing their mundane nursing activities and, importantly, this mcludes what constitutes 'real' nursmg 'Real' nursing IS what 'real' nurses do, l e qualified nursmg practitioners, and this usually entails technical, medically devolved procedures (Pearson & Vaughan 1986) Moreover, any teaching undertaken by 'real' nurses also usually focuses on technical procedures, quahfied nurses tend neither to 1474
undertake activities of living care nor to teach it (Fretwell 1982, Gott 1984) This could account for student nurses' perceptions of 'good' and 'poor' wards (Fretwell 1982), 'good' wards offer a vanety of technical procedures to leam whereas 'poor' wards are largely concemed with basic nursing care And further, technical nursmg is perceived as 'leammg' activity whereas basic nursing care is simply 'work' (Fretwell 1982, Seed 1991) To sum up m practice the focus of nursmg is physical disease and not the persoa nursing consists in getting through the workload at almost any cost, 'real' nursing is technical nursmg and mundane nursing activities are 'just basic nursmg' Patients are seen, therefore, pnmanly as work objects and nursing generally in terms of a routine practicality Such are the theones-in-use ('hoofed' behefs) of nurse practitioners and, therefore, student nurses It IS important to note that these theones-in-use are not transmitted deliberately nor leamed consaously because this would subvert nursing's espoused service ideals This implies that such theones-in-use are leamed madentally and largely unconsaously from nurse practitioners who lmphcity require and reward their acquisition and deployment m mundane nursing activities (Kelly 1991, Chavasse 1992, French 1992) The differences between nursing in theory and nursing
in practice appear compellmgly stark. Indeed, the theorypractice divide m nurse education is now an estabhshed component of nursing tradition (McCaugherty 1991) This IS due to an apparent compartmentalization of concepts required for theory situations and concepts required for practtce situations m the cognitions of student nurses 'Compartmentalization' is, of course, used metaphoncally here (see below), it is a useful term, however, because it is so evocative A descnption of the nature, function and acquisitive and activation processes of concepts follows, it is informed by a cognitivist view of the person
COGNITIVISM Bnefly, cogrutivism (or, cognitive constructionism) views the person as a skilled information processor who interactively and selectively constructs, at differing levels of awareness, lntemal models or representations of expenential objects, events, sensations and actions m order to interpret subsequent stimuli and react appropnateiy to them The represartations of reality constructed (concepts) are a function of what the person already knows, the situation withm which she finds herself and the purposes to which the concepts will be put (Sanford 1984) Concepts, their interrelationships and activation processes are
Desenstttzatton of student nurses
progressively 'chunked' together in highly organized hierarchies which can be accessed and activated, simultaneously and as required, again at diffenng levels of awareness
Concepts and schemata Concepts and schemata are both mental representations which allow the categonzation of stimuli as mstances or non-mstances of a category and they are both leamed by abstracting mformation from actual mstances Moreover, they are both representative of organized units of knowledge which relate to each other hierarchically
phenomenon itself, the cogruzer, the conditions under which it IS leamed and the use to which it will be put For instance, to be dassified as a tnangle any twodimensional geometnc shape must possess the following properties (a) three straight sides, (b) sides are joined at each end, and (c) angles add up to 180 degrees Thus, (a) and (b) are perceptual features observable through the senses and (c) is a formal property, that is a mathematical property that cannot be discovered by visually examinmg tnangles In order for a tnangle to be a tnangle and not some altemative geometnc shape it must possess (a), (b) and (c) In short, (a), (b) and (c) constitute a descnption of the necessary and sufficient conditions for the category 'tnangle' and this descnption serves as a definition of 'tnangle'
