Adjusting Philosophies to Support Affective Teaching in Nursing Education

It has been our duty as educators in nursing to support the learning, measurement, and objective focus of our content for students. This process is required by accrediting agencies and state

boards of nursing. In addition, it is what all conference presenters are asked to provide before they present. These requirements have been around for a long time, and we have discussed some of the reasons for their existence. This chapter takes us on a journey that helps us understand what we are doing and looks at where we build our ability to be educators who can also move students toward affective literacy. We already know we have not interpreted our forerunners correctly as they guided us to having course objectives, but now what do we do about it?


In 2005, the National League for Nursing (NLN) published Core Competencies of Nurse Educators, which presents eight competency domains. They are to:

1. Facilitate learning

2. Facilitate learner development and socialization

3. Use assessment and evaluation strategies

3.Participate in curriculum design and evaluation program outcomes

4. Function as a change agent and leader

5. Pursue continuous quality improvement in the nurse educator role

6. Engage in scholarship

7. Function within the educational environment

The first three competencies address the need for faculty to be competent in affective teaching. The first competency states: “Nurse educators are responsible for creating an environment in classrooms, laboratory, and clinical settings that facilitates student learning and the achievement of desired cognitive, affective, and psychomotor outcomes” (NLN, p. 1).

The specific objectives related to affective teaching in the first three competencies include the following expectations of faculty:

1. Engage in self-reflection and continued learning to improve teaching practices that facilitate learning

2. Model critical and reflective thinking

3. Use personal attributes (e.g., caring, confidence, patience, integrity, and flexibility) that facilitate learning

4. Facilitate learners' self-reflection and personal goal setting

5. Foster the cognitive, psychomotor, and effective development of learners

6. Use a variety of strategies to assess and evaluate learning in the cognitive, psychomotor, and affective domains

In addition, Halstead (2007) edited a collection of evidence for the NLN addressing a host of educational imperatives. With hundreds of references in this text, the reader will once again see a theme of relational teaching, student-centered pedagogy, flexibility, intrapersonal awareness, knowledge of content, positive desire for teaching the content, and a concern for the whole student in and out of the classroom. One referenced author, Lowman (1995), summed it up in two educator dimensions: “(1) creating intellectual excitement, which includes knowing and presenting content and stimulating emotions associated with intellectual activity, and (2) developing interpersonal rapport, both psychological and emotional, that reflects respect for the student” (p. 19). Again, for an educator to be effective, he or she must address how he or she will impact the emotional side of the student as a way to inspire and create long-lasting change. It would appear teachers functioning under these standards would certainly need to balance cognitive, affective, and psychomotor learning every day in a host of ways. However, there is a serious lack of affective teaching or modeling at the present, even with some faculty members in various parts of the country using care pedagogy.

Another nursing credentialing agency is the American Association of Colleges of Nursing (AACN), which focuses on baccalaureate and graduate nursing programs. They produced the Nursing Faculty Tool Kit for the Implementation of the Baccalaureate Essentials in 2009. The AACN has produced nine integrative learning strategies called the Essentials to “delineate the outcomes expected of graduates of baccalaureate nursing programs” (p. 2). The AACN states, “the purpose of the document is to provide nursing programs with examples of educational approaches that actively engage the learner and integrate liberal education, nursing science, clinical reasoning, and ethical considerations into both classroom and clinical learning” (p. 3). The AACN does present the Essentials with a host of teaching needs to be met and gives suggestions on how this can be accomplished. “The learning strategies include a variety of methods, such as unfolding case studies, simulation, and reflective practice exercises to assist with implementation of a well-integrated curriculum based on the AACN's Baccalaureate Essentials” (p. 3). The examples provided by the AACN may make the teaching methods different from what you might be doing, but it would not be difficult to conduct these teaching methods using cognitive, affective, or psychomotor strategies. However, in the specific teaching goals listed under the Essentials, one can see some need for affective methods. For example, the Essentials indicate faculty should “Provide opportunities to reflect on one's own actions and values to promote ongoing self-assessment and commitment to excellence in practice” (p. 4, under Essential 1). Twenty-six of the 187 goals or subgoals have affective characteristics based on the literature and taxonomy constructed and presented in detail in Chapter 6 and Appendix 6.1 (Ondrejka, 1998). There were times when the AACN would provide some specific strategies for best teaching methods, but they were more general in their recommendations, which may serve the large variety of institutions offering the baccalaureate degree in nursing.

