By Susan Sportsman, RN, PhD, ANEF, FAAN
An idea gaining momentum in nursing education over the last decade or so suggests that student engagement promotes success in school, on the NCLEX examination, and ultimately in practice. In response to the resulting “Flipping the Classroom” mantra, most of us have instituted some level of active learning into our classrooms as a means of encouraging student engagement. Despite grumbling from some students (“Why do we have to teach ourselves?”), these approaches have often seemed effective—at least for many students.
As I talk to faculty from across the country, I hear discussion about the results of these adventures into active learning. I hear stories about the success of such strategies, but I also hear complaints, ranging from the time such activities take to the questionable relevance of some of the activities. What are the reasons for the diversity of opinion regarding the impact of active learning upon student engagement? I would suggest that there may be at least two reasons:
• Students (and perhaps, some of those of us who are teaching) don’t understand the physiological response of the brain to various teaching-learning activities and the impact of these activities on student engagement.
• Using active learning strategies in the classroom in a random manner, not associated with an intentional plan, reduces the effect of active learning on the brain’s functioning and the success of the strategies.
Let’s examine each of these issues more closely:
How does the structure and function of our brain affect learning? We are all born with at least 100 billion neurons (nerve cells) in our brain. When we listen to, talk about, or practice a concept or topic, dendrites begin to protrude from related neurons. As we learn, these dendrites grow and we build an increasingly wide network of them. When two dendrites grow close together, chemical or electrical messages can be sent from one neuron to another. Over time—and numerous synapses—the pathways related to the topic are made stronger, allowing the student to connect and act upon learned ideas (Envision, 2015).
Presenting material in a way that relates directly to something students already know enhances the building of the neural network (Envision, 2015). In addition, seeing, hearing and using the knowledge over and over again in a variety of situations results in relevant dendrites growing thicker, becoming coated with a fatty layer. With enough repetition, these thickened brain fibers eventually form double connections to one another (Cirino, 2015), increasing the retention of the information. The more times the network is stimulated, the more ingrained it becomes, and the more efficiently the learned materials can be recalled and applied (Benard, 2010).
Moving from the cellular level, as the human brain evolved, the two cerebral hemispheres differentiated into specialized functions and skills. In general, the left hemisphere emphasizes language processing, linear thinking, and pro-social functioning. The right hemisphere is involved in visual-spatial processing, strong emotions, and private experiences. Unlike the notion behind the “right brain-left brain” discussion of years past, most tasks involve contribution from both hemispheres; thus teaching-learning activities must encourage both cognition and emotional experiences.
When learning activities require cognition AND the expression of emotion, thus activating both hemispheres of the brain, students are more likely to be engaged. This stimulates changes in the brain. This ability of the brain to change is known as neuroplasticity. Since the 1990s, research using functional magnetic resonance imaging (fMRI) has confirmed that the brain has the ability to reorganize itself throughout one’s life as a result of environment, behavior, thinking, and emotions (http://www.ascd.org/ascd-express/vol1/123-mcbride.aspx). This means that the old notion that an adult’s brain is static and cannot change is not correct. Intelligence can, in fact, be improved, because practice makes permanent (Cozolino, 2013).
Equally important, the type of practice influences what is learned. It turns out that there is a connection between the emotions that are generated during the learning process and the extent to which the learning activity is similar to real-life experiences. So, in order to develop competency in an area, students must not just listen to someone else talk about the competency, they must also actually perform the related skills (Cirino, 2015). Learning is also increased when student participation triggers the brain to make associations with the contextual experiences (Walker, 2011). As a result, the net effect of asking students to plan nursing care in class based on a case study will enhance their ability to plan care in the clinical setting.
Students’ engagement triggers neurochemical changes in the brain. Merzenich (2013) notes that when the student is alert and motivated, the brain will release neurochemicals that support brain change during learning. Conversely, when students are disengaged, inattentive, distracted, or doing something that does not require some effort, neurochemicals will not be released. In addition, student engagement becomes observable through physical, emotional, or verbal behavior. Since student engagement is the means by which learning (and brain change) occurs, faculty must consider ways to activate multiple engagement behaviors. From a practical perspective, how can we encourage these behaviors in our classroom? Here are some suggestions:
1. Students can sit and listen for only about 15-20 minutes before the sedentary position causes a decrease in blood and oxygen flow to the brain, reducing their engagement. Inserting a physical activity into the flow of the class, even if it is only turning to their neighbor to discuss an idea, will increase students’ engagement. If the idea is something that generates an emotional reaction—and much of nursing practice triggers emotions—this short activity will also trigger emotional engagement. In addition, when students must explain what they think they have learned (verbal engagement), the mental rehearsal required leads to retention of the material being discussed (Almarode, Miller, 2013).