CONCEPTS One of the most important charadenstics of cognition is that entities and events in the world, although individually different, are treated m thought and language as conceptual categones The concept 'chair', for instance, is a mental groupmg of objects which are individually different but which tend to share certain common properties or features Concepts or conceptual categones are, therefore, mental representations of objects, entities, events, etc, stored m memory (Roth 1986, Howard 1987) The ability to categorize is a central and integral part of cognition (Bruner elal 1956, Smyth 1987) for without such categonzation each object, event, etc, would be expenenced as novel and would be unrecognized and un-named Thus, the fundamental property of perception is the abihty to place objects in conceptual categones Without recognition or name we would not know what to do ivith or about each novel stimulus that bombarded our attention, categonzation is, therefore, prerequisite to mtelligent action It IS also required for the effiaent functioning of memory and for efifiaent commumcation (Howard 1987) The construction of concepts also accounts for how people habituate to repeated stimulation (see below) By treating objects, entities and events as members of conceptual categones, the world is divided into distinct chunks and m this way structure is imposed upon it The categones formed are designed to minimize cognitive effort by takmg advantage of perceived world structure and representing it m the most economical way This is known as the prmaple of cognitive economy Consistent with this, phenomena are classified according to their attnbutes or features, their function and even their formal properties (Roth 1986), a further and crucial pomt is that the danty, accuracy and adequacy of categonzation or classification is a fimction of the mteraction between the
Not all clear-cut Unfortunately, however, not all categones are so dear-cut Many examples, particularly of 'everyday' categones (Roth 1986) do not seem to possess features which are necessary or necessary and suffiaent, for example, 'chair' The obvious psychological implication of this is that conceptual categones such as 'chair' are not mentally represented in terms of lists or properties which dearly define categones and distinguish them from other categones The representation of such categones is said to be lU-defined or fuzzy and is thought to be based on the properties or charactenstics of typical members of the class Atypical members will share little m common with the representation of the typical and the cognizer may well expenence difficulty in deadmg whether or not the member under scrutiny is actually a member of the class in question Of cntical importance, however, m this sort of situation is that context will influence categonzation (Howard 1987) It seems, therefore, that fuzzy boundanes eire due to the existence of common categoncal features It IS not uncommon, moreover, for a person to possess both well-defined and fuzzy representations of the same category for use in dififerent situations (Howard 1987) For example, a zoologist may have a fuzzy representation of 'dog' which she uses for everyday purposes such as talking to children and a relatively clear-cut definition of dog which she uses in her saentific work There are two pedagogically sahent points to note here Fust, theones-m-use are a type of fuzzy representation, they are usually 'everyday' concepts the interpretation of which IS heavily dependent on context This implies that they will be observed, surfaced and, possibly challenged more easily in the contexts which contnbute to their meaning 1475
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Second, mdividuals can possess both clear cut and fuzzy representahons of the same phenomenon for use m differmg situations, this is, of course, reflechve of discrepant espoused ('mouthed'/'headed') theones and theones-m-use ('hoofed') Thus, a student nurse can possess a fuzzy concept of nursmg as gethng through the workload for prachcal purposes and also a dear cut conc^t of nursmg as mdividualised, health-onented care for classroom discussion and exaninahon purposes Nursmg education should, therefore, at the very least, help her to bnng to consaous awareness these two diffenng and mconsistent concepts of nursmg Schemata Concepts or categones and their mterrelationships are further organized mto larger, well-mtegrated chunks of knowledge, the mam function of which is to faalitate our understandmg of complex situahons and allow us to behave appropnately m them (Eysenck 1984) Each schema IS composed of 'vanables' or 'slots' and their mterrelationships For mstance, the human face schema has lips, dun, eyes and nose (at least) but these slots have to be organized m a certam way, that is, eyes above nose, nose above hps and lips above dun Any radical departure from this prescnbed arrangement, even if all the slots are present, will not be a face Each person knows an enormous number of schemata to guide and mterpret a wide vanety of soaal and other achvihes and situahons Without them persons could neither behave appropnately nor predict the behaviour of others ACTION SCHEMATA These may be construed as a type of event schema which represent only procedural knowledge An example is probmg an abscess Each schema consists of slots for graspmg the probe, steadymg it ready to msert by tensmg the appropnate musdes (and relaxmg others) judging the distance to the abscess, the force needed to penetrate it and then actually probmg the abscess The slots occur m a certain order and can be filled with a vanety of actual behaviours, for example, the probe can be grasped at difJFenng pomts along its length, with diffenng gnps, etc Achon schemata are the means whereby an agent's overall mtenhon is translated mto hierarchically organized mstnichonal units which reflect the structure of the movements required and whidi eventually issue m achon Such schemata are also known as produchon systems (Schmidt 1975) 1476