By the absence of the words cognitive, affective, and psychomotor, the impression is given that the authors of the AACN Essentials are avoiding this classification process; one can only speculate on the reasons. Certainly there has been a movement in the past going back to Bloom's Taxonomy and later presented by Krathwohl (Krathwohl, Bloom, & Masia, 1999) where he felt there was no reason to create the distinction between the cognitive and affective domains, as they had a tendency to be intertwined.

Certainly, affective teaching, whether explicitly referred to or not, has a role to play in the education of today's nurses because it addresses a need for critical thinking and self-awareness that is crucial to effective nursing and happens to be an essential of nursing education advocated by nursing accreditors. The most recent comprehensive study on nursing education has recently been published by Benner, Sutphen, Leonard, and Day (2010). In it, the authors make “a call for radical transformation,” as outlined in the title of the book. These authors suggest we know three major issues regarding nursing education:

1. U.S. nursing programs are very effective in forming professional identity and ethical comportment.

2. Clinical practice assignments provide powerful learning experiences, espe-

cially in those programs where educators integrate clinical and classroom teaching.

3. U.S. nursing programs are not generally effective in teaching nursing science, natural sciences, social sciences, technology, and humanities. (pp. 11–12)

Their findings emphasize the problems being seen in classroom education everywhere that faculty rely heavily on scripted PowerPoint presentations as the primary teaching method. Fortunately, nursing has a significant clinical component and there are many opportunities for teachers to create and recommend clinical reflection into the classroom or vice versa. Experiential learning is emphasized as a key attribute for effective learning using the simulation lab and clinical practice. However, there is a continued concern that our current complex hybrid educational model allows the professional nurse to graduate with the least amount of education of any profession in the United States because nurses can still be licensed as associate degree nurses, and professional nurses do not have a residency requirement before full licensure. All schools include a capstone clinical requirement typically ranging from 180 to 350 hours, but there is no guarantee that this makes them competent as a novice nurse even after licensure. Benner et al. therefore support residency programs as a way to collect this additional knowledge that is a gap between new nurses' educational preparation and the expectations in their first practice position. One study on the practice gap states, “Ninety percent of nursing school leaders believe that new grads are ready to provide safe and effective patient care, but only 10% of hospital nursing executives agree” (Mosby Suites, n.d.). The United Kingdom has suggested there is a similar gap for all nursing graduates in that country as well (Maben, Latter, & Clark, 2005). In spite of all these gap assessments for new graduates, there is no discussion regarding affective illiteracy. The primary remedy by most research suggests the need for a 12-month residency program that deals with communication skills, conflict resolution, teamwork, and attitudes, and continues knowledge–practice integration and knowledge of current quality measures (RN Journal, n.d.).

Although there are clear benefits to affective teaching methods (see discussions of teacher immediacy, an understanding of proxemics, etc., in Chapter 4), it is also important to point out that all teaching methods deserve a critical eye as we see continued gaps develop between nursing education and clinical practice needs. Benner et al. (2010) examined many experiential, theatrical, authentic role play, and game-based pedagogies currently being used in classrooms. They present a noteworthy, critical assessment of such pedagogies that challenges a simple acceptance of these teaching methods in nursing education today. For example, in some cases, the experiential learning was lacking and seemed to be disconnected to the more critical thinking needs of the situation. The theatrical and authentic role playing by faculty often brought excellent student evaluations, and thus the faculty member continued to use an experiential learning exercise that was actually lacking in effective teaching.

Classroom games were also critically examined and in many instances, these were played in a way that the students were rewarded for guessing, which raised concern for the researchers. Many strategies that are used in the affective domain of teaching had the potential to reinforce nursing attributes that are not quality learning outcomes for a professional nurse, according to these authors. The researchers found some good use of humor as a faculty member relayed a personal story about her own past practice to make a clinical point. Again, these researchers may be pointing to the fallacy that a teaching technique by
itself is a valuable affective teaching tool. It may be that any affective teaching method without the clinical integration or the thoughtful reflection of its deeper meaning, may not be valuable for the desired student outcomes.