2. Story telling by the faculty is a strategy that can capture both students’ cognitive powers AND their feelings (Cozolino, 2013). Telling stories about clinical experiences has long been a strength of many nursing faculty. Recognizing that there is actually a physiological response to this approach to teaching reinforces the need to integrate stories into the classroom experience.
3. Fear and stress impair learning. Stressful situations trigger the release of the stress hormone cortisol, which interferes with neural growth (Cozolino, 2013). Offering students the opportunity to learn stress reduction strategies has long been a remediation strategy in nursing programs. Promoting an environment which is supportive, rather than punitive, will also reap many benefits.
Despite the actions of the faculty, most nursing students experience stress during their clinical experience. (I still remember not being able to sleep before my first day of each clinical rotation many years ago.) While this stress is probably unavoidable, a supportive faculty-student interaction can mitigate the stress of the uncertain environment. In addition, the use of simulation as a means of experiencing patient care in a safe environment will also reduce the effects of negative stress when the student encounters a similar situation in the clinical setting.
How can the idea of neuroplasticity help us plan meaningful teaching-learning activities for nursing students? Here are some ideas:
Adult students must believe that they can improve as a student—even when the process of improving is difficult. Lessons on the ways that learning changes the structure and function of the brain, and how this improves their performance, are key to motivating students to take charge of their own learning. Presenting strategies on the use of cognitive and metacognitive strategies to increase their own learning is also helpful.
Since repetition of content is important, I can imagine that presenting the idea of neuroplasticity in pathophysiology and in the study of neurological problems could be helpful in reinforcing this point for nursing students. A section on learning how to learn in the study-skills section of an early nursing course would support developing the necessary skills for engagement. (This emphasis may also help to alleviate some of the student complaints of “we have to teach ourselves.”) For faculty, this also reinforces the notion that when students struggle, it is because they need to be engaged in their studies and be provided with additional practice and instructional support. It is not because they cannot learn (Wilson, 2014).
Planning for Active Learning
The science of the brain compels us to use active learning in our classrooms. However, randomly interspersing activities without a plan for the class, the course, or in a broader perspective, the curriculum, reduces the power of the brain in the learning process for the individual student and/or the group. How can we be sure that the power of the active learning activities is maximized?
The goal of active learning is to draw attention to the most important content. Therefore, it would be appropriate to use the objectives of the course (which identify the most important content) to determine what should be emphasized via active learning. In addition, the faculty should be mindful of the limitation of time, the students’ interest, and the number of “big ideas” that are to be emphasized during a particular class period when choosing an activity.
Next, the faculty should ask themselves how the structure and content of the chosen learning activity will help students to use this material in their role as a nurse. This is important for two reasons. First of all, instructors should be as clear as possible in their own minds about the desired outcomes in order to evaluate the activity’s effectiveness. In addition, when the activity is explained to the students, they should be told what outcomes to expect. This will reinforce the importance of student engagement and of students being responsible for their own learning.
Finally, at the end of the activity there should be an opportunity for students to debrief. This may include simply asking a question: “What did you learn from this activity?” or “What will you do with what you learned from this activity?” Remember that active learning may involve doing things or thinking about things. (Yale Center for Teaching and Learning) Short discussions can foster students to think about what they have just done. If time allows, the faculty may implement a debriefing approach similar to those outlined in the INACSL Standards of Best Practice.
Nursing curricula are tightly linked sets of courses which make up the basis for the students’ nursing practice following graduation. To insure that the knowledge gained in each course builds upon previous knowledge, faculty must work together to provide the repetition in different contexts, so student can use the knowledge and skills across the entire curriculum. Nursing faculty often analyze their courses or curriculum to insure that learning objectives reflect the program’s student learning outcomes. Similarly, in pre-licensure programs, they evaluate the presence or absence of the NCLEX categories in courses. (See September, 2017 and February, 2018 CMC Blog.) I would recommend that faculty use a similar process to review the use of active learning strategies tied to important concepts which are emphasized across the curriculum, paying particular attention to the:
• Extent to which the course objectives are reflected in the active learning approaches;
• Extent to which the goals of active learning strategies are based on previous knowledge which encourages students to apply the concept/content in increasingly more complex scenarios throughout the curriculum; and
• Frequency with which the active learning approaches represent student learning outcomes the faculty hopes to see at the time of graduation.
Developing the plan of instruction for each class period is the responsibility of the individual faculty member assigned to the content. However, since classes blend together to make a course and the courses provide the basis for students’ nursing practice upon graduation, faculty across the curriculum must collaborate to insure that students are prepared to draw on past knowledge to solve new problems as they develop into competent nurses.
The idea that we can use principles of brain functioning to plan learning activities to enhance student engagement is interesting to contemplate. Using the principles of brain functioning will provide a foundation for both faculty and students to build the necessary competencies in order to provide safe, compassionate care as a novice nurse.
Happy Active Learning!
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