Produchon system theory is a usebA way of understandmg how knowledge may be organized m the service of action at dififerent levels (Sloboda 1986) At the level of mdividual achons, for mstance, particular environmental patterns can tngger immediate knowledge of the nght thmg to do m the parhcular situations, in dnvmg, a green hght turrung to amber tnggers the immediate pressing of the brake pedal A further cntical pomt is that knowledge may be completely maccessible until the arcumstances which demand its use occur Moreover, production system theory is useful m the understandmg of the nature of plarming and structure m skilled action, and the abihty to keep track of where one is at any particular pomt m its execution because produchon system theory by itself is inadequate to this task. The elucidahon of the structure of skilled action requires, m addition to the notion of production systems, the posihng of a workmg memory system m which a 'goal stack' is held For mstance June is m a Devonshire village but wants to return to London immediately, she sets the goal 'return to London' This goal then acts as conshtuent of a production rule 'if the goal is return London then set the goal of getting to the nearest railway stahon', thus the goal 'return to London' is pushed down the goal stack and the goal 'get to the nearest railway stahon' may then call up another produchon rule 'if the goal is to get to the nearest railway stahon then set the goal to find out where it is' and the goal IS to get to the nearest railway station' is pushed down the goal stack and the goal 'find out where the nearest railway stahon is' now sits on top as the current goal with two unachieved goals beneath it This may call up further goals 'ask a local person', 'look m a telephone directory', 'find a public telephone' etc, etc, unhl at some point the current, top goal will call into play a production rule mvolvmg the achon sequences which achieve it When this happens the topmost and recently achieved goal IS jettisoned and the second m the stack becomes uppermost, this is achieved followed by the next and so on through the goal stack until there are no goals left It is, therefore, the goal stack which gives direchon and structure to the total behaviour (Sloboda 1986) Uncoordinated without a goal Without a goal stack behaviour would have to be dnven by the current situahon and would be, therefore, by definihon, uncoordinated. Without the adequate retenhon of goals m the goal stack, moreover, there would be a partial breakdown m behaviour and this sort of breakdown can be seen m certam types of absentmmded errors (Reason & Myaelska 1982) which occur to all of us There cannot be
Desensitizaium of student nurses
many people who have never walked into a shop only to stand there rather foolishly trying to remember what it was they came in for The goal "bujang X' led to new goals 'go to shop' but on the way they started to think of other things and intervening cogrutive achvity led to the loss of the onginal goal from the stack It should be remembered that people pursue many and varying goals but can never be consciously working on more than one or two of them, it follows, therefore, that the abibty to remember what one's goals are, and how far one has got m achieving each of them, is an important skill It seems that the role of external memory aids is particularly important here, for example, lists of chores, articles placed on bnefcases, etc, etc, all point to the fact that external stimuL are the best and most reliable triggers of action The activation of relevant schemata in the execution of intention becomes progressively more rapid and fluent until automahaty is reached Such automatic tnggenng of component schemata is a function of the strength of the linkages between them, and this, m tum, is a function of their repeated activation and deployment through practice m relevant task situations (Roth 1986) What this implies is that the task situation itself provides its own appropriate retrieval cues This theory of schematic activation could provide insights into the 'compartmentalization' of theory and practice m the cognitions of student nurses The use of the term 'compartmentalization' is, as already indicated, metaphorical, it merely points to the clear differentiation of 'theory' and 'practice' schemata because of the weaknesses of their lnterhnkages Thus, goals of passing assessments and getting through the workload, for instance, will be tnggered by appropnate environmental cues and the requisite sequence of constituent schemata will be run off automatically The appropnate environmental cues, moreover, are likely to be, respectively, those persons and objects assoaated with nursing theory and those assoaated with nursmg practice