Benner et al. (2010) suggest that nursing education take on four strategies that would allow for improved student outcomes. The first is “focus on covering decontextualized knowledge to an emphasis on teaching for a sense of salience, situated cognition, and action in particular clinical situations” (p. 89). Having a sense of salience means to take a piece of knowledge and know how it would be used in a certain situation, which may be difficult for those who see everything as either black or white. An example of this would be a nurse who saw that his or her patient's blood pressure was 142/94; how would the nurse respond differently to this measurement if the patient was a 40-year-old in outpatient treatment, a 65-year-old postoperative inpatient, or a child of age 6 during a wellness examination? This certainly seems to be a challenging expectation for the educator, especially if his or her student's maturational thinking was not at a level that it should be.

The second recommendation by Benner et al. (2010) is to change your teaching, “from a sharp separation of classroom and clinical teaching to an integrative teaching in all settings” (p. 89). This strategy is often lost by having different faculty for both settings with each having their own curriculum design that may not be linked in content or in methodology. This seems like a relatively easy thing to fix, but not when we continue to have such gaps between the didactic and the clinical or laboratory instructors. One way to resolve this might be to have the same faculty doing both, but this could be costly to the institution. A second strategy is to have the didactic course always incorporate critical reasoning scenarios with problem solving and discussion on rationales. The lab and clinical session would also need to have a theoretical application session involved, which would take advantage of time already set aside for clinical postconferences and lab lectures.

The third recommendation by Benner and colleagues (2010) is to move “from an emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking that include critical thinking” (p. 89). The challenge of this pluralistic view is that it would require the faculty to use higher levels of thought that they may or may not understand based on their own maturational level. Such an instructor might get stuck on what he or she consider to be highly scripted and may even reprimand the student for using creative thinking as an alternative for a certain patient issue. I have even heard faculty confront a student and say, “as long as you are in my clinical setting, you will do this procedure this one way without exception.” This entire recommendation reinforces our need to raise the maturational thinking level of some faculty in order to implement the recommendation of Benner et al.

The fourth recommendation by Benner et al. (2010) is for faculty to move “from an emphasis on socialization and role taking to an emphasis on formation” (p. 89). This is such a critical element in order to know I am a nurse and transition from a student nurse or one who is not accountable to being the one who

Vignette 5.1

I was teaching a course on the professional practice role of a master's-prepared nurse in a course in Vietnam in 2010. Each Vietnamese institution certified trained nurses to practice within their facility, and then the nurse was certified to work. There were certain practices that were universal for all nursing graduates, but they were then hired by various hospitals to practice using the institution's standards—similar to the United States where we practice using the hospital policies and procedures. However, in the United States we continue to say we practice using evidence-based practices, and we also are licensed by our states under a certain practice act.

In Vietnam, prior to nurses getting a master's degree, all nurses are expected to practice under the direction of a physician. There is no patient advocacy, or professional independence in their practice. They are accountable to listen to and abide by the directions of the hospital they work for and the physicians of that facility. However, I still saw a difference between the young nurses who were task driven versus the older and more experienced nurses who knew they were nurses and had a voice related to their positions. I did notice that none of the master's degree students had a “voice of agency” directly to the profession, where they knew what they offered in the context of nursing care, patient care interventions, and how they partnered with physicians for a patient's best outcomes. I asked the nurses in the course to proclaim loudly, with a strong voice, “I know what I offer my patients as a nurse, and my practice does matter!” This was difficult for them, and many would laugh with anxiety as they said it. I am not sure if the same isn't true for most nurses in the United States. Do U.S. nurses really have an inner voice of who they are in their profession—do they have a sense of professional nursing formation?

is accountable. We do emphasize how students are student nurses, have student nursing uniforms, and work with others who are accountable, and thus we tend to emphasize the role of the professional nurse as a more abstract person.

Do you remember the day you believed you were a nurse—the person accountable to the state board where you were licensed, and you were responsible for your patient's well-being? You knew you had to own your practice. Vignette 5.1 outlines a relatively recent event regarding the concept of formation of a professional nurse with master's-prepared students in Vietnam.

It appears that the concept of salience and having an internal sense of nursing formation is a challenging issue to teach. That does not mean faculty should stop trying. It means we need a way to teach to such ends. The next section takes that next step, outlining how we may begin to use affective teaching practices to address our challenging issues in nursing education.

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