qualihed nurses who are strugglmg to cope with mcreasmg patient dependency and through-put m the face of limited or dimmishmg resources These colleagues may not have time to attend to the learrung needs of student nurses Moreover, they may not have been educated to the same level as students allocated to their areas This, combmed with the additional theoretical components of the new Diploma programmes, suggests that tutonal involvement in clinical areas is necessary now and at least until such post-registration educational requirements (and workload issues) have been addressed
HABITUATION Habituation refers to an orgcinism's loss of responsiveness to a repieated or continuously present stimulus For instance, if a strange object is placed m a mouse's cage it will onent towards it and show avoidance responses, after a short while, however, it will habituate to the object and show no response At cellular level, repeated stimulation of a single neurone will lead to diminished responsiveness to subsequent stimulation, the neurone habituates to the stimulus and this can be explained biochemically At the level of whole animals, however, habituation is typically defined as lack of interest m, or inattention to repeated visual or auditory stimulation This is due to the construction of concepts/schemata which allow subsequent, unconsaous recognition of the stimuli m question (Gellatley 1986) People habituate to repeated, mundane stimuli and habituation could account for the failure of some student nurses and, indeed, qualified nursing practitioners to notice some of the events and situations which can edarm and disappoint new students, research and tutonal colleagues one nurse just used to hold his nose and pour this stuff down him and he'd swallow or choke (First year student respondent, in Seed 1991)
Pedagogical implicahons
CONCLUSION
Agam, the pedagogical implications seem clear For if nurse teachers are senously concerned to equip student nurses with appropnate, adequate and dear-cut practice schemata, the clinical expenences to which they are exposed should be carefully structured to promote their cor«truction and subsequoit activation. Additionally, the utilization of such schemata should be required and rewarded by 'real nurses' working with them It should be noted, however, that at the present time in the United Kingdom clinical faahties are staffed largely by
It has been suggested that student nurses can become desensitized to human need through repeated, mundane exposure to poor nursing practice in dirucal environments that neither require nor reward the construction and utilization of 'appropnate' action schemata In addition, it has been suggested that student nurses' apparent cognitive compartmentalization of theory and practice is a function of the weakness of the interlinkages Nursmg theory is learned, typically, m dassrooms and IS learned from nurse teachers and nursmg literature and 1477
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because of this is likely to be stored m dear-cut categones Moreover, nursing theory is presented in discrete, pulsed 'packets' which punctuate a student's 3-year training from time to time and is generally mugged up intensively pnor to assessments and examinations The retneval cues of nursing theory concepts and schemata may, therefore, be these classrooms, and that which is typically found in them, mdudmg nurse teachers and the goals of passmg exanunations and assessments
Eysenck M W (1984) A Handbook of Cognitive Lawrence Erlbaum Associates, London French P (1992) The quality of nurse education in the 1980s Joumal of Advanced Nursing 17,619-^31 Fretwell JE (19SZ) Ward Teachmg and Learning Royal College of Nursing, London Gellatley A (1986) The nature of memory In The Skilful Mind An Introduction to Cognitive Psychology (Gellatley A ed), Open University Press, Milton Keynes Gott M (1984) Learning Nursing Royal College of Nursing, London Howard R W (1987) Concepts and Schemata An Introduction Fuzzy concepts Cassell Education, London Kelly B (1991) The professional values of English undergraduates In contrast, pradice is leamed in hospitai wards and Joumal of Advanced Nursmg 16, 867-872 commumty care facilities and it is leamed from qualified Kozier B & Erb G (1988) Concepts and Issues m Nursmg Practice colleagues, fellow students and nursing auxilianes Addison-Wesley, Menlo Park, Ctilifomia Additionally, since routine mundane expenences typically Kramer M (1974) Reality Shock Why Nurses Leave Nursmg C V neither eliat nor require dear-cut categones, the concepts Mosby, St Louis stored are likely to be fuzzy The retneval cues of nursmg Lewis L W & Timby B K (1988) Fundamental Skills and Concepts practice concepts and schemata may, then, mclude all those in Patient Care 4th edn Lippincott, Philadelphia phenomena typically encountered in practice such as clini- McCaugherty D (1991) The theory-practice gap in nurse education its causes and possible solutions Findings from cal nurses and patients and the goals of 'gettmg through' or an action research study Joumal of Advanced Nursing 17, 'ftttmg m' Importantly, moreover, the goal of 'gettmg 1055-1061 through the workload' will tngger, progressively automatically, a host of relatively fuzzy schemata to achieve Madeod Clark J & Hockey L (1979) Research for Nursmg HM&M Publishers, Aylesbury, Buckinghamshire this These schemata might typically mdude those which McFarlane J & Castledine G (1982) A Guide to the Practice of allow the skimping of work or the use of incorrect nursmg Nursing Using the Nursing Process C V Mosby, Oxford procedures Melia K M (1981) Student nurses' accounts of their work and trainFinally, it has been suggested that if nurse education is to ing a qualitative analysis Unpublished PhD thesis Edinburgh help render nursmg care more mtelligently responsive to University, Edinburgh human need, nurse teachers should deliberately structure Meha K M (1987) Leaming and Working The Occupational clinical learning environments to promote the construction Socialisation of Nurses Tavistock, London and utilization of adequate, clear-cut action schemata This Mynck F (1988) Preceptorship a viable altemative clinical teaching staiegyl Joumal of Advanced Nursmg 13, 588-591 will entail, at least mto the foreseeable future, gettmg into NichoUsKA {1984) Psychological Care and Physical Illness Croom the adion with student nurses and, mdeed, hard-pressed Helm, Beckenham, Kent dinical nurse colleagues For unless they do, there is a real Nursmg Times (1985) Editonal Nursing Times 81(44), 3 nsk that the new programmes will merely fumish a broader Orton H (1983) Ward leaming climate and student response In range of more complex theory for students to leam to view Research into Nurse Education (Davis B D ed), Croom Helm, as practically irrelevant Beckenham, Kent Pearson A & Vaughan B (1986) Nursing Models for Practice Heinemann, Oxford References Proctor S (1989) The functioning of nursing routines m the management of a transient workforce Joumal of Advanced Argyns C & Schon D (1974) Theory m Practice Jossey Bass, San Nursmg 14,180-189 Franasco Reason J &MycielskaK {1982) Absent-minded^ The Psychology of Bruner J S , Goodrow JJ & Austin G A (1956) A Study of Mental Lapses and Everyday Errors Prentice-Hall, Englewood Thinking John Wiley, New York Cliffs, New Jersey Chevasse J M (1992) Guest editonal "The dimensions of Reid N G (1985) Wards m Chancery^ Royal College of Nursing, anpowerment in nursing — and challenges Joumal of LcHidon Advanced Nursmg 17(1), 1-2 Roper N (1976) Clinical Expenence m Nurse Education A Survey of Available Nursing Expenmce for General Shtdenls in Scotland Didcoff J &Jan)esP (1970)Behefsandvalues bases for cumculum design Nursmg Research 19(5), 415-426 Churchill Livingstone, Edinburgh 1478
Desensittzation of student t Roth I {1966) Perception and Representation A Cognitive Approach tration Unpublished PhD thesis CNAA, Leeds Polytechnic, Open University Press, Milton Keynes Leeds Royal College of Nursmg (1985) Commission on Nursmg Sloboda J (1986) Acquinng skill In The Skilful Mind An Education Judge Report) The Education of Nurses A New Introduction to Cognitive Psychology (Gelatley A ed). Open Dispensatton Royal College of Nursmg, London University Press, Milton Keynes Salvage I & Kershaw B (eds) (1986) Models for Nursing John Smyth M M (1987) Cognition in Action Lawrence Erlbaum Wiley & Sons, Chichester Assoaates, London Sanford A J (1984) Cognition and Cognitive Psychology Lawrence UKCC (1986) Project 2000 A New Preparation for Practice United Erlbaum Assoaates, HiUsdale, New Jersey Kingdom Central Council for Nursmg, Midwifery and Health Schmidt R A (1975) A schema theory of discrete motor skill Visitmg, London leammg Psychological Review 8Z, 415-451 Walton L & Macleod Clark J (1986) Making contact Nursmg Seed A (1991) Becoming a registered nurse the students' perspective Times 82(3), 28-32 A longitudinal, qualitative analysis of emergent views of a cohort of Wilson A & Startup (1991) Perceptions of the nurse teacher an student nurses during their three year training for general regisempincal study Health Education Journal 50(4), 186-190